Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No.

11  1

Stunting Status of New Children Enter Elementary School

Between Urban and Rural Areas in Jayapura City, Papua

Wahida Y. Mapandin

Lecturer of Nutrition Department, Faculty of Public Health, Cenderawasih University

Abstract
Background: The optimal growth of school-age children depends on providing nutrition with good and
correct quality and quantity. One way that can be done to determine the implementers of nutrition improvement
is to determine or see the physical size, both in height and weight. A person’s physical size is closely related
to nutritional status. Measurement of nutritional status in school children can be done by anthropometry.
Based on WHO 2007 anthropometry standards for children aged 5-18 years, the nutritional status of children
is determined based on the value of Z-score TB/U and BMI/U. Objective: The purpose of this study was to
determine whether there were anthropometric differences in children entering primary school based on the
index TB/U and BMI/U. Method: The type of research used is descriptive analytical research with cross
sectional approach. The study population was 84 children who had just entered elementary school and this
study used the Total Sampling Technique, where the number of samples was the same as the population of
84 school children. Results: The results of the study showed that there were no anthropometric differences
in children entering primary school based on the TB/U and BMI/U index in urban and rural areas. Statistical
analysis of TB/U using a non-parametric test shows the probability value (sig)> 0.05 (0.078> 0.05). While
the BMI/U is known the probability value (sig)> 0.05 (0.140> 0.05). Energy and protein intake for urban
and rural school children tends to be less. Nutritional deficiency is a factor associated with the nutritional
status of school-age children. This is exacerbated by the high incidence of infections in children and most of
the parents of disadvantaged people so that the purchasing power of food in households is low. Conclusion:
There is no anthropometric difference in children enrolled in primary school based on the TB/U and BMI/U
index in urban and rural areas.

Keywords:  TB/U, BMI/U, School Children, City, Village.

Introduction blood sample tubes is an issue of measuring serum zinc

in the population. The relationship between serum zinc
Protein is needed to build, maintain and repair
and growth is associated with zinc function increasing
body tissues. Protein also has an important role in
pituitary secretion as a raw material for growth hormone/
growth. Children who have a high risk of stunting may
GH. Studies in Thailand show that low serum zinc levels
have limited essential amino acids (such as tryptophan
tend to occur in short boys. In studies in rural China,
and lysine) in their food intake1. Stunting in children,
which geographically contained low zinc in the soil, the
besides being caused by a deficiency of macro nutrients,
prevalence of zinc deficiency was <25%3-5. The study
is also associated with zinc (Zn) deficiency. Zinc (Zn)
in Ethiopia showed no difference in serum zinc levels
is an essential mineral that plays a role in the synthesis,
based on the severity of stunting. The results of several
secretion, and control of growth hormones (Growth
studies on the comparison of serum zinc levels according
Hormones). The low synthesis of growth hormones can
to the status index of height according to age in children
inhibit linear growth and is thought to cause stunting
are still inconsistent and studies that reveal serum zinc
conditions in infancy.
levels in children in coastal areas have not been widely
Zinc serum is one of the biomarkers that is often used in Indonesia.
used to assess zinc status2. The timing of serum zinc
The International Zinc Nutrition Consultative Group
sampling, contamination of blood samples with other
(IZiNCG) estimates that more than 25% of the population
materials such as dust, and the use of non-metallic
2  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
in developing countries is at risk for zinc deficiency. The
prevalence of moderate zinc deficiency of 5-30% occurs
in children and adolescents. Insufficient zinc intake is a
major cause of zinc deficiency in developing countries
including Indonesia. The zinc content in vegetable,
vegetable and fruit foods depends on the zinc content
in the soil. The coastal area is one area where the zinc
content in the soil is low. Quantitative data on zinc intake
in school-age children in coastal areas of Indonesia has
not been widely documented.6-10
In children in families with low income levels,
inadequate zinc intake can occur because most of the
intake comes from plant foods and consumes little animal
food. The coastal area of Jayapura City, Papua is an area
rich in fishery products. Fishery products are one of the
foods that contain iron and zinc, however, consumption
of food containing high and possibly higher because it is
more affordable in terms of the economy. Another thing
is evidenced by the still high rate of stunting of children
under five in Jayapura City by 16.4%. It is suspected that
school-age children on the coast are one group with a
risk of insufficient zinc intake.
This study aims to describe the intake of protein,
zinc and calcium and to know the differences in protein,
zinc, and calcium intake with the incidence of stunting
in elementary school children in the coastal area of
Jayapura City.
Materials and Method
This research is an observational study with the
research design used is case control. The research was
carried out in selected elementary schools, namely
Kotaraja Public Elementary School which is included in
the administrative area of Jayapura City. Data collection
is planned for June to August 2018. The population in
this study were all elementary school children in the
Jayapura City area. The sample inclusion criteria were
elementary school students aged 9-12 years who were
enrolled as students in Kotaraja Elementary School,
while the subject exclusion criteria were school children
suffering from mental disorders and physical disabilities.
Calculation of sample size is calculated using the
sample size formula for the control case study and the
determination of the proportion of cases refers to the
results of the Neldawati study, with α = 5%, β = 10%, p1
= 0.781, p2 = 0.5, the number of samples is 92 people,
then the estimated lost of follow is 10% so the number
of samples is 46 people. In this study using a case and
control ratio of 1: 1 so that the number of samples
was 46 cases and 46 controls or a total of 92 samples
divided into schools with different areas of residence for
students11-13.
Primary data collected was height measured using
microtoice with a precision level of 0.1 cm. Data on
food consumption patterns including energy, protein,
calcium, zinc and dietary intake were obtained by
performing 1 x 24 hour food recall, food frequency data
obtained through the Food Frequency Questionnaire.
Data processing was carried out using the chi square test
at a significance level of 95% (α = 0.05). Variables are
bound to the incidence of stunting while the independent
variables of this study are intake of protein, zinc and
calcium.
Research Results
Effects of Protein Intake on Stunting Events:
Protein intake was obtained from the results of filling
food form 1 x 24 hours which was then processed using
nutrisurvey. Based on the research that has been done,
the results of protein intake can be seen in the following
table:
Table 1. Effect of Protein Intake on the incidence of
Stunting Children in SD Inpres Kotaraja
Stunting incidence
Protein Intake Stunting Normal
n % n %
Less 20 69 12 41.4
Enough 9 31 17 58.6
Total 29 100 29 100
p=0,035; OR = 3.148
Based on table 1 above, it can be seen that the
proportion of stunting for low protein consumption habits
is 20 children (69.0%) while only 9 children are high
(31.0%). Normal children with low protein consumption
habits as many as 12 children (41.4%), while the high as
many as 17 children (58.6%). The results of statistical
analysis using the chi-square test showed that, there was
a significant relationship between protein consumption
habits and the incidence of stunting (p = 0.035; OR =
3.148). Thus the protein consumption habits that have
less risk are 3,148 times stunting compared to normal.
Effect of Zinc Intake on Stunting Events: Zinc
intake was obtained from the results of filling 24-hour
food recall forms for 1 day, the results of the recall were
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  3
processed using nutrisurvey which was then compared Discussion
with the nutritional needs of school children. Based on
Protein is needed to build, maintain, and repair body
the research that has been done, the results of zinc intake
tissues. In addition, protein also plays an important role
can be seen in the following table:
in growth. Protein is a nutrient needed by the body for
Table 2. Effect of Zinc Intake on Stunting Children growth, building body structures (muscles, skin and
in SD InpresKotaraja Elementary School bones) and as a substitute for worn-out tissue6. Based on
the results of research by Sulistianingsih and Ari Madi
Stunting incidence Yanti in 2015 it was found that protein was associated
Zinc Intake Stunting Normal with the incidence of p-value 0.002 stunting. This
n % n % is in accordance with the study of the theory that the
Less 18 75.9 10 34.5 function of protein is as a builder substance. The entire
Enough 11 24.1 19 65.5 cell layer consists of proteins that carry micronutrients.
Total 29 100 29 100 Protein functions in carrying out body regulation and the
formation of new DNA for the body. Long-term protein
p=0,036; OR = 3.109
deficiency will cause disruption of body regulation
Table 2 above shows that the proportion of stunting and growth hormone can be disrupted which can cause
for low energy consumption habits is 18 children nutritional disorders such as stunting. The results of the
(62.1%), while the high is 11 children (37.9%). Normal chi square statistical test in Chastity research in 2017
children with low energy consumption habits are also showed a positive relationship between protein
10 children (34.5%), while the high children are 19 intake and the incidence of stunting in adolescents with a
children (65.5%). The results of statistical analysis using value of p = 0.001 which means that there is a significant
the chi-square test showed that there was a significant relationship between protein intake and the incidence of
relationship between zinc intake and the incidence of stunting.
stunting (p = 0.036; OR = 3.109). Thus zinc intake which
is less risky is 3,109 times stunting compared to normal. The tight relationship between protein and growth
causes a child who lacks protein intake to experience
Effects of Calcium Intake on Stunting Events: slower growth than children with sufficient protein
Table 3. Effect of Calcium Intake on Stunting Children intake (Bender, 2002) and in conditions that are worse
in SD Inpres Kotaraja Elementary School. in protein shortages over a long period of time can result
in cessation of the growth process. Children’s protein
Stunting incidence needs include tissue maintenance, changes in body
Calcium Intake Stunting Normal composition, and the formation of new tissues. Protein
n % N % requirements for growth are estimated to range from 1-4
Less 22 75.9 10 34.5 g/kg to additional body tissue.
Enough 7 24.1 19 65.5
Total 29 100 29 100 The normal concentration of total calcium in plasma
is 2.4-2.5 mM while the concentration of free calcium
p=0,002; OR = 5.971 ions ranges from 1.25-1.3 mM. Effective calcium
Based on table 3 above it is known that the stunting homeostasis is important in many biological processes,
proportion for low calcium consumption habits is 22 including bone metabolism, cell proliferation, blood
children (75.9%), while the high is only 7 children coagulation, hormonal signaling transduction and
(24.1%). Normal children with low calcium intake as neuromusular function. Calcium balance is maintained
many as 10 children (34.5%), while the high as many by 3 main organs, namely: the gastrointestinal system,
as 19 children (65.5%). The results of statistical analysis bones, and kidneys.Adequate calcium intake can help
using the chi-square test showed that, there was a protect bones throughout our lives. In children and
significant relationship between calcium consumption adolescents, adequate calcium intake can help produce
habits and the incidence of stunting (p = 0.002; OR = higher bone mass. Partial loss of calcium daily through
5.971). Thus calcium intake which has less risk of 5,971 ekresi (urine and feces), sweat, and lungs when we
times stunting compared with normal intake. breathe is normal, consuming enough calcium every
day can restore lost calcium. Lack of calcium intake
4  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
in children will increase the risk of bone fracture
in children, so that children cannot achieve optimal
bone growth15-17. During growth, demands for bone
mineralization are very high, very low calcium intake
can cause hypocalcemia, despite the secretion of the
maximal parathyroid gland, which can result in low
bone mineralization matrix and osteoblast dysfunction14
Calcium deficiency will affect linear growth if the
calcium content in the bone is less than 50% of the
normal content. In infants, lack of calcium in the bones
can cause rickets, whereas in children, lack of deposits
can cause growth retardation18-19. During growth,
demands for bone mineralization are very high, very
low calcium intake can cause hypocalcemia, despite
the secretion of maximal parathyroid glands, which can
result in low matrix mineralization of new bone deposits
and osteoblast dysfunction. Calcium deficiency will
affect linear growth if the calcium content in bone is less
than 50% of normal content. In infants, lack of calcium
in the bones can cause rickets, whereas in children, lack
of deposits can cause growth retardation19-21
Source of Funding: Self
Conflict of Interest: None
Ethical Clearence: Obtained from Faculty
committee, Cendrewaih University.
Conclusions
Protein, zinc, and calcium intake was significantly
lower in stunting children than in non-stunting children
of primary school age in Jayapura City. Stunting is a
chronic nutrition problem that can be addressed in an
early warning by monitoring nutritional status, especially
height, at the posyandu so that it can be detected and
given immediate intervention.
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6  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Determinants of Exclusive Breastfeeding in

6 Months Old Infant in Jeneponto District

Nur Ulmy Mahmud1, Tahir Abdullah2, Arsunan A.A.2,

Burhanuddin Bahar2, Veni Hadju2, Masyita Muis2, Sri Sumarmi3
1Postgraduate School Students Faculty of Public Helath, Hasanuddin University of Indonesia, 1Faculty of Public
Health, Muslim University of Indonesia, 2Faculty of Public Health, Hasanuddin University of Indonesia, 3Faculty
of Public Health, Airlangga University, Indonesia

Abstract
Background: The coverage of exclusive breastfeeding in Indonesia is still very low, especially in Jeneponto
district. The purpose of this study was to determine the determinants of exclusive breastfeeding. METHOD:
This study is a continuation of the main research, the design used is an experiment followed by a study
cohort involving pregnant women and their babies then analyzed at the age of 6 months. 340 samples
were randomly divided into 3 groups (Moringa leaves powder (MLP), Iron Folic Acid (IFA), Moringa
leaves extract (MLE)) given to pregnant women (2nd trimester) and 1 month after delivery. Data analysis
using logistic regression.RESULTS: The results showed that of 340 samples intervened (MLP32.6%; IFA
35.9%; MLE 31.5%)), as many as 42.9% of infants were exclusively breastfed and 57.1% of infants were
not exclusively breastfed. The logistic regression test results showed that babies who received colostrum
at birth were 3.185 times more likely for exclusive breastfeeding than those who did not get colostrum
(AOR 3.185, CI95% 1.324-7.659); mother’s work (AOR 1.923, CI95% 1,044-3,540); family income (AOR
2,050, CI95% 1,202-3,498); Mother’s education (AOR 2.512, CI95% 1.451-4.351), maternal knowledge
(AOR 1.679, CI95% 1.020-2.764) and birth weigthhas the possibility of exclusive breastfeeding compared
to the comparison. CONCLUSION: The results showed that the determinants of exclusive breastfeeding
in 0-6 months infants in JenepontoDistrict were giving colostrum, mother’s work, family income, mother’s
education, and mother’s knowledge about the benefits of exclusive breastfeeding

Keywords:  Exclusive breastfeeding, mother’s knowledge, mother’s education, family income.

Introduction six months, accompanied by nutritious foods that are

The neonatal period is an important period for
survival in infancy. Nutrition and breastfeeding are
the things that are most needed in this period for the
physical and mental development of babies. Breast milk,
colostrum and prelacteal feeding are strongly influenced
by knowledge, mother’s beliefs and socio-culture.
UNICEF recommends breastfeeding should begin within
half an hour after giving birth. Delays in breastfeeding
can affect the quantity of milk produced. In addition, late
stimulation can cause hypoglycemia, hypothermia and
acidosis, especially for those at high risk such as low
birth weight (LBW). Breast milk contains antibodies
from mothers that help fight disease, protect babies from
diarrhea and acute respiratory infections. Breastfeeding
also stimulates the baby’s immune system and responds
to vaccination. Continuing breastfeeding for more than
sufficient, safe and appropriate, soft, and also help ensure
good nutritional status and protect against disease. It is
estimated that optimal breastfeeding of children under
the age of two has the potential to prevent 1.4 million
deaths in toddlers in developing countries each year1,2,3
Globally, only 43% of six-month-old infants receive
breast milk exclusively (UNICEF 2016). In low and
middle income countries, more than 68 million children
born this year are not exclusively breastfed. Most non-
breastfeeding children exclusively consume water, milk,
formula milk, or complementary foods other than breast
milk, often causing infections in unsafe environments,
only 45% of breastfed children within one hour after
birth and only 46% continuing to breastfeed up to the
age of two (UNICEF 2016). Exclusive breastfeeding and
continued up to two years can accelerate body weight
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  7
gain and body length in the first few months of life,
based on globally reported data, 6.9 million children
under five died in 2011, around 1 million could be saved
simply as breastfeeding exclusive4,5,6Galactagogues
are herbs that increase volume and facilitate the
flow of milk. Several studies confirm the efficacy of
galactogogue in helping nursing mothers. However, it
is usually promoted and given 3 days after giving birth
to induce lactation. Moringa leaves increase the effect of
lactation as evidenced by a greater increase in maternal
serum prolactin levels. Prolactin is the most important
hormone in lactation initiation. Moringa leaf powder
is an effective galactagogues to increase volume and
facilitate ASI7
In Indonesia, the coverage of exclusive breastfeeding
for infants aged 0-6 months is fluctuating. In 2007 only
around 62.2% and in 2008 it was 56.2%. Meanwhile,
based on the provincial health office report in Indonesia
in 2018 for exclusive breastfeeding coverage of 37.7%.
The coverage of exclusive breastfeeding in South
Sulawesi Province in 2009 to 2014 is still below the
national standard. In 2014, the exclusive breastfeeding
coverage was still 56.31%. Jeneponto Regency in 2008-
2012 showed exclusive breastfeeding coverage was far
from the 80% national standard. In fact, from the profile
data of the South Sulawesi Provincial Health Office in
2012, Jeneponto district is the district with the lowest
coverage of breastfeeding, which is around 20.57%.
Furthermore, in 2013 it showed an increase to 67.66%8,9
Method
This research is a continuation of the main research.
The research method used in this study was an experiment
followed by a cohort involving pregnant women (second
trimester) with their babies from birth to age 6 months.
This study will be divided randomly into 3 groups, the
first group is pregnant women who get Moringaoleifera
flour, the second group is pregnant women who get Fe
tablets and the third group is pregnant women who get
extracts. The intervention will be given in the second
trimester (pregnancy to 4 to 6 months) and followed by
intervention after giving birth until their baby is 1 month
old.
The population in this study was the number of
pregnant women in 6 sub-districts located in Jeneponto
Regency, South Sulawesi. Sub-district elections will be
carried out based on an agreement with the Jeneponto
Health Office with consideration of the performance of
health workers in the Puskesmas, especially midwives
and nutrition workers who oversee the sub-district so
that this research can be carried out properly.
Samples were all mothers who participated in the
previous study of 600 pregnant women but with various
reasons several mothers had dropped out, so the number
of samples participating in this study were mothers who
had given birth and had babies aged 0-6 months as many
as 340 babies
Data that has been collected will be processed and
analyzed using SPSS software. Before further statistical
tests, all data processing variables will be presented
in the form of averages, standard deviations, ranges
and frequencies. Normality test is useful to determine
whether the collected data is normally distributed or not,
unpaired t test is used to compare differences between
treatments in variables, logistic regression test is used
to identify factors related to exclusive breastfeeding,
bivariate analysis is used to select candidate variables
that will included in multivariate regression
This research was carried out after obtaining approval
from the Ethics Commission of the Faculty of Public
Health, Hasanuddin University number UH16090723.
Before the implementation of measurements and
interviews will be given an explanation of the actions to
be taken for each respondent (Mother and baby). After
the explanation, the respondents were asked for approval
to participate in this study by signing an informed
consent
Results
The results of this study were carried out in 6 Districts
of Jeneponto District. This research was conducted by
interviewing respondents in the area
Table 1. Socio-demographic characteristic of
respondents
Variable Frequency (n) Percent (%)
Mother Age (n=340)
<26 year 134 39.4
≥26 year 206 60.6
Gender of the child (n=340)
Man 177 52.1
Women 163 47.9
8  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Variable Frequency (n) Percent (%) Variable Frequency (n) Percent (%)
Mother education (n=340) Birth Weight (n = 340)
Low 230 67.6 LBW (<2500gram) 12 3.5
Height 110 32.4 Normal 328 96.5
Mother’s Work (n = 340) Exclusive breastfeeding (n = 340)
Does not work 277 81.5 Not 146 42.9
Work 63 18.5 Yes 194 57.1
Monthly income (IDR) Pralacteal (n = 340)
<2 million 253 74.4 Not 241 70.9
≥ 2 million 87 25.6 Yes 99 29.1
Intervention Group (n = 340) Giving Colostrum (n = 340)
MLP 111 32.6 Not 26 7.6
IFA 122 35.9 Yes 314 92.4
MLE 107 31.5 Mother’s knowledge about the benefits of breast milk (n = 340)
Do not know 228 67.1
Source: Primary data
Know 112 32.9
Based on Table 1 Socio-demographic characteristic
Number of children
of respondents based on mother’s age, it is known that
the highest number of respondents was at the age of ≥26 1 109 32.1
years as much as 60.6% and the least at age <26 years >1 231 67..9
as many as 39.4%. Based on the sex of the child, it is
known that the highest number of respondents is male Source: primary data
sex as much as 52.1% and women as much as 47.9%. Based on Table 2 Distribution of characteristic
Most maternal education at the low education level is related to breastfeeding in mother based on place of birth,
as much as 67.6% and the level of higher education is it is known that the highest number of respondents gave
32.1%. For the work of mothers, it is known that more birth to health facilities as much as 87.9% and those at
mothers do not work, namely as much as 81.5% and home as many as 12.1%. Based on the birth process, it is
those who work as much as 18.5%. Family income in known that the highest number of respondents gave birth
monthly is at most <2 million, 74.4% and 2 million as normally as much as 93.8% and sectio as much as 6.2%.
much as 25.6%. For normal birth weight as much as 96.5% and LBW as
Table 2. Distribution of characteristic related to much as 3.5% For breastfeeding patterns, it is known that
breastfeeding in mother more babies are exclusively breastfed as much as 57.1%
and those without exclusive breastfeeding are 42.9%.
Variable Frequency (n) Percent (%) Prelacteal is 70.9% and not prelactealas much as 29.1%.
Childbirth Place (n = 340) For giving colostrum as much as 92.4% and those who
did not get colostrum 7.6%. The knowledge of mothers
House 41 12.1
about the benefits of breastfeeding is the most that is not
Health facility 299 87.9
years of benefits, namely as much as 67.1% and those
Childbirth Process (n = 340) who know as much as 32.9%. Whereas the number of
SecarSectio (SC) 21 6.2 children at most mothers who have more than 1 child is
Normal 319 93.8 67.9% and those who have 1 child are 32.1%
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  9
Table 3. Factor Affecting Exclusive Breastfeeding: Results of Univariate and Multivariate Logistic
Regression

Practiced Exclusive Breastfeeding

Socio Demographic Features OR Crude (95% CI) OR Adjusted* (95% CI)
Yes No
Giving Colostrum
Yes 9 17 2.709 (1.171–6.266) 3.185 (1.324-7.659)**
Not 185 129 1.0 (reference) 1.0 (reference)
Mother’s Work
Not 163 114 1.476 (0.853-2.555) 1.925 (1.042-3.559)**
Yes 31 32 1.0 (reference) 1.0 (reference)
Family Income (IDR)
<2 million 152 101 1.612 (0.988-2.6322) 2.028 (1.183-3.476)**
> = 2 million 42 45 1.0 (reference) 1.0 (reference)
Mother education
High 73 37 1.777 (1.108-2.851) 2.512 (1.451-4.351)**
Low 121 109 1.0 (reference) 1.0 (reference)
Knowledge of the benefits of breastfeeding
Know 73 39 1.655 (1.037-2.642) 1.679 (1.020-2.764)**
Do not know 121 107 1.0 (reference) 1.0 (reference)
Birth Weight
Normal 190 138 2.754 (0.813-0.9328) 3.205 (0.870-11.805)
Low Birth Weight 4 8 1.0 (reference) 1.0 (reference)

*Each Factor adjusted for the others. Odds ratios from univariate and multiple generalized estimation equation logistic regression
models, **Significant (Cl 95% >1)

Identifying factors related to exclusive breastfeeding,
bivariate analysis was performed to select candidate
variables to be included in multivariate regression.
The results of giving colostrum, work and mother’s
education, family income, and mother’s knowledge of
the benefits of breastfeeding for children associated with
exclusive breastfeeding.
Multivariate logistic regression is used to
identify predictor variables after controlling variable
confounding. All variables <0.25 in bivariate analysis
were included in the model namely Colostrum, Mother’s
Work, Family income, Mother’s education, Mother’s
knowledge, Birth weight.
the possibility of exclusive breastfeeding compared to
the comparison.
Discussion
The results of the study on Aged 6 Months
In JenepontoDistrict Determinants Of Exclusive
Breastfeeding On Infants revealed that of 340 infants,
about 57.1% of infants were exclusively breastfed
and 42.9% were not exclusively breastfed. Based on
the results of the logistic regression test, colustrum
administration, mother’s work, family income, mother’s
education level and mother’s level of knowledge about
the benefits of breastfeeding.

The results can be seen in table 3. The mother who
gave the child a collection, was 3.185 times more likely
to give exclusive breastfeeding than those who did
not give it (AOR 3.185, CI95% 1.324-7.659). as well
as employment, income, education, knowledge of the
benefits of ASI and birth weight, namely (AOR 1.923,
CI95% 1.044-3.540); (AOR 2.050, CI95% 1.202-3.498);
(AOR 2.512, CI95% 1.451-4.351); (AOR 1.679, CI95%
1.020-2.754); (AOR 3.205, CI95% 0.870-11.805) has
In this study 92.4% of mothers gave colostrum
and 7.6% who did not give colostrum. This is because
when the baby is born, the mother does not directly have
breast milk. About 67.1% of mothers who do not know
the benefits of breastfeeding and only 32.9% of mothers
who benefit from breastfeeding, even though mothers
do not know the benefits of breastfeeding but mothers
continue to give exclusive breastfeeding to their babies
due to very low family income
10  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
In line with the research conducted by Marhamah,
A.AArsunan, Wahiduddin2012), the results of this
study indicate that the results of this study indicate that
breastfeeding is the most important factor in the study of
breastfeeding until the baby is 6 months old. So, it is a
continuous lactation education program from prenatal to
postnatal to increase breastfeeding practices involving
husband or the mother’s family10.
Breast milk is the best natural food a mother can give
to a newborn child, besides its composition is suitable
for the growth and development of a baby who changes
according to the needs of the baby at all times. Breast
milk also contains protective substances that can prevent
various infectious diseases. Giving ASI also has an
extraordinary emotional influence that affects the inner
relationship of mother and child and the development
of the child’s soul (Azwar, 2001). Research conducted
by (Pujiati Abbas, 2011) that breast milk contains zinc
minerals that have been proven effective for reducing
pneumonia (pneumonia), diarrhea and other infectious
diseases. Zinc can also reduce the duration and severity
of ARI11.
In line with research conducted by (Namangboling
et al., 2017) that exclusive breastfeeding can prevent the
occurrence of diarrhea caused by infection in infants
and can maintain the nutritional status of infants,
because breast milk is the best food with complete
nutrition and is very good for baby’s needs in its growth
and development. The provision of ASI carried out
exclusively can reduce the prevalence of the incidence
of malnutrition in children. Breastfeeding promotion
is considered as an intervention that aims to maintain
nutritional status, individual health status, and can
reduce mortality by 8% globally12
ASI provides all the energy and nutrients needed by
babies during the first six months of life. Giving breast
milk to the baby in the first hour of birth can accelerate
the removal of the placenta, reduce postpartum
bleeding and also accelerate recovery from the trauma
of childbirth and can help the mother’s uterus to return
to size before pregnancy 1,13. A data from developing
countries showed that babies who did not get ASI were
six times more likely to die from infectious diseases in
the first two months of life 14-16
Conclusion
The results showed that the determinants of exclusive
breastfeeding in 0-6 months infants in JenepontoDistrict
were giving colostrum, mother’s work, family income,
mother’s education, and mother’s knowledge about the
benefits of exclusive breastfeeding
Ethical Clearance: Taken from University
committee.
Source of Funding: Self
Conflict of Interest: Nil
References
1. Glassman, M. E., McKearney, K., Saslaw, M. &
Sirota, D. R. Impact of Breastfeeding Self-Efficacy
and Sociocultural Factors on Early Breastfeeding in
an Urban, Predominantly Dominican Community.
Breastfeed. Med.2014; 9, 301–307
2. Latha, S. Newborn Feeding Practices in India : A
Review. Nursing (Lond).2016; 5, 3–6
3. Kuziga, F., Adoke, Y. & Wanyenze, R. K.
Prevalence and factors associated with anaemia
among children aged 6 to 59 months in Namutumba
district, Uganda: a cross-sectional study. BMC
Pediatr.2017; 17, 25.
4. Kramer, M. S., Moodie, E. E. M., Dahhou, M. &
Platt, R. W. Breastfeeding and infant size: Evidence
of reverse causality. Am. J. Epidemiol.2011; 173,
978–983
5. Statement, P. Breastfeeding and the Use of Human
Milk.2012;129,
6. Who, World Health Organization. World Heal.
Organ. Dep. Child Adolesc. Heal. Dev.2003 ;570,
7. Krusnadi, D. Edisi revisi maret Pus. Inf. DAN
Pengemb. Tanam. KELOR Indones. Lemb.
Swadaya Masy.–Media Peduli Lingkung. 2015.
8. Riskesdas. Hasil UTAMA RISKESDAS 2018. 88
9. Kesehatan, P. Profil Kesehatan Indonesia 2017.
10. Marhamah, A. A Arsunan, W. Factors related to the
children under five occurrence of ARI bontongan in
the village district of enrekang. 2012; 1–15.
11. Pujiati Abbas, A. S. H. Hubungan Pemberian
Asi Eksklusif Dengan Kejadian Infeksi Saluran
Pernapasan Akut (ISPA) Pada Bayi. 2011.
12. Namangboling, A. D. et al. Hubungan Riwayat
Penyakit Infeksi dan Pemberian ASI Eksklusif
dengan Status Gizi Anak Usia 7-12 Bulan di
Kecamatan Kelapa Lima Kota Kupang *. 2017; 19,
91–96.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  11
13. Tyndall, J. A., Kamai, R. & Changchangi, D.
Knowledge, Attitudes and Practices on Exclusive
Breastfeeding in Adamawa, Nigeria. Am. J. Public
Heal. Res. Vol. 4, 2016, Pages 112-1194, 112–119.
14. Mihrshahi, et al. Prevalence of exclusive
breastfeeding in Bangladesh and its association with
diarrhoea and acute respiratory infection: results of
the multiple indicator cluster survey 2007. J Heal.
Popul Nutr25, 195–204.
15. Azniah Syam, Muhammad Syafar, Ridwan
Amiruddin, Muzakkir, Darwis, Sri Darmawan, Sri
Wahyuni and Anwar Mallongi,. Early breastfeeding
initiation: impact of socio-demographic, knowledge
and social support factors. Pak. J. Nutr., 2017; 16:
207-215.
16. Prasetyo, D., Sabaroedin, I. M., Ermaya, Y. S.
& Soenarto, Y. Association between Severe
Dehydration in Rotavirus Diarrhea and Exclusive
Breastfeeding among Infants at Dr. Hasan Sadikin
General Hospital, Bandung, Indonesia. J. Trop.
Med.2015, 4–7 (2015).
12  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Analysis of Microplastic Content in Baronang Fish

(Siganus sp) and Kakap Fish (Lutjanus sp) in the
Coastal Area of Bangkala Subdistrict, Jeneponto Regency

Yuliati1,2, Anwar Daud3, Anwar Mallongi3, Burhanuddin Bahar Bahar4

1Postgraduate Student of Public Health Departement, Hasanuddin University, Makassar City, South Sulawesi,
2
Faculty of Public Health, Muslim University Indonesia Makassar City, South Sulawesi, 3Departement of
Environmental Health, Faculty of Public Health, Hasanuddin University Makassar City, South Sulawesi,
4
Department of Nutrition, Faculty of Public Health,Hasanuddin University Makassar City, South Sulawesi,
Indonesia

Abstract
Background: Micro plastic is a problem for the environment and public health measuring 0.3-5 mm.

Objective: To analyze the microplastic content of Baronang Fish and Snapper Fish in the Coastal of
Bangkala Subdistrict.

Method: The method used is the analytical survey, laboratory approach with Minitab software 16. Fish
samples were identified using FishBase. The obtained microscopy was calculated based on number and type,
photographed with optilab, and measured by raster image software.

Results: The microplastic content of Snapper Fish is higher than that of Baronang Fish at each station. The
microplastic content of Snapper Fish at Station 1 is 18 particles/fish while Baronang Fish is 14 particles/
fish. The microplastic content of Snapper Fish at Station 2 is 18 particles/fish while Baronang Fish is 13
particles/fish. The microplastic content of Snapper at station 3 is ten particles/fish while Baronang Fish is six
particles/fish. This happens because Snapper Fish has more prominent characteristics than Baronang Fish,
including having faster growth, having excessive eating behavior, tolerant of turbidity and salinity and more
actively moving. Based on these characteristics, the chances of microplastic entering the body of Snapper
Fish through eating activities are greater than that of Baronang Fish. The largest type of microplastic fiber is
found in the digestive tract of Snapper and Baronang Fish.

Conclusion: Baronang and Snapper Fish originated from Bangkala Subdistrict Beach, Jeneponto Regency
containing microplastic. The microplastic content of Snapper Fish is greater than that of Baronang Fish.

Keywords:  Microplastic, Baronang Fish, Snapper Fish.

Introduction If continuous disposal of waste into the sea, then feared

Waste is a problem for people throughout the world,
both garbage originating from land and sea. Many years
people do not care about marine pollution because of the
large volume of seawater, and its ability to thin all types
of foreign substances so that it almost not cause an impact
at all. Therefore the sea is considered as waste dumps.
However, this view began to gradually to change. This is
due to, among other things, the waste is thrown into the
sea increasingly the more time and in high concentration,
so it happens environmental pollution on a local scale1.
there will be a global impact of marine pollution. One
type the most common waste in the land and sea area is
a plastic waste2.
Marine litter (marine debris) can be defined as a
solid,produced or processed by humans, directly or
indirectly,accidentally or accidentally, thrown away or
left in the environment sea3. Bellas J, et al4 estimate that
10%of all newly produced plastics will be discharged
through the river and end at sea.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  13
Plastics are synthetic polymer materials made
through the processpolymerization5. Everyday human
life in this century is inseparable from plastic usage.
Its nature is difficult to degrade in nature to make itthe
biggest waste contributor that causes damage to the
balancenature6. The continued use of plasticincreasing
worldwide causes plastic waste to become an issue
environment that is often discussed.Disposal of
plastic waste tothe environment can cause various
environmental problems7.
Eriksen M, et al8 estimate that at least there are
250,000 tons of plastic waste that floats in the ocean.
Plastic waste buried in the sea has the potential impact
of chemical waste tends to increase with decreasing
plastic particle size (microplastic).Microplastic is less
sized plastic particlesfrom 5 mm9. Microplastic has the
potential to have an impactmore serious than plastic that
has a larger size because it can be ingested by fish and
plankton so that it can disrupt the chain systemfood in
the water10.
One plastic waste that can affect the food cycle
atcoastal and marine areas aremicroplastic.Microplastic
is wrongone part of marine waste which when piled up in
the waterswill cause disruption of the food chain to fish11.
Research conducted by12on the coast of China, the results
obtained from 263 fish examined were 26 commercial fish
species. 32.7% were identified as swallowing more than
one type of microplastic. Of all the types of fish examined,
63.5% were benthic fish and 36.5% were pelagic fish.
A total of 73 types of microplastic were identified, 48
(65.8%) were fibers and 25 (34.2%) fragmented, the
rest were polymers (polypropylene, polyethylene, alkyd
resin, rayon, polyester, nylon, and acrylic).Potentially
threatening more serious microplastic thanwith large
plastic materials as organismsinhabit lower tropics,
like the plankton, have particles susceptible to the
microplastic digestion process as consequently it can
affect high levels of tropical organisms through the
processbioaccumulation13.Laboratory test results show
thatmicroplasticcan be digested by marine organisms
when one particle frommicroplastic can resemble food14.
Microplastic pollution also occurs in Indonesia.
Research conducted byMasanti YDin Semarang, the
results obtained by Belanak Fish (Mugilcephalus)
contain microplastic of 15 particles/fish. This is what
inspires researchers to conduct microplastic research on
Baronang (Siganus. Sp) and Snapper Fish (Lutjanus. sp)
aroundBangkalaSubdistrict, Jeneponto Regency because
JenepontoRegency is the largest fish producer in South
Sulawesi.The purpose of this study was to determine
the microplastic contents of Baronang (Siganus. Sp)
and Snapper Fish (Lutjanus. Sp) in the vicinity of
BangkalaSubdistrict Beach, Jeneponto Regency.
Material and Method
Sampling: The fish sample is put in a thermos of
ice fish that has been filled with icestone.In addition,
interviews were also conducted with local fishermen
tofind out the location of the arrest
Microplastic Identification in Fish: All equipment
is sterilized with acetone and distilled water. Sample
fish identified using Fishbase. Fish is taken by the
channeldigestion from the base of the esophagus to the
anus then the canaldigestion soaked in 20% alcohol.
Fish digestive tractcrushed with a mixture of a solution
of nitric acid (65%) and perchloric acid (68%) with a
ratio of 4: 1, so the channel comparisondigestion and a
mixture of solutions of nitric acid and perchloric acid
are1: 5.Soaking is carried out for 24 hours in an acidic
room.Next, the suspension was boiled for 10 minutes
and left for 30 minutes.The suspension is then diluted
with distilled water 4 timesdilution and filtered with a
0.5 mm filter.The pelletthe filter is then transferred to
a petri dish, pierced with a hot needle to ensure that the
pellet is microplastic, and observed by type (fiber, film,
fragment, pellet) and colorusing a stereo microscope.
Next is the microplasticobtained is calculated the
number of each type, photographed with optilab,
andthen measured by raster image software.The process
is done as much astwo treatments in fish digestive tract
samples and controls.Treatment of controls is carried out
by following all procedures onfish but only use quads.
Processing Data Analysis: Data analysis used
descriptive statistical analysis for knowing the number of
microplastic between stations. Data analysis performed
namely the laboratory approach using Minitab 16
software.
Result and Discussion
Microplastic on the Fish Digestion: Microplastic
content found in the digestive tract of Baronang Fish
(Siganus.Sp) and Snapper Fish (Lutjanus.Sp) found
around the Beach Bangkala District, Jeneponto Regency.
14  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Based on Picture 1. From the results of the study
indicate that Snapper Fish (Lutjanus. Sp) contains
more microplastic with an average of 18 particles/fish
compared to Baronang (Siganus. sp) with average 14
particles/fish.
Based on Picture 2. From the results of the study
indicate that Snapper Fish (Lutjanus. Sp) contains
more microplastic with an average of 18 particles/fish
compared to Baronang (Siganus. sp) with the average of
13 particles/fish.
Based on Picture 3. From the results of the study
indicate that Snapper Fish (Lutjanus. Sp) contains
more microplastic with an average of 10 particles/fish
compared to Baronang (Siganus. sp) with average6
particles/fish.
The results of research from all stations show
that Snapper Fish (Lutjanus. Sp) contains the most
microplastic. This happened because snapper (Lutjanus.
sp) has several characteristics more prominent than
Baronang fish (Siganus. sp), among others, have relative
growth faster and tends to have greater eating behavior
(greedy). In addition, Snapper Fish (Lutjanus sp) is
very tolerant of turbidity and salinity. Based on these
characteristics, the potential or microplastic opportunities
enter the body of Snapper Fish (Lutjanussp) through
eating activities higher than grouper. The results of
this study are in line with research conducted at Ancol
Beach, Port Queen, and Labuan. The results obtained
showed that Snapper fish (Lutjanussp).
Small microplastic size (≤ 5 mm) allows microplastic
has high potential to be digested by various marine
organisms15. Fiber (filamentous), filament, and films are
also found in fish mesopelagic with an average length
of 2.2 mm16. A new study on microplasticproves that at
each stage of ontogenic Catfish (Clariasbatrachussp) in
estuary waters in the south-west part of Atlantis, all of
them contain microplastic17.The microplastic ingested by
fish or marine organisms will have an impact on marine
organisms both physically and chemically.If ingested,
microplastic can be passing through the intestine or can
be maintained in the digestive tract18.
Fiber is the most common type of microplastic on
the digestive tract of Snapper Fish (Lutjanussp) and
Baronang Fish (Siganus. Sp). This is in accordance
with the research carried out by Lusher et al. (2013)
who reported that the highest type of microplastic
being in the digestive tract of fish is fiber (68.3%).
If plastic particles accumulate in amounts of large
intestines in small animals, will have the same effect
as garbage large plastic and clogging the digestive
system19.Accumulation of garbage in the digestive
tract can cause taste full fake. This causes the fish to
experience a decrease in appetite eat20. There are also
concerns that if swallowed by organisms, small objects
from plastic waste may facilitate chemical contaminant
transportation21. Microplastic found in marine biota
such as fish, of course, make an impact if consumed
by humans. Health effects that can arise are intestinal
disorders and stomach (irritation). Chemicals contained
in plastic can increase cancer cells growth22-24.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  15
Conclusion
Baronang fish (Siganus. Sp) and Snapper Fish
(Lutjanus sp.) Originating at around Bangkala District
Jeneponto Regency contains microplastic. Macroplastic
in Snapper Fish (Lutjanussp).More compared to
Baronang Fish (Siganus. sp).Microplastic content in
Snapper Fish (Lutjanus sp.) at station 1 an average of
18 particles/fish, station 2 averages 18 particles/fish and
station 3 averages 18 particles/fish.
Acknowledgment: The author would like to thank
the government of Jeneponto Regency, especially the
community of BangkalaSubdistrict, who have received
and helped in this study so that researchers can attend
the international conference APACPH-KL EARLY
GLOBAL HEALTH CONFERENCE CAREER, Faculty
of Medicine, Universitas Malaya, Kuala Lumpur.
Ethical Clearance: Taken from University
committee.
Source of Funding: Self
Conflict of Interest: Nil
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Le Grand A, Duval H, Cesar G, et al. Threat of
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bulletin. 2018;127:684-94.
2. Neves D, Sobral P, Ferreira JL, Pereira T.
Ingestion of microplastics by commercial fish off
the Portuguese coast. Marine pollution bulletin.
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3. Karlsson TM, Vethaak AD, Almroth BC, Ariese
F, van Velzen M, Hassellov M, et al. Screening
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microplastic accumulation. Marine pollution
bulletin. 2017;122(1-2):403-8.
4. Bellas J, Martinez-Armental J, Martinez-Camara
A, Besada V, Martinez-Gomez C. Ingestion of
microplastics by demersal fish from the Spanish
Atlantic and Mediterranean coasts. Marine
pollution bulletin. 2016;109(1):55-60.
5. Rochman CM, Tahir A, Williams SL, Baxa DV,
Lam R, Miller JT, et al. Anthropogenic debris in
seafood: Plastic debris and fibers from textiles in
fish and bivalves sold for human consumption.
Scientific reports. 2015;5:14340.
6. Zarfl C, Fleet D, Fries E, Galgani F, Gerdts G,
Hanke G, et al. Microplastics in oceans. Marine
pollution bulletin. 2011;62(8):1589-91.
7. Nel HA, Froneman PW. A quantitative analysis
of microplastic pollution along the south-eastern
coastline of South Africa. Marine pollution bulletin.
2015;101(1):274-9.
8. Eriksen M, Mason S, Wilson S, Box C, Zellers
A, Edwards W, et al. Microplastic pollution in
the surface waters of the Laurentian Great Lakes.
Marine pollution bulletin. 2013;77(1-2):177-82.
9. Mason SA, Garneau D, Sutton R, Chu Y, Ehmann
K, Barnes J, et al. Microplastic pollution is
widely detected in US municipal wastewater
treatment plant effluent. Environmental pollution.
2016;218:1045-54.
10. Anderson PJ, Warrack S, Langen V, Challis
JK, Hanson ML, Rennie MD. Microplastic
contamination in Lake Winnipeg, Canada.
Environmental pollution. 2017;225:223-31.
11. Bour A, Haarr A, Keiter S, Hylland K.
Environmentally relevant microplastic exposure
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12. Ding J, Zhang S, Razanajatovo RM, Zou H,
Zhu W. Accumulation, tissue distribution, and
biochemical effects of polystyrene microplastics
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13. Li J, Yang D, Li L, Jabeen K, Shi H. Microplastics
in commercial bivalves from China. Environmental
pollution. 2015;207:190-5.
14. Masanti YD. Identification Of MicroplasticIn Sea
Mullet (Mugil Cephalus)In Ngebruk Fish Pond,
Semarang. 2017.
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CM, Shi H. Using the Asian clam as an indicator
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Microplastic ingestion in fish larvae in the western
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S, Deudero S. Microplastic ingestion by Mullus
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22. Anwar Mallongi, Irwan and A.L. Rantetampang,
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 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  17

Factors Associated with the Appropriate Time of

Complementary Feeding among Infants in Jeneponto Districs,
South Sulawesi

Sumiaty1,2, Tahir Abdullah3, Burhanuddin Bahar3, Nurhaedar Jafar3,

Veni Hadju3, Masyita Muis3, Sri Sumarmi4
1DoctoralStudent in public Health, Hasanuddin University of Indonesia, 2Faculty of Public Health,
Moeslim University of Indonesia, 3Faculty of Public Health, Hasanuddin University of Indonesia,
4Faculty of Public Health, Airlangga University, Indonesia

Abstract
Background: Nutritional problems in infants aged 6-11 months are strongly influenced by complementary
feeding. The inaccuracy of time in complementary feeding to infant.

Aims : To examine the factors associated with the appropriate time of complementary feeding to infant in
Jeneponto districs.

Method: This was a cros sectional study. The sample were mothers who had infants aged 8 and 10 months
with total 125 infants. Bivariate analysis using chi-square and multivariate logistic regression were conducted.

Results: The results of the bivariate analysis showed that frequency of following ANC (p = 0.045), birth
weigth status (p = 0.025) and mother occupation (p = 0.029) were independently associated with the
appropriate time of complementary feeding. Based on multivariate analysis indicated that mothers who
visited to ANC [AOR: 4.14 (95% CL: 1,576-10,885)], mothers who had normal birth weight status of infants
(95% CI: 2.142-88,628)] and mother who consumed iron capsules [AOR 5.27 (95% CI: 1.72-16.06)] were
found key factors the appropriate time of complementary.

Conclusions: The appropriate time of complementary feeding was significantly associate with maternal
occupation, frequency of visiting ANC and birth weight status. The variable that most influences the
appropriate time of complementary feeding was birth weight status.

Keywords:  Complementary feeding, infant, determinant.

Introduction five years, which are generally victims of diseases and

Complementary feeding is defined as a process
that starts when breast milk alone is no longer enough
to meet a baby’s nutritional needs, and therefore other
foods and fluids are needed, along with breast milk (1).
Infants (ages 0-11 months) are a golden period as well
as a critical period because at this time there is rapid
growth and development which reaches a peak at the age
of 24 months where nutritional deficiencies and diseases
contribute globally to higher levels of malnutrition
among children children under the age of five1.
The problem of malnutrition causes four out of one
hundred babies born each year to not survive more than
conditions exacerbated by these nutritional problems;
one in three toddlers has a growth disorder and almost
one fifth of toddlers experience less weight2.
The problem of malnutrition still a major problem
in Indonesia. This is evidenced by the still finding cases
of malnutrition in children in various regions. One factor
that can affect nutritional status is intake. A person’s
nutritional status is a picture of what he consumes.
Children aged 6-24 months get nutritional adequacy
from breast feeding and complementary feeding3.
Child development will be disrupted if
complementary feeding are not introduced at the age of 6
18  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
months, or given in an improper way. Because at the age Materials and Method
of 6 months, the baby’s needs for energy and nutrition
This type of research is observational analytic
begin to exceed what is provided by breastfeeding, and
with crossectional study design. The location of the
complementary feeding is needed to meet those needs.
study was carried out in the district with a population
Nationally, based on 2013 basic health research, of 482 babies The sample in this study were mothers
national stunting prevalence reached 37.2% consisting who had babies aged 8 and 10 months as many as 125
of 18.0% very short children and 19.2% short children, children. The reason for choosing samples that were 8
increased from 2010 (35.6%) and 2007 (36, 8%)4. and 10 months old was because that age was a transition
of complementary feeding at texture and frequency.
Babies are very vulnerable during the transition The sampling technique is accidental sampling. Data
period when complementary feeding begins. Ensuring collection through interviews using a questionnaire. Data
their nutritional needs are met thus requires that analysis using bivariate with chi-square and multivariate
complementary food be on time-meaning it is introduced with logistic regression.
when energy and nutrients are needed beyond what can
be provided through exclusive breastfeeding and often5. This research was carried out after obtaining approval
from the Ethics Commission of the Faculty of Public
Provision of prolonged exclusive breastfeeding Health, Hasanuddin University number UH16090723.
has the potential to cause a lack of energy and nutrition Before the implementation of measurements and
when the introduction of complementary food is interviews will be given an explanation of the actions to
incorrect or delayed. Meeting the nutritional needs be taken for each respondent (Mother and baby). After
of infants aged 6-12 months based on the intake of the explanation, the respondents were asked for approval
advanced breastfeeding on Demand and complementary to participate in this study by signing an informed
feeding. Age of infants 6-12 months is the age that is consent
susceptible to malnutrition due to the provision of
complementary feeding which is not appropriate both Results
time and composition. Inappropriate time is <6 months
Table 1: Characteristics of Infant
or <7 months, while the improper composition is lack or
excess nutrients. Some complementary feeding babies Variable n (125) %
lack fat intake and some excess carbohydrates derived Sex of infant
from simple carbohydrates, the introduction of food Boys 68 54.4
taste in infants 6-12 months will determine the eating Girls 57 45.6
habits of these children6. Maternal Age
<20 25 20.0
Introducing complementary feeding at an earlier
20-24 25 20.0
risk of obesity at a higher economic level and delaying
25-29 33 26.4
complementary feeding causes the supply of energy and
30-34 24 19.2
protein and other micronutrients to be inadequate for
≥35 18 14.4
babies7.
Intervensi
Other studies have shown that early feeding can Moringa flour 40 32.0
increase the risk of eczema. However, there are few Iron 50 40.0
data that support the relationship between early solid Moringa extract 35 28.0
feeding and other allergic conditions8. In addition, the Parities
initial introduction of solid foods can cause malnutrition One 47 37.6
results such as low iron stores by displacing rich energy Two 49 39.2
More than two 29 23.2
and iron which is highly bioavailable in breast milk,
and continues to increase the risk of diarrheal disease. Maternal Occupation
The aims of this study was to look at factors associated Housewife 108 86.4
with the timing of complementary feeding in infants in Employed 17 13.6

Jeneponto Districs.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  19

Variable n (125) % Timely of Initiation

Maternal education Complementary Feeding
Variable N(%) P-Value
Low 90 72.0
<6 bulan >=6 bulan
High 35 28.0
Intervensi
Household Income
Moringa flour 17 (42.5) 23 (57.5
< 2 million 91 72.8
Iron 12 (24.0) 38 (76.0) 0.174
≥ 2 million 34 27.2
Moringa extract 12 (34.4) 23 (65.7)
Number of ANC follow up
Parities
<4 times 71 56.8
One 18 (38.3) 29 (61.7)
≥ 4 times 54 43.2
Two 14 (28.6) 35 (71.4) 0.582
Place of delivery
More than two 9 (31.0) 20 (69.0)
Home 1 5.6
Maternal Occupation
Health Institution 118 94.4
Housewife 31 (28.7) 77 (71.3)
Birth weight Status 0.029*
Employed 10 (58.8) 7 (41.2)
BBLR 8 6.4
Maternal education
Normal 117 93.6
Low 26 (28.9) 64 (71.1)
Post Natal Care 0.200
High 15 (42.9) 20 (57.1)
Yes 35 28.0
Household Income
No 90 72.0
< 2 million 27 (19.7) 64 (70.3)
0.315
Table 1. The results of univariate analysis showed ≥ 2 million 14 (41.2) 20 (58.8)
that the sex of boys was 54.4% and women were 45.6%, Number of ANC follow up
the maternal age ≥ 35 years was 14.4% and 25-29 years <4 times 29 (40.8) 42 (59.2)
0.045*
were 26.4%, intervention Moringa flour 32.0%, iron ≥ 4 times 12 (22.2) 42 (77.8)
40.0% Moringa extract 28.0%, second child 39.2% and Place of delivery
children more than 2 by 23.2%, maternal occupation as Home 3 (42.9) 4 (57.1)
0.866
a housewife by 86.4% and Employed by 13.6%, low Health Institution 38 (32.2) 80 (67.8)
maternal education level 72.0% and high by 28.0%, Birth weight Status
household income > 2 million at 72.8% and ≤ 2 million BBLR 6 (75.0) 2 (25.0)
0.025*
at 27.2%, frequency of ANC <4 times at 56.8% and ≥ 4 Normal 35 (29.9) 82 (70.1)
times at 43.2%, place of birth at home 5.6% and health Post Natal Care
services 94.4%, birth weight status the LBW is 6.4% Yes 9 (25.7) 26 (74.3)
0.401
and Normal is 93.6%, Post Natal care is 28.0% and not No 32 (35.6) 58 (64.4)
72.0%.
Table 2. The results of bivariate analysis showed
Table 2. Relationship characteristics with that the factors of the sex of the baby (p = 1,000),
Complementary Feeding maternal ages (p = 0.165), intervention group (p =
0.174), the sequence of children (p = 0.582), maternal
Timely of Initiation education (p = 0.200),household income (p = 0.315),
Complementary Feeding
Variable P-Value place of delivery (p = 0.856) and post natal care (p =
N(%)
0.401)with the time of complementary feeding were not
<6 bulan >=6 bulan
related. The maternal occupation (p = 0.029), Frequency
Sex of infant
of following ANC (p = 0.045), BBL status (p = 0.025)
Boys 22 (32.4) 46 (67.6)
1.000 with the time of complementary feedingwas related.
Girls 19 (33.3) 38 (66.7)
Maternal Age
<20 7 (28.0) 18 (72.0)
20-24 6 (24.0) 19 (76.0)
25-29 14 (42.4) 19 (57.6) 0.165
30-34 11 (45.4) 13 (54.2)
≥35 3 (16.7) 15 (83.3)
20  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Table 3. Factor Affecting complementary Feeding visits (ANC) are more likely to introduce complementary
practice among children 6-12 months feeding on time than children whose mothers have never
had antenatal care services when they are pregnant9-11.
Socio
OR Crude (95% OR Adjusted* (95%
Demographic BBL status is a determining factor in the time to
CI) CI)
Features
introduce MP-ASI. Normal-born babies are more likely
Maternal Age
to introducecomplementary feedingin a timely manner
<20 1.0 (reference) 1.0 (reference) than babies born with a weight below normal (<2500).
20-24 1.23 (0.34-4.37) 0.96 (0.225-4.163)
Babies born normally are faster growth and development
25-29 0.52 (0.17-1.60) 0.41 (0.114-1.490)
because exclusive breastfeeding is not problematic
30-34 0.46 (0.14-1.50) 0.27 0.066-1.116)
compared to those below normal birth weight so it is
>=35 1.94 (0.42-8.85) 2.18 (0.372-12.771)
possible to delay of complementary feeding earlier.
Maternal Education
Whereas babies born under normal have problems
Low 1.0 (reference) 1.0 (reference)
at birth due to having to be hospitalized so they part
High 0.54 (0.24-1.21) 0.36 (0.136-0.989)
with their mothers. This causes low exclusive breast
ANC
feeding and is replaced by formula milk. This study is
< 4 times 1.0 (reference) 1.0 (reference)
consistent with the results of a study in Brazil showing
>=4 times 2.41 (1.08-5.36)* 4.14 (1.576-10.885)*
that the relationship between types of breastfeeding
Birth weight Status
and difficulties in providing complementary food,
BBLR 1.0 (reference) 1.0 (reference)
especially in food rejection, as well as an increased
Normal 7.02(1.35-36.54)* 13.77 (2.142-88.628)*
chance of formula-fed infants having difficulty serving
Intervensi
complementary meals compared to other types of
Moringa flour 1.0 (reference) 1.0 (reference)
breastfeeding. In addition, they also need prolonged
Iron 2.34(0.95-5.77) 5.27 (1.72-16.06)*
hospitalization, contributing to low milk production or
Moringa leaf 1.41(0.55-3.62) 1.98 (0.65-6.00)
extract even disrupting mother-baby bonds that might reduce the
possibility of forming a full breastfeeding pattern12,13.
Table 3. The results of multivariate analysis showed
that the possibility of giving complementary feeding Tablet fe consumption during pregnancy
correctly to mothers who during pregnancy were ANC is a determining factor in the time to introduce
visits ≤4 times higher than ANC> 4 times [AOR: 4.14 complementary feeding. Babies born to mothers who
(95% CL: 1,576-10,885)], possible complementary consume Fe tablets during pregnancy may introduce
feeding in infants born with normal weight is higher complementary feeding in a timely manner compared
than babies born with low body weight [AOR: 13.77 to babies born to mothers who consume Moringa flour
(95% CI: 2.142-88,628)] and the possibility of giving capsules and Moringa extract. Supplements given to
complementary feeding correctly to mothers given pregnant women in order to prevent anemia. Prevention
capsules iron is higher than those given Moringa flour of anemia during pregnancy will prevent low birth
[AOR 5.27 (95% CI: 1.72-16.06)]. weight, this is consistent with other studies that say that
the treatment of anemia in pregnant women must be done
Discussion because it has an impact on fetal growth and development
such as low birth weight (LBW) and this will have an
This study found that the frequency of participating
impact on later growth and development14-16. If the baby
in ANC was a determining factor in the time to intoduce
is born normally, the growth and development is in
complementary feeding. Pregnant women who follow
accordance with his age so that the time of introduction
ANC> = 4 times may intoduce complementary feeding
of complementary feeding can be appropriate.
correctly compared to pregnant women who participate
in ANC <4 times this is because visits that are more Conclusion
frequent to health services make it possible to obtain
information from health workers about the importance This study showed that the timing of the introduction
of providing complementary feeding properly time to of complementary feeding was significantly associated
baby. This study is consistent with studies conducted in with ANC visits at the time of pregnancy, consumption
Ethiopia that children whose mothers have antenatal care of Fe tablets during pregnancy and birth weight. The
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  21
more pregnant women go to health services, the more
exposed they are to information about the importance of
introducing MP-ASI to babies. For the next researcher, it
is expected to look deeply into the reasons for the mother
not introducing MP-ASI on time by using a qualitative
research design.
Acknowledgement: The author would like to thank
all the respondents for their willingness to participate in
this research. Likewise, University of Malaya Malaysia
has provided an opportunity for writers to present this
research in the form of posters. And thank you also to
Hasanuddin University where the writer is studying
and the Indonesian Muslim University where the writer
works.
Ethical Clearance: Taken from Hasanuddin
University committee.
Source of Funding: Self
Conflict of Interest: Nil
Reference
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Subdistrict, South Semarang District, Semarang
City) Status In The Range of Age 4 to 24 Months.
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A., Mortensen, E. K., & Michaelsen, K. F. (2010).
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than duration of breastfeeding, may protect against
adult overweight. American Journal of Clinical
Nutrition, 91(3), 6. Am J Clin Nutr. 2010;(7):1–9.
8. Tarini, Carroll, Sox C. Systematic Review of the
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Disease. 2006;160(May):502–7.
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Complementary Feeding among Caregivers of
Children. 2018;1–7.
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A review of phytate , iron , zinc , and calcium
concentrations in plant-based complementary foods
used in low-income countries and implications for
bioavailability. 2010;31(2):134–46.
11. Sisay W, Edris M, Tariku A. Determinants of timely
initiation of complementary feeding among mothers
with children aged 6–23 months in Lalibela. BMC
Public Health [Internet]. 2016;1–9. Available from:
http://dx.doi.org/10.1186/s12889-016-3566-z
12. Steinberg C. Complementary feeding in infants
born prematurely Alimentação complementar em
lactentes. 2018;1782(6):1–7.
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born premature admitted to an ICU and neonatal
UCI. 2015;16(1):5–8.
14. Anwar Mallongi, Anwar Daud, Hasanuddin Ishak,
Ruslan La Ane, Agus Bintara Birawida, Erniwati
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22  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Analysis of Risk Factors Maternal Mortality in Sinjai District

Fitriani1, Masni1, M. Nadjib Bustan2, Ummu Salmah1, Stang1, Muh. Syafar3

1Department of Reproduction Health, Faculty of Public Health, Hasanuddin University, 2Department of Statistics
Faculty of Mathematics and Natural Sciences, Makassar State University, 3Departement Promotion Section
Faculty of Public Health, Hasanuddin University.

Abstract
The maternal mortality rate is the number of maternal deaths during pregnancy, labor and childbirth.
Maternal mortality is an important problem because it causes the state to lose a number of productive forces,
increasing child morbidity and mortality. This study aims to determine the risk factors for maternal mortality.
The research used was analytic observational with a case control study design with a sample size of 120
people consisting of 30 case groups and 90 control groups with a ratio of 1: 3, Data analysis used bivariate
analysis with Odds Ratio and multivariate analysis with multiple logistic regression. The results found there
are three variables which are risk factors for maternal mortality, namely late referral (OR = 4,620, 95% CI =
1,513-14,113), history of maternal disease (OR = 3,028, 95% CI = 1,095-8,669), and obstetric complications
(OR = 3,081, 95% CI = 1,161-7,896). While antenatal examination, family planning history, parity and
distance of pregnancy are not risk factors for maternal mortality. Health workers are advised to strengthen
the referral network system, conduct early detection of risk factors and manage obstetric complications.

Keywords: Maternal Mortality, Obstetric Complications, Maternal Disease History Antenatal Examination,
Family Planning History.

Introduction such as Sub-Saharan Africa 179,000, South Asia 69,000,

and Southeast Asia 16,000. The maternal mortality rate
Globally in 2015 around 830 women died every day
in Southeast Asian countries is ranked first by Laos,
and in Indonesia 38 women were due to complications
namely 357 per 100.00 Births, Vietnam 49 per 100,000
during pregnancy or childbirth. Based on the Intercensal
live births, Thailand 26 per 100,000 live births, Brunei
Population Survey (SUPAS 2015) the Maternal
27 per 100,000 live births, Malaysia 24 per 100,000 live
Mortality Rate (MMR) is 305 per 100,000 live births.
births and Singapore have a maternal mortality rate of 7
Total maternal deaths were 14,640, reported 4,999
per 100,000 births.
mothers and those not reported 9,641 maternal deaths.
The agenda for reducing the MMR’s Sustainable The Maternal Mortality Rate in Indonesia still
Development Goals (SDGs) globally by 2030 is 70 per reaches 305 per 100,000 live births, this figure places
100,000 live births and Indonesia targets MMR in 2024 Indonesia as the country with the second highest
to be 232 per 100,000 live births1. mortality rate in Southeast Asia. It is still very far
compared to neighboring Malaysia and Singapore. Based
Nearly 20% of maternal deaths occur before
on data from the South Sulawesi Health Office in 2015
delivery, 82% occur after labor or abortion, 46% occur
the number of maternal deaths was 149 cases, in 2016
within 24 hours of delivery and 69% occur within seven
there were 156 cases and the number of maternal deaths
days after delivery. Most reported maternal deaths occur
in 2017 reached 115 cases. South Sulawesi Province is
in health facilities. The highest maternal mortality sites
included in the top 10 list of provinces contributing to
were 77% in hospitals, 15.6% at home, 4.1% occurred
maternal mortality in Indonesia in 2017. Sinjai District
in trips to hospitals/health facilities, 2.5% in other health
ranks the second highest in MMR in South Sulawesi
facilities and 0.8%2.
province. Based on the health profile of Sinjai district,
The World Health Organization (WHO) in Maternal Mortality Rate in 2016 was 293 (12 cases)
developing countries in some countries have high AKI per 100,000 live births, decreased in 2017. Namely the
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  23
MMR reported 148 (6 cases) per 100,000 KH, the target Data analysis: Data on general characteristics
of the 2017 Strategic Plan is 113 per 100.00 KH. In 2018 of respondents, independent variables and dependent
the MMR was 297 per 100,000 KH (12 cases), the target variables were processed using SPSS. To determine the
of the Strategic Plan 2018 was 113 cases per 100,000 risk factors for maternal mortality in pregnant, childbirth
Births3. and postpartum mothers in Sinjai District, data analysis
was used using univariate analysis, and multivariate
Cases of maternal deaths due to pregnancy, analysis with multiple logistic regression.
childbirth, and childbirth in Sinjai District are generally
caused by bleeding, hypertension, pre-eclampsia, Results
eclampsia, infection, abortion, anemia, nutritional status
and others. Most deaths occur within seven days after Table 1 shows the comparison of the proportion of
saline or the puerperium. Some studies show maternal age between cases and controls, the age category with
mortality is influenced by factors related to maternal the lowest presentation at age> 35 years where the case
factors, reproductive status factors, factors related to group and controls presented the same number (43.3%).
obstetric complications, factors related to health services, Comparing the proportion of education levels between
socio-economic factors and socio-cultural factors. cases and controls, the education level with the lowest
presentation was at the low education level where the
Materials and Method control group was higher (60.0%) than the case group
(50.0%). Comparison of the proportion of employment
Location and Design of Research: This research status between cases and controls, the lowest status of
was conducted in the working area of the Sinjai District work with presentations was for mothers who worked
Health Office. This type of research is observational where the case group was higher (16.7%) than the
analytic with case control design. control group (15.6%).
Population and Samples: The population in Table 1. Distribution of general characteristics of
this study were all pregnant women, maternal and mothers in Sinjai District 2016-2018
postpartum mothers at 13 (thirteen) Puskesmas from
16 (Sixteen) Puskesmas located in the Sinjai District Case Control Total
Variable
Health Office area for the period 2016 to 2018. Samples n % n % n %
were 120 mothers in which groups cases are all maternal Age
deaths (maternal mortality, maternal mortality and 20-35 17 56,7 51 56,7 68 56,7
postpartum maternal mortality) and the control group >35 13 43.3 39 43,3 52 43,3
are all pregnant women and mothers giving birth in Level of
the Puskesmas area where there are cases of maternal education
deaths, with a case sample ratio: control is 1: 3, so Low 15 50,0 54 60,0 69 57,5
Minimum sample amount is 30:90. The withdrawal of High 15 50,0 36 40,0 51 42,5
case and control samples was done by selecting samples Job status
randomly from all mothers who gave birth in the area of Work 5 16,7 14 15,6 19 15,8
Does not work 25 83,3 76 84,4 101 84,2
the Sinjai District Health Office.
30 100,0 90 100,0 120 100,0
Method of collecting data: This study uses
secondary data obtained from the Sinjai District Health Table 2. Shows that variables including risk factors,
Office. Data collected from 13 (thirteen) Puskesmas in which are thought to influence the occurrence of maternal
Sinjai District for 2016 to 2018 are: Balangnipa Health deaths in Sinjai District, show: the results of multiple
Center, Island IX Health Center, Bulupoddo Health logistic regression tests, which are assessed through
Center, Samataring Health Center, Kampala Health significance (Sig.) and “B” coefficients, and Exp (B)
Center, Samaenre Health Center, Aska Health Center, shows that there are three independent variables entered
Mannanti Health Center, Lappadata Health Center , into the test simultaneously, the significance values are
Manimpahoi Health Center, Manipi Community Health described as follows:
Center, Central Lembang and Puskesmas Biji Nangka.
24  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Table 2. Multivariate analysis of risk factors for maternal mortality in Sinjai District 2016-2018
Variable B Wald
Late Referral 1,350 7,217
Disease History 1,108 5,133
Obstetrics Complications 1,125 4,454
Referral delay, with B value = 1,350, p = 0,007,
with the risk being assessed through Exp (B) = 4,620,
this value implies that late referrals have a significant
influence (p = 0,007) on the incidence of maternal
mortality with a 4,620 risk times greater than mothers
who are not late to be referred.
Disease history, with a value of B = 1.108, p =
0.023, with the risk being assessed through Exp (B) =
3.028, this value implies that the history of the disease
has a significant influence (p = 0.023) on the incidence of
maternal mortality with a large risk 3,028 times greater
than mothers who did not have a history of disease.
Obstetric complications, with a value of B = 1.125,
p = 0.033, with the risk being assessed through Exp (B)
= 3.081, this value implies that obstetric complications
have a significant influence (p = 0.033) on the incidence
of maternal deaths with a large risk 3,081 times
greater than mothers who did not experience obstetric
complications.
Discussion
In this study showed a significant result that the
delay in referral, provided a risk of 4.620 greater for the
occurrence of maternal deaths. The results of this study
are in line with the research of Aeni (2013) that the
delay in referral was proven to be significantly related to
maternal mortality (OR = 10; p value = 0.013, 95% CI =
1.34-74.5). Factors of delay are especially late in making
decisions to refer to and delay in reaching a referral
place related to maternal death. This happens because
the mother’s unwillingness to go to a health facility
immediately and considers the signs of complications
that are common in pregnancy, while other family
members do not know the signs of emergency in obstetric
complications. In general, this occurs in mothers with
parity> 1 because they feel experienced in a previous
pregnancy.
The results of the study were also in line with
Atjo’s4 study, which was one of the causes of maternal
95.0% C.I. for EXP(B)
Df Sig. Exp
Lower Upper
1 0,007 4,620 1,513 14,113
1 0,023 3,028 1,095 8,669
1 0,033 3,081 1,161 7,896
deaths due to the delay in deciding to refer to a hospital,
meaning that the delay from arriving to the hospital until
medical treatment became one of the causes of maternal
and childbirth deaths and numbers maternal mortality
(Maternal Mortality Rate) is the ratio of the number of
maternal deaths to 100,000 live births, this figure is an
important indicator in efforts to achieve better quality
of health services for pregnant and childbirth mothers
in the city of Palu. When viewed from the Odds Ratio
(OR), the delay in medical treatment also has the highest
OR (30,447) compared to the others.
Other infectious diseases that are still the main
problem of public health are Tuberculosis (TB). In
pregnant women. In pregnant women TB can worsen
maternal health and nutritional status, and affect fetal
growth and development and the risk of contracting the
baby3.
Research results in line with the research conducted
by Jayanti, et al5 indicate that there is an influence
between history of history of illness on maternal
mortality. Mothers with a history of illness increased
the risk of maternal death by about 9 times greater than
those of women without a history of disease (OR = 8.9
95% CI; 2.76-28.71).
Godefay et al6 study of risk factors for maternal
mortality in Tigray Ethiopia states that a history of
maternal disease affects maternal mortality where
mothers with a history of disease have a risk of 5.58
times compared to mothers with no history of disease.
In this study obtained the most existing history of
disease data in the case group that is equal to 56.7%. The
types of diseases found include chronic diseases such
as cardiac hypertension asthma and infectious diseases
such as TB, syphilis and nutritional problems, namely
SEZ. Based on data on causes of maternal mortality, it
was found that there were 2 (two) maternal deaths due
to TB disease, 2 maternal deaths due to diagnosed heart
disease and other maternal deaths due to eclampsia
caused by hypertension in the mother before pregnancy.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  25
A history of maternal disease is a disease that has
been suffered by the mother before the last pregnancy
based on the results of an antenatal examination and
the results of laboratory tests. With a mother who has
a history of chronic diseases that can interfere with the
mother’s pregnancy journey or aggravate the problem of
her pregnancy.
The results of this study indicate a significant risk of
a history of maternal disease against maternal mortality.
The history of maternal disease is a disease that has
been suffered by the mother before the last pregnancy
based on the results of an antenatal examination and
the results of laboratory tests. With a mother who has
a history of chronic diseases that can interfere with the
mother’s pregnancy journey or aggravate the problem of
her pregnancy.
The results of this study are in line with Suriani’s7
research, in this study showed that there was a significant
relationship between the history of the disease and the
incidence of maternal mortality. The statistical test
results show that mothers with a history of risky diseases
have 15 times the chance to experience a maternal death
event. This is because the history of the disease during
pregnancy cannot be avoided by pregnant women
because the history occurs before pregnancy and affects
later in pregnancy.
Factors that contribute to maternal mortality are
direct causes of maternal death, namely factors associated
with complications of pregnancy, childbirth, and
childbirth such as bleeding, infection, hypertension in
pregnancy (HDK) preeclampsia/eclampsia, congestion
and abortion. Maternal mortality caused by obstetric
complications In 2017, hypertension was 33.07%,
obstetric bleeding 27.03%, other obstetric complications
12.04%, infections in pregnancy 6.06% and 4.81% due
to other causes3
Obstetric complications such as hypertension in
pregnancy are a major trigger for the occurrence of pre-
eclampsia and eclampsia in pregnant, maternity and
postpartum mothers. As many as 10% of pregnancy
problems in the world are caused by hypertensive
disorders including pregnancies with hypertension and
pre-eclampsia8.
The results of this study indicate that obstetric
complications are significant risk factors for maternal
mortality. This research is in line with the risk factor
research conducted in Gowa South Sulawesi by using
a case control study design by looking at the effect of
health status consisting of pregnancy complications
stating that women with high risk health status were
found with (OR = 9,750) having 10 times more risk large
maternal mortality compared to mothers who have low
risk health status9.
The yego et al.10 study of risk factors for maternal
mortality in tertiary hospitals in Kenya stated that a
history of complications affected maternal mortality with
a value (OR 9.0, 95% CI 4.2-19.3), in which mothers
with complications such as eclampsia has a risk of dying
as much as 9 times higher than women who do not have
a history of obstetric complications.
Researches found that the main cause of obstetric
bleeding complications was uterine atony, placental
retention, mothers with a history of previous bleeding,
Pre eclampsia, labor induction and macrosomia (large
infants)11,12.
In this study 76.7% of obstetric complications
occurred in the case group. The complications that
occur are as a direct result of pregnancy, and the types
of obstetric complications that occur are anemia,
hypertension, congestion, bleeding Pre eclampsia/
eclampsia, infection, Early Rupture of the membranes
(KPD) and Hyperemesis Gravidarum. Some cases of
complications were detected when the mother performed
an ANC examination but no collaboration was conducted
for laboratory examinations and even some cases were
not referred to for treatment. For example, mothers who
have hypertension are detected by a midwife in the
village but no further treatment is done. Likewise, the
handling is done by referring to the Hospital, but when
the mother goes home, no monitoring is carried out, even
the mother is never visited, so the mother experiences
severe complications.
Conclusions
Based on the results of research and discussion
with reference to the formulation of the problem and
the research hypothesis, conclusions can be drawn,
namely the delay in referral, obstetric history and
complications (Complications of Pregnancy, Childbirth
and Postpartum) are significant risk factors for the
incidence of maternal deaths in Sinjai District.
Ethical Clearance: aken from Faculty of Public
Health, Hasanuddin University committee.
Source of Funding: Self
Conflict of Interest: Nil
26  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

References Kesehatan dalam Pelaksanaan SDGs” (pp. 119-

128). Fakultas Kesehatan Masyarakat Universitas
1. World health statistics. Monitoring Health For
Ahmad Dahlan. 2017.
The SDGs, Sustainable Development Goals.
Geneva:World Health Organization. 2017. 8. Sutton, Amelia LM., Harper, Lorie M., Tita, Alan
TN. Hypertensive disorders in pregnancy. Obstetrics
2. Dinas Kesehatan Kabupaten Sinjai. ProfilKesehatan
and Gynecology Clinics, 2018; 45(2):333-347.
Kabupaten Sinjai. 2018.
9. Ikhtiar, M dan Yasir, Y. Analysis of Maternal
3. Kemenkes RI., PedomanPelayanan Antenatal
Mortality Determinants in Gowa District South
Terpadu. 2015.
Sulawesi Province, Indonesia. American Journal of
4. Atjo, Siti Rahmawati.. Survey Kematian Ibu Public Health Research, 2015; 3(3): 113-115.
Hamil Dan Melahirkan Dengan Faktor Antara
10. Yego, F., C D’Este, J. Byles, J.S Williams and P.
(Intermediate Determinan) di RS Undata dan
Nyongesa. Risk Factors for Maternal Mortality in a
Masyta Kota Palu Jurnal Ilmu Kesehatan, 2017;
Tertiary Hospital in Kenya : A Case Control Study.
8(11):52-56.
BMC pregnancy & Childbirth, 2014; 14(1):38-41.
5. Jayanti, K. D., & Wibowo, A.. Faktor yang
11. Anwar Mallongi, Ruslan La Ane and
Memengaruhi Kematian Ibu (Studi Kasus di Kota
AgusBintaraBirawida, Ecological risks of
Surabaya). Jurnal Wiyata Penelitian Sains dan
contaminated lead and the potential health risks
Kesehatan, 2017; 3(1):46-53.
among school children in Makassar coastal area,
6. Gudefay, H., P. Byass, W.J. Graham, J. Kinsman., Indonesia. J. Environ. Sci. Technol., 2017. 10: 283-
dan A. Mulugeta. Risk Factors for Maternal 289.
Mortality In Rural Tigray Northern Ethiopia : A
12. Firmin, M., Carles, G., Mence, B., Madhusudan, N.,
case–Control Study. Journal PloS one, 2015;10(12):
Faurous, E., & Jolivet, A. Postpartum hemorrhage:
144-975.
incidence, risk factors, and causes in Western
7. Suriani, S.. Analisis Faktor Kejadian Kematian French Guiana. Journal of gynecology obstetrics
Ibu di Kabupaten Serang Banten. In Prosiding and human reproductio, 2018; 48(1):55-60.
Seminar Nasional IKAKESMADA “Peran Tenaga
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  27

The Influence of Family on He Use of Child Birth Facilities in

Muna Indonesia: A Cross Sectioal Study

La Ode Muhamad Sety1, Arsunan A.A.2, Darmawansyah3, Muhammad BasirPalu4

1PostgraduteProgram, Hasanuddin University, Makassar, 1Senior Lecturer of Departemenof Epidemiology,
Halu Oleo University, 2Professor of Departemenof Epidemiology, Hasanuddin University, 3Senior Lecturer
of Departement of Administration and Policy, Hasanuddin University, 4Senior Lecturer of Departement of
Administration and Policy, Universitas Indonesia Timur

Abstract
Background: Until now, maternal mortality is very high. Every day, around 830 women die from preventable
causes related to pregnancy and childbirth. Most occur in developing countries and related to the ability
of low family resources. The research objective is to determine the effect of family factors on the use of
childbirth facilities.

Method: The study design used a cross sectional study, starting September 2016 to February 2017. Samples
were 730 baby mothers, spread in 22 health center areas in Muna Regency. Sampling in proportion to simple
random sampling.

Results: Most respondents preferred to give birth at home 473 people (64.8%). The family component that
is significantly related to the place of delivery is communication with husband OR = 2.23, family structure
OR = 2.89, community support OR = 2.76. Husband’s occupation, marital status, access and wealth do
not show a significant relationship with the place of delivery. Further analysis by multivariate, variables
significantly related were husband communication (Adjusted Odds Ratio (AOR): 1.61 [1.02-2.53]), family
structure (AOR: 2.56 [1.82-3.59]), and community support (AOR: 2.17 [1.09-4.32]).

Conclusion: Communication with the husband, family structure, and community support have a significant
relationship with the choice of place of delivery while the husband’s work variables, marital status, access
and wealth are not related.

Keywords: Family, facilities, childbirth.

Introduction influences the decision to use health services6. The

state of maternal health in Indonesia is still far from
One factor in maternal and infant mortality is home
expectations, marked by the high mortality rate, which is
delivery2.Most maternal deaths arise from unpredictable
still showing 305/100,000 KH in 2015, while the MDGs
complications. Therefore the role of trained health
target 102/100,000 KH7 and even the medium-term
workers is important for the safety of mothers and
development plan for 2019, Indonesia targets 306 per
babies during childbirth3. Women do not get services in
100,000 KH8. Hard work must be done to achieve the
health facilities due to lack of trained health workers and
targets set for sustainable health development (SDGs)
family support factors4. The role of the family context
of less than 70 per 100,000 KH in 20309.Southeast
that influences reproductive health service decisions
Sulawesi Province also has a high maternal mortality of
such as delivery in health facilities and trained delivery
312/100,000 KH with an increasing number of maternal
attendants has received serious attention especially
deaths10. To support these efforts, the government of
in Asia and Africa5. The family factor is a feature of
the Republic of Indonesia since 1989, began a safe
social organization related to marital status, partner
motherhood movement with a village midwife program
communication, access, community support, poverty,
that succeeded in increasing the proportion of births
which is bound by a norm and trust in the community
28  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
by trained health workers from 43% in 1989 to 79% in
199711.
Claims of delivery by the puskesmas for maternal
conditions on delivery at a health care facility8. To
enhance the role of the family, in 2010, an active alert
village program was declared, where husbands, families
and communities are expected to be active in order to
better recognize danger signs and complications of
pregnancy and increase births by trained personnel in
health facilities12,13. The family factor is very important
that determines the decision of the mother to choose the
place of delivery as some previous studies in Asia and
Africa14, but researchers want to see the other side that is
different in the region of Indonesia, especially the eastern
part. , marital status, communication with husband,
family structure, access to facilities, community support
and wealth with decisions on where to deliver in Muna
Regency
Materials and Method
The study design used a cross sectional study,
starting September 2016 to February 2017. The sample
was 730 infants from 2,222 populations spread across 22
health centers in Muna Regency. Sampling in proportion
to simple random sampling. Data analysis consisted of
univariate, bivariate by classifying variables into two
categories of husband’s work; (not working; if you do
not have a permanent job and work; have a permanent
job), Marital status (Not married; if you do not have
a marriage certificate or divorced and Married; have
a marriage certificate) communication with husband
(no; no discussion; There is if there is discussion with
the husband), family structure (no; no influence and
no; there is influence) access to facilitation (difficult;
very difficult or difficult and not difficult; easy or very
easy), community support (not support; not support or
very unsupportive and supportive; supportive or very
supportive), wealth based on total asset scores in Quintil
(low; Q1 to Q2 and high; Q3 to Q5) and further analysis
by multivariate.
Results
Characteristics of Respondents: The number who
participated until the end of the study was 730 mothers
who had children aged 0-1 years. The description of
research results can be seen in the following table 1.

Table 1. Characteristics of family components by place of delivery in Muna District in 2017

Variabel Delivery in Home (%) Delivery in health facility (%) Total N (%)
Delivery places 473 (64.8) 257 (35.2) 730 (100)
Husban job
Not work 66 (14) 40 (15.6) 106 (14.5)
Labor 86 (18.2) 29 (11.3) 115 (15.8)
Farmer 132 (27.9) 26 (10.1) 158 (21.6)
Fishery 20 (4.2) 8 (3.1) 28 (3.8)
Business 43 (9.1) 18 (7.0) 61 (8.4)
Private staff 25 (5.3) 34 (13.2) 59 (8.1)
PNS/TNI/POLRI 17 (3.6) 35 (13.6) 52 (7.1)
Other, Honorer 84 (17.8) 67 (26.1) 151 (20.7)
Marital status
Not marriage 1 (2) 1 (4) 2 (3.0)
Marriage 472 (99.8) 256 (99.6) 728 (99.7)
Husband communication
None 111 (23.5) 31 (12.1) 142 (19.5)
Yes 362 (76.5) 226 (87.9) 558 (80.5)
Family Struktur
Self willing 241 (51) 68 (26.5) 309 (42.3)
Husband 162 (34.2) 107 (41.6) 269 (36.8)
Parent 55 (11.6) 52 (20.2) 107 (14.7)
Father in low 50 (12.1) 8 (31) 18 (2.5)
Community leader 1 (2) 0 (0) 1 (0.1)
Friend/neighbor 1 (2) 2 (8) 3 (0.4)
Health staff 3 (6) 20 (7.8) 23 (3.2)
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  29

Variabel Delivery in Home (%) Delivery in health facility (%) Total N (%)
Access to facility
Very difficult 11 (2.2) 6 (2.3) 17 (2.3)
Difficult 18 (3.8) 13 (5.1) 31 (4.2)
Easy 338 (82) 195 (75.9) 583 (79.9)
Very easy 56 (11.8) 43 (16.7) 99 (13.6)
Community support
Very support 89 (18.8) 51 (19.8) 140 (19.2)
support 332 (70.2) 195 (75.9) 527 (72.2)
Not support 51 (10.8) 11 (4.3) 62 (8.5)
Very not support 1 (2) 0 (0) 1 (0.1)
Wealthy
Q1 13 (2.7) 5 (1.9) 18 (2.5)
Q2 71 (15) 28 (10.9) 99 (13.6)
Q3 162 (34.2) 82 (31.9) 244 (33.4)
Q4 213 (45) 119 (46.3) 332 (45.5)
Q5 14 (3) 23 (8.9) 99 (5.1)

Based on marital status, generally the marital status
is 728 people (99.7%). Based on the family structure,
most decisions are determined by the mother’s own will
of 309 people (42.3%). Access to childbirth facilities is
generally easy namely 583 people (79.9%). Based on
community support, generally it supports 527 people
(72.2%). Wealth status, most are in the range of Q4
(rich) ie 332 people (45.5%)
Family factors related to the place of delivery: To
see the relationship between family components related
to the choice of place of delivery (Table 2), a bivariate
and multivariate analysis was performed. The results of
the bivariate analysis showed that the husband’s work,
marital status, access to labor facilities and wealth
did not have a significant relationship with the place
of birth (p> 0.05). Communication with husband has
a significant relationship (p <0.05) OR = 2.23. This
shows that mothers who do not communicate with
their husbands regarding planning helpers and delivery
places have 2.23 times the chance to give birth at home
compared with those who communicate. The family
structure has a significant relationship (p <0.05) OR =
2.89. This shows that the absence of the role of family
structure towards pregnant women has a potential 2.89
times that mothers will give birth at home compared
to those who have a role. Community support also has
a significant relationship (p <0.05) OR = 2.76. This
shows that mothers who do not have the support of the
community have 2.76 times the opportunity to give birth
at home compared to those who have the support of the
community. Next we conducted a multivariate analysis.
The test results using logistic regression analysis with
back ward elimination method. The results show that
women who do not communicate with their husbands
regarding birth planning (Adjusted Odds Ratio (AOR):
2.61 [1.02-2.53]) are more likely to give birth at home
than those who communicate with their husbands. In
the absence of the role of family structure in pregnant
women (AOR: 2.56 [1.82-3.59]), it is 2.56 times more
likely to give birth at home compared to mothers whose
families have influence. The lack of community support
for pregnant women (AOR: 2.19 [1.57-3.06]) has the
potential of 2.19 times mothers giving birth at home.

Table 2. Family factors related to the place of delivery in Muna District in 2017

Bivariable Analysis Multivariable analysis

Variable Unadjusted odds Adjusted odds ratio
r r
ratio (OR) 95% CI (OR) 95% CI
Husband job
Not work Ref. 0.555
Work 0.88
(0.58-1.35)
30  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Bivariable Analysis Multivariable analysis

Variable Unadjusted odds Adjusted odds ratio
r r
ratio (OR) 95% CI (OR) 95% CI
Marital status
Not marriage Ref. 0.666
Marriage 0.54
(0.03-8.71)
Husband communication
None Ref. *0.000 Ref. *0.040
Yes 2.23 1.61
(1.45-3.44) (1.02-2.53)
Family structure
None Ref. *0.000 Ref. *0.000
Yes 2.89 2.56
(2.07-4.02) (1.82-3.59)
Access to facility
Difficult Ref. 0.511
Not Difficult 0.82
(0.45-1.49)
Community support
Not support Ref. *0.003 Ref. *0.027
support 2.76 2.17
(1.14-5.39) (1.09-4.32)
Wealthy
Low Ref. 0.085
Hihg 1.47
(0.95-2.26)

* signifikan

Discussion
Our study aims to look at the determinants of the
influence of family factors on the use of health facilities
as a place of delivery. WHO recommends that safe
deliveries should be performed in a health facility16, but
in this study only 35% were found. This figure is still far
below the coverage of Southeast Sulawesi 61.7% even
nationally 83.7%7. Most of the respondents’ husbands
work as farmers and laborers. The husband’s work
is very important in terms of improving the family’s
economy which can determine the ability to give birth
in a health facility17, 18. In this study it was found that
mothers with farmer husbands, laborers or unemployed
have limited abilities so that labor tends to be done at
home. If they want to go to the puskesmas or hospital,
they depend more on the cost of childbirth on the poor
health insurance (Askeskin), assistance from parents or
in-laws19.
The importance of communication with the husband
appears in this research. Planning a helper and place of
delivery if done earlier will make the husband have the
responsibility in preparing funding for delivery. A similar
previous study, found the importance of communication
with a partner during pregnancy to be able to prepare for
labor by trained staff at a facility20-22.
The influence of family structure largely determines
labor in a home or health facility. In this study it was
found that there were no strong interventions from
families regarding the place of delivery, giving the
opportunity for pregnant women to give birth 2.89 times
at home. More worrying is the culture of giving birth at
home by midwives and traditional healers may have the
support of the family23-25. Distance and economy are the
reasons for not using facilities as in previous studies26,
but this study is different because access to facilities is
quite easy and the level of wealth is quite high. This
evidence of family support for giving birth at home is
very strong11.
As social beings we need the support of other people
or the community around us in life, including support
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  31
when giving birth. Support from the surrounding
community comes from neighbors, relatives, or other
relatives27. In this study it was found that pregnant
women who did not get community support had 2.7
times the chance of giving birth at home. Therefore
community support is very important in encouraging
pregnant women to use health facilities as a place of
delivery. Such community support may be in the form of
financial assistance, thoughts, health service information
or moral support that encourages pregnant women to
give birth in a health facility28-31
Conclusion
The results showed the husband’s communication
factors, family structure, and community support had
a significant relationship with the choice of place of
delivery while the husband’s work, marital status, access
to facilities and wealth were not related.
Ethical clearance-Taken from Faculty of Public
Health ethical committee
Source of Funding: Self
Conflict of Interest: Nil
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Attendants for Home Deliveries in Indonesia:
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Survey 2002/2003 and 2007. Maternal and Child
Health Journal. 2011;15(8):1400-15.
12. Hill PS, Goeman L, Sofiarini R, Djara MM. ‘Desa
SIAGA’, the ‘Alert Village’: the evolution of an
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with institutional delivery in Ghana: the role of
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measure to improve birth outcomes. PloS one.
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16. WHO K. Buku Saku Pelayanan Kesehatan Ibu.
Jakarta: Kemenkes RI; 2013.
17. Moyer CA, Mustafa A. Drivers and deterrents of
facility delivery in sub-Saharan Africa: a systematic
review. Reprod Health. 2013;10:40.
18. Abeje G, Azage M, Setegn T. Factors associated
with Institutional delivery service utilization among
mothers in Bahir Dar City administration, Amhara
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Feeley FG, Sabin LL. Health facility and
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 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  33

Accessibility of Availability of Public Health Services Dayak

Tribe in Samarinda “Qualitative Study”

Ansar Arifin1, Muhammad Alwy Arifin2, Darmawansyah2, Yusri Abadi2,

Dian Saputra Marzuki2, Suci Rahmadani2, Muhammad Al Fajrin2
1Department of Anthropology, Faculty of Social and Political Science Hasanuddin University, 2Department of
Health Administration and Policy, Faculty of Public Health Hasanuddin University

Abstract
In Indonesia, health service are still a problem both in terms of financing, quality, and public access. The
purpose of this study to analyze the availability of public health services in the Dayak tribes. Informants
in this study are indigenous Dayaks Society, the Society who were and had experienced/illness, Dayak
Customary Chief, Head of health center and health workers. Analysis of the data in this study using thematic
analysis. The primary data obtained from direct observation and in-depth interviews and focus group
Discuccion (FGD), while the secondary data obtained from the study documents. Based on this research,
accessibility of public health services in the Dayak based on an interview to the informant still have limited
Human Resources (HR), infrastructure, medical equipment and pharmaceuticals (drugs). Advice to the city
administration should have to provide health care facilities that can be accessed 24 hours as “Homecare
Health Center” mainly Dayak and other communities who live on the outskirts of the city of Samarinda.
There needs to increase the number of health workers, especially doctors and surveillance personnel.

Keywords: Aksesinilitas, LayananKesehatan, Dayak.

Introduction transport in urban areas while in rural areas 8.5 percent

Health workers there were more concentrated
in urban areas, it is possible urban health centers
are economically better and very promising in very
remote health centers appeal. Remote areas and rural
disadvantage, not only because it has fewer health care
facilities, but also the difficulty associated with health
sector workers1. Access is not only distance, but also the
availability of resources, namely the means (Tumanggor
2010)2, infrastructure, and human resources and
budgeting3-5.
Households knowledge about the existence of the
practice of a midwife or maternity hospitals nationwide
was 66.3 percent, the highest in Bali (85.2%) and
lowest in Papua (9.9%). Knowledge of the existence of
integrated health service post as much as 65.2 percent,
the highest in West Java (78.2%) and lowest in Bengkulu
(26.0%). Proportion of Households using various modes
of transportation motorcycle to the government hospital
in 53.6 percent of urban and 46.5 percent rural. To use
public transport in urban areas 28.0 percent and 35.5
percent rural. While using more than one mode of
11.4 percent.
Samarinda city is one of the most multi-ethnic settled
because the number of immigrants from other regions and
indigenous people who are looking for work in the city
of Samarinda, thus requiring attention related to public
access to health services remains low and is not covered,
the number of health workers are still lacking, time and
distance to health care is still a problem. Past research
has studied some of the dimensions of accessibility, but
research is mostly done using quantitative Method and
yet many researchers who studied qualitatively. Among
some of the existing research dimension, the dimension
of accessibility proposed consists of the accessibility
factor approachability, acceptability, availability and
accomodation, affordability and appropriatenes has not
been widely used as a reference in the accessibility of
health services research6-8. Based on several research
studies, theories about the accessibility of health
services, the researchers were interested in examining
the accessibility of the availability of health services for
the Dayak people in the city of Samarinda.
34  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Materials and Method
In this study, researchers used a qualitative research
method with case study approach is a study that aims to
describe and understand and explain how the accessibility
of health services availability Dayak community in
Samarinda. The research was conducted in the city of
Samarinda which are urban areas wulayah Kalimantan
Dayak tribal communities. The election procedure
informants in this study is using purposive procedure.
The informant in this research that indigenous Dayaks
Society, the Society that are and have experienced/
illness, Dayak Customary Chief, Head of health center
and health professionals. Analysis of the data in this
study using thematic analysis, The data collection was
obtained by conducting interviews with informants.
Results
Factors Availability and Accomodation all kinds of
health services needed by the people is not difficult, as
well as its presence in the community at any time that
it takes the form of infrastructure, equipment adequate
health, pharmaceuticals (drugs) and health human
resources (doctors , midwives and nurses).
Infrastructure: Infrastructure for health services
provided in the city of Samarinda felt was sufficient.
Health infrastructure as befits a provincial capital in
other places, there are many choices for accessing and
utilizing health facilities especially the government and
private Hospitals.
One of the key informants, addressing conditions
of health care infrastructure in the city of Samarinda, as
follows.
“Infrastructure in general is sufficient, in the sense
of being rich, the infrastructure of the ingredients may
need additional kinds of things, such as parking and all
kinds” (DK)
This is confirmed also by other informants:
“the building is good, sir” (DI2, 58 Th)
Medical tools: Medical equipment is something
that people felt inadequate, because there are still some
requirements with appropriate equipment for quality
health care. It is revealed from the following disclosure
of some key informants:
“Praise be to God,it is enough because we are not
hospitalized, it is not treated like that” (DK)
“So thank God, if that at least we have fulfilled”
(JM)
“Primary health care problem in Pampang is
sometimes there is no blood check equipment, cholesterol
check tools and other checks” (DI2, 58 Th)
Pharmacy: Procurement and availability of drugs,
especially in the health center, was considered good
enough as explained by key informant described below:
“Use it as possible. Alhamdulillah, right now the
health center has already had a pharmacist, let alone
want to accreditation, the goal must be that it must be
complete”(DK)
“There was once, and it happened indeed in the
pharmaceutical warehouse is empty. But whatsitsname
that there are drugs that his choice another term is no
other choice he did the same, but could not really empty
consumables same “(JM)
“Then there is the doctor or the spouse who is
checking this pain, right, right, there is always no
medicine, you just have to come back home who has a
fever, sir, how come you come to the doctor, uh, to the
health center again tomorrow is closed again. So what
should I do, the puskesmas is 24 hours, sir. Now that
drug is often not there sir. The area here is including the
city area, near samarinda”(DI1, 60 Th)
“Only the medicine at the health center for the
illness that was not so severe, the severe illness was
immediately referred to, which I saw there was no blood
and cholesterol check”
“So if I, I am my disease because I am old, I am
72, my prostate disease must go to a public hospital,
so this month I went to the public hospital to take
prostate medication, no medicine this month. So if at
the puskesmas why should I go to the hospital to take
medicine, why don’t the medicine go to the health center
so that it is also close to mine, also the cost from Pampang
is 50 Kepuskesmas can also be sent if they do, but it is
also difficult every month I get there this month there is
no medicine. So they told me to wait for the drug this
month but I haven’t left But thankfully because I have
no problems with urinary problems, it’s a disorder if the
prostate is a genuine parent. I also had surgery for stone
kidney stones yesterday, if the service at that time is ok,
the service is only because of the reason we postpone
the long delay until 1 month wait, many women say
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  35
we suffer from us too long we wait, suffer the cost of
suffering pain ha ha ha ha” (DI2, 58 Th).
Human Resources: Human Resources for Health
is required to create an appropriate health services and
qualified patient needs.
“Iyah Intership, every year right we can be an
additional 5, 5 so so very helpful at both the field and
what it later so. But his own doctor if power is actually
also “(DK).
The existence of human resources for health in the
city of Samarinda, especially PHC is recognized, a key
informant had provided, as stated below.
“The doctors we are actually hospitalized we had 3,
under 4 we have 7 but e just now just one doctor mutase
to Jogja follows husband, one doctor again pulled out
due to be Acting head of the health centers in lempake
that here one doctor learning tasks in Unhas also, So
under the 2 remaining above 2 to 4, dentist 1 “(JM)
“Because we hear complaints so even if we are not
allowed stay where where but complaints that we need
to hear this society procession. Moreover, they go for
treatment was not often come for treatment to the clinic
there was no doctor there is also no cure “(DI1, 60 Th).
“if I sir, if here we want to go to health services,
there should be a midwife or a spouse. there is no
midwife because we as housewives want complaints
from women as well, we have to have the midwife only
if we are ... if we consult the womb pain difference, the
midwife knows we feel free we feel we want to “(DI7,
50 Th)
Discussion
Factors Accessibility all kinds of health services
needed by the people is not difficult, as well as its
presence in the community at any time that it takes
the form of availability of facilities and infrastructure,
equipment adequate health, pharmaceuticals (drugs) and
the source human resources (HR) factors accessibility
Availability (Availability and Accomodation) all kinds
of health services needed by the people is not difficult,
as well as its presence in the community at any time that
it takes the form of infrastructure, equipment adequate
health, pharmaceuticals (drugs) and the source health
human resources (doctors, midwives and nurses).
Infrastructure: Infrastructure for health services
provided in the city of Samarinda felt was sufficient.
Health infrastructure as befits a provincial capital in
other places, there are many choices for accessing and
utilizing health facilities especially the government and
private hospital. Currently, the city of Samarinda at least
have had the health facilities (infrastructure), such as the
hospital as much as 17 government and private hospitals,
24 health centers with various levels of stratification
continues level to meet the standards and quality of
health services measured.
Although health service infrastructure rated
adequate, but the following few key informants
suggested still the need to improve infrastructure in order
to meet the standards of quality healthThere is a desire to
rehabilitate the building, especially at the primary care
level to plan their special space to care for the elderly,
their meeting place/meetings broader staff and meet the
standards supported boardroom meeting facilities.
With the potential power of health service
infrastructure, especially 24 health centers scattered
throughout the districts, and villages, health centers in
the city of Samarinda can initiate emergency services
24 hours, gradually based on the medical needs of
emergency in the district area (based kominitas such
ethnic Dayak tribes and rural communities Samarinda
city). To support the 24-hour service for emergency
conditions needed some cars faster health care (home
care). This car is equipped with a small body supporting
health facilities for those suffering from heart disease
and more importantly equipped with telemedicine.
Medical tools: Medical equipment is perceived
all health care-related partners (providers and users/
patients) are still inadequate. This was revealed by some
health care providers who say certain types of equipment
not available, the patient is required in the examination.
For example, dental care unit facilities, can already
kindling revocation of all kinds, the term in accordance
with service standards. When referring to the Minister
of Health, especially the basic examination (not
hospitalization), the equipment available is deemed to
have complied.
Based on the recognition of some participants in
the discussion (FGD) from the Dayak tribe, they say
if standard hospital equipment such as hospitals Abdel
Wahab Syahranie (Hospital AWS) and RS Abdul Muis
and other hospitals (private hospitals) in Samarinda city,
judged complete and adequate.
36  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Pharmaceuticals (Drugs): Pharmaceuticals
(Drugs) are available both in auxiliary health center and
health centers have never experienced problems in terms
of both supply and availability. Drugs that are needed
by the community can be obtained easily, especially in
auxiliary health center. Demand for drugs from auxiliary
health center conducted every month, adjusted for the
needs of island communities. For drug distribution
auxiliary health center parties should come to the clinic
to take the demand for drugs by using the services in
every single month which coincides with the monthly
health center workshop.
Human Resources (HR) Health: Not only in
Indonesia, the physical availability of health services
begins with the service, but the distribution of services
and medical personnel are not uniform across Australia.
The concentration of medical practitioners, for example,
the highest in large cities (392 medical practitioners
equivalent full per 100,000 population), and significantly
lower in the remoteness of the other, with outdoor areas
that have the lowest rates (206 medical equivalent of a
full time practitioners per 100,000 population9-13.
The problem of inadequate staff and lack of health
care services reverberate throughout the interview.
“There is no chemist, no doctor, no other services,
so everything is pretty limited at this stage”. Some
reportedly in need of services including X-rays, a
defibrillator, a local surgery, kidney dialysis services.
Issues of health human resources is still a problem that
needs to be resolved. Interesting facts discovered why
health care workers who are in the area of the island is
always deficient because when the life of a health worker
has been prosperous, so they decided to leave the place
where he works, and chose to live and serve in place
better and have better access anyway
Ethical Clearance: Taken from favultu of public
health ethical committee
Source of Funding: Self
Conflict of Interest: Nil
Conclusion
Based on the description above, it can be concluded
that the availability of Dayak community health services
is inadequate, this is based on the availability of
facilities and infrastructure in health facilities which are
considered inadequate, such as infrastructure, medical
equipment, pharmaceuticals and unmet health human
resources. needs of health care facilities.
References
1. World Bank. World Bank Annual Report 2014.
2. Tumanggor, R.. Socio-cultural problems in Health
Development at Indonesia. Journal of Society &
Culture, Volume 12 No. 2 of 2010, pp. 231-254.
3. Achmadi, U. F. New Horizon Public Health in
Indonesia.Jakarta: Rineka Reserved. 2008
4. Fortney, JC, Kaufman, CE, Polloa, D., Beals,
J., Edlund, C., Novins, DK, & Team, A.-S..
Geographical Access and the Substitution of
Traditional Healing for Biomedical Services in
Two American Indian Tribes. Medical care, 2012;
50 (10), 877.
5. Garcia-Subirats, I. Vargas, I., Mogollon-Perez,
US, De Paepe, P., da Silva, MRF, Unger, JP,. ,
, Vazquez, ML Inequities in Access to Health
Care in Different Health Systems: A Study in
Municapalities of Central Colombia and North-
Eastern Brazil. International journal of equity
in health, 2014; 13(1), 10.
6. Ministry of Health.. Road Map Towards National
Health Insurance Jakarta: RI Ministry of Health.
2013
7. Republic of Indonesia Ministry of Health. Handbook
on Socialization: National Health Insurance (JKN)
in the Jakarta National Social Security System:
Ministry of Health of the Republic of Indonesia.
2013
8. Sari, RM, Ambarita, LP and Sitorus, H., The health
care access and the incidence of malaria in the
province of Bengkulu. Media Health Research and
Development, 2014; 23 (4), pp.158-164.
9. Le, Q., Nguyen, HB, Auckland, S., Hoang, H.,
& Terry, D. Access to health Care Services in an
Australian Rural Area-A Qualitative Case Study.
International Journal of Innovative Interdisciplinary
Research, 2012; 1 (3), 29-36.
10. Massie, RG and Kandou, GD, Basic Needs of
Public Health in Small Island: A Case Study in
Ganges Island Likupang Western District of North
Minahasa regency of North Sulawesi province.
Health Systems Research Bulletin, 2013; 16 (2
APR).
11. Suharmiati Suharmiati, Lestari Handayani, Lusi
Kristiana. Factors That Influence The Affordability
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  37
Of Health Services In Health Center Of Border- Sri Wahyuni and Anwar Mallongi, 2017.
Located Areas In Sambas District (Case Study Early breastfeeding initiation: impact of socio-
at Sajingan Besar Community Health Center). demographic, knowledge and social support
Bulletin of health System Research. 2012; Vol.15 factors. Pak. J. Nutr., 16: 207-215.
No.3 July. 13. Balitbang MoH RI. Basic Health Research;
12. Azniah Syam, Muhammad Syafar, Ridwan RISKESDAS. Jakarta: Balitbang MoH RI, 2013.
Amiruddin, Muzakkir, Darwis, Sri Darmawan,
38  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Role of Genetic Polymorphisms of Angiotensin Converting

Enzyme to Cardiovascular Endurance in Men Ages 13-14
Years After Fartlek Training for 3 Months

Fatoni1,2, Haerani Rasyid1, Rosdiana Natsir1, Ilhamjaya Pattelongi1,

Andi Ihsan², Adam Mappaompo², Sudirman²
1Faculty of Medicine, Universitas Hasanuddin, 2Faculty of Science, Universitas Negeri Makassar, Indonesia

Abstract
Physical ability is influenced by two factors, namely environmental and genetic factors. Environmental factors
that influence are exercise intensity, nutritional intake, and age. Another factor that is not less important in
influencing cardiovascular endurance is genetic factors. One of gene variation that is considered to determine
the athlete’s potential is the variation in the ACE gene symbolized by I and D. The ACE gene insertion/
deletion polymorphism (I/D) has an important relationship with cardiovascular fitness with genotype II
which shows a lower level of cardiorespiratory fitness with VO2max than the Non II genotype (ID and DD).
The purpose of this study was to assess how the role of the ACE gene in male cardiovascular endurance
aged 13-14 years. This study provides a three-month fartlek training program and conducts cardiovascular
endurance tests before and after taking a three-month fartlek training program. In group II genotype subjects
showed the results of increased cardiovascular endurance compared to the Non II genotype subject group.
Research can conclude a strong relationship between the variation of the angiotens in converting enzyme
gene II genotype against male cardiovascular age 13-14 years.

Keywords: ACE gene, cardiovascular endurance, fartlek training.

Introduction physical performance is influenced by genetic profiles1.

Efforts to improve sports performance cannot be
separated from physical conditions, because the physical
condition supports when practicing or competing to
show the best performance by displaying techniques
and tactics effectively and efficiently. Good physical
condition is one of the absolute requirements to achieve
optimal performance. Sports training strategies focus on
athletes’ interests and achievements. Genetic potential
of individuals must be considered to get high achieving
athletes, because with the appropriate genetic variation
there is a greater chance of producing accomplished
athletes than athletes who have inappropriate genetic
variations if they receive the same training intervention
and motivation. This research concentrates on finding the
right genetic profile to contribute to sports performance.
One of the main objectives of this research is to help
trainers to identify and guide individuals with genetic
potential to become elite athletes.
ACE gene is an important factor that needs to be
considered. The results of this study provesthat human
Allele I was found to have a beneficial effect on
higher maximum oxygen uptake values. Characteristic
distribution of genotypes was found, where allele II was
more common in individuals doing aerobic exercise
and DD alleles in individuals who were disciplined in
anaerobic exercise2.
The role of ACE gene polymorphism with
cardiovascular response with irregular resistance
training in women. The subject of DD alleles is greater
in post-exercise hypotension, While the allele I showed
a greater increase in heart rate after endurance training3
the integration of several genes added to environmental
factors, identification of talents and prescription of
training programs that maximize the athlete’s individual
potential based on genetic variable characteristic,
will be able to make a revolution in sports science.
polymorphism gene ACE II which states higher ACE
activity has a correlation with the ability for sports that
require endurance, while DD polymorphisms and higher
ACE activity are related to sprint ability4. Variations
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  39
in the Angiotensin Converting Enzyme gene which
were interacted with resistance showed differences in
changes in endurance results, namely genotype II which
was better than the variation of DD genotype, with an
average increase of 11.57ml/kg/minute, while the DD
genotype decreases by an average of-8ml/kg/minute5.
There is an individual variability characterized
in response to endurance training, and some research
results suggest that this part of the variation is genetically
regulated6. In addition, the results show that genetic
variation. The ACE gene can affect blood pressure
response to exercise, although more research is needed
to confirm this finding7.
Research results of Myerson S, et al.8His analysis
showed a linear tendency to increase the frequency of
allele I with running distance. The allele I ACE gene
is associated with improved endurance performance. In
addition, the insertion/deletion (I/D) type polymorphism
of the ACE gene also influences the process of
performance in the heart as the results of the study.
Aziza, L., et al.9which states that the insertion/deletion
(I/D) type polymorphism of the ACE gene affects ACE
concentration in the blood and affects blood pressure.
Blood pressure changes are affected by changes in
angiotensin II, aldosterone or active vaso substances10.
This relatively new approach needs to be considered
by sports institutions in determining the right strategies
to foster the seeds of young athletes to improve sports
performance. So, research can be utilized by considering
the variation of the genotype II of the ACE gene in the
search for potential talent for Indonesian endurance
athletes. If the genetic information of prospective young
athletes obtained earlier, is expected to have a significant
influence on the effectiveness of sports training in
general.
Research Method
This type of research is a retrospective cohort study
using a cross-sectional design or approach to describe
the correlation between factors and effects. Research
in October 2018 January 2019 in South Sulawesi. The
population in this study were SMP N 3 Sungguminasa
students with a age range of 13-14 years, amounting to
78 people to be the number of samples in this study but
those who completed until the end of the study were 59
samples. Data were analyzed using SPSS version 24.
The results are displayed in the form of narratives and
tables.
Measurement Procedure: The 12-minute run
test designed by Cooper is a field test that is relatively
easy and inexpensive, because it requires enough
running track or can also use public roads and time
measuring devices (watch or stopwatch). The cooper
test (running 12 minute) is used to determine endurance.
The implementation of the 12-minute run test requires
a rather complicated procedure, in which participants
are required to stop when the 12-minute time has been
exceeded, then they need to give a sign where the stop is,
to immediately measure the distance the result is taken.
If there are many test participants, it needs carefulness to
measure it. The distance reached is then confirmed in the
physical fitness category table to determine the fitness
status of the sample. The test categories are distinguished
by sex and age group. In the implementation the
12-minute run test requires a running track even though
it can be carried out on the streets.
Test implementation
1. Beginning attitude
2. Participants stand behind the start line
3. Movement:
a. In the “READY” command, the participants
took a stand, ready to run
b. On the “YES” command the participants ran
as much as possible until the time showed 12
minutes
c. After reaching 12 minutes the stopwatch is
turned off and the runners are told to stop at
their respective places
d. What is measured is how many meters can be
taken while running for 12 minutes. If it stops it
is considered a failure
e. Record of results
The distance taken during a 12-minute run is
recorded in meters, as a result of the test takers.
Ways To Calculate Cooper’s VO2max test
(Distance (Meter)  504,9)
Vo2max (ml/kg/mnt) 
44,73
Results obtained from the above calculations. After
that, classify according to the fitness category table
based on the Cooper test.
40  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Result and Discussion Table 2 provides information on the gene variations

angiotensin-converting enzyme found among the
This study was conducted from October 2018 to
sample population. There are two variations group of
January 2019. Selection of respondents by age category
the ACE gene in which samples with a variation within
and sex at SMPN3 Sungguminasa Gowa Regency by
the variations in Non II genotype have a greater number
ages 13 to 14 years old. In this study involved 59 male
than II genotype from 59 samples in this study.
sex students. Characteristics of research subjects include
age, weight, and height. Table 3. Cooper Test Results before the fartlek
training program
Table 1: General characteristics of research subjects
No. Gene Variation n %
No. Variable Means± SD Min-max P
1 II 25 42,4
1 Age 13,02 + 0,13 13-14 0,000
2 Non II 34 57,6
2 Weight 37,07 + 8,073 25-64
Total 59 100
3 Height 144,51 + 6,654 129-159
*Paired T test **Independent T test
Source: Primary Data, 2018
Based on Table 3 above it can be seen that the effect
Table 1 above present information on average age
of fartlek training for 3 months showed an increase in
of sample 13,02 years old with a range of 13 to 14
cardiovascular endurance (VO2max) significantly p <
years old, average weight of 37,07 kg with a range of a
0.001 by (4.9 ± 0.7) ml/kg/min, from (27.6 ± 4.5) ml/kg/
minimum weight of 25 kg and a maximum weight of 64
min to (32.5 ± 3.8) ml/kg/min in the genotype II group.
kg, the average height of 144,51 cm with the range of
Whereas the Non II genotype showed a significant
129-159 cm.
increase in VO2max p <0.001 by (2.6 ± 0.1) ml/kg/
Table 2. Characteristics of the subject gene min, from (29.2 ± 4.9) ml/kg/min to (31.8 ± 4.8) ml/kg/
variation min. Furthermore, the fitness test category can be seen
in table 4.
Cardiovascular Endurance
Gene VO2max (ml/kg/min)
Varia- P* P**
tion Before After Change
Mean±SD Mean±SD Mean±SD
II 27,6±4,5 32,5±3,8 4,9±0,7 0,000 0,000
Non II 29,2±4,9 31,8±4,8 2,6±0,1 0,000
Total 28,5±4,8 32,1±4,4 3,6±1,8 0,000

Table 4. Fitness Test Category (VO2max) for Men (value in ml/kg/min)

Age Bad Lower average Average Above average Excellent Superior

13-19 < 35.0 35.0-39.9 40.5-45.1 45.2-50.9 51.0-55.9 > 55.9
20-29 < 33.0 33.0-39.0 39.9-43.3 43.9-48.7 49.3-52.5 > 52.6
30-39 < 31.5 31.5-38.4 38.5-41.8 42.4-47.4 48.0-51.4 > 51.6

The increase in VO2max due to the effect of fartlek
training for 3 months on subjects in the II genotype
and Non II genotype groups showed an increase in
cardiovascular endurance (VO2max) significantly p
<0.001, however the increase did not change the category
of fitness level which was still in the “Bad” category, if
adjusted to the table above categories.
Statistical test results obtained significance value of
0.000 (P <0.005), so it was concluded that there was a
difference in Test cooper on the first measurement with
the second measurement score.
To see a comparison of the increase in cardiovascular
endurance (VO2max) in both groups of II genotypes and
Non II genotypes ACE genes after taking 3 months of
fartlek training.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  41
Conclusion
In this study, the distribution of 59 participants
who were students aged 13 to 14 years at SMP N 3
Sungguminasa, Gowa Regency obtained II genotype
57.6% and Non II genotype 42.6%.
Based on the results of the variation of the angiotens
in converting enzyme gene that was interacted with
changes in cardiovascular endurance showed male
subjects aged 13-14 years who took fartlek training for
3 months with the ACE gene, that group II genotypes
had a greater increase than the Non II genotype group
either through approach to distance when running for
12 minutes or the ability of VO2max. However, the
increase in cardiovascular endurance of subjects in both
genotypes II and Non II subjects did not change in the
fitness category.
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: From the University
Hasanuddin committee.
References
1. Ma F, et. al. The Association of Sport Performance
with ACE and ACTN3 Genetic Polymorphisms: A
Systematic Review and Meta-Analysis.2013
2. Holdys J, et. Al. ACE I/D Gene Polymorphism
in Athletes of Various Sports Disciplines. Human
movement vol. 2011; 12 (3), 223–231.
3. De Souza JC, et. al. Association of cardiovascular
response to an acute resistance training session with
the ACE gene polymorphism in sedentary women:
a randomized trial. BMC Cardiovascular Disorders
2013, 13:3.
4. Fernanda M and Slocombe R. The Use of
Angiotensin-I Converting Enzyme I/D Genetic
Polymorphism as a Biomarker of Athletic
Performance in Humans. Biosensors 2012, 2, 396-
404.
5. Arimbi et.al. Role of Genetic Polymorphisms
of Angiotensin-Converting Enzyme Insertion
Resistance to the Performance of Badminton Youth
Athlete. Journal of Applied Environmental and
Biological Sciences. J. Appl. Environ. Biol. Sci.,
2015.; 5(8)134-138,
6. Rankinen T, et. al,. Genetics and Blood Pressure
Response to Exercise, and Its Interactions With
Adiposity.2002
7. Goessler KF, et.al., ACE polymorphisms and
the acute response of blood pressure to a walk in
medicated hypertensive patients. Journal of the
Renin-Angiotensin-Aldosterone System2015, Vol.
16(4) 720–729.
8. Myerson S, et al. Human angiotensin I-converting
enzyme gene and endurance performance. the
American Physiological Society.2017.
9. Aziza, L. Hipertensi: the silent killer. Jakarta:
IkatanDokter Indonesia. 2007.
10. Goncalves R et al.. Genetic polymorphisms
determining of the physical performance in elite
athletes. Rev Bras Med Esporte2007; Vol. 13,
No 3.
42  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

The Expression of miR-21 and miR-29c in Blood Plasma of

Nasopharyngeal Carcinoma Patient Post-Chemoradiotherapy

Eka Savitri1, Indira Maharis2, Abdul Kadir3, Riskiana Djamin4, Sofia Mubarikaand5, Tirta Wardana6
1Department of ENT Health Sciences, Faculty of Medicine, Hasanuddin University, Makassar, 6Department of
Histology and Cell Biology, Faculty of Medicine, Gadjah Mada University, Yogyakarta, 7Department of Molecular
Biology, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia

Abstract
Background and Objective: Radiotherapyandchemoterapy aremain therapy for tumor.Nasopharyngeal
carcinoma (NPC) is a malignant tumor which come from nasopharyngeal epithelial cells (a squamous cell
carcinoma). MicroRNAs (miRNAs) are non-coding RNAs, acting as post-transcription regulatiors in the
target gene. MiRNAs have an important role in the pathogenesis of NPC, they may act as tumor suppressor
genes or as oncogenes and their regulation is related to the prognosis of the disease and the outcome of
therapy in the target gene. This study aims to determine the effects of chemoradiotherapy on miR-21 and
miR-29c in blood plasma of nasopharyngeal carcinoma patient.

Materials and Method: Prospective cohort was used as a research design. The study was conducted in
Wahidin Sudirohusodo Hospital Makassar in February-November 2017. Plasma of blood collected after
chemoradiotherapy will be isolated, then synthesized into c-DNA and calculated the quantitative amount
with qRT-PCR.

Result: There were 16 samples consisting of 9 NPC plasma post chemoradiotherapy and 7 plasma
NPC post radiotherapy. From the plasma we detected miR-21 and miR-29c. The expression of miR-21
in post chemoradiotherapy decreased compared to pre-therapy, in contrast, the expression of miR-29c in
postchemoradiotherapy increased compared with pre-therapy. The expressionsof miR-21 and miR-29c in
post radiotherapy decreased compared to pre-therapy. The expression of miR-21 in post chemoradiotherapy
decreased compared to post radiotherapy, in contrast, the expression of miR-29c in post chemoradiotherapy
increased compared with post radiotherapy.

Conclusion: We found essential differentiation between mRNA-29c expression before and after radiotherapy
at nasopharyngeal carcinoma patient, so it can consider as predictive factor for therapy responses.

Keywords: Nasopharyngeal carcinoma, miRNA, miR-21, miR-29c, chemoradiotherapy, radiotherapy, qRT-PCR.

Background The first known miRNA characteristic in NPC is

miR-29c (Sengupta et al). It was also found that miR-
MicroRNA is an endogenous RNA non-protein-
29c serves as tumor suppressive, enhances migration
coding molecule with size of (18-25nt), its primary
and invasion of NPC cells through regulation of
function is to decrease transcription and/or protein
extracellular dimetric components.21While the study
content in its target.9MicroRNAs (miRNAs) have
by Zhang et al showed that the decrease of miR-29c
been shown to play a role in the clinical and biological
occurred in increased resistance to apy and platinum-
behavior of human cancer cells, including NPC. In NPC,
based chemotherapy through regulation of antiapoptotic
miRNA plays an important role in the pathogenesis of
Mcl-1 and Bcl-2. Like other miRNAs, miR-29c can
NPC as tumor and oncogene suppressor genes and its
work through multiple ways to suppress proliferation,
regulation is related to disease prognosis and therapy
survival, and motility of NPC cells.27
outcomes.9
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  43
Among all types of miRNA, miR-21 is a key
oncogene, since it was found in many cancers and
contributes to multiple malignant processes such as
increasing proliferation of NPC cells, suppressing
apoptosis, tumor growth in MCF-7 cells and decreasing
invasion and metastasis in MDA-MB-231.15
Nasopharyngeal carcinoma (NPC) is a malignant
tumor which comes from nasopharyngeal epithelial
cells (a squamous cell carcinoma (SCC), a multifactorial
genetic disease with endemic characters. An estimation
of 87,000 new cases of nasopharynx appear each year.1-
2 of NPC is primarily found in men of reproductive age
(the ratio of male and female patients is 2.18:1) and 60%
of patients between the ages of 25 and 60. The highest
incidence rate in the world is found in the province of
Southeast China with 40 to 50 cases of nasopharyngeal
cancer among 100,000 inhabitants.
In Indonesia, nasopharyngeal carcinoma is ranked
4th after breast cancer, cervical cancer, and lung cancer
with an incidence of about 4.7 per 100,000 population
(GLOBOCAN 2012).Most patients who come for
treatment are already in an advanced stage, resulting in
poor treatment outcome and prognosis. In Dadi hospital
and Dr. Wahidin Sudirohusodo hospital during the 10-
year period (1990-1999) found 274 cases (47.98%) of
NPC from malignant head and neck tumors in the ratio
between male and female of 2.6:1 From Nasopharyngeal
carcinoma profile data at Dr. Wahidin Sudirohusodo
hospital Makassar, South Sulawesi province from
January 2004 to June 2007 NPC has constituted 33% of
malignancy in the ears, nose, and throat, (2000-2009)
found 362 cases (57.28%) of malignant head and neck
tumors6,7
Despite improvements in chemoradiotherapy, the
prognosis of NPC remains poor with a 5-year survival
rate of less than 60%. The main cause of treatment
failure and metastasis is the occurrence of resistance to
radioactive substances and antitumor drugs.27
Based on these backgrounds, this research was
conducted to determine the effects of chemoradiotherapy
on the expression of miR-21 and miR-29c in blood
plasma of patients with nasopharyngeal carcinoma.
This study has no conflict of interest. Source of
Funding: are independent.
Materials and Method
Location and Time of the Research: The study
was conducted at ENT Head & NeckDr. Wahidin
Sudirohusodo hospital the period of February-November
2017.
Design and Variable Research: This study is
a prospective cohort study. Independent variables
(chemoradiotherapy and radiotherapy), intermediate
variables (nasopharyngeal carcinoma), dependent
variables (miR-21 and miR-29c expression) and external
variables (EBV infection, lifestyle, and genetic).
Population and Sample: Thestudypopulationwas
NPC patients of stage I, II, III, IV whohadnotbeentreated,
cametothe Polyclinic of ENT Head & NeckDr.Wahidin
Sudirohusodohospital, thenmonitoredduringtherapy
(chemoradiotherapy) during February-November 2017.
The sample is the entire population that meets the
research criteria.
Research Ethics: Any action is made on the consent
of the patients/the parent(s) of the patients through
the informed consent sheet and fulfilled the ethical
requirements to be implemented from the Commission
on Biomedical Research Ethics in Human Faculty of
Medicine Hasanuddin University. Recomendation
number: 921/H4.8.4.5.31/PP36-KOMETIK/2017
Method of collecting data: Sampling was done by
consecutive sampling, all patients with nasopharyngeal
carcinoma that has not been treated, either by
chemotherapy / radiotherapy / chemoradiotherapy that
meets the inclusion criteria.
Theinclusioncriteriawere NPC patients (allstages)
who had been diagnosed based on histo pathologic
examination, aged> 15 years, no malignancy found in
otherorgans, no history of hemostaticdisorders, NPC
patients with chemotherapy regimens Cisplatin +
Paclitaxel, and are willingto be researchsamples.
The exclusion criteria are NPC patients who
have received chemotherapy, radiotherapy, or
chemoradiotherapy.
The dropout criteria were lysis blood samples,
the patients who died before the chemoradiotherapy
protocol was completed, the change the chemotherapy
regimen (Carboplatin/Docetaxel).
44  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Group 1: Blood plasma samples after treatment
(neoadjuvant chemoradiotherapy), regimens of cisplatin
and paclitaxel, followed by radiotherapy.
Group 2: Blood plasma samples after radiotherapy
only.
The both groups received the same treatment process,
as (± 2-5ml of blood plasma) is taken and inserted into
the tube which has been given EDTA 10%. After that it is
centrifuged at 3000 rpm for 10 minutes. Plasma is taken
and stored in the-800C refrigerator and labeled. Then the
isolation of RNA is done with the plasma samples using
miRCURY RNA Isolation Kit-BiofluidExiqon (Cat
No.300112, Exiqon), then synthesized into cDNA using
the Universal cDNA Synthesis Kit II (Cat No. 203301,
Exiqon).Then the quantitative quantity is measured by
qRT-PCR (Bio-radinc, C1000). The tool used is Exilent
SYBR Green Master Mix 2.5mL (Exiqon, Denmark),
Primer set miRCURY LNA has-miR-21-5p (Cat No.
204230) with primary sequence, has-miR-29c-3p (Cat
No. 204729) with primary sequence and has-miR-16-
5p as reference genes (Cat No. 2057020) with primary
sequence.
Statistic analysis: The statistical analysis used CFX
Manager 96 Software (version 3.0 for windows, Bio-Rad
Laboratories Inc, California). The steps were data entry,
select tools, Exiqon PCR wizard. Select CFX 96, enter
data file containing panel layout. Entry fail data of each
sample ct. Set the interpolate calibrator, internal control,
sheet validation and normalization with gene reference.
The data was stored in control panel software. The
analysis was done by T-test, heat map and descriptive
statistic.
Results
Results Analysis of miR-29c and 21 expression in
patients with nasopharyngeal carcinoma
There are 3 graphs generated from PCR quantification
performed using BIORAD and analyzed using CFX 96
Manager software: graph amplification, melt curve and
melt peak. Each chart has been distinguished based on
the three target colors red = miR-21, blue = miR-29c and
green is the reference gene of miR-16.

Amplification Curve:

Figure 1 shows the amplification results of all samples in RFU (Relative Fluorescence Unit). The result of
fluorescence captured in each quantification cycle is translated into curve form. The more left or the earlier
fluorescence is captured, indicating a higher level of miRNA expression.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  45
a. Melt Curve

Figure 2 shows a melt curve, where the higher the temperature, the sample will be denatured and the
captured fluorescence will end. This curve shows the total reaction that occurs, so we can know that the
sample preparation is good enough.

b. The melt curve peak

Figure 3 is a graph that can be used to view the sensitivity and specificity of amplification targets. In this
study, total reaction of each reaction has peak.
46  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
The value of the cycle of quantification (cq) obtained is:

Pre therapy Chemo-radiotherapy Radiotherapy

Sample
Code Cq- Cq-miR- Cq- Cq- Cq-miR- Cq- Cq- Cq-miR- Cq-
miR-21 29c miR-16 miR-21 29c miR-16 miR-21 29c miR-16
1 28.2 32.4 27.8 32.94 29.76 24.6
2 26.53 30.96 25.78 32.43 36.69 24.35
3 30.18 33.12 29.05 28.13 33.28 24.86
4 30.34 31.34 27.96 24.21 27.59 24.93
5 25.85 29.25 24.75 26.08 25.58 24.31
6 26 29.85 26.09 26.45 28.88 24.6
7 29.77 29.86 27.47 29.77 29.17 24.595
8 26.52 30.08 25.8 26.62 26.28 24.59
9 26.46 27.25 23.72 25.81 30.53 24.585
10 25.84 31.46 24.57 30.27 30.02 24.65
11 24.93 28.23 24.98 32.23 29.94 24.53
12 25.83 29.42 24.53 28.04 31.79 24.31
13 26.73 28.64 24.7 24.7 30.02 24.91
14 29.75 34.19 24.69 27.31 34.8 24.74
15 23.58 27.56 24.682 28.4 33.06 24.796
16 32 33.72 24.678 36.08 38.22 24.852

Some of the results that have been obtained are:

a. The results of quantification of miR 21 and miR-29c expression in NPC patient samples who were given
chemoradiotherapyand regimens compared with untreated samples.
Post Chemoradiotherapy (n=9) Pre therapy(n=9)
Variabel Median Median p
Mean SD Mean SD
(Min-Max) (Min-Max)
25,90 28,09
miRNA-21 expression 26,28 3,05 27 1,89 0,81
(24,21-29,57) (25,85-30,34)
31,13 30,18
miRNA-29c expression 32,10 3,71 30,45 1,75 0,81
(25,58-36,69) (27,25-33,12)

Data presentin mean and deviation standard. p>0,05 considered not significant diffrentiation, with Dependent Sample T-test.

b. The results of quantification of miR 21 and miR-29c expression in NPC patient samples who were given
radiotherapy compared with untreated samples.
Post Radiotherapy (n=7) Pre Therapy (n=7)
Variabel P
Median (Min-Max) Mean SD Median (Min-Max) Mean SD
27,33 27,79
miRNA-21 expression 26,89 3,71 26,95 2,92 0,10
(22,58-32,08) (23,58-32)
32,02 30,87
miRNA-29c expression 32,03 3,10 32,46 2,69 0,05
(29,94-38,22) (27,56-34,19)

Data present in mean and Deviation Standard. p<0,05 at mIRNA-29c expression considered significant, while p>0,05 at mIRN-21
expression considered not significant, with Dependent Sample T-test.

The results of quantification of miR 21 and miR-29c expression in NPC patient samples who were given
chemoradiotherapy and regimens compared with given radiotheraphysamples.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  47
Post Chemoradiotherapy(n=9)
Variabel
Median (Min-Max) Mean
25,90
miRNA-21 expression 26,28
(24,21-29,57)
31,13
miRNA-29c expression 32,10
(25,58-36,69)
Data present in mean and Deviation Standard. p>0,05 considered not significant, with Independent Sample T-test.
Discussion
This study collected 27 samples of venous blood of
NPC patients. However, of all the samples collected there
were only 16 plasma samples consisting of 9 samples of
post chemoradiotherapy and 7 post radiotherapy samples
which can be continued up to qPCR examination for
technical reasons. Initially, DNA isolation and DNA
synthesis were done at the hospital of Hasanuddin
University Hospital. Samples in the form of cDNA were
then sent to the molecular biology laboratory of Gajah
Mada University for qPCR examination. We found
increased of miR-21 expression from 5 NPC post chemo-
radiotherapy samples, this caused by unresponsive
to therapy and biogenetical mutation. This study also
found decreased of miR-29c expression in 1 sample of
NPC post radiotherapy, this caused by unresponsive to
therapy and biogenetical mutation, so we need further
examination to see dedaiser mutation.
Conclusions and Recommendations
Based on our study we conclude that the expression
of miR-21 in patients with nasopharyngeal carcinoma
who have been treated with chemoradiotherapy is lower
compared with patients who have not received therapy.
In this study, it can also be concluded that the expression
of miR-21 in patients with nasopharyngeal carcinoma
who have been treated with radiotherapy is also lower
compared with patients who have not been treated
with therapy.Whereas the comparison between miR-21
expression in patients with post-therapy nasopharyngeal
carcinoma with chemoradiotherapy was higher when
compared with post-therapy with radiotherapy alone.
But the expression of miR-29c post-chemoradiotherapy
therapy obtained the opposite result to the expression
miR-21.
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: Obtained from Hasanuddin
University ethical committee.
Post Radiotherapy (n=7)
P
SD Median (Min-Max) Mean SD
27,33
3,05 26,89 3,71 0,38
(22,58-32,08)
32,02
3,71 32,03 3,10 0,19
(29,94-38,22)
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 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  49

Audiometric Profile of Fishermen Using Motor Boat in

Barombong Village, Makassar

Muhammad Anwar1, Eka Savitri1, Trining Dyah1

1Department of Otorhinolaryngology Head and Neck Surgery, Medical Faculty, Hasanuddin University, Indonesia

Abstract
Objective: To analyze the audiometric profile of Indonesian fishermen in the village of Barombong as well
as determine the prevalence and degree of hearing loss and its related factors.

Method: This was an observational, cross-sectional study of adult full-time fishermen recruited from the
village of Barombong in the city of Makassar within the province of South Sulawesi who were part of a
voluntary screening for hearing loss. All pure tone audiometry tests were conducted by a single, experienced
audiologist using the same pre-calibrated Interacoustics AD226 Diagnostic Audiometer. Noise intensity of
the participant’s working environment was sampled by a single audiologist using the same pre-calibrated
Extech 407732 sound level meter for a duration of 30 minutes.

Results: The mean age of the study group was 43.93±8.10 years with 95% confidence interval of 26.65-
34.04 years, the mean working period was 19.45±3.95 years with 95% confidence interval of 11.48-15.31
years. The mean noise intensity the participants were exposed to was 101.7±2.342dB with 95% confidence
interval of 98.9-101.7dB. There was a statistically significant (P<0.05) positive relationship between the
age of participants and degree of hearing loss with r-value of 0.6467. Degree of hearing loss was also
significantly related (P<0.05) to the working period of participants with r-value of 0.6203. There was also a
significant (P<0.05) positive correlation between degree of hearing loss and noise intensity the participants
were exposed to with r-value of 0.2482.

Conclusion: Our study showed that a significant majority of fishermen working in the Barombong village
experienced hearing loss. Significant decline in hearing threshold was observed and was significantly related
to age, working period and noise intensity the participants were exposed to. Hence, there is a great need
to raise awareness regarding the dangers of noise-induced hearing loss among fishermen and the need for
preventive measures to be put in place to prevent hearing loss and therefore a declining quality of life for
the fishermen.

Keywords: Noise-induced hearing loss, sensorineural hearing loss, occupational hearing loss.

Introduction predominantly occupied by fishermen. Fishermen work

South Sulawesi has a strategic geographical position
with a long coastline of 1,937 km2 and large fishing
grounds that extend beyond the Makassar Strait to the
Flores Sea and Bone Bay, with as many as 199,216
fishermen. In the coastal city of Makassar, yearly catch
produced up to 18,000 tons while marine fisheries
production reached 12,731 tons per year. Earlier surveys
of the fishing population places the number of fishermen
to be around 11,497 with 4934 units of fishing gear1-3.
The village of Barombong in Makassar city is
almost every day with frequent sea trips using a motor
boat as their means of water transport in order to fish.
However, most fishermen are unaware that exposure
to noise from the machine of their fishing boats is an
insidious cause of hearing loss.
Most fishermen whom experience damage to their
hearing is due tonoise-induced hearing loss (NIHL).
Noise-induced hearing loss (NIHL) is damage to
hearing that is caused by prolonged exposure to loud
noise, usually ten years or more. Noise is defined as the
50  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
mixture of various pure tone sounds with differening
frequencies. Noise with intensity of 85 dB or more
can cause damage to the Corti hearing receptors in the
inner ear. The Corti’s organ sound receptors are often
damaged at frequencies of 3000-6000 Hz frequency and
most heavily affected at the 4000H Hz frequency. This
is classified as sensorineural hearing loss that typically
affects both ears to similar degrees4-5.
Pure tone audiometry (PTA) is a tool commonly used
to assess the type of hearing loss and hearing threshold
to those who experience hearing problems. Furthermore,
PTA can help evaluate the degree of hearing loss and
is useful in screening for hearing problems. Pure tone
sound means the sound produced only has one frequency,
expressed in the number of vibrations per second.
Audiometric examination requires a sound proof room,
and audiologist and a cooperative patient.
Preliminary surveyof fishermen in Barombong
village in Makassar city revealed that fishermen are
exposed to motorboatsthat generate noise of high
intensity for long hours. This working condition has a
great potential to cause hearing loss among fishermen
that can significantly reduce their quality of life with
time. Furthermore, most fishermen do not use protective
equipment to minimize noise exposure and have been
working for more than 10 years for more than 8 hours
per day. Thus, our study aims to provide a closer look
at the audiometric profile of Indonesian fishermen in
Barombong, determine the prevalence and degree of
hearing loss and its related factors as well as establish
the need for preventive measures against noise-induced
hearing loss.
Materials and Method
This study is an observational, cross-sectional
analysis conducted between 21st December to 30th
December 2018 performed according to the tenets of the
Declaration of Helsinki and approved by the institutional
review boards of Wahidin Sudirohusodo Hospital.
Subjects: Participants were full-time fishermen
recruited from the village of Barombong in the city of
Makassar within the province of South Sulawesi and
consisted of adults over the age of 21 working in the
village of Barombong who were part of a voluntary
screening for hearing loss. Exclusion criteria included
past history of ear infections, past history of trauma to
the ear and past history of ear surgery.
Sound Level Measurement: Noise intensity of the
participant’s working environment was sampled by a
single audiologist using the same pre-calibratedExtech
407732 sound level meter for a duration of 30 minutes.
Pure Tone Audiometry: All pure tone audiometry
tests were conducted by a single, experienced audiologist
using the same pre-calibrated Interacoustics AD226
Diagnostic Audiometer. Participants were required
to avoid exposure to noise for at least 12 hours prior
to audiometry test. All tests were performed with
participants in a soundproof booth that met ambient
noise level standards at multiple frequencies.
Classification of Noise-induced Hearing Loss:
Hearing loss was defined as the mean of hearing threshold
at 1000, 2000, 3000 and 4000 Hz that is more than 25db
in either ear. The degree of hearing ability was classified
as normal (≥25 dB), mild (26 to 40 dB), moderate (41 to
55 dB), moderately severe (56 to 70 dB), severe (71 to
90 dB) and profound (>90 dB) hearing loss.
Statistical Analysis: The acquired data was
analyzed using a commercial analytical software
program (GraphPad Prism 8.0, San Diego, CA, USA).
Descriptive statistics were obtained based on survey
results. Spearman correlation analyses were conducted
to determine the correlation value (r) of age, length of
working period, noise intensity of working environment
and hearing threshold in regards to degree of hearing loss.
Degree of hearing loss were represented numerically as
0 for normal, 1 for mild, 2 for moderate, 3 for moderately
severe, 4 for severe and 5 for profound hearing loss. A
P-value of <0.05 indicated that the variables considered
was statistically significant.
Results
Pure tone audiometric of 40 fishermen were included
for analysis in this study. All of the participants were
male. As summarized in Table 1, 18 out of 40 (45%)
participants were between the age of 30 to 40,13 out of
40 (32.5%) participants were between the age of 41 to 50
and 9 out of 40 (22.5%) participants were over the age of
51. 4 out of 40 (10%) participants worked as fishermen
for 5 to 10 years, 2 out of 40 (5%) participants worked
for 11-15 years, 20 out of 40 (50%) worked for 16 to 20
years while 14 out of 40 (35%) of participants worked
for more than 21 years as full-time fishermen.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  51
Table 1: Characteristics of participants Spearman correlation analysis showed that there was
a statistically significant (P<0.05) positive relationship
Number of people Percentage (%) between the age of participants and degree of hearing
(n) loss with r-value of 0.6467 as shown in Figure 1. Degree
Male 40 100 of hearing loss was also significantly related (P<0.05)
Age (years) to the working period of participants with r-value of
30-40 18 45 0.6203 as shown in Figure 2. There was also a significant
41-50 13 32.5 (P<0.05) positive correlation between degree of hearing
≥ 51 9 22.5 loss and noise intensity the participants were exposed to
Working period with r-value of 0.2482 as shown in Figure 3.
(years)
5-10 4 10
11-15 2 5
16-20 20 50
≥ 21 14 35

The mean age of the study group was 43.93±8.10

years with 95% confidence interval of 26.65-34.04
years, the mean working period was 19.45±3.95 years
with 95% confidence interval of 11.48-15.31 years. The
mean noise intensity the participants were exposed to
was 101.7±2.342dB with 95% confidence interval of
98.9-101.7dB Figure 1: The relationship between age and degree
of hearing loss
Table 2: Mean and 95% CI of Age, Working Period
and Noise Intensity

Variable Mean ± SD 95% Confidence Interval

Age 43.93±8.10 26.65-34.04
Working Period 19.45±3.95 11.48-15.31
Noise Intensity 101.7±2.342 98.9-101.7

Prevalence and degree of hearing loss were analyzed

in 80 ears from 40 participants. Only 2 out of 80 (2.50)
ears showed normal hearing, while 78 out of 80 (97.50%)
ears showed hearing loss. 42 out of 80 (52.50%) ears
showed mild hearing loss, 35 out of 80 (43.75%) ears Figure 2: The relationship between working period
showed moderate hearing loss while 1 out of 80 (1.25%) and degree of hearing loss
ears showed moderately severe hearing loss. No severe
or profound hearing loss was observed.

Table 3: Prevalence of Hearing Loss

Prevalence of
Number (n) Percentage (%)
Hearing Loss
0: Normal 2 2.50
1: Mild 42 52.50
2: Moderate 35 43.75
3: Moderately severe 1 1.25
4: Severe 0 0
5: Profound 0 0 Figure 3: The relationship between noise intensity
and degree of hearing loss
52  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Discussion
Most participants in this study have been working
for more than 15 years as full-time fishermen while
being exposed to noise of loud intensity from motor
boats with an average of 101.7 dB.Furthermore, the
fishermen surveyed had little awareness about NIHL
and its implications. None of the participants exercised
any noise-proofing measures. Such long term exposure
to high noise levels cause fishermen to be at high risk for
occupational NIHL.
Our study revealed that a significant majority
(97.50%) of fishermen experienced noise-induced
hearing loss although they had no habits that exposed them
to loud noise and had no previous medical condition of
the ear. Hence it can be deduced that hearing impairment
experienced by the fishermen was due to occupational
NIHL. Most fishermen experienced mild tomoderate HI,
with percentages of 52.50% and 43.75% respectively,
while 1.25% presented with moderately severe HI loss.
No HI was found in 2.50% of that surveyed which could
be explained by shorter working period (5-10 years) and
younger age (30-40 years) of the participant.
Studies on occupational NIHL have generally
shown that the higher the intensity of noise exposure
received by the workers, the higher the risk of such
workers have hearing loss. It has been proven that the
fishermen in our study experienced hearing loss due to
exposure to noise over threshold value, and the degree of
hearing loss is has positive correlations with factors such
as age, working period and therefore period of exposure
to noise, as well as the level of noise intensity stemming
from the motor boat. Anies et al found that the risk of HI
was not significant although participants were exposed
to noise level ≤ 75 dB for more than 8 hours per day.
Even at the level of exposure to 80 dB, there could be
no increase in the risk of HI, but when noise level ­is
between 85-89 dB HI is significant after 5 years of work,
with 1% showing significant HI, 3% after 10 years and
5% after 15 years. When exposed to noise level of 90-94
dB, 4% experienced HI after 5 years, 10% after 10 years
and 14% after 15 years. When the noise level was above
95 dB HI increased to 7% after 5 years, 17% after 10
years and 24% after 15 years6-9.
The difference in hearing threshold values in both
ears of the participants are likely to be influenced by the
position and type of activities carried out at the time on
the boat. Working position of the participants that are
closer to the machines that is the main source of noise
in the boat affects the hearing threshold of participants.
For example, participants whosteer the boat adjacent
to the diesel motor engine would have higher hearing
threshold than those who work further away from the
engine. Participants who steer from the left and those
who steer from the right of the engine would also
experience different hearing threshold between both
ears. This is also supported by study of NIHL among
Gulf Coast fishermen, whom showed different levels
of hearing loss that is significantly influenced by their
position on commercial fishing boats, with fishermen
working at the engine rooms having greater severity of
HI than those working out of the engine rooms.
There is a need to implement and provide easy
access to hearing protection devices (HPDs) among
fishermen to prevent progression of NIHL. Most resist
wearing HPDs with a misconception that the use of
HPDs will interfere with daily verbal communication
and sensitivity to warning sound signals. However,
studies have shown that HPDs in a noisy environment
does not affect quality of communication or perception
in those with normal hearing. However, when HI is
significant, quality of hearing is reduced drastically and
cause greater problems in communication and perception
of sound.
Hearing loss prevention programs should also be put
in place to assess noise levels in the working environment,
regulation of noise levels and audiometric monitoring
of hearing loss. Education and the implementation of
prevention Method at primary healthcare institutions
should become an important part of preventive healthcare
especially among fishermen who make up a large part of
the working population in Indonesia.
Limitations: There were several limitations to our
study as it was performed in a single fishing village.
Hence, findings of this study may not be representative
of the larger Indonesian population. Furthermore, as
a cross-sectional study, further longitudinal study is
needed to better shed light to the process of chronic
exposure that causes progression of noise-induced
hearing loss in fishermen.
Conclusion
Our study showed that a significant majority
of fishermen working in the Barombong village
experienced hearing loss. Significant decline in hearing
threshold was observed and was significantly related
to age, working period and noise intensity from motor
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  53
boats the participants were exposed to. Hence, there is
a great need to raise awareness regarding the dangers
of noise-induced hearing loss among fishermen and
the need for preventive measures to be put in place to
prevent hearing loss and therefore a declining quality of
life among fishermen.
Acknowledgements: The researchers would like to
thank all people who have helped them in the research
process.
Ethicalclearance: Taken from university Hasanudd
in ethical committee
Source of Funding: Self
Conflict of Interest: Nil
References
1. Ali A, Nazri C, Roslinah M et al.Auditory profile of
undergraduate university motorcyclists: prevalence
of hearing loss and hearing impairment. 2017.
EnvironmentAsia. 11(1) :217-229.
2. Gunny A, Rafidah H, Sriyana A. Noise-Induced
Hearing Loss: engineering control atindustry and
clinical audiology approach at hospital level. 2018.
OP Conference Series: Materials Science and
Engineering. 429.
3. Jain A, Nidhi G, Garima B et al. Impact of noise
exposure on hearing acuity of marble factory
workers. 2017. Indian J Physiol Pharmacol; 61(3)
: 295–301.5.Kerr M. J., Neitzel R. L., Hong O.,
Sataloff R. T. Historical review of efforts to reduce
noise-induced hearing loss in the United States. Am
J Ind Med. 2017;60(6):569-577.
4. Levin J. L., Curry W. F., 3rd, Shepherd S., Nalbone
J. T., Nonnenmann M. W. Hearing Loss and Noise
Exposure Among Commercial Fishermen in the
Gulf Coast. J Occup Environ Med. 2016;58(3):306-
313.
5. Liberman M. C. Noise-Induced Hearing Loss:
Permanent Versus Temporary Threshold Shifts
and the Effects of Hair Cell Versus Neuronal
Degeneration. Adv Exp Med Biol. 2016;875:1-7.
6. McBride D. Evidence updates on risk factors for
occupational noise-induced hearing loss (ONIHL).
2018. ONIHL Expert Advisory Group. p.1-31.
7. Nelson D. I., Nelson R. Y., Concha-Barrientos M.,
Fingerhut M. The global burden of occupational
noise-induced hearing loss. Am J Ind Med.
2005;48(6):446-458.
8. Robinson T., Whittaker J., Acharya A., Singh D.,
Smith M. Prevalence of noise-induced hearing loss
among woodworkers in Nepal: a pilot study. Int J
Occup Environ Health. 2015;21(1):14-22.
9. Sha S. H., Schacht J. Emerging therapeutic
interventions against noise-induced hearing loss.
Expert Opin Investig Drugs. 2017;26(1):85-96.
54  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Implementation of Partnership betwen Midwives and

Traditional Birth Attendants Inkotabaru District

Anggrita Sari1, AdrianaPalimbo1,3, Angga Irawan1, Sukamto2, Isda Herlina4

1Lecturer
of Sari Mulia University, Banjarmasin, Indonesia, 2South Kalimantan Provincial Health Office,
Banjarmasin, 3Student Doctoral of Public Health, Hasanuddin University, Makassar, Indonesia, 4Public Health
Center of Berangas, Kotabaru

Abstract
Background: Maternal and infantmortality ratio, in the Kota Baru high enough, one of them because of
labor that much by the Traditional Birth Attendants (TBA). Midwives offer fewer deliveries and coverage
has not reached the 95% target and fewer midwives than TBA.

Objectives: This study aims to know the implementation of the partnership program between midwives
and traditional birth attendants in Kotabaru District.

Method: This study use da qualitative approachto the design of case studies, with purposive sampling
technique. The number of the maininformantasmuchas 3 people and informanttriangulation 6 people. This
research was conducted for 1 month consists of content analysis and data processing.

Results: The results show human resources are still lacking, inadequate facilities and funding partnership
that is often paid late. Midwivesand TBA is not made a written agreement, and over the role of the TBA will
not be in accordance with there gulations. The support from the village head and community leader that there
is no information and the number of TBA partneringis still less.

Conclusion: Our findings conclude the importance of cross-program coordination and involvement in the
District Health Office and across sectors at the District Government level. This participation is urgently
needed from local stakeholders playing a major role in the successful implementation of maternal and child
health programs.

Keywords: Midwives; traditional birth attendants;implementation of partnerships.

Introduction 40 days. TBA’s knowledge of pregnancy and birth is

Traditional Birth Attendant’s (TBAs), ”dukun
beranak” in Indonesia, has been around for a long time,
and are still practicing labor and childbirth, where most
deliveries occur at home and are not assisted by skill birth
attendant such as midwives. This situation increases the
risk of death for the mother and her baby.1 TBA is a
trusted employee in the family and community in all
matters relating to women’s reproductive problems and
their work is obtained from generation to generation.2
Indonesia, which has a variety of tribes, customs, and
cultures in the community, they are considered capable
of providing emotional comfort and security to mothers
during pregnancy check-ups, assisting mothers and
caring for their mothers and babies after birth for up to
so lacking that if complications arise they are unable to
overcome them even realize it. 3 However, in addition
to providing technical assistance, TBA also practices
unsafe abortion and contraception at high risk and
threatening the life of the pregnant woman.4
Family TBA is someone who has been appointed
by a large family to attend a birth in that family.
Trained TBAs are family TBAs who have received
short training courses through the modern health care
sector to improve their skills.5-6 So, starting in 2007, the
government initiated a partnership program by village
midwives and traditional birth attendants aimed at
reducing maternal and child mortality and morbidity.7
This statement reveals that the higher the number of
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  55
deliveries assisted by TBA, the more high risk that
will potentially endanger the safety of the mother and
baby. This is because the traditional birth attendants
do not have enough ability and knowledge to handle
obstetric complications and emergencies (EMOC) that
occur during and after labor.8 Then, between midwives
and doulas, they offer physical, emotional, and ongoing
support while simultaneously encouraging patient
autonomy. However, disagreements between them also
occur from the Middlemiss study in the UK, differences
in the role of doulas and midwives and identify potential
for conflict if the role of doulas is misunderstood. Some
experts have identified antagonistic attitudes towards
doulas that create challenges for midwives9 and lead
to inter-professional conflicts in the dynamics between
midwives and doulas.10 In Canada, this misconception,
midwives and nurses fear that doulas will take over their
roles and “grass” jobs.11-12
Death that occurs in a hospital is a referral for labor
handled by TBA. Furthermore, in some cases TBAs
called on midwives when their mother’s condition was
severe. At this time, there are 329 TBAs in Kotabaru
District. Their presence is spread in 21 sub-districts.
Meanwhile, only 220 midwives served.. The coverage
of childbirth assistance by health workers is 68.2%
which has not increased and has not reached target
95%from 2014 to 2017.13 Based on this problem, this
research is intended to know the implementation of the
partnership program between midwives and traditional
birth attendants in Kotabaru District.
Materials and Method
The study design uses an explorative qualitative
approach. A total of 9 participants consisted of 3 village
midwives and 6 triangulation informants. This study
was conducted at the Berangas Public Health Center
in Kotabaru District, South Kalimantan Province.
The selection of research locations was taken through
considerations, among others: First, coverage of delivery
assistance by health workers in the last 3 years had not
met the District target of 95%. Second, their have the
highest number of traditional birth attendants from the
number of midwives. And, third, their has an ongoing
partnership program indicator.
Data collection uses in-depth interviews, and
semi-structured interview guides. Processing data
with content analysis. The aspects studied include the
system of implementing partnerships, namely 1) Human
Resources, funding, facilities, and data collection and
mapping of traditional birth attendants; 2) Fostering
of traditional birth attendants; Written Agreement for
Midwives and TBA; and the role of TBA; and 3) Support
of Village Heads and Community Leaders.

Results
Characteristics of Participants

Table 1: Characteristic of Participant

No Code Informant Age Sex of Gender Education Background Work Status Period of Work
Main Informant
1 IU 1 28 Female Midwifery Diploma Midwife of Berangas Six years
2 IU 2 28 Female Midwifery Diploma Midwife of Sungai Limau Three years
3 IU 3 29 Female Midwifery Diploma Midwife of BatuTunau Seven years
Triangulation Informant
1 BK 39 Female Midwifery Diploma Coordinating Midwife 21 years
2 DB 55 Female No school TBA Partnered Five years
3 DT 70 Female Primary School TBA Not Partnered 30 years
4 TM 47 Male High School Community Leader 20 yearsin village
5 KD 49 Male High School Village Head Three years
Mothers is served by
6 M 29 Female Primary School Second Labor
Midwives and TBA

Sources: Health Office Report, 2017

56  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Analysis of Results
Human Resources: Thirteen midwives were
obtained: 1 coordinating midwife and 12 other midwives
serving in the village and in the puskesmas who were
also double the task of fostering villages that did not
have a mid wife. From the interviews, information
was obtained that 1 midwife served 2 to 3 villagesat a
time,because other villages that did not have midwives
to cover all villages in their work area.
“..Serving three villages, meaning one village has
three regions: Rampa Kapis, Batu Tunau and the Coal
Mining Company.” (IU2) “Each place only has a few
empty villages” (IU1, IU 3)
Interview for six triangulation informants, we
obtained a statement that three midwives were still not
living in the village but were willing to come at any time
if needed.
“..do not live in the village every day, if called they
are willing” (KD, M) “there is no residence in Berangas
village, but if anyone wants to give birth, they are ready
to come” (BK)
Half of the midwives, residing in districts and
villages, have areas with a geographical area that vary
by a distance of 25-30 km.
“I live in urban areas for about 30 minutes from
Berangas Village because my children go to school in
there” (IU3) “..back and forth to the village, but don’t
stay overnight” (BK, M)
Midwives as MNH service providers and partners in
implementing partnerships still lack adequate capacity.
In terms of management, there are still two villages that
do not have midwives. They also caseload to serve other
programs. Type of inpatient health centers located in
isolated areas.
Facilities and Infrastructure: Access and difficult
terrain is also an obstacle. It must be taken on foot.
Medical equipment is very unnoticed, so they add unsafe
ingredients to the baby’s umbilical cord.
Funding Source: Specific funds for partnerships
do not exist. Companion funds come from Health
Operational Assistance (BOK). The funds according to
them are insufficient because they are considered too
little. Disbursement of funds is not routine every month
but has to wait a long time.
Written Agreement for Midwives and TBA:
Information from two people revealed never made
a written agreement. Only an oral request to call the
midwife if there is something
“..nothing.. we just talked..” (IU1, IU2)
Even they do not know the information about the
partnership. the coordinating midwife stated that the
agreement had not been made, it was still in the planning
stage and had not been implemented.
“..up to now has not been implemented, because
many other health programs take precedence” (BK)
TBA will call the midwife, if the baby has been born
and delivery has been completed just to cut the baby’s
umbilical cord.
“..because I am not allowed to cut the umbilical
cord with a knife and concoctions” (DB)
Fostering of TBAs: Fostering shamans only through
refreshing once a year and not all of them are invited.
Midwives provide guidance on useful knowledge.
“Guidance and refreshing shamans have been
carried out ..This year is only once, this year just once”
(BK, TM)
Different from the 3 other triangulate informants
who claimed to have never known and were never
invited to refreshing the shaman.
“..never really meetings, try to be invited to
meetings” (DB, DT, KD)
The Role of TBAs: Only one midwife informant
who collaborated and applied the transfer of roles with
TBAs.
“..if at my place, TBA tells me that pregnant women
will give birth.. we usually join together to help until
parturition “ (IU1) “they usually massage, make herbal
concoctions, and midwives care.” (IU2)
Other different information TBAs are not partners,
refuse cooperation and complete change of role. Only
ever accidentally help together give birth.
“..Ever..she only held the abdomen, if part of the
birth ..of course midwife”(IU3)”..Postpartum mothers
still visited by midwives.” (BK,DB, M)
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  57
Midwives and TBAs seem to compete and look less
harmonious. “..they (midwives) hold mother’s full ..if
her signs of birth appear, you call me, I better go home”
(DT)
it can be concluded that TBA not partnered still does
not work together so that their role is still helping birth
and the baby independently.
Support of Village Heads and Community
Leaders: Real support was provided from the village
head and community leaders, but information about the
partnership program was not yet optimal. During this
time they made requests to give birth with midwives at
the health center.
Discussions
Human Resources: Resources hold an important
influence in the implementation of health care systems,
especially partnerships. Resources include implementing
personnel, infrastructure, service facilities, and funding.
Midwives are competent health workers who are
stationed and should reside 24 hours in the work area
of the puskesmas.14One of the factors that caused the
community to choose to be assisted by a dukun is the
distance between the community’s house and the dukun
in the adjacent village and the TBA is always 24 hours.
While many of the midwives reside in areas farthest
from the reach of the community.1,7
Facilities and Infrastructure: Geographical
conditions make it difficult to call midwives so that
pregnant women choose TBA who are domiciled around
their homes.15 To be able to realize the partnership,
childbirth must be assisted by midwives, the government
must be able to facilitate adequate health facilities and
ensure the availability of quality midwives in each
village and easy access to services.16,17
Funding Source: The availability of a budget
plan for the Birth Waiting Home which is a temporary
residence for pregnant women who will give birth until
the postpartum period including their babies and their
companions (husband/family/cadre)6.
Written Agreement for Midwives and TBA: A
written agreement between the midwife and the dukun
is made together, in accordance with the implementation
manual which contains information on the mechanism of
reference for pregnant women, the referral mechanism
for labor cases, the mechanism for distributing labor
costs and the schedule for regular meetings. In line with
the results of research by Rochmayanti the partnership
did not go according to expectations and targets despite
having a memorandum of agreement between them18
Fostering of TBAs: TBAs are also not equipped
with knowledge of detection of danger signs in pregnant
women, maternity, postpartum and newborn babies as
well as ways of referring midwifery.In terms of benefits,
some TBAs want to follow the call so that they don’t
help their own deliveries anymore. But the appeal is not
optimal so that they are still many who help deliveries
unsafe.19
The Role of TBAs: In the period of childbirth:
remind the family to prepare transportation to the
midwife, prepare safe delivery facilities such as clean
water and clean cloth, and accompany the mother when
giving birth. Some things in the puerperal period are:
making home visits and motivating mothers to use
contraception after giving birth, and motivating referrals
if needed and reporting to midwives if if the prospective
acceptor wants to use contraception.20
Support of Village Heads and Community
Leaders: The support of community leaders is needed
in collaboration between midwives and TBAs. This
support includes socialization and direction through
village meetings, mediation between midwives and
TBAsand helps influence other parties such as posyandu
cadres, village officials, and TBAs to take an active role
in the partnership.21,22 Some other village heads did not
yet know information about the program.
Conclusions
Some obstacles in implementing the partnership
program are midwives and TBAs on the utilization
of SBA and strengthening the role of each available
resource. Funding management from Jamkesmas, DAK
and other fund allocations needs to be maximized so that
the community realizes that safe delivery with midwives
and in health facilities is accompanied by TBAs, not
obstacles or concerns from families and communities.
Training of skilled TBAs needs to be considered as a
refresher in the skills of their childbirth practices under
the supervision of the District Health Office, the priority
of areas that are difficult to reach.
Conflict of Interest: None
Ethical Clearance: Obtained from university
committee.
Source of Funding: Author him self
58  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
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 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  59

Risk Factors and Criminogenic Needs of Indonesian Inmates

Hasnida1, Etti Rahmawati1, Juliana Irmayanti Saragih1, Namora Lumongga Lubis2

1Faculty of Psychology, 2Faculty of Public Health, Universitas Sumatera Utara, Indonesia

Abstract
This research was the initial stage of the main research. It aimed to get the constructs about risk factors
and criminogenic needs of adult individuals committing crimes in the field, people of North Sumatera
using Qualitative approach through Grounded Theory.Six hundred and nine participants were involved
with a variety of respondents based on criminals (inmates) and not criminal such as the general public and
significant persons who were considered to have had a lot of contacts and understood the reasons for adult
individuals committing crimes. In general public and inmate respondents, the interview method was used to
collect data about risk factors for committing a crime resulting in imprisonment and criminogenic needs that
can be used as a solution to overcome recidivist. While the significant persons, the focus group discussion
was used to obtain the field data. The results found eight factors: economic, social, personality, family,
educational, prohibited substance, spiritual or religious, and criminal justice system.

Keywords: Adult inmates, criminogenic needs, construct,grounded theory, risk factors.

Introduction Risk assessment and needs assessments studies

In Indonesia, risk assessment and needs assessment
for inmates began to take effect with the issuance of
Regulation of the Minister of Law and Human Rights
of the Republic of Indonesia No.12 of 2013 concerning
risk assessment and needs assessment for inmates and
correctional clients. This assessment was introduced in
2012 through collaboration between the departments of
the New South Wales State prison and the Indonesian
Directorate of Corrections. The instrument used to
predict the level of risk and needs was Asesmen Risiko
Residivisme Indonesia (RR-I) which was an adaptation
of the Level of Service Inventory-Revised1.
Widyadarma2 conducted a risk and needs assessment
study on six inmates who would be released using
a qualitative approach based on Risiko Residivisme
Indonesia (RR-I) assessment. The category of crimes
they have committed is related to economic motives.
Other research on risk assessment and needs assessment
was conducted by Sulfin and Hendiarto3. Using the
LSI-R instrument, they assessed 100 inmates in Klas I
Cipinang Prison. The results showed that drug/alcoholic
beverages abuse and emotional/personality problems,
that were significantly related to criminal records. Other
factors such as the history of crime, education/work,
finance, and family had no significant relationship with
the crime of the research subject3.
conducted in Indonesia, as far as researcher known, still
use instruments from western countries. There were no
risk and criminogenic needs assessment instruments of
inmates that refer to the risk principle and criminogenic
needs principle based on the characteristics of Indonesian
adult inmates (Indonesian version) which have good
psychometric qualities. The purpose of this study is to
identify precisely and deeply what factors are behind an
adult prisoner in North Sumatera to commit a crime. The
factors obtained will later be used as a predictor of an
inmate committing repeated crimes.
Research Method
This study used a qualitative approach through the
exploration of constructs about the risk factors and the
criminogenic needs of inmates. The method of analyzing
data through Grounded Theory was used as a strategy
to explore the phenomena that want to be studied by
exploring new concepts or theories from field data.
The interview method was used in the data collection
process. Respondents in this study were divided into
three groups, namely 500 general public, 102 inmates,
and seven informants who were considered to understand
the problem of criminal acts consisting of two religious
leaders, one lawyer, one prosecutor, one police officer,
one prison officer and one law faculty lecturer with
criminology specialization. All respondents were asked
60  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
to answer the open questions put forward, namely, “in Variable Categories F %
your opinion, what are the reasons behind someone Not Providing Information 21 3.4
committing a crime or crimes that causes them to go to
Late Adolescents 61 10.0
jail”? The data obtained in this interview process were
Early Adulthood 284 46.6
then analyzed using coding techniques4 Age
Middle Adulthood 238 39.1
Data Analysis Method: The initial stage of the Late Adulthood 5 .8
coding process was open coding,the second stage is Total 609 100.0
axial coding, and the final stage, the selective coding. Student 11 1.8
This stage was also called the determination of the main
College Student 72 11.8
factor of the research.
Unemployed 27 4.4
Results and Discussion Private Employees 190 31.2
Employment
Entrepreneur 144 23.6
Respondents’ demographics background: Status
Government Employees 105 17.2
Respondents who participated in this study were 609
people, having diverse demographic backgrounds Housewife 58 9.5
with the aim of obtaining more comprehensive data. Religious leader 2 .3
Demographic descriptions based on gender, marital Total 609 100.0
status, ethnicity, age, employment status, and final No Formal Education 13 2.1
education are presented in Table 1. Elementary School 32 5.3
Junior High School 50 8.2
Table 1: Demographics description
Senior High School 237 38.9
Variable Categories F % Final
Diploma Degree 33 5.4
Education
Female 251 41.2 Bachelor Degree 222 36.5
Gender Male 358 58.8 Master Degree 20 3.3
Total 609 100.0 Doctoral Degree 2 .3
Not Married 216 35.5 Total 609 100.0
Marital Married 369 60.6
Status Divorced 24 3.9 The majority of respondents involved in this study
were male (58.8%), and more than 50% (369) of the
Total 609 100.0
total respondents had married status. Respondents
Not Providing Information 26 4.3
had an ethnic background that varied greatly with the
Batak 362 59.4
majority of Batak and Javanese tribes which is around
Javanesse 105 17.2 59.4% (362) and 17.2% (105), around 4.3% did not
Padang 26 4.3 provide information about ethnic groups. Based on
Nias 15 2.5 age, more than 85.7% of respondents came from early
Aceh 30 4.9 adulthood and middle adulthood age groups, about
Melayu 29 4.8 3.4% were not willing to provide information about
Tionghoa 8 1.3
age. The educational background of the respondents
Ethnicity also varied from not completing elementary school to
Banjar 1 .2
doctoral level. The majority of respondents have a senior
Betawi 1 .2
high school (38.9%) and a Bachelor (36.5%) education
Bugis 2 .3 level. Viewed from the status of employment, most
Tamil 1 .2 respondents work as private employees (31.2%) and
Buton 1 .2 entrepreneurs (23.6%).
Sasak 1 .2
Criminal background: The results of the field
Dayak 1 .2
data text unit in the form of keywords related to the
Total 609 100.0
background of someone committing a crime shows in
table 2.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  61
Table 2: The factors and indicator of someone vulnerable to directing someone to act aggressively12,
committing a crime. detained for violent behavior13 and committing a
recurrent crime (recidivism)14. Furthermore, Damm &
Factors Indicator Dustmann15 added that a child who was raised in an
Unemployment environment with a high crime rate was also predicted to
Economic
Financial problems commit a crime during the next development period. The
Residence influence of the living environment on the occurrence of
Media influence criminal acts can be seen from the presence or absence
Social
Social environment of norms and collective efficacy which will act as a
Chance defense against criminal acts16 17.
Anti-social
Personality Self control
Liquor also greatly affects a person’s thinking power
which in turn could cause people to commit criminal
Psychological problems
acts. The forms of crime that often occurred due to
Forbidden Drugs
the influence of alcohol are murder, persecution,and
Substances Liquor
rape18,theft, hijacking19. The results of a survey conducted
Not harmonious family
by the BadanNarkotikaNasional (National Narcotics
Family Parenting
Agency)20 in 2016, 18 provinces in Indonesia found that
History of family members involved in crime
certain types of drugscould lead to excessive aggressive
Not afraid of God behavior on users and often resulted in behavior or acts
Spiritual or
Lack of religious knowledge of violence. Some even commit criminal acts such as
Religion
Lack of gratitude stealing and selling drugs. In addition, in the effort to get
Low education level drugs, users commit fraud and sell themselves.
Education
Lack of knowledge about criminal behavior
Judicial Some descriptions of the personality of criminals
Law enforcement is weak
System were relatively high intellectual abilities, difficulties
in controlling the inner drive, easily suspicious, acting
Discussion without thinking and unstable emotions21. Listwan,
Piquero, & Van Voorhis22,then attempts to explain
Lumenta, Kekenusa, & Hatidja5 showed that the
the relationship of personality to criminal behavior.
total population and unemployment had a direct effect
In subsequent studies, he also stated that the type of
on crime, while the number of industries and poverty
neurotic and aggressive personality directed a person to
had an indirect effect on crime; unemployment was a
commit repeated acts of crime (recidivism). In addition
factor that had the greatest direct positive effect on crime,
to personality types, other factors that were expected to
followed by educational and moral factors factors with a
direct a person to commit a crime were psychological
direct influence with6. The type of crime committed by
problem or disorder23.
the community, namely theft, embezzlement, fraud, and
persecution, had a background of poverty7 8. Adult individuals received their first education
from their families during childhood. Tangkudung24
The effect of impressions and exposure to
conducted a study on the role of family communication
information from the media on criminal behavior could
in preventing juvenile delinquency. Seventy-nine
explain by the Modeling or Vicarious Learning theory
teenagers aged 13-18 years were respondents of this
proposed by Albert Bandura9. Based on the explanation
study. By looking at the intensity of communication,
of this theory, criminal behavior could occur by
attention, and children’s needs, the results of the study
observing or being exposed to information both in the
found that parent communication with children was at
form of fiction and non-fiction from media shows. More
a very good level, so it could prevent teenagers from
than 1,000 studies aimed at seeing the effects of violent
committing illegal acts.
television and film shows over the past 40 years have
produced a consistent conclusion that violent shows In addition to social norms or customary norms,
would increase aggression, social anxiety, and also religion was one of the rules that could control
negative perspectives on reality in the world10 11. Living individuals in behaving in society. Wahyuni25 conducted
in an environment that was predominantly poor was qualitative research to see the role of religious education
62  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
in preventing deviant behavior. Research respondents
were principals, teachers, and fourth-grade students.
The results showed that the implementation of teaching
practices such as prayer, juz’ Ama reading, and spiritual
giving are effective enough to prevent deviant behavior
in elementary school students. Other research on the
role of Islamic religious education in family and society
was examined by Nasution26. The results of the study
concluded that the application of religious education
(tauhid, aqidah, worship, morality, and sharia) in
the family in adolescents could shape them in actual
behavior.
Research showed that low education could
become an individual background in committing a
crime27 28 29. The influence of age, education, income,
and number of family dependents towards thievery
crime rate in prisoners was the study of Maulana29.
66 inmates who were committed thievery crimes in
LapasKlas 1 Kedungpane in Semarang City were
the respondents of the study. The results of multiple
regression analysis showed that of the four independent
variables, namely age, education, income and number of
family dependents, only the age variable that was not
significant. Educational variables had a negative and
significant influence, the income variable had a negative
and significant effect, the number of family dependents
had a positive and significant relationship while the age
variable had a significant negative effect.
An elements of law enforcement such as police,
prosecutors, judges, and even prison officials had recently
been in the spotlight of the Indonesian people30. Police
who act without conscience (misusing the power they
had) were often found, it was uncommon for prosecutors
to extort and amend cases just to get material benefits,
court decisions that are often not accepted by the public.
Such conditions were exacerbated by the behavior of
law enforcement officers who were less praiseworthy
and carried out actions that tarnish themselves and their
own institutions. The bribery case that occurred in the
Supreme Court was one sign that law enforcement in
Indonesia was indeed faced with a big problem30.
Conclusion
The findings in the field showed eight factors namely
economic, social, personality, alcohol and prohibited
substances, family, spiritual or religious, education and
the criminal justice system that was behind an adult
individual committing a crime and imprisoned for his
actions.
Conflict of Interest: Nil
Ethical Clearance: Research Institute of Sumatera
Utara University and the Faculty of Public Health
University of Sumatera Utara.
Funding: Grant of the Directorate of Research and
Community Service. General of Strengthening Research
and Development Ministry of Research, Technology
and Higher Education 2018.
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64  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Vitamin D Receptor Gene Polymorphism Fok 1 and Vitamin D

(25-OH)D Status in Type 2 Diabetes Mellitus Patients with
Pulmonary Tuberculosis

Wahiduddin1,2, Agung Pranoto3,4, Sudjarwo5, Ni Made Mertaniasih6

1DoctorateDegree in Medical Education, Postgraduate Programme, Faculty of Medicine Universitas Airlangga,
2
Department of Epidemiology, Faculty of Public Health Universitas Hasanuddin, 3Department of Internal
Medicine, Faculty of Medicine Universitas Airlangga, 4Dr. Soetomo Teaching Hospital, Surabaya, 5Department of
Chemical Pharmacy Faculty of Pharmacy Universitas Airlangga, 6Department of Clinical Microbiology, Faculty
of Medicine Universitas Airlangga

Abstract
Vitamin D plays a role in supporting macrophage activation via vitamin D receptor. Polymorphism of Fok1,
vitamin D receptor gene, can show the different level of susceptibility to pulmonary tuberculosis (PTB).This
research aimed to analyze the comparison of polymorphisms of the Fok1region of the vitamin D receptor
(VDR) gene and vitamin D status in patients with type 2 diabetes mellitus (T2DM) with PTB. A descriptive
comparative study of adult T2DM patients seeking treatment at the endocrine clinic, internal medicine
clinic, and pulmonary clinic in two government hospitals in the city of Surabaya. The result showed that
F allele frequency (63.3%), f allele (36.7%), FF genotype variation (40.0%), Ff (46.7%) and ff (13.3%) in
T2DM group with PTB while in T2DM group without PTB obtained frequency of F allele (54.8%), f allele
(45.2%), variation of FF genotype (33.3%), Ff (46.7%) and ff (20.0%). Polymorphism in T2DM group with
PTB (60.0%) and DMT2 group without PTB (66.7%). Plasma vitamin D levels were found median (IQR)
20.26 (0.78) ng/ml in the T2DM group with PTB and 20.18 (1.25) ng/ml in the T2DM group without PTB.
There were no differences in polymorphism in the frequency of F and f alleles, FF genotype variations,
Ff, ff in the Fok1 region of the VDR gene, and the average vitamin D level between T2DM patients with
and without PTB. Further research is needed on the linkages and gene interactions encoding macrophage
activation proteins.

Keywords: Fok1 region polymorphism, vitamin D level, type 2 diabetes mellitus, pulmonary tuberculosis,
PCR-RFLP, DNA Sequencing.

Introduction TB or late diagnosis3. Reports from research in several

Diabetes mellitus (DM) is one of the factors that
influence the pathogenesis of tuberculosis (TB) in
immunoc ompromized conditions. The condition of
DM is a decrease in the patient’s immune response,
which in turn can facilitate the occurrence of infection
by Mycobacterium tuberculosis can develop into TB
disease1. DM is one of the main risk factors with a three
times greater relative risk of TB, reported in 22 countries
with a high prevalence of TB including Indonesia2.
Populations with DM have a three times higher risk of
experiencing TB compared to populations without DM.
About 15% of TB cases are globally associated with DM,
most people with DM accompanied by undiagnosed
countries said the prevalence of DM among TB patients
was found to be 1.9% to 35%, while the prevalence of
TB among DM patients was found to be 1.7% to 36%
4,5
. It is estimated that more than a quarter of people with
DM have latent TB infections, studies in Mexico found
prevalence of 51.3% and in Singapore 28.2%6,7.
Single Nucleotide Polymorphisms (SNPs) in the
VDR gene show different levels of vulnerability and
resistance in different subjects and populations. One
of the SNPs associated with TB is polymorphism in
the VDR gene which is located in exon two, which is
a transition to T to C (ATG to ACG). There are two
potential translation initiation sites in exons that can be
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  65
identified by the Fok1 endonuclease restriction enzyme, a 4-parameter immunoassay. In this study vitamin D
the individual with the C allele (called F) initiating levels were said to be deficiencied if found (<20 ng/ml),
translation on the second ATG codon and the absence of insufficiency (20-30 ng/ml) and sufficiency (> 30 ng/
three-NH2 terminal amino acids from the overall length ml)10.
of vitamin D receptor proteins. Individuals with T alleles
(indicated by f) initiate translation of the first ATG Results
codon and synthesize the entire length of the vitamin D Averaged age sampel 51.91 years ± 7.93 years,
receptor protein (full-length with 427 amino acids)8,9. with proportion > 50 years(62.2%) in T2DM with PTB,
This research aimed to elucidate the polymorphism whereas T2DM group without PTB average age was
of VDR gene and vitamin D concentration in T2DM 55.78 ± 7.36 years, with proportion > 50 years (77.8%),
patients with PTB in Surabaya city, Indonesia. the greather proportion was female, (53.3% and 88.9%).
From laboratory measurements and examinations,
Materials and Method T2DM group with PTB had lower BMI, SBP,and DBP,
whereas average FBG, 2hPBG, and HbA1c were higher
Research with a descriptive comparative study on than T2DM group without PTB (Table 1).
subjects from endocrine polyclinic outpatients, internal
medicine clinics and pulmonary disease clinics in two Table 1: Demographic and clinical characteristics of
government hospitals in Surabaya City was conducted in subjects
October 2017 to January 2018,samples consisted of 45
patients each of T2DM with and without PTB.
T2DM
with witho
PCR-RFLP test and DNA, DNA isolation on cell Characteristics pulmonary TB pulmona
pellets was carried out as directed in QIAamp® DNA mean ± SD or mean ± S
mini and Blood Mini Kit (Qiagen, cat. no. 51104) n (%) n (%
Age (year) 51.91 ± 7.93 55.78 ±
Amplification of DNA isolation results for VDR gene Gender
with Fok1 primer with forward sequences 5’AGC TGG Male 21 (46.7%) 5 (11.1
CCC TGG CTCT3 TGA CAC ‘and reversed 5 ‘GAA Female 24 (53.3%) 40 (88.
ATG ACA TGC TTC TTCT3’ to produce DNA products BMI (kg/m2) 22.39 ± 3.71 26.13 ±
at the target 267 bp. The PCR conditions for all reactions SBP (mmHg) 129.56 ± 18.39 139.80 ±
DBP (mmHg) 74.78 ± 11.44 78.64 ±
were 35 cycles for denaturation of 950C for 1 minute, FBG (mg/dl) 202.11 ± 78.68 175.29 ±
annealing 570C for 30 seconds, and extension at 720C 2hPBG (mg/dl) 283.20 ± 107.2 208.22 ±
HbA1c (%) 11.2 ± 2.61 9.34 ±
for 30 seconds. Electrophoresis was performed with 3%
BMI : body mass index, SBP: systolic blood pressure, DBP:
agarose gel in 0.5 x TAE solution and ethidium bromide. diatolic blood pressure, FBG:fasting blood glucose, 2h PBG ;
RFLP product description in the form of T allele (f) in 2 hours postprandial blood glucose, HbA1c: hemoglobin A1c,
the form of fragments measuring 69 bp and 198 bp as T2DM: type 2 diabetes mellitus, TB: tuberculosis
well as nonpolimorphic images C (F) allele consisting
The results of PCR-RFLP using Fok1 restriction
of one fragment, 267 bp and heterozygous Ff gives a
enzymes show that is a band intersection in variations
description of the three fragments 267 bp, 198 bp and
genotypes FF, Ff, and ff genotypes
69 bp. Furthermore, DNA sequencing was examined to
confirm the results of cutting on the VDR gene using a Figure 1, ELISA plasma vitamin D examination
reverse primer. showed median (IQR) of vitamin D levels in T2DM
group with PTB higher than T2DM without PTB (20.26
Vitamin D examination using an ELISA from
(0.78) ng/ml vs. 20.18 (1.25) ng/ml).
DBC Diagnostic Biochem. Vitamin D calculation uses
66  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Figure 1: Comparison of plasma vitamin D between T2DM with PTB and without PTB.
Discussion
Polymorphism is a variation of DNA sequences that
give rise to genetic diversity in a pool gene. The amino
acid sequence in proteins was determined by information
contained in genes compiled by DNA. Genes that
have different sequences was considered polymorphic
has neutral effect on biological functions, but some
conditions can cause disturbance of biological functions.
This changes in arrangement DNA that encodes
proteins. So that genetic polymorphism was different
form of same allele in the population. “Normal” alleles
was referred to as wild type alleles, while their variants
called polymorphic or mutant alleles. Polymorphism
was different from mutations because frequency of
occurrence higher than repetitive mutations. As per
provisions, the polymorphic locus was occupied by at
least two alleles, each frequency of occurrence of more
than 1%. Alleles whose frequency of occurrence less
than 1% was repeated mutations 11.
The results of this research found that no difference
in genotype variation of Fok1polymorphismVDR gene
in T2DM patients with or without PTB. In India (2013),
110 active PTB patients who reported proportion of
Fok1 genotypes as follows FF (46.36%), Ff (41.82%),
ff (11.82%). The results of this study stated that there
were no differences in genotype variation between
patients and controls. The frequency of FF genotypes
from the Fok1 polymorphism VDR is higher than the
mutant type 13. Also in line with Fok1 polymorphism
research of pulmonary TB patients in Egypt reported FF
genotypes (30.0%), Ff (50.0%) and ff (20.0%).As well
as a study in Iran of TB patients reported the proportion
of Fok1 genotypes each FF (52.4%), Ff (39.3%) and ff
(8.3%) These results also reported no difference between
genotype variations between cases of PTB with controls
14,15Research in North Sumatra Indonesia of PTB patients
reported the proportion of FF genotypes (35.5%), Ff
(55.3%) and ff (9.2%), these results indicate there was
no association between Fok1 genotype variation and the
incidence of PTB (p = 0.311)8.
Different results were found in Fok1 polymorphism
of T2DM patients in Morocco, stated FF genotype
49.43%, Ff (45.45%) and genotype ff (5.11%) The results
of the study found an association between genotype ff
and T2DM risk (p-value=0.018) 16. Similarly, research
in Santiago de Chile of T2DM patients and without
diabetes received each proportion of FF genotype
variation (17.3% vs 22.0%) Ff (62.3% vs 47.0%)
and ff genotype (20.2% vs 30.8%). The results of the
study found the risk of T2DM especially in the F allele
genotypes Ff and FF (p-value = 0.0361) 17.
Some studies on vitamin D status of T2DM patients
showed varied results, among others, studies in Morocco
received an average vitamin D level of 26.07 ± 13.03 ng/
ml with normal vitamin D status of 31.0%, insufficiency
of 29.0% and those with deficiency as much as 40%.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  67
Vitamin D levels showed a significant difference
between T2DM patients and controls (p-value<0.001) 16
.Study in China of T2DM patients reported a proportion
of 20.14% of vitamin D 25 (OH) D deficiency, 62.27%
of insufficiency and 17.59% of normal 18.
Fok1 polymorphism research of T2DM patients
and vitamin D status in Morocco results of vitamin
D measurements based on the variation of genotype
obtained FF (28.18 ± 12.72 ng/ml), Ff genotype (28.61
± 12.82 ng/ml), and ff genotype (25.83 ± 17.49 ng/ml)
with p values in the comparison of FF vsFfgenoties (p
= 0.774) and FF vsff (p = 0.083). These results indicate
there was no relations between vitamin D levels and
Fok1 genotype16. Research in Santiago de Chile of
T2DM patients received vitamin D deficiency (<20 ng/
ml) based on variations in genotype namely FF genotype
(16.6%), Ff (59.0%) and ff (24.4%) 17.
Some of the results of the research on TB patients
with DM were obtained as follows: A research on 2017
in hospitals and TB clinics in urban and rural areas in
China received a median vitamin D level of 12.1 ng/
ml. Normal vitamin D status 2.3%, 14.1% insufficiency,
53.9% deficiency and severe deficiency of 29.7% 19.
Another study in South India reported a vitamin D
level of 13 ng/ml in the range (8-20) ng/ml lower when
compared with TB patients with a diagnosis of new DM
and TB patients without DM. The results showed that
there was a significant relationship (p = 0.026) between
the three groups 20. Study in Tanzania reported a low
vitamin D status (<75 nmol/l) reaching 50.0% with an
average age of 43.5 years and an average BMI of 20.5
kg/m2 when compared with DM patients with low
vitamin D status, only 29.7% with an average age of 43.5
years and an average BMI of 28.5 kg/m2, no correlation
between low vitamin D status between the two groups
(p-value = 0.22) 21.
There are differences in the prevalence of vitamin
D status in various regions has different risk factors.
Vitamin D deficiency is influenced by various factors
such as lifestyle, genetics, traditions, and activities so
that further research, multifactorial,and multigenes
interrelation needed and macrophage activation
interactions in the incidence of T2DM comorbid TB.
Conclusion and Suggestion
From this study there were no differences in the
frequency of F and f alleles and FF genotype variations,
Ff, on Fok1 regional polymorphism in the VDR gene
between T2DM with or without PTB, and there was no
difference in vitamin D level status with PTB in T2DM
patients. Further research is needed on the relationship
and interaction of genes encoding macrophage activation
proteins.
Acknowledgment: Thank you to the directoship of
Dr. Soetomo and Dr. Mohamad Soewandhie Hospital
Surabaya Indonesia, as well as to Prof. Kuntoro, and Dr.
Pudji Lestari for the assistance in methodology analysis;
Dr. Daniel Maranatha and Dr. Susanthy Djajalaksana for
the assistance in tuberculosis study. The author would
also like to thank the Institute of Tropical Diseases (ITD)
Universitas Airlangga for supporting this laboratory
research to conduct this research and to Ilham Harlan
and Muhammad Amin, the technicians who assisted
with this research.
Conflict of Interest: None
Ethical Clearance: This study has obtained ethical
feasibility information No. 533/Panke.KKE/IX/2017
from the Ethics Committee of the RSUD Dr. Soetomo
Surabaya.
Source of Funding: Directorate General of
Strengthening Research and Development at the Ministry
of Research, Technology and Higher Education for the
Doctoral Dissertation Research (PDD) Grant in 2018.
References
1. Esmail H, Barry CE, Young DB, Wilkinson RJ.
The Ongoing challenge of latent tuberculosis. Phil.
Trans.R.Soc.B 2014; 369: 1-14.
2. Jeon C, Murray MB. Diabetes mellitus increases
the risk of active tuberculosis:a systematic review
of 13 observational studies. PLoS Medicine 2008;
5: 1092-100.
3. World Health Organization. Global tuberculosis
report. Geneva, WHO 2015.
4. Viswanatha V, Kumpatla S, Aravindalochanan V,
Rajan RCC, Srinivasan RMSJ, Kapur A. Prevalence
of Diabetes and Pre-Diabetes and Associated Risk
Factors among Tuberculosis Patients in India.
PLOS ONE 2012; 7: 1-9.
5. KapurA, Harries AD. The double burden of diabetes
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68  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
6. Aguilar GM, Serrano CJ, Delagado JEC, Segura
NM, Delgadillo NH, Moreno LE, et al. Associated
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in Subjects with Diabetes. Archives of Medical
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7. Leow MKS, Dalan R, Chee CBE, Earnest A,
Chew DEK, Tan AWK, et al. Latent Tuberculosis
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9. Huang L, Liu C, Liao G, Yang X, Tang X,
Chen J. Vitamin D Receptor Gene Fok1
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10. Holick MF, Vitamin D status: measurement,
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11. Lanham-New SA, Macdonald IA, Roche HM.
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12. Chocano P, Bedoyo, Ronnenberg AG. Vitamin D
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13. Joshi PM, Penmetsa SRNP, Valluri V & Gaddam S.
Serum Vitamin D Levels and VDR Polymorphisms
(BsmI and FokI) in Patients and their Household
Contacts Susceptible to Tuberculosis, Scandinavian
Journal of Immunology, 2014; 79: 113-9.
14. Mahmoud AA, Ali AHK. Vitamin D receptor
gene polymorphism and 25 hydroxy vitamin
D levels in Egyptian patients with pulmonary
tuberculosis. Egyptian Journal of Chest Diseases
and Tuberculosis 2014; 63: 651-5
15. Rashedi J, Asgharzadeh M, Moaddab SR, Sahebi
L, Khalili M, Marzani M, et al. Vitamin D receptor
gene polymorphism and vitamin D plasma
concentration: Correlation with susceptibility to
tuberculosis. Advanced Pharmaceutical Bulletin.
2014;4 (Suppl 2): 607-11.
16. Abdeltif E, Benrahma H, Charoute H, Barakat
H, Kandil M, Rouba H. Vitamin D receptor
gene polymorphisms and vitamin D status and
susceptiblity to type 2 diabetes melllitus in
Moroccans patients. International Journal of
Scientific and Research Publication 2014; 4: 1-7.
17. Angel B, Lera L, Marquez C & Albala C. The
association of VDR polymorphisms and type 2
diabetes in older people living in community in
Santiago de Chile. Nutrition and Diabetes Journal.
2018; 3: 1-9.
18. Huang Y, Li X, Wang M, Ning H, A L, Ling Y,
et al. Lipoprotein lipase links vitamin D, insulin
resistance, and type 2 diabetes: a cross-sectional
epidemiological study. Cardiovascular Diabetology
2013;12:1-8.
19. Zhao X, Yuan Y, Lin Y, Zhang T, Ma J, Kang W,
et al. Vitamin D status in tuberculosis patients with
diabetes, prediabetes and normal blood glucose in
China: a cross-sectional study. BMJ open 2017:
1-7.
20. Kornfeld H, West K, Kane K, Kumpatla S,
Zacharias RR, Martinez-Bolzano C, Li W &
Viswanathan V. High prevalence and heterogeneity
of diabetes in patients with TB in South India.
Journal.publication.chesnet.org. 2016: 1501-8.
21. Boillat-Blanco N, Bovet P, Ramaiya KL, Mganga
M, Minja LT, Saleh L, et al. Association between
tuberculosis, diabetes and 25 hydroxyvitamin D in
Tanzania: a longitudinal case control study. BMC
Infectious Disease 2016; 16: 1-9.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  69

An Overview of Socio-Cultural Factors on the Utilization

of Antenatal Care Services in Bajonese Pomalaa, Southeast
Sulawesi

FatmahAfrianty Gobel1, A.M. Multazam2, Andi Asrina2, Ella Andayanie2

1Sinior Lecturer of School of Public Health, 2Lecturer of School of Public Health,
Muslim University of Indonesia, Makassar

Abstract
Maternal and infant mortality rate is one indicator of health status in one region. These can be seen from the
low utilization of antenatal care (ANC) service which influenced by socio-cultural aspect. This study aims
to obtain in-depth information about the influence of socio-cultural aspects on the utilization of antenatal
care services in Bajonese Pomalaa.

This was a qualitative research with ethnographic approach. Six informants were interviewed. Data were
obtained through observation, in-depth interviews and documentation.

Results shows that community are more prioritizing shaman to do their pregnancy check. They consider that
shaman has certain rituals and more experienced than health workers. This causes a psychological impact
where they feel more secure with their pregnancy after they were check by shaman.

The low coverage of ANC services is due to the fact that community is more entrusted their pregnancy check
by shaman than health workers. It is suggested that health workers can develop partnership with shaman on
assisting the community especially women during pregnancy and labor.

Keywords: Antenatal Care, Shaman, social, culture, Bajonese.

Introduction still go to shamans to check their pregnancy and use

shaman as a helper on delivering their child, especially
Maternal and Child Health is one indicators that
in remote areas. This reality shows that there is linkages
can be used to measures health status and prosperity of
between socio-cultural and health aspect, where culture
a country. Maternal Mortality Rate (MMR) and infant
can form habits and responses toward health behavior and
mortality (IMR) are two things that can be used as
occurance of disease in society3,4. This phenomenon also
parameters to measure the success of health services in
happens in the Bajo tribe in Coastal Area of Hakatutobu
a region. Data from Health Ministry in 2015 shows that
Village Pomalaa District Southeast Sulawesi.
Maternal Mortality Rate (MMR) is 305 per 100,000 live
births, while for Infant Mortality Rate (IMR) in 2016 is Bajonese people still adheres to their culture and
25,5 per 1,000 live births. This data is still far from the traditions due to maternal health seeking behavior, where
target of Sustainable Developments Goals (SDGs) which society are tend to have more trust in shaman in doing
is 70 per 100,000 live births for Maternal Mortality Rate their pregnancy check and giving help in delivering their
(MMR) and 12 per 1,000 live birth Infant Mortality child3. They believe that shaman has been possessed
(IMR) by 20301,2. by their ancestral spirits which is called MboJanggo.
Bajonese people assume that the shaman can solve their
The high level of MMR and IMR in Indonesia is
health problems through mantras which they believe can
caused by the low utilization of maternal health service
help smooth their pregnancy and delivery process5.
facilities. Socio-cultural conditions in each region also
contribute, where there are still many areas where people
70  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Based on this background, this research was
conducted to find out how socio-cultural factors as a
determinant factor in the utilization of maternal health
services in Bajo Tribe, Pomalaa District. This research
aims to obtain in-depth information related to socio-
cultural aspects in the utilization of maternal health
services in Bajo Tribe, Pomalaa District.
Materials and Method
This research was conducted in Hakatutobu Village,
Pomalaa District, South East Sulawesi. This was a
qualitative research with ethnographic approach as a
procedure to describe, analyze, and interpret elements of
a cultural group such as behavioral pattern, belief, and
language that develops from time to time.
Information was obtained through observation, in-
depth interviews and documentation. Observations were
made by observing and make some notes about how
Bajonese people behave towards utilization of maternal
health care services during pregnancy and childbirth.
In-depth interviews were conducted to obtain in-depth
information about socio-cultural aspects, traditions
and beliefs of Bajonese people related to pregnancy
and childbirth matters. Documentation was carried
by collecting data, recording and reviewing every
information that are considered to be important and
associated with this research.
This research involves six informants which consist
of four common informants, which are pregnant women,
maternity women and postpartum mother, midwives as
key informants and shaman as supporting informants.
Results and Discussion
Based on the indepth-interviewed and observation,
it shows that in Bajonese society shamans are society’s
first priority when they want to do health checks related
to pregnancy and to handle their delivery process.
Bajonese considered that shaman has more experience
than health workers (midwife), they also feel more
comfortable interacting with shaman because they think
that shaman is more familiar and all ritual that performed
is not conflicted with customs that they believe.
The ritual that performed by shamans for pregnant
women is called “mabbetang” which intend to provide
safety during pregnancy for mother and their child.
Although this ritual is perform only by giving spells
on the thread and then tied to the wrist of pregnant
woman, but it contains very deep meaning because they
believe that it can protect them from evil spirit during
their pregnancy. This ritual is performed by shaman at
pregnant women’s first visit. Bajonese people believe
that this ritual can keep them away from the dangers
and evil spirits that can harm their pregnancy. That is
the reason why pregnant women will directly come to
shaman as soon as they know that they are pregnant.
From all informant statements it can be concluded
that socio-cultural factors have an enormous contribution
to the low utilization of antenatal care services in
Bajonese Pomalaa, Southeast Sulawesi where shaman
have more dominant role than health workers (midwife).
In this study, shaman is considered as the main health
service provider. Although at the end there are some
pregnant women who will go to midwife for pregnancy
check, but they will prioritize their first pregnancy check
by shaman, so does when they seek help for their delivery
process. Society assume that shamans can provide spells
for safety during pregnancy and delivery.
This results were similar with a study about Behavior
of delivery assistance by shaman in Karawang regency
which shows that almost all people believe in sahaman’s
ability in helping delivery process, because the shaman
is considered to have a reliable spiritual power6. In rural
areas, most pregnant women still believe in shaman to
help their delivery.
Result of previous study stated that Maternal
and Child Health problems related to socio-cultural
community is becoming problems that require a more
in-depth and specific study in each region and certain
ethnicities7. This because one of the most dominant
determinants that encourage mothers to choose shaman
for pregnancy check and getting help for delivery
process is due to cultural factor which has passed down
through generations, where society still rely on shaman
in giving health services including pregnancy service6,7.
The pattern of cultural behavior during pregnancy
and childbirth which passed down through generations
provides a conceptual framework for understanding
the essence of all human behavior, including behavior
on the selection of service providers for maternal and
child health. So it can be understood that each cultural
community has its own perspective and different
behavior, that is why cultural factors should be getting
attention from various related sectors to increase
coverage of mother and child health services 8.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  71
The main health problem in Indonesia is low public
health status, which can be seen from the high number
of maternal and infant mortality rates and also thre are
still many indicators of maternal health services (KIA)
that is still not ideal7,9. Maternal mortality and morbidity
problems are not inseparable from socio-cultural and
environmental factors in the society where they live10, 11.
The low utility of existing health facilities in rural
area is often cause by society’s belief in their culture
which is still preserved until now, resulting in the low
coverage of health services in general and also maternal
and child health12,13. Various factors that influence the
utilization of health facilities for ANC (Antenatal Care)
examination, have an impact on the low coverage of
ANC (Antenatal Care). The utilization level of health
facilities is different in every society, including in coastal
communities which have a strong belief in local culture.
This statement can be proven from the results of
research that has been carried, where most pregnant
women prefer shaman than midwife on their health
seeking behavior related to their pregnancy check
and delivery help. This is cause by cultural factors
and society’s high belief in shaman’s knowledge and
experience. Selection of helper during pregnancy and
delivery can also be seen from the observation conducted
during the research, where there are 14 pregnant women,
which nine of them doing pregnancy check on shaman
with their average pregnancy age is above four months
old, while the rest five pregnant women doing their
pregnancy check to midwife.14-19
Conclusion
1. Socio-cultural factors still plays an important role
in Bajonese community, where they still perform
certain ritual when it comes to health seeking
behavior.
2. The low coverage of ANC services is due to the fact
that community is more entrusted their pregnancy
check by shaman than health workers, altough there
are still some people who also go to health care
facilities.
Ethical Clearance: Taken from Faculty member
committee
Source of Funding: Self
Conflict of Interest: None
References
1. Annisa Nurahmawati, Tradisi Kepercayaan
Masyarakat Pesisir Mengenai KesehatanIbu di Desa
Tanjung Limau Muara Badak Kalimantan Timur
Tahun 2008, Fakultas Kesehatan Masyarakat,
Universitas Mulawarman, Samarinda. 2008.
2. Depkes RI. Pedoman Pemantauan Wilayah
Setempat Kesehatan Ibudan Anak, (PWS-KIA).
2011.
3. Depkes RI, Cakupan Pelayanankesehatan antenatal
danimunisasi tetanus toxoid kepadaibu. http://www.
depkes.go.id/download Online, diaksestanggal 10
agustus 2016
4. Desa Hakatutobu. Profil Desa Hakatutobu, 2016
5. Dinas Kesehatan Provinsi Sulawesi Tenggara,
2016, Profil Pencapaian Sasaran KIA, 2015
6. Hadara, Ali. Etnografi Suku-Suku di
Wakatobi,Surabaya, RinekaCipta,2014.
7. Harjati, dkk, Konsep Sehat Sakit Terhadap
Kesehatan Ibudan Anak Pada Masyarakat Suku
Bajo Kabupaten Bone Sulawesi Selatan, Jurusan
Promosi Kesehatan, Universitas Hasanuddin. 2012.
8. Idianto Muchtar. Pelayanan Kesehatan Primer
Melalui Pendekatan Sosial Budaya, Jakarta,
Megapoin. 2013,
9. Ira Yusnita, Analisis Rendahnya Pemanfaatan
Layanan Persalinan Oleh Tenaga Kesehatan di
Wilayah Kerja Puskesmas Wakaokili Kabupaten
Buton. Fakultas Kesehatan Masyarakat Universitas
Diponegoro, Semarang, 2015.
10. Kemenkes RI, ProfilCakupan KI dan
K4 padakehamilan. Dirjen Bina Gizidan
KIA,Kemenkes. RI,2016
11. Koentjaraningrat, PengantarAntropologi I,
Jakarta,RinekaCipta. 2011
12. Linda, Persepsi Budaya Dan Dampak Kesehatannya,
USU Digital Library. 2011.
13. Moorman, Dimensi Sejarah Budaya Dan
Kepercayaan,Jakarta, PustakaProfresif. 2011.
14. Mulyawan Candra, Budaya Masyarakat Pesisir Dan
Pemanfaatan Laut Sebagai Sumber Kehidupan,
Unhalu Press. 2012.
15. Nita Iyabu, Ritual Pengobatan NyanyaOkang
Orang Bajo, Universitas Negeri Gorontalo. 2014.
16. Notoatmodjo Soekidjo, Promosi Kesehatan Dan
Ilmu Perilaku, Jakarta, Rineka Cipta. 2010.
72  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
17. Polindes Hakatutobu, PWS-KIA Desa Hakatutobu, 19. Mallongi, A., Puspitasari, A., Ikhtiar, M., Arman,
2016. Arsunan, A.A. Analysis of risk on the incidence
18. Posmaningsih, D.A., Aryasih, G.A.M., Hadi, of scabies Personal Hygiene in Boarding School
M.C., Marwati, N.M., Mallongi, A..The influence Darul Arqam Gombara Makassar. Indian Journal
of media booklet in behavior change of waste of Public Health Research & Development, April-
management in elementary school students, South June 2018, Vol.9, No. 4
Denpasar, Bali. Indian Journal of Public Health
Research & Development. 2018.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  73

Utilization of Mother and Child Health Services in Bajo

Transport in the Coastal Area of Hakakutobu Village,
Pomalaa District

A.M. Multazam1, Fatmah Afrianty Gobel1, Ella Andayanie1, Andi Asrina1

1Lecturers of Universitas Muslim Indonesia

Abstract
One of the causes of the still high maternal mortality rate (MMR) and infant mortality rate (IMR) is due to
the low utilization of antenatal care (ANC) services, especially by people in remote areas. The low utilization
of ANC can be influenced by many factors. This study aims to obtain in-depth information related to the
utilization of maternal and child health services in the Bajo tribe in the coastal area of Hakakutobu Village,
Pomalaa District in terms of economic aspects, family support and community beliefs.This research is a
qualitative research with ethnographic approach. Data obtained through observation and in-depth interviews.
Informants in this study were 15 people. Data analysis through three channels, namely data reduction, data
presentation, and drawing conclusions. The results show that the low utilization of ANC services is due to
the economic limitations of the community so that they find it difficult to access ANC service facilities. Lack
of support from her husband’s main family also makes mothers not motivated to take advantage of ANC
services. The high level of community trust in traditional birth attendants as pregnancy examiners and birth
attendants is due to their high confidence in the ability of traditional healers during hereditary and cultural
influences related to rituals they must undergo during pregnancy and childbirth.

Keywords: Antenatal care, economy, family support, belief, Bajo.

Introduction a TBA in 2015 was 2 cases. Coverage of K1 in 2013 was

Maternal and child health is an indicator of a country’s
health status. Based on the World Health Statistics 2017
Monitoring Health for the SDGs by WHO, around 830
women die every day worldwide due to complications of
pregnancy and childbirth in 2015. The SDG target is to
reduce the global maternal Mortality Rate (MMR) from
216 per 100,000 births life in 2015 to be less than 70 per
100,000 live births in 20301.
Indonesia’s Health Profile in 2017 shows that the
percentage of maternity mothers assisted by health
workers in the health care facilities of Southeast Sulawesi
Province is only 60.35%, relatively low compared
to other provinces in Indonesia 4. Pomalaa District
maternal mortality rate is 3% and infant mortality rate is
5%. For the achievement of K1 of 80.9%, K4 of 71.6%,
delivery by health workers 68.3%, postpartum visits
(KF3) 60.59% and neonatal visits (KN3) 60.59% 5.
PWS-MCH data Hakatutobu village showed a maternal
mortality rate in 2014 of 2 deaths due to bleeding and in
2015 a case of 1 and the infant mortality rate assisted by
38%, in 2014 it was 42%, in 2015 it was 40%. The K4
target is 95% while the K4 coverage for 2013 is 30%,
in 2014 it is 33%, and in 2015 it is 39%. The target of
deliveries by health workers is 90%, while the coverage
of deliveries by health workers in 2013 is 28%, in 2014
38% and in 2015 40%. The childbirth visit target (KF3)
is 90%, neonatal visit is 90% while the achievement
of childbirth visit (KF3) and neonatal visit (KN3) for
2013 is 40%, 2014 is 50%, in 2015 is 45% 6. Village
Achievement Hakatutobu is still far below the Renstra
standard compared to other villages in the sub-district.
Materials and Method
This research is a qualitative research with an
ethnographic approach that aims to get in-depth
information about the Utilization of Maternal and Child
Health Services in the Bajo Tribe in the Coastal Area of
Hakakotubu Village, Pomalaa District. This research was
conducted in March 2018. Data were obtained through
observation and in-depth interviews. There were 15
research informants consisting of ordinary informants
74  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
(pregnant women and post-partum mothers), supporting
informants (traditional birth attendants and midwives)
and key informants (community leaders). Data analysis
through three channels, namely data reduction, data
presentation, and drawing conclusions.
Results
Economy: Economy is the entire amount of family
income obtained to meet daily needs that can affect the
use of ANC services. The interviews found information
that,1 The majority of the main sources of income of
informants’ families are from seafood (fishermen)
where the average daily income is Rp. 100,000 which
is only enough to meet their daily food needs, so they
have difficulty if they have to incur additional costs for
examining pregnancy in health care facilities.2 If the
informant has a pregnancy check at the puskesmas, they
are charged a certain fee at each visit so they feel heavy
about the costs.3 Two informants stating that they prefer
to have a pregnancy check up by a shaman, because the
fees charged are in accordance with their abilities, the
form of payment does not have to be in the form of money,
but can be in the form of goods. 4 Three informants who
stated they did not want to go to a health care facility
because they had to pay additional transportation costs to
go there, whereas if they were examined by a dukun they
only waited at their home, because the shaman would
come to their home.5 Informants prefer to go to a shaman
because with payment according to their respective
abilities and is only done once, the shaman not only
checks their pregnancy but carries out postpartum care.
Family support: Three people The informant stated
that they did not get support from their husbands during
their pregnancy. The informant said that their husbands
did not have time to deliver to the health workers because
they were busy working.2,3 Two informants stated that
their husbands did not want to take them to have their
pregnancy examined because the location of the health
service facility was far from their home.
Community Confidence: Four informants stated
that they were more confident to have a pregnancy check
up and give birth in a dukun because they considered
shamans to be more skilled and experienced3 Two
informants expressed public confidence in the ability
of shamans not only as a helper during pregnancy
and childbirth but could also help for those who have
difficulty getting pregnant. In addition, healers are
also believed to have the ability to keep away from
spirits.4Three informants prefer to check the pregnancy
to the dukun because of emotional closeness, where the
dukun is one of the figures considered important in the
daily life of the Bajo people.
Discussion
The Economy: Economy is the overall income
derived from the work carried out by the head and family
members. The level of the household economy affects
all aspects of the lives of family members, including
health aspects. The higher the level of the economy in
a household, the greater the chance of accessing and
utilizing health services, and vice versa.Families with a
low economic level cannot afford to provide funds for
antenatal care and preparation for birth, because their
income runs out just to meet their daily needs. This can
also indirectly have an impact on the lack of nutritional
intake in mothers and babies during pregnancy and
childbirth. Unlike families with adequate economic
capacity, they can carry out routine pregnancy checks,
plan deliveries to health workers and make other
preparations related to pregnancy and childbirth so that
the condition of the mother and baby can be optimally
maintained.
The economic status of the Bajo is very minimal and
even tends to be below the poverty line. The location
of settlements that are above the sea resulted in the
majority of them depending their daily lives on marine
products both for sale and for their own consumption.
The maximum income they can get from selling seafood
in a day is 100,000, and even then it will usually be used
up to pay off debt to. To increase family income, the
wives sometimes collect waste to be sold even though
the results are not much. For daily consumption, if they
don’t have side dishes then they only consume rice
sprinkled with salt.
Unlike the case when checking the pregnancy
and childbirth with the help of a shaman, they are not
charged a certain nominal. Shamans are sufficiently
rewarded according to the ability of mothers who can be
in the form of money or goods, so that the community
does not feel burdened in terms of financing. According
to Gamelia about the reasons for antenatal care and
childbirth assistance, explained that subjects who use
the services of a dukunberanak are because the cost of
conducting a pregnancy check-up and birth attendant at
a dukun are lighter than examining a midwife, the fee
to the dukun is Rp. 10,000 often do not even set a price,
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  75
as sincere as giving. It also obtained the ease of making
payments which can usually be repaid 7.
According to Kotler and Armstrong there are many
factors that influence the decision to use goods and
services differently for each individual. These factors
are; (a) cultural factors, (b) social factors, (c) personal
factors, and (d) psychological factors 8. This theory also
applies to the Bajo people related to the use of health
services, where the economic condition of the family has
an impact on the lack of utilization of the ANC.
Family Support: Support or motivation is
something that supports the formation of a person’s
actions or behavior. Support is anything that refers to
encouragement and efforts to satisfy the needs of life
or to achieve certain goals. Support is a reason for
someone to act in order to meet their needs 9. During
pregnancy and childbirth, a mother does not live alone
but lives in a social environment with a complex family,
community and culture that is rich in diversity both in
terms of culture and tradition. In fact the main role of the
husband’s family has a very big influence for pregnant
women in supporting every behavior of pregnant women
including the utilization of health services. Snehendu B.
Kar’s theory concludes that a person’s health behavior
is determined, among others, by the presence or absence
of support from the surrounding community (social
support) 10. People who live in an environment that
upholds the health aspect will have a high enthusiasm
to make various efforts related to health care and vice
versa.
During pregnancy until delivery, a mother needs
various forms of support, especially from her husband.
The lack of husband support can have a variety of
negative effects including the lack of a loving bond
between the mother and baby, including in the aspect of
health care during pregnancy and carrying out checks on
health care facilities. The greater support gained during
pregnancy, the greater the chance for mothers to use
ANC services.
The results showed that the support of husband
and family during pregnancy and childbirth in the Bajo
tribe community was still very minimal, because their
culture was still very thick with patriarchal culture.
They assume that everything related to pregnancy and
childbirth is the responsibility of a mother/wife. In daily
life a husband only functions as a breadwinner while
the task of educating and raising children is left entirely
to his wife. This is in line with research conducted by
Titaley et al. 11 which shows that social support has a
significant effect on the utilization of ANC services.
Observation also shows that the husband and
family prefer to encourage the mother to check the
pregnancy and assist the delivery process to the dukun
rather than to the health service facility because they
assume that the dukun is far more experienced than the
health worker. This also applies even if pregnancy and
childbirth complications occur. These results are in line
with research conducted by Reskiani, et al. Showing that
there is a relationship between family support and the
utilization of ANC services at Antang Health Center.
Pregnant women who use ANC services because they
have adequate family support, where the husband/family
reminds mothers about the schedule of antenatal care
and takes the pregnant woman to the puskesmas to check
her pregnancy12.
Husband’s support is very important during
pregnancy because sometimes the wife is faced with
situations of fear and solitude, so that the husband is
expected to always motivate and accompany pregnant
women. Besides the support provided during pregnancy
can also reduce anxiety and restore the confidence
of expectant mothers during pregnancy. This is in
accordance with the concept of standby husband, the
husband’s awareness of the danger signs of pregnancy
and the husband’s readiness to accompany his wife to
a health service for pregnancy checks needed at each
pregnancy check-up visit, the husband should always
accompany his wife so they know the condition of his
wife’s pregnancy.
Good support from her husband can provide
positive motivation for mothers in checking their
pregnancy. Actual forms of actions that can be taken by
the husband during the process of pregnancy to delivery
include delivering a wife for antenatal care, meeting
nutritional needs, inviting a wife to do light exercise,
helping to do daily chores, preparing for labor costs,
participating in choosing a place to give birth to his wife
, accompany or accompany his wife during childbirth,
and remind his wife to provide exclusive breastfeeding.
The involvement of the husband from the beginning of
pregnancy until delivery and the postpartum period will
improve the behavior of the care of pregnant women so
as to determine the success of the mother in pregnancy
until the postpartum period.
76  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Confidence: Beliefs are assumptions and beliefs
that are considered correct by an individual or group,
regarding concepts, events, people and certain things.
Beliefs grow with the world view that is affirmed by the
community, are considered positive and true, forming
behavior in a predisposition, beliefs can still be changed
depending on the interventions provided. Usually,
beliefs tend to differ from one community group to
another. This is conditioned by the customs or traditions
adopted by the community. As seen in the Bajo tribe
who believe in non-medical aspects of their health
problems, shaman is a figure that is believed to be able to
help health problems including for the health of mothers
and children. In this study, the Bajo tribe entrusted the
problem of pregnancy and childbirth to untrained birth
attendants because it was a hereditary habit.
The tendency to prefer shamans for pregnancy
and childbirth problems in the Bajo tribe is a challenge
for local health workers. Feeling safe and comfortable
when served by a shaman is a psychological factor
felt by a mother who subjectively forms beliefs. It has
become common in traditional societies who always
rely on treatment based on their beliefs, as is the case
with Bajo people who believe in dukun expertise in
facilitating pregnancy and childbirth through certain
rituals. The traditional Bajo community has taboos
(pamali) which must not be violated for fear that there
will be consequences. This conviction was strengthened
because so far there had never been a case that they
considered endangered the health and safety of pregnant
and childbirth women as a result of being assisted by a
shaman.
Linking Rosenstock’s theory of the Health Belief
Model to the Bajo community with healthy behavior,
the Bajo community does not feel any health problems
during pregnancy and childbirth when assisted by a
dukun, so that it does not change the perception, attitude
and actions to find solutions in handling pregnancy
and childbirth . Based on this theory, perceptions of
health problems are influenced by three things namely;
a) Health values in general, (interests and attention to
health); b) Confidence in one’s vulnerability to health
problems; and c) Confidence in the consequences arising
from health problems13.
Changing the basic beliefs in utilizing health
facilities such as the Bajo community requires attention
in exploring problems, motives for change, and
strengthening social factors and values that are hereditary.
Likewise, various activities that are intended to be
improved and developed through posyandu, puskesmas
and counseling programs that are run separately. This
needs to beattention because all of these are efforts to
tackle health problems that stem from behaviors that do
not harm health.
Conclusion
The inability of the community’s economy, resulting
in them preferring to have a pregnancy check up and
deliver a birth assisted by a dukun rather than a midwife
or to a health care facility. 2. Husband and family support
for mothers during pregnancy and childbirth is still very
minimal. 3. The Bajo community’s belief in dukunbirun
because it is a hereditary habit, and they do not feel any
health problems during pregnancy and childbirth when
assisted by dukunberanun.
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: Obtained from Universitas
Muslim Indonesia.
References
1. WHO, World Health Statistics2017 Monitoring
Health for The SDGs, Switzerland. 2017
2. BKKBN, BPS, Kemenkes, Survei Demografidan
Kesehatan Indonesia 2012. Jakarta
3. Din Kes Provinsi Sulawesi Tenggara, Profil
Kesehatan Sulawesi Tenggara Tahun 2015, Kendari
4. Kemenkes RI, Profil Kesehatan Indonesia tahun
2017, Jakarta
5. Polindes Hakatutobu, PWS-KIA Desa Hakatutobu,
2015
6. Puskesmas Pomalaa PWS-KIA Puskesmas
Pomalaa 2015
7. Gamelia, E .Determinan Perilaku Perawatan
Kehamilan. Jurnal Kesehatan Masyarakat Nasional,
2013;Vol. 8. No.3.
8. Kotler, Philip, Manajemen Pemasaran, Edisi
Millenium 2, jilid 1 dan 2, Edisi 5. Erlangga,
Jakarta 2002..
9. Notoatmodjo. S. Metodologi Penelitian Kesehatan.
Jakarta: Rineka Cipta2010.
10. Notoatmodjo. S. Pendidikan Dan PerilakuKesehatan.
Jakarta ;RinekaCipta2003.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  77
11. Titaley, C, R,.Dibley, M, J,.et al. 2010. Factors Care Di PuskesmasAntang. Skripsi. Fakultas
associated with underutilization of antenatal Kesehatan Masyarakat, Universitas Hasanuddin.
care services in Indonesia: results of Indonesia 2014.
Demographic and Health Survey 2002/2003 and 13. Rosenstock IM, Strecher VJ, Becker MH. Social
2007. BMC Public Health 2010, 10:485 Learning Theory and The Health Belief Model.
12. Reskiani., Balqis., Nurhayani. HubunganPerilakuIbu Vol. 15. 175183. San Francisco. Diaksestanggal 12
Hamil Dengan Pemanfaatan Pelayanan Antenatal Juli 2016.
78  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Influence of Customer Value on BPJS Patients with IUR Cost

Satisfaction in Hospital of Makassar City

Marwah Thaha1, Amran Razak2, Indar2, Fridawaty Rivai3

1Postgraduated Student Faculty of Public Health, 2Professor of Health Administration and Policy Department,
3Lecturer of Hospital Management Department, Faculty of Public Health, Hasanuddin University

Abstract
Hospital as a provider of service of health to the public should be able to improve the quality of service
because a good quality of services will be able to generate customer value or good impression in thepatients
or satisfaction, as the purpose of service of the public which is to satisfy the public.The aimed of the study
is to determine the influence of customer value on BPJS Patients with IUR cost Satisfaction in Hospital of
Makassar City. The type of research is quantitative analytic method using the approach of cross-sectional,
held pad a July to August 2019 in the city of Makassar. The population of the study are BPJS patients that
use IUR cost or the difference in cost over the service that they receive in the year 2019. Total sample
as many as 30 people were obtained using the technique of purposive sampling. Data collection is done
through interviews using a questionnaire. Data were analyzed using a test correlation Pearson on SPSS then
presented in the form of tables and narrative. The result shows that there is a correlation between customer
value with the satisfaction of BPJS patients use IUR costs at hospital of Makassar with p = 0.001 and the
value of Pearson Correlation (r) = 0.701. Based on the results of the research can be concluded that the
satisfaction of patients affected by customer value and 70.1% of satisfaction of patients is determined by
customer value in patients BPJS use IUR costs at the hospital of Makassar city.

Keyword: Iur cost, BPJS, satisfaction.

Intoduction facility health both physically and socially for people to

Health becomes a necessity that is fundamental to
society. The need is what makes the community feel
the need to maintain health and obtain health services.
In line with the increasing demands of society towards
servicing the medical cause people to become more
selective in choosing a hospital. Changes are caused also
by further increasing education and state socio-economic
society that give rise to the demands of the community
to get good service and quality. Indonesian government
through the Ministry of Health since 1st January 2014
held health insurance for the community through the
Badan Penyelenggara Jaminan Sosial (BPJS), so the
government shall provide the services of health that
quality.1
Ministry of health is a right fundamental human
being that must be met by the government , things are
contained in Law No. 36 the year 2009 about Health
Article 15 which states that: “ The Government shall
be responsible on availability environment, structure,
achieve the highest degree of health2 Under the terms
of it, the government is obliged to provide facilities or
services health through BPJS Health with service that is
of quality, in order to meet the needs of patients . Public
interest in the BPJS program is shown by the amount of
community interest in being a participant in the BPJS
program.
Based on the data month September 2014 the number
of participants BPJS Health in Indonesia as much as 127.3
million inhabitants (65%) and continues to increase,
the month of November 2017 recorded 183 579 086
participants or approximately (70%) and in September
2018, the number of participants reached 201,660,548
people , andon February 1, 2019, reached 217,549,455
people . By the numbers, 217 million inhabitants of this,
meaning that the number of participants BPJS Health
have reached 81.8% of the total population of Indonesia
is around 265 million inhabitants, as the data are quoted
from page official BPJS.3 Data BPJS South Sulawesi
shows that in the year 2019 the number of participants
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  79
BPJS Makassar City as much as 500 061 participants study. This research was conducted in Makassar City.
PBI and 857 262 participants of non-PBI. In general, The population in the study is that BPJS patients that
the number of total participants JKN in Makassar that as use IUR fee or the difference in cost over the service that
many as 1,357,323 people.4 they receive in the year 2019. Samples were obtained
by using the purposive sampling and get 30 people
Data BPJS health of South Sulawesi in 2019, respondents. Data are collected through interviews
especially in the 4 (four) regency/municipality by using questionnaire. The data that collected are
comprised of District Barru , Pare-pare, Pinrang and characteristics of respondent,BPJS class and class of the
SidenrengRappang which is under the office branch treatments are used, customer value, the perception of
cities Parepare , noted that as many as 863 053 people the IUR cost patients BPJS and satisfaction of patients.
users JKN, on in January up to July, and there are 15% of Analysis of the data is done by univariate and bivariate
patients using the IUR fee , to the the nonparticipants as
many as 183 587 people by using the IUR cost as much Results
as 23%.4 Things that indicate that high expectation or
expectations of the services on the service of health who Results of the study showed that the group age
qualified with the consequences of the service to pay most is the group aged 36-45 years as many as 6 people
the difference in price of a standard right services that (23.1%), while the group age most bit is the group 76
are acceptable by the patient. BPJS program health in years and above as much as 1 (3.3%). Respondents
the ministry, would not be separated from the financing education areBachelor as many as 14 people, Magister
of health, because the cost of healthcare is the number as much as 1 (3.3%) and other 8 (26.7%) persons. Class
of funds that must be provided to organize and or take participation BPJS that most lots are class I as many as
advantage of the various efforts of health is needed by 20 people (66.7%). Class II as many as 4 people (13.3%)
individuals, families, groups and communities. and class III as many as 6 people (20%). Patients BPJS
are taking class care that 1 level is higher than the class
The research that is done on the quality of service , of membership. So that class I patients who increased
value for the customer and the satisfaction of patients at their class of care to VIP there was 20 people (66.7%).
Home Hospital General in Regency Bandung, Indonesia Class II rise into the class I as many as four people
obtained the results of the study indicate that there is (13.3%) and class III rising levels into grade II as many
the effect that significant to the quality of service at as six people (20%).
value for customers and satisfaction of patients, where
the services are supplied by hospital can improve Table 1. Result of the Univariat Analysis
implications of customer value on patient satisfaction
Univariat Analysis
.5 The creation of positives rating of the customer on
Variable n = 30 %
the service that they receive is a necessity, so it can
Age (Years)
be understood that the creation of customer value is a
≤25 6 20
comparison between the perception of the service that
26–35 5 16,7
is received with expectation before getting the service 36–45 10 33,3
it. If expectations are met, means the service that has 46–55 4 13,3
been giving a quality that is beyond the ordinary and 56–65 1 3,3
also will lead to satisfaction were high. Conversely, if 66–75 3 10
the expectation is not achieved, it means that the quality 76≤ 1 3,3
of service does not meet what is expected.6 Based on the Sex
description at the top then the researchers are interested Male 15 50
to do research on the influence of customer value Female 15 50
(assessment of customers) to the satisfaction of patients BPJS Class
BPJS that use IUR costs in Hospital of Makassar City Ist Class 20 66,7
in 2019. IInd Class 4 13,3
IIIrd Class 6 20
Materials and Method Nursing Class
The type of research is using quantitative Method of VIP Class 20 66,7
descriptive-analytic with the approach of cross-sectional Ist Class 4 13,3
IInd Class 6 20
80  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
The test results of normality of data by using a test 0.412 so that the value of p> 0.05, it can be interpreted
Kolmogorv-Sminor v Test obtained result value of p = that the data distributed normally.

Figure 1. Graphic of Normality Test

Then test used is a test Pearson Correlation to see Customer Value

the influence of ratings of customers (customer value) Independent Extremely Total
High
to the satisfaction of patients BPJS using Iur costs in Variable High
Rumah Sakit Makassar. n % n % N %
Nursing Class
Table 2. Bivariat Analysis of The Independent
VIP Class 17 85 3 15 20 100
Variable and Dependent Variable
Ist Class 2 50 2 50 4 100
IInd Class 5 83,3 1 16,7 6 100
Customer Value
Independent Total Bivariate Analysis
Extremely
High R=0,701
Variable High
Customer Value-Patient Satisfaction
n % n % N % P=0,001
Age
The result of the test using SPPS obtained value
Young 14 82,4 3 17,6 17 100
of p = 0.001 and the value of the coefficient of Pearson
Adult 10 76,9 3 23,1 13 100
Correlation (r) = 0.701. It is can be interpreted that the
Sex
customer values affect the satisfaction of patients BPJS
Male 12 80 3 20 15 100
Female 12 80 3 20 15 100
using Iur costs in the hospital of Makassar City where
BPJS Class
70.1% of satisfaction of patients are determined by
Ist Class 17 85 3 15 20 100 customer value.
IInd Class 2 50 2 50 4 100
IIIrd Class 5 83,3 1 16,7 1 100
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  81
Discussion
Regulation of the Minister of Health No. 51 the
Year 2018 defines that IUR cost is an extra cost that is
paid p Participants at the time of obtaining the benefits
of ministry of health that can lead to abuse of the service.
While that meant the difference in fee is an additional
fee that is paid Participants at the time of obtaining the
benefits of ministry of health which is higher than the
right. Special increment costs, Article 10 paragraph 5
Permenkes 51/2018 regulate that participants JKN-KIS
only can go up one level much higher than the class that
became due.7 Chief of Bureau of Law and Organization
of the Ministry of Health of the Republic of Indonesia
Sundoyo explained that the purpose of the con fee and
the difference in cost for participants Guarantee of
Health National (JKN) which was held BPJS Health as
the control of quality and cost , as well as preventing the
misuse of the service facilities of health in the service
of JKN.8
The value of the customer (customer value) is the
difference between the value of customer total and
charge customers total in which the value of customer’s
total is a set of benefits that are expected by customers
of products or services specified and charge the
customer the total is a set of costs which are expected
by consumers who incurred to evaluate, acquire, use and
discarding products or services . Value customers and the
loyalty of customers is very important and useful for the
improvement of services of the service. Customer value
or customer perceived value is customer perception of
the value where the company must consider the value in
developing products and services so that it is in line with
what the customer expects. Monroe states that the value
of the customer is the ratio between profit or benefit that
is perceived by the sacrifices incurred. 9
The satisfaction of customers is the response of
customers to the discrepancy between the level of
interest before and the performance of real-time that he
felt after use. The satisfaction of customers is influenced
by perceptions of the quality of service, quality of
product, price and factors that are personal and that is
the situation for a moment. The satisfaction of customers
is the response of customers to a discrepancy between
the level of interest before and the performance of
real-time that he felt after use.10 One of the factors that
determine the satisfaction of customers is the perception
of customers regarding the quality of services that
focuses on five dimensions of quality of services. The
quality that is perceived as directly has the effect of
positively towards the satisfaction of customers as a
whole. The satisfaction of customers as a whole will
impact negatively on the complaints of customers and
impact positively on the loyalty or loyalty of customers.
Levels of satisfaction were obtained by the customer
is usually highly related closely to the standard quality
of the goods or services are enjoyed and services other
form of service pre-sales, the current transaction and
after-sales. The level of satisfaction is a function of
the difference between the appearance of the felt with
expectations. Patients are satisfied after receiving
services that meet their expectations, the patient decides
to provide an assessment of services and acts based on
satisfaction. So the value of service quality is the most
important part and a measure of patient satisfaction for
the hospital.
Assessment of patients to care nurse comes from the
experience of patients. The aspect of patient experience
can be interpreted as a treatment or action of a nurse who
is or has been experienced, felt and borne by someone
who uses nurse services. aspects of the satisfaction of
the patient is very determined on a model or engineering
services, where the provider of services provide care
professionally, so that the recipient of service feel
satisfied on the service that they receive , and will give
you a sense of confidence to hospital as one of the
places receiving services are special . The satisfaction
of patients who seek treatment at home sick will have an
impact on the number of visits to patients at the hospital.
Visits were so this by itself will increase the sources of
income for hospital. 11
Results of the research showed that customer value
effect is significant to the satisfaction of patients, where
70.1% of satisfaction of patients obtained from the
customer value. It is in line moved at the research that is
done by Alimuddin, et al. rgery Surabaya obtain results
that there is a direct influence of the customer value to
the satisfaction of 0.845. Soit can be interpreted that the
direct influence of customer value on satisfaction is very
significant and positive. Then increasingly higher levels
of the value of customer service hospital, getting high
is also the satisfaction of the customer and vice versa.12
The results of the research is also supported by research
that is conducted by Maya Utami Ikasari, Sri Sutyoko
and Sendhang Nurseto (2013) who find that the variable
value of the customers influences the variable patient’s
satisfaction. 13 If the level of assessment of customers
82  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
(customer value) higher then getting high also the level
of satisfaction of the patient’s homesick, especially
in patients BPJS using Iur costs. This is because the
patient chooses a class of care that is more than their
participation certainly with the hope that the service will
get better.
Conclusions
The study is concluded customer value or assessment
of customers is significantly affecting the satisfaction of
patients BPJS use IUR costs at home sick of Makassar.
As for the advice that can be given are hospital need to
improve the quality of service, attitude of social officers
and factors other that can be re-established as well as
increase customer value to satisfaction of patients can
be further improved so that helped increase the loyalty
of patients which resulted in increased profits hospital.
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: Obtained from Faculty of
Public Health, Hasanuddin University.
References
1. Khasanah, Imroatul and Octarina Dina Pertiwi.
Analysis of the Effect of Service Quality on
Consumer Satisfaction of St. Elisabeth Semarang .
Asset Journal. 2010; 12 (2): 117-124.
2. RI. Undang undang No. 36 Tahun concerning
Health. Jakarta: President of Republic Indonesia.
2009.
3. BPJS. 2019. https://bpjs-kesehatan.go.id/bpjs/
index.php/number of Participants . (accessed
August 26, 2019).
4. Rianingsih Abdul Khoha, Uliya Bilqis Fikrotul,
Lestari Karisma Indah and Lestari Puji. Journal
of Non-Recipient Health Insurance Participant
Satisfaction Participants in the Quality of Clinical
Services.
5. Achmad Rizal, YR. Relationship between the
Quality of Health Services and the Level of Patient
Satisfaction at BP. Gigi Kelayan Puskesmas in
Banjarmasin City. An Nadaa Journal of Public
Health, Faculty of Public Health, UNISKA .2014
6. RI Ministry of Health.. Regulation of the Minister
of Health of the Republic of Indonesia Number
51 Year 2018 t Entang Imposition of deliberation
Cost d an excess fee d nature’s Health Insurance
Program . Jakarta: Ministry of Health Republic of
Indonesia. 2018
7. Arisandy, W.. Health Service Strategies in
Improving the Quality of Health Services through
the CRC (Citizen Report Card) Method in the City
of Surabaya. Airlangga University.2015
8. Vanessa, Gaffar.. Customer Relationship
Management and Public Relations Marketing.
Bandung: Alfabeta. 2007.
9. Rangkuti, Freddy, The Concept of Satisfaction
Measurement. PT. Gramedia Pustaka Utama,
Jakarta .2002.
10. Arisandy, W.. Health Service Strategies in
Improving the Quality of Health Services through
the CRC (Citizen Report Card) Method in the City
of Surabaya. Airlangga University.2015
11. Alimudin , Arasy, et al. Model of Customer
Value Approach for Improving Satisfaction of the
Hospital Patients. SYNERGY; 2017: 30-40
12. Murti, A., Deshpande, A. and Srivastava, N.
‘Service Quality, Customer (Patient) Satisfaction
and Behavioral Intention in Health Care Services:
Exploring the Indian Perspective’, Journal of
Health Management, 2013;15 (1), pp. 29–44
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  83

Determinant Factors Affecting the Development of Motor,

Cognitive and Socioemotional Children Ages 18-12 Months in
the District Jeneponto, Indonesia

Sarih Karmila1, Siradjuddin Saifuddin2, Abdullah Tahir2, Hadju Veni3

1Doctoral Student, Faculty of Public Health, Hasanuddin University, 2Public Health Faculty,
Hasanuddin University, Indonesia

Abstract
Background: Malnutrition during pregnancy and early childhood causes delays in physical growth, the
motor development, and cognitive development disorders.

Objectives: This study aims to Determine the factors that influence motoric, cognitive and socio-emotional
development of children aged 18-24 months in Jenepontodistric.

Method: This study is an analytical study with cross-sectional approach. Samples consisted of 32 children
aged 18-24 months. Child development was measured using the Caregiver Reported Early Childhood
Development Index (CREDI) instrument. Statistical analysis to test the factors that influence motoric,
cognitive and socioemotional development using an unpaired T-test with a significance level of 95%.

Results: This study reported that of 32 children born to mothers aged 20-35 years (68.8%), <20 and> 35 years
(31.3%) with a primary education level of 34.4% and 65.6% intermediate level. Bivariate analysis found that
factors affecting the motor development were birth weight (p = 0.004), cognitive development influenced
by maternal age (p = 0.021) and birth weight (p = 0.000) and socioemotional development influenced by
maternal education (p = 0.050), breastfeeding (p = 0.010) and stimulation (p = 0.004).

Conclusion: The factors that influence motoric development are birth weight, cognitive development
influenced by birth weight and maternal age, while maternal education, breast feeding, and stimulation
Affect socioemotional development.

Keywords: Motoric development, Cognitive, and Socioemotional, Children aged 18-24 months.

Introduction However, environmental factors, such as adequate

In 2010, an estimated 33% of children aged 3 and
4 years in countries of low and middle income, 80.8
million children fail to meet basic standards in cognitive
development and or socioemotional.1 In 2013, the
national prevalence of malnutrition in children under five
years-less by 19.6%, which means heavy-less nutritional
problem in Indonesia is still a public health problem of
high prevalence approaching. Among the 33 provinces,
three provinces, including the very high prevalence
categories, namely West Sulawesi, West Papua and East
Nusa Tenggara.2
The Cognitive development of children is influenced
by genetic and environmental factors. The child has
the potential of genetically cognitive development.
nutrition and the ability of parents to improve food and
stimulating home environment also has a positive effect
on cognitive development of children3, Optimal health
education in the mother can optimize the growth and
development of children.4
Adequate support to the development of a child
when a child can effect motoric development, language,
cognitive, social, emotional and behavior, influencing
the long-term health and reduce health inequalities
and socioeconomic,5 In children suspected of having
developmental delays or disorders, medical evaluation
should be done and development (development
assessment) so that early intervention can be done
immediately (ealy intervention) on the child.6
84  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Based on the phenomenon of the above results,
the main purpose of this study was to determine the
determinant factor of motor development, cognitive and
socio-emotional in children aged 18 to 24 months in
Jeneponto Indonesia.
Research Method
This study consisted of children whose mothers
enrolled in trials of Moringa leaf powder supplements
provided prenatal and postnatal district Jeneponto.
Children of mothers who were enrolled in the trial and be
eligible to participate in the study of child development
when children aged 18 to 24 months time recruitment
selection. We chose one district and call mom at random
to participate in the study of child development between
December 2018 to January 2019, and get as many as 32
children aged 18-24 months. The sample size is limited
by those who were not in place when the data collection
was done as well as funding constraints.
Child development was assessed using Caregiver
Reported Early Childhood Development Index (credi).
Credi is a simple device, low cost reported by the
caregivers or child care givers, for the household survey.
To monitor and measure the child’s development, two
research assistants trained in the local language setempet
Credi and anthropometric measurements for children
and adults, and other study procedures.
We did a statistical analysis to examine the factors
that influence a child’s development using an unpaired
t test with significance level of 95%, and a linear
regression model that is tailored to the characteristics
Table 1. Effect of the characteristics of the mother and child to the development of motoric, cognitive and
socioemotional children aged 18-24 months in Jeneponto
Motor
Characteristics
Mean (SD) p Mean (SD)
Characteristics of Mother
Age Mothers
Age 20-35 years 4.13 (0.69)
0705
Age <20 and> 35 years 4.00 (1.22)
Education
Secondary school 4:14 (0.65)
0661
Primary school 4:00 (1:18)
IMT mother
Normal + skinny 3.95 (0.58)
0202
Obese + obese 4.36 (1.20)
of mothers and children with a significance values at p
<0.05.
Results
a. Maternal characteristics, prenatal and child
development: The relationship between mother
and child development characteristics are presented
in Table 1. This study found that children whose
mothers aged 20-35 years scored significantly
higher on cognitive development CREDI (p =
0.021) compared with children whose mothers aged
over 35 years. Children whose mothers complete
high school education earned scored significantly
lower on socio-emotional development (p = 0.05)
compared to children whose mothers completed
primary education. Maternal body mass index,
Moringa leaf powder supplementation and second-
trimester anemia status did not significantly affect
any of the scales of child development.
b. Characteristics of children, follow-up and
development of children: The relationship between
the characteristics of children, follow-up and
development of children are presented in Table 1. In
this study, it was found that children who had birth
weight ≥2500 grams have significantly higher scores
(p = 0.004) in motoric development, and p = 0.001
on cognitive development than children who had
birth weight <2500 g. Children who were breastfed
exclusively had lower scores were significantly (p =
0.01) in the socio-emotional development compared
with children given non-exclusive breastfeeding.
Cognitive Socioemotional
p Mean (SD) p
14.65 (1.49) 13.6 (3.26)
0021 * 0494
12.66 (3.16) 12.77 (2.39)
14.14 (1.45) 12:47 (2:20)
0867 0050
14.00 (3.34) 15.09 (3.70)
14:57 (1:50) 12.76 (2.68)
0095 0114
13.18 (3.09) 14.54 (3.41)
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  85

Motor Cognitive Socioemotional

Characteristics
Mean (SD) p Mean (SD) p Mean (SD) p
Supplementation
Moringa flour 3.88 (0.35) 15:38 (1:50) 14.25 (3.49)
Moringa extract 4:18 (0.75) 0.71 14.00 (1.67) 0:14 13.27 (3.26) 0.63
Tablet Fe 4.15 (1.14) 13.38 (2.75) 12.92 (2.63)
Prenatal Anemia Status
Hb ≥ 11 g/dl 4:05 (0.99) 13.65 (2.45) 13.30 (3.01)
0715 0:15 0.86
Hb <11 g/dl 4:16 (0:57) 14.83 (1.64) 13:50 (3:17)
Characteristics of Children
Sex of the Child
Man 4:05 (0.93) 14.05 (2.79) 13.50 (2.57)
0.78 0915 0796
Woman 4:14 (0.77) 14.14 (1.29) 13.21 (3.62)
Birthweight
Normal (≥ 2,500 g) 4.25 (0.64) 14.6 (1.42) 13.5 (3.01)
0004 * 0.00 * 0545
LBW (<2,500 g) 3.00 (1.41) 10.5 (3.69) 12.5 (3.41)
Age Pregnancy
At term (≥ 37 weeks) 4.09 (0.97) 14.13 (2.55) 13.81 (3.12)
0978 0876 0224
Preterm (<37 weeks) 4:10 (0:56) 14:00 (1:41) 12.40 (2.67)
Nutritional Status of
Children
Index BB/U (WAZ)
Normal 4.00 (0.89) 13.84 (2.37) 13:00 (2.91)
0202 0197 0147
Under weight 4.50 (0.54) 15:16 (0.98) 15.00 (3.22)
Index PB/U (HAZ)
Normal 4.00 (0.81) 14:20 (1:13) 12:50 (2:46)
0683 0.86 0277
Stunting 4:13 (0.88) 14.04 (2.60) 13.77 (3.22)
Index BB/PB (WHZ)
Normal 4:06 (0.86) 14:03 (2:29) 13:40 (3:11)
0497 0562 0.86
Wasting 4.50 (0.70) 15:00 (0:00) 13:00 (1:41)
Breastfeeding 6 Months
First
Exclusive breastfeeding 4:07 (0.75) 14.30 (1.03) 11.92 (1.32)
0928 0661 0010 *
Non exclusive breastfeeding 4:10 (0.93) 13.94 (2.79) 14.36 (3.46)
Giving Stimulation
High scores (score 6-11) 4.3 (0.63) 14.84 (1.67) 15.3 (3.19)
0249 1,116 0004 *
Low score (score 0-5) 3.94 (0.97) 13:57 (2:45) 12.05 (2.09)
Verbal and Physical Punishment
Not 4.37 (0.74) 14.75 (1.98) 12.87 (1.8)
0291 0346 0483
Yes 4.00 (0.88) 13.87 (2.3) 13.54 (3.34)

* Correlation is significant at the 0:05 level (2-tailed)

86  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
c. Factors affecting the development of motoric, development (p = 0.000), and on socio-emotional
cognitive and socioemotional children ages 18-24 development (p = 0.001). The results that the birth
months weight of 28.5% a negative effect on the development
of motoric (p = 0.003, t =-3.283), and 65.1% negative
The results of multiple linear regression analysis
effect on cognitive development (p = 0.000, t =-5.348).
(Table 3) to test the independent variables that
Giving stimulation 65.1% negative effect on cognitive
most influence on the high score between maternal
development (p = 0.035, t =-2.234), and a negative effect
characteristics of child development characteristics
on the development of socioemotional 48.4% (p = 0.002,
of children. In this study it was found that all of the
t =-3.519).
variables examined in linear regression simultaneous
effect on motoric development (p = 0.001), cognitive

Table 2. Results of Regression Testing Factors that influence Motoric development, cognitive and
socioemotional children aged 18-24 months

Independent Variables Dependent Variables t Sig.

(Constant) 6242 0
Birth Weight -3283 0003
Motor Trend Children’s nutritional status (WAZ) 0734 0469
Stimulation Award -1327 0196
IMT Capital 1,473 0152
R2 (R2adj) 0.614 (0.285)
F (Sig) 4.082 (0.010)
(Constant) 10 843 0
Birth Weight -5348 0,000
Status of Child Nutrition (WAZ) 1,345 0191
Stimulation -2234 0035
Cognitive Development
age Mothers -1621 0118
IMT Capital -1.2 0242
Anemia Status 1402 0174
Prenatal supplements -1866 0074
R2 (R2adj) 0.854 (0.651)
F (Sig) 9.263 (0.000)
(Constant) 4,891 0
Age Pregnancy -0824 0416
Children’s nutritional status (WAZ) -1.64 0113
Developments Socioemotional breastfeeding 2,499 0019
Stimulation -3473 0002
Mother education 1,122 0273
IMT Capital 0171 0866
R2 (R2adj) 0.764 (0.484)
F (Sig) 5.838 (0.001)

Discussion the characteristics of the mother’s age with cognitive

development in children. A child requires special
Effect of Age Mothers with Children’s Cognitive
attention to the optimization of growth. Optimizing
Development: In this study, the results obtained with p
the development of the necessary interaction between
value = 0,021 which means there is an influence between
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  87
children and parents, especially the mother’s role is
very beneficial to the overall process of development of
children because parents can immediately recognize the
disorder as early as possible the process of development
of their children.7
If adjusted to international opinion, then an early
age in Indonesia are those from birth (age 0 years) until
well into the early primary school level. However, some
studies show that since the time of conception (in the
womb), the developing fetus and have proven to do
stimulation to develop a variety of sensitivity and basic
abilities.8Given the 80% growth and brain development
in children pasa currently developing an early age, at the
age of 1 year of brain growth reached 70% of the adult
brain, and in the age of 3 years of a child’s brain has
reached 90% of the adult brain. Thus, this period should
be best utilized to improve the intelligence of children.9
The influence of birth weight with Motor and
Cognitive Development of Children: Prenatal and
natal factors that affect the development of children one
of whom is the birth weight. An estimated 10-15% of
premature infants with low birth weight or impaired
development, as well as infants born with very low
birth weight 3-4 times greater risk for experiencing a
developmental disorder. Babies with low birth weight
have a brain disorder that can be observed through
MRI and a greater risk of an abnormal signal by a
larger amount. Besides infants with low birth weight,
premature and very low birth weight had serum CRP
levels were higher.10
According to Piaget, the first stage lasts Cognitive
Development in children from birth until the age of 2
years is a sensory motoric development. At this stage
the baby to build an understanding of the world by
coordinating sensory experiences (sensory) them, such
as seeing and hearing) with motoric movement (physical)
they, like grabbing, or touched, because that is called
sensorimotor. At the beginning of this stage, the baby
showed no more than a reflective pattern for adapt with
the world, towards the end of this stage, babies showed a
pattern more complex sensory-motor.11
The results of previous studies which stated that
infants with a history of premature or low birth weight
risk of impaired cognitive development and motor
development and research shows that babies born
with low weight the potential to have a developmental
disorder in the future.12 Babies born with low birth
weight, especially in infants born with very low birth
weight, may have abnormalities in brain structure.
Abnormalities of the brain in infancy can affect the
child’s development in the future.13
Effect of Breastfeeding with socioemotional
development Children: Breastfeeding is one of the
environmental factors are known to provide a variety of
nutritional and immunological advantages in infants.14
The American Academy of Pediatrics recommends
breastfeeding for human use as an ideal source of
nutrition for infant feeding. Infant formula is the second
choice and third choice of soy formula.15
In this study showed that breastfeeding for 6
months had a significant influence on socio-emotional
development in infants aged 18-24 months. The
development of socio-emotional during infancy and
early childhood is described as the ability of children
who thrive on experience, control and express feelings,
establish connections close interpersonal and secure,
investigate the environment and learn, all within the
scope of the family, society and culture.
Some studies in the encyclopedia concluded
that breastfeeding is not a panacea, but as a mother
can breastfeed optimally, the infant or child they will
get many benefits, one of them for psychosocial and
emotional development in children.
The influence of Stimulation with socioemotional
development Children: The development of socio-
emotional during infancy and early childhood is
described as the ability of children who thrive on
experience, control and express feelings, establish
connections close interpersonal and secure, investigate
the environment and learn, all within the scope of the
family, society and culture.
Results of research on the behavior of giving
stimulation to the 32 mothers found that children were
stimulated high by their parents have higher scores were
significantly (p = 0.004) on the development of socio-
emotional compared to children who are less stimulated
by their parents.
According to research results Supinah, mostly by
53% stimulation skills are good mothers and produce
the majority of children aged 2-3 years at 71% had
the appropriate gross motor development. Analysis
Spearman rho rank generating value calculated at 0.687
88  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
indicates that the stimulation skills of mothers with
gross motor development in children aged 2-3 years
have a strong closeness. That is a good or bad skill in
stimulating her mother will be very influential in his
gross motor development.
Conclusions
Based on research that has been done above, it can
be concluded that factors affecting motor development
is birth weight (p = 0.004), cognitive development is
influenced by maternal age (p = 0.021) and birth weight
(p = 0.000) and the development of socioemotional
affected by breast feeding (p = 0.010) and providing
stimulation (0,004).
Ethical Clearance: Ethical clearance was issued by
the Health Research Ethics Committee of the Hasanuddin
University School of Public Health, and subjects were
asked to sign an agreement before being included in the
study.
Source of Funding: Self
Conflict of Interest: Nil
References
1. Pitchik H, Fawzi W, McCoy D, Darling A,
Abioye A, Tesha F, et al. Prenatal Nutrition,
Stimulation, and Exposure to Punishment are
Associated with Early Child ff Motor, Cognitive,
Language, and Socioemotional Development in
Dar Es Salaam, Tanzania. Child Care Health Dev.
2018;44(6):841‑9.
2. Ministry of Health. Basic Health Research in 2013.
Jakarta; 2013.
3. Angelsen, N., Vik, T., Jacobsen, G., & Bakketeig L.
Breastfeeding and Cognitive Development at Age 1
and 5 Years. Arch Dis Child. 2001;85(3):183–8.
4. Saleh, A., Nurochmah, E., As’ad, S., & Hadju
V. Effect of Health Education with A Modeling
Approach to Knowledge, Practical Skills and
Confidence in Stimulating Maternal Infant Growth
0-6 Months. Thesis Faculty of Nursing, University
of Hasanuddin.; 2014.
5. Lancaster G, McCray G, Kariger P, Two T, Titman
A, Chandna J, et al. Creation of the WHO Indicators
of Infant and Young Child Development (IYCD):
Synthesis Metadata Across 10 Countries. Glob
Heal BMJ. 2018;3(5).
6. Meita Dhamayanti M. Cognitive and Language
Disorders Screening Using Scales Capute
(Cognitive Adaptive Test/Clinical Linguistic
and Auditory Milestone Scale-Cat/Clams). Sari
Paediatr. 2009;189–98.
7. Febriana, and SH, Lestari P. The Influence
of Stimulation at 12-36 Months Childhood
Development in Sub Sedayu, Bantul. Nurses
Midwifery J Indones. 2016;4(1):44–8.
8. Cendy Dwiayu Ashari, W. Utami S. Relations
Parenting Parents with Cognitive Development
Children Aged 3-4 Years in early childhood
Southern District of Magelang. Nurs News
(Meriden). 2017;2(2).
9. MOH. Stimulation Guidelines, Detection and Early
Intervention Growth in the Level of Primary Health
Care. 2006;
10. Chamidah A. Nur. Early Detection of Impaired
Growth and Development of Children. J. Educators.
Specifically. 2009;83–93.
11. Khadijah. Early Childhood Cognitive Development.
Terrain: Prime Publishing.; 2016.
12. Oudgenoeg-Paz, O., Mulder, H., Jongmans, MJ,
van der Ham, IJM & Van der Stigchel S. The Link
Between the Motor and Cognitive Development
in Children Born Preterm and/or with Low Birth
Weight: A Review of Current Evidence. Neurosci
Biobehav. 2017;382–93.
13. Luttikhuizen dos Santos, ES, de Kieviet, JF, Konigs,
M., van Elburg, RM & Oosterlaan J. Predictive
Value of the Bayley Scales of Infant Development
on Development of Very preterm/Very Low Birth
Weight Children: A Meta-Analysis. Early Human
Development. 2013;487–96.
14. Whitehousea, AJ, Robinsona M, Lia J, Oddya
a. W. Duration of Breastfeeding and Language
Abilities in Middle Childhood. Pediatric Perinatal
Epidemiology. 2010;44–52.
15. Aline Andres, P., Mario A Cleves P, Jayne B.
Bellando P. Developmental Status of 1-Year-Old
Infants Fed Breast Milk, Cow’s Milk Formula, or
Soy Formula. American Academy Pediatrics. 2011.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  89

Analysis of Human Platelet Antigen (HPA) in

Thrombocytopenia Patients

Rachmawati Muhiddin1, Nelly1, Asvin Nurulita1, Tutik Harjianti2, Moch Hatta3, Mansyur Arif1
1Department of Clinical Pathology, 2Department of Internal Medicine, 3Department of Microbiology,
Medicine Faculty Hasanuddin University, Makassar, Indonesia

Abstract
Human Platelet Antigen (HPA) is a form of immunogenic polymorphism of platelet membrane glycoproteins.
Human Platelet Antigen can cause platelet alloimmunization response will be clinical manifestations of
immune thrombocytopenia, such as Fetal Neonatal Allo-immune Thrombocytopenia (FNAIT), Post
Transfusion Purpura (PTP), and Platelet Transfusion Refractory (PTR), Idiopathic Thrombocytopenic
Purpura (ITP). The aim of this study to research on seroprevalence (genotype and frequency) of Human
Platelet Antigen (HPA) in Patients with Non-Immune and immune Thrombocytopenic.

A Cross sectional study was conducted to 66 patients with thrombocytopenia, Samples were collected during
the period Mei-July 2019, and HPA genotypes were identified in buffy coat blood samples. Samples were
examined by PCR examination to detect HPA genotype at Medical-Research Center Laboratory/Medical
Faculty of Hasanuddin University Hospital, Makassar. Data was analysis by the statistical tests used were
Independent-t, Mann-Whitney, Chi-Square and Fisher Exact tests. The results of the test were significant
statistically if the p-value <0.05.

Result. From 66 patients thrombocytopena, ages 19-82 years, . 41 (62.1%) women and 25 (37.9%) men.
31 (47.0%) patiens were non immune thrombocytopenia and 35 (53.0%) were Immune Thrombocytopenia.
The highest HPA frequency (100%) was HPA-1b, 2a, 4a were obtained in both non-immune and immune
thrombocytopenia. In this study, there were frequency of HPA 1b, 15a, in both non-immune and immune
thrombocytopenia where was not found in the normal population in Makassar (in our research before).
Frequency of HPA-4b (2.8%) was obtained in the population of immune thrombocytopenia that was not
found in non-immune thrombocytopenia. The Positive distribution HPA-3b was found to be significantly
higher in the Immune group (22.9%) than in the Non-Immune group (3.2%) (p <0.05).

Conclusion: The frequency of HPA-3b was found to be significantly higher in immune thrombocytopenia
than non-immune thrombocytopenia.

Keyword: Human Platelet Antigen, Non immune, Immune, Thrombocytopenia.

Introduction results of the International Working Group (IWG)

Thrombocytopenia is a platelet count less than
normal, the normal platelet value is 150,000-400,000/
μL. The mechanism underlying thrombocytopenia is due
to suppression of platelet production, increased platelet
consumption and platelet lysis or damage through
immune or non-immune reactions. Thrombocytopenia
causa immune is one of the immune diseases characterized
by platelet counts of less than 100,000/μL without other
causes of thrombocytopenia, with or without a decrease
in other haematological parameters (based on consensus
panel in 2009 which published the provided guidance).
1 Decreased platelet count is caused by platelets bound
by antibodies, especially IgG, which originate from
the patient’s own body.2 The aetiology of immune
thrombocytopenia is still unclear, environmental and
genetic factors play an important role in pathogenesis.3
Human Platelet Antigen (HPA) is a form of
immunogenic polymorphism of platelet membrane
glycoproteins. The HPA nomenclature has now identified
21 HPA bineal systems, generally composed by Single
90  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Nucleotide Polymorphism (SNP) in genes that encode
the glycoprotein membrane that is relevant except for
one arranged single amino acid substitution.4,5
Platelet plasma membranes consist of many
glycoproteins (GP) and phospholipids. The most platelet
glycoproteins are GPIIb-IIIa, GPIa-IIa, and GPIb-IX.
Twenty-four HPAs have been identified serologically,
and the molecular basis of 22 of them has been identified.
Twelve HPAs are grouped into six bineals (HPA-
1a/1b, 2a/2b, 3a/3b, 4a/4b, 5a/5b, and 15a/15b). Higher
frequency alleles are defined as “a” (such as HPA-1a)
and low-frequency alleles “b” (such as HPA-1b). 6
The frequency of the HPA genotype varies between
populations and different ethnic groups. 4,5,6
Human Platelet Antigen can cause platelet
alloimmunization response which can cause clinical
manifestations of immune thrombocytopenia, such
as Fetal Neonatal Allo-immune Thrombocytopenia
(FNAIT), Post Transfusion Purpura (PTP), and
Platelet Transfusion Refractory (PTR), Idiopathic
Thrombocytopenic Purpura (ITP). 5,7,8 Establishing
an HPA system pattern is the basis for diagnosing
and managing risk and managing the diagnosis. 4,5,9
Knowledge of the HPA genotype and frequency of
antigens in a population is important, especially for the
supply of appropriate blood components for patients
with PTR. 4,8
Pai SC, et al., have conducted HPA-1 through-6
and HPA-15 allele genotypes in 998 platelet donors by
PCR-RT method at 6 blood service centres in Taiwan,
the results of the study showed based on the frequency
of HPA-15b alleles. and HPA-3a, which have the
most important role as causative factors, FNAIT, PTP,
and PTR followed by HPA-2,-6,-1,-5, and-4. Besides,
HPA-4b and HPA-5b are also considered to cause
immunogenicity.8
Data on the genotype and frequency of HPA in
populations in Indonesia do not yet exist, especially
in Makassar, so researchers want to research on
seroprevalence (genotype and frequency) of Human
Table 1: Basic data from the study sample
No Variable Mean
1. Age (years) 44,0
2. Gender:
Women
Men
Platelet Antigen (HPA) in Patients with Non-Immune
and immune Thrombocytopenic. Researchers hope the
results of this study can be the basis for further research,
especially in the management of diseases associated
with platelets.
Method
Samples and DNA extraction: Blood samples
were collected from 66 patients Thrombocytopenia,
31 patients were Non-Immune Thrombocytopenia
and 35 patients were Immune Thrombocytopenia. The
hematologic examination was performed with a Sysmex
automatic haematology analyser. DNA was prepared
from whole blood in ethylenediamine tetra acetic acid
(EDTA) by standard Method. The genotypes of HPA-
1 system were determined using the polymerase chain
reaction sequence-specific primers (PCR-SSP) method
designed by Skogen et al. and the SSPs were used to
discriminate between the alleles encoding the six major
HPAs in a series of patients and normal blood donors.
The thermocycler program consists of an initial step of
94°C for 5 min, followed by 32 cycles of 94°C for 30
s, 65°C for 60 s, 72°C for 60 s, and a final extension
step of 72°C for 10 min. The PCR products (15 μL)
were subjected to gel electrophoresis on standard
1.5% agarose gel containing 0.5 μg per ml of ethidium
bromide. The typing results were examined under UV
light transillumination.
Statistical analysis: Statistical analysis was
performed using SPSS version 12 statistical package
for windows. Allele and genotype frequencies were
calculated by direct counting.
Results
In this study, 66 samples study were obtained, with
a diagnosis of thrombocytopenia, ages 19-82 years, 41
(62.1%) women and 25 (37.9%) men. In this study, an
analysis of the frequency and genetic HPA of non-immune
thrombocytopenia and immune thrombocytopenia also
carried out an analysis of the haematological parameters
of platelets, leukocytes, and haemoglobin
Max Min Total %
82 19
41 62.1%
25 37.9%
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  91

No Variable Mean Max Min Total %

3. Platelet count (103/μL) 55.4 99 1
4. Leukocyte count (103/μL) 8.7 98 0.72
5. Haemoglobin levels (gr/dL) 10.1 17.7 3.34
6. Diagnosis
Non-Immune Thrombocytopenia
-  Malignancy 18 58.0%
-  Infection 12 38.7%
-  Malnutrition 1 3.3%
Immune Thrombocytopenia
-  Primary 24 68.5%
-  Secondary 11 31.5%

Data analysis was performed to assess the normality of numerical data distribution, the Kolmogorov-Smirnov
test was used, the statistical tests used were Independent-t, Mann-Whitney, Chi-Square and Fisher Exact tests. The
results of the test were statistically significant if the p-value <0.05

Table 2: Descriptive Statistics of age Platelets, Leukocyte, and Haemoglobin data distribution (n = 66)

Variable Min Max Median Mean SD p

Ages (years) 19.0 82.0 44.0 43.2 16.9 0.042
Platelets (103/μL) 1.0 99.0 60.0 55.4 31.2 0.195
Leucocytes (103/μL) 0.3 98.0 6.3 8.7 12.1 0.000
Haemoglobin (mg/dL) 3.3 17.7 10.0 10.1 2.9 0.032

*Kolmogorov-Smirnov test

Note:
· Age data of subject, Leucocytes value and Haemoglobin distribution was not normally (p <0.05)
· Platelets have values between 1.0-99.0 with a mean of 55.4 ± 31.1. PT data distribution is normal (p >0.05)
Table 3. Test results of sex differences in non-immune and immune thrombocytopenia

Groups
Gender Total
Non-Immune Immune
N 18 7 25
Men
% 58.1% 20.0% 37.9%
N 13 28 41
Women
% 41.9% 80.0% 62.1%
N 31 35 66
Total
% 100.0% 100.0% 100.0%

Chi-Square test (p=0,001)

Note: The distribution of men was significantly more in Non-immune (58.1%) than in Immune, while the distribution of women was
more in Immune (80.0%) compared to Non-immune (p <0.01)

Table 4. Test results for differences in age, number of leukocytes, haemoglobin, and platelets in immune and
non-immune thrombocytopenia

Variable Groups N Min Max Median Mean SD p

Non-Immune 31 19 82 53.0 50.9 15.6 0.000
Ages (Years)
Immune 35 19 68.0 35.0 36.5 15.2
92  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Variable Groups N Min Max Median Mean SD p

Non-Immune 31 19 68 35.0 36.5 15.2 0.797*
Leukocytes (103/μL)
Immune 35 0.3 16.3 6.1 7.4 4.3
Non-Immune 31 9.0 17.3 10.2 10.9 1.9 0.017*
haemoglobin (gr/dL)
Immune 35 3.3 17.7 9.3 9.4 3.4
Non-Immune 31 1.0 99.0 65.0 64.1 28.4 0.031**
Platelets (103/μL)
Immune 35 1.0 98.0 55.0 47.6 31.9

*Mann-Whitney test **Independent-t-test

Note: · Mean platelets were significantly lower in Immune

· The age of the subjects in the Immune group was
significantly lower than the age in the Non-Immune
group (median and mean) (p <0.001)
· The mean haemoglobin was significantly lower in
Immune (9.4) than in Non-Immune (10.9) (p <0.05)
(47.6) than in Non-Immune (64.1) (p <0.05)
The results of the examination of the frequency and
genotype of platelet HPA in non-immune and immune
patients the following results are obtained:

Table 5. Frequency and Genotype results of HPA in non-immune and immune thrombocytopenia

HPA- HPA- HPA- HPA- HPA- HPA- HPA- HPA- HPA- HPA- HPA- HPA-
Thrombocytopenia
1a (%) 1b (%) 2a (%) 2b (%) 3a (%) 3b (%) 4a (%) 4b (%) 5a (%) 5b (%) 15a (%) 15b (%)
Non-Immune 87.1 100 100 96.7 87.0 3.2 100 0 38.7 0 16.1 0
Immune 85.7 100 100 94.2 82.8 22.8 100 2.8 20 0 5.7 0

Furthermore, an analysis of the frequency and thrombocytopenia and immune thrombocytopenia with
genotype of HPA in patients with non-immune the following results

Table 6. Test results of differences in the frequency of HPA in non-immune and immune thrombocytopenia

Non-Immune (n: 31) Immune (n: 35) P

HPA
Positive n (%) Negative n (%) Positive n (%) Negative n (%)
HPA-1a 27 (87.1) 4 (12.9) 30 (85.7) 5 (14.3) 1.000
HPA-1b 31 (100) 0 (0) 35 (100) 0 (0) -
HPA-2a 31 (100) 0 (0) 35 (100) 0 (0) -
HPA-2b 30 (96.7) 1 (3.3) 33 (94.2) 2 (5.8) 1.000*
HPA-3a 27 (87.0) 4 (13.0) 29 (82.8) 6 (17.2) 0.739*
HPA-3b 1 (3.2) 30 (96.8) 8 (22.8) 27 (77.2) 0.030*
HPA-4a 31 (100) 0 (0) 35 (100) 0 (0) -
HPA-4b 0 (0) 31 (100) 1 (2.8) 34 (97.2) 1.000*
HPA-5a 12 (67.7) 19 (32.3) 7 (20) 28 (80) 0.094**
HPA-5b 0 31 (100) 0 35 (100) -
HPA-15a 5 (38.7) 26 (61.3) 2 (5.7) 33 (94.3) 0.240*
HPA-15b 0 (0) 31 (100) 0 35 (100) -

*Fisher Exact test, **Chi-Square test

 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  93
Discussion
In this study, 66 study samples were obtained,
with a diagnosis of thrombocytopenia, ages 19-82
years, 41 (62.1%) women and 25 (37.9%) men. Non
Immune Thrombocytopenia was 31 (47.0%) patients,
immune Thrombocytopenia was 35 (53.0%) patients,
consisted of 24 (36.3%) patients with primary immune
thrombocytopenia, and 11 (16.7%) patients with
secondary immune thrombocytopenia.
Based on the age of the subjects in the Immune group
significantly lower than the age in the Non-Immune group
(median and mean) (p <0.001). while the distribution of
women had more Immune (80.0%) compared to Non-
Immune (p <0.001). This study was appropriate with
previous research by Grace, et al, (2012) showed that
immune thrombocytopenia generally occurs at a young
age and is completely healed, and a small portion
continues into adulthood. In this study it was found
that there were significant differences in the gender,
where women higher than men, this is under research
by Andrès E et al. Andrès E, Immune thrombocytopenia
often occurs in young adults, especially women in the
third or fourth decade. Female dominance shows that
sex hormones can play a role in various aspects of ITP.10
In this study also carried out an analysis of the
haematological parameters obtained Leukocytes mean
lower in Immune than in Non-Immune but statistically not
significant (p> 0.05). In this study the comparison of the
mean Haemoglobin was significantly lower in Immune
than in Non-Immune (p <0.05) and the Thrombocyte
mean was significantly lower in Immune than in Non-
Immune (p <0.05). In non-immune patients, leukocytes
range between 300-98,000/μL. Increased leukocytes
due to the response to infection and also the neoplasm
process in leukaemia patients and thrombocytopenia
occur due to the inflammatory response an increase
in platelet consumption, whereas in neoplasms the
hematologic malignancies of thrombocytopenia occur
due to suppression of thrombopoiesis. In patients
with immune thrombocytopenia caused by platelet
lysis by an immunological response, an anti-HPA
antigen reaction to platelet HPA occurs. The degree
of thrombocytopenia depends on the immunological
process. The immunological process does not directly
cause effects on other hematologic parameters but does
have an impact when the platelet count is very low and
causes bleeding.
In this study found the frequency and genotype
of non-immune thrombocytopenia patients as follows
HPA-1a (87.0%), 1b (100%), 2a (100%), 2b (96.7%),
3a (87.1), 3b (3.2%), 4a (100%), 4b (0%), 5a (38.7%),
5b (0%), 15a (16.1%), 15b (0%). The frequency and
genotype of immune thrombocytopenia of HPA-1a
(85.0%), 1b (100%), 2a (100%), 2b (94.2%), 3a (82.9%)
3b (22.8%), 4a (100%), 4b (20%), 5a (20%), 5b (0%),
15a (5.71)%, 15b (0%).
In the study of Muhiddin R et al. get the frequency
and genotype of HPA in 100 people donor population in
Makassar was as follows HPA 1a (100%), 2a (100%),
2b (80.83%), 3a (75.83%), 3b (57.5%), 4a (99.17%),
and 5a (39.17%) were found in the Bugis, Makassarese,
Mandarese, and Toraja tribes in Makassar with the most
HPA genotypes found, namely HPA 1a and 2a. The
HPA genotypes 1b, 4b, 15a, and 15b were not found in
the blood donor population in Makassar.11
The results of this study showed positive results on
HPA-1b both non-immune thrombocytopenia (100%)
and immune (100%), while the results found in Muhiddin
R showed no frequency of HPA-1b was found in normal
donors. In this study also found the frequency of HPA-
4b was not found in non-immune thrombocytopenia
but found in HPA immune thrombocytopenia (20%).
In this study, the frequency of HPA-15a was found in
both non-immune thrombocytopenia (16.1) and immune
thrombocytopenia (5.7). This study shows that in
percentage there is a difference in HPA-3b and HPA-
15a in non-immune and immune thrombocytopenia with
frequency and genotype in the normal population in
Makassar.11
The results of this study differ from those found by Pai
SC, et al., having conducted HPA-1 through-6 and HPA-
15 allele genotypes in 998 platelet donors, the results of
the study showed based on the frequency of HPA-15b
alleles. and HPA-3a, which has the most important role
as causative factors, FNAIT, PTP, and PTR followed by
HPA-2,-6,-1,-5, and-4. Besides, HPA-4b and HPA-5b
are also considered to cause immunogenicity.8
In this study a statistical analysis of the differences
in the frequency of HPA-1a, 2b, 3a, 4a, 4b. 5a, and 15a,
in non-immune and immune thrombocytopenia, but not
significantly.
Positive HPA-3b distribution was found to be
significantly higher in the Immune group (22.9%) than
in the Non-Immune group (3.2%) (p <0.05). How the
mechanism of these differences still requires further
research.
94  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Conclusion
In conclusion, the highest HPA frequency 1b, 2a,
4a were obtained in both non-immune and immune
thrombocytopenia. In this study, their frequency
of HPA 1b, 15a, in both non-immune and immune
thrombocytopenia was not found in the normal
population in Makassar. Frequency of HPA-4b is
obtained in the population of immune thrombocytopenia
that is not found in non-immune thrombocytopenia.
The frequency of HPA-3b was found to be significantly
higher in immune thrombocytopenia compared to non-
immune thrombocytopenia
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: Obtained from university
ethical committee.
Reference
1. Anke K, Bergman, Grace R, Neufeld EJ. This
genetic study Pediatric ITP; outlook, feasibility and
requirements. Annual of Hematology. HHS Public
Access. Ncbi.nlm.nih.gow. 2014.
2. Neunert C, Lim W, Crowther M, Cohen A, Solberg
L and Crowther MA., Clinical Practice Guideline
on The Evaluation and Management of Immune
Thrombocytopenic Purpura, (ITP). American
Society of Hematology. 2011.
3. Wang T, Zhao H, Ren H, Type 1 and type 2 T-cell
profiles in idiopathic thrombocytopenic purpura.
Haematologica., 2005; 90:914–923
4. Jia-Yi T, Lay-Hoong L., Veera SN, Genetic
polymorphisms of human platelet antigens-1 to-
6, and-15 in the Malaysian population. Blood
Transfus; 2012,; 10: 368-76
5. Ruolin L, Lan Y., Jianghui Z., Xiuyun L., Genetic
polymorphism of human platelet antigens-1 to-17w
in the multi-ethnic Chinese Guangxi population Int
J Clin Exp Med 2016, ; 9(7):12992-12999
6. Mojgan S., Shahram S., Zahra A., Tahereh M.,
Jahangir A., Azita A., Leila K., Frequency of Human
Platelet Antigens (HPA-2/3/5) Polymorphism in
Iranians Evaluated by RFLP-PCR IJBC, 2011, ;3:
101-105
7. Mangerona CM, Garcia FB, Moraes H.,Frequency
of human platelet antigens (HPA)-1,-2,-5 and-
15
in Brazilian blood donors and establishment of
a panel of HPA-typed donors. Transfus Med. 2015
Jun;25(3):189-94.
8. Pai SC, Burnouf T, Chen JW, Lin LI., Human
platelet antigen alleles in 998 Taiwanese
blood donors determined by sequence-specific
primer polymerase chain reaction. Biomed Res
Int.;2013:973789.
9. Higgins M., Hughes A., Buzzacott N., Lown J.,
High‐throughput genotyping of human platelet
antigens using the 5′‐ nuclease assay and minor
groove binder probe technology, Vox Sanguinis ,
2004; Volume 87, Issue 2

10. Andrès E1, Mecili M, Fothergill H, Zimmer J,
Vogel T, Maloisel F., Gender-related analysis of
the clinical presentation, treatment response and
outcome in patients with immune thrombocytopenia.
Presse Med. 2012.
11. Muhiddin R, Nurulita A, Nelly, Hardjianty T,
Hatta M, Arif M., Seroprevalensi (Genotype Dan
Frekuensi) Human Platelet Antigen Di Makassar.
Proceeding Book Indian Ocean Rim Laboratory
Haematology Congress, 2019.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  95

The Application of Nesting and the Light Protective Cover of

Incubator to the Stability of Oxygen Saturation and the Pulse
of Low Birthweight Babies in the Newborn Intensive Care Unit
in RSU Undata Palu, Central Sulawesi

Andi Fatmawati Syamsu1, Aminuddin2

1Postgraduate Program of Medical Faculty, Faculty of Medicine, Hasanuddin University, Makassar,
2Senior Lecturerof Poltekes Kemenkes Palu. Indonesia

Abstract
Background and Objectives: During the care period of low birth weight babies (LBWB) at the Undata
Hospital, Palu, the nests used consisted of blankets that could change the low birthweight baby (LBWB)
and the thin layer incubator cover which still allow lightingto penetrate the incubator. Thus, the researchers
initiatedto use phlanyl and darco nests and thick incubator covers and observed the effects on the physiological
stability of LBWB.

Materials and Method: The study was conducted at the Undata Palu Public Hospital in 2018. Total
subjects were 12 LBWB consisting of 7 males and 5 females. The research design was One-group Prestest-
Posttest (Single Group Before and After Intervention) because it could collect more reliable data that it was
conducted the same subject with two different tests (before and after the intervention). Paired-sample t-test
was a statistical test used for a single group that proposed two different tests.

Results: The total means of oxygen saturation before and after intervention were 93.20% (CV = SD =
6.26%; variant = 39.18%) and 96.32% (CV = SD = 3.70%; variant = 13.70%), respectively. The total mean
of heart rate before and after the intervention was 93.20% (SD = 6.26%; variant = 39.18%) and 96.32% (SD
= 3.70%; variant = 13.70%). There was a significant difference between the oxygen saturation before and
after the intervention (p = 0.012 <0.05 significance level) and no significant difference before and after the
intervention (p = 0.012 <0.05 significance level).

Conclusion: The nest from phlanyl & dacron and thick incubator cover were proven increasing oxygen
saturation of LBWB and not proven to provide a useful contribution in lowering the LBWB pulse. It was
probably due to the temperature of LBWB as a confounding factor.

Keywords: Nesting, incubator cover, developmental care, physiological response, low birthweight baby.

Introduction high in East Nusa Tenggara (28.7%) and the lowest in

Based on the Indonesian Demographic and Health
Survey in 2007, the infant mortality rate in Indonesia
was 34 per 1000 births with a neonatal mortality rate of
19 per 1000 live births (Wijaya, 2009). LBW prevalence
was less than 11.1% in 2010 to 10.2% in 2013. Variations
between provinces were very striking from the lowest in
North Sumatra (7.2%) to the highest in Central Sulawesi
(16.9%). For the first time in 2013, data was collected
on the length of the baby born, with the National rate of
<48 cm short-born babies was 20.2%, varying from the
Bali (9.6%)1.
A number of studies have revealed that stress
reduction in newborn babies can be obtained in the
Newborn Baby Intensive Care Unit which includes
the provision of low light, low sound, warmth, soft
touch, pain control, lamping and nesting2, adjusting
the humidity levels of incubators for LBWB during
the first two weeks of age since LBWB was born,
temporarily held the infants in the incubator until it had
adjusting temperature ability to the changes in ambient
96  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
temperature, giving an incubator cover to protect his
eyes from the light3.
The baby’s body position affects stress on LBWB.
Supine position has the opportunity to reduce 40%
of infant mortality due to infant suds syndrome and
prone position to support neuromuscular development,
especially the neck and head muscles. Based on the
empirical facts as observed, the researchers applied
nests that mimicked the condition of the mother’s womb
made of phlanyl delicate material containing pieces
of cloth (darco) with a length of approximately 121-
132 cm and can be adjusted to the baby’s body length.
Dacro materials are more elastic and can be adapted
to the baby’s posture. The cover of the incubator used
was made of a thicker cloth fabric that resembled a dark
blanket and covered the entire surface of the incubator,
thus preventing the direct lights entering the incubator2-4.
Based on the background of the problem stated
above, the purpose of this study was to examine the
effect of phlanyl and darco body position support media
and thick protective light incubator cover on oxygen
saturation and pulse Low Birth Weight Babies in
Newborn Intensive Care Units (NICU) at Home Undata
General Hospital, Palu, Central Sulawesi.
Materials and Method
Research location: The study was conducted in the
Newborn Intensive Care Unit of Undata Hospital in Palu
City from January 1st to May 2018.
Research Design: The experimental design chosen
in this study was One-Group Pretest-Posttest (Single
Group Before and After Intervention),
Population and sample: The number of samples
was determined using differences test of a paired-group.
(Dawson and Trapp, 2001-not in the reference) stated in
the equation:
n=
Where:
n = number of samples
μ1 = mean score group 1
μ2 = mean score group 2
Z, α/2 = significance level 5%
Z, 1-β = 80% test power
σ2 = difference in variation of 2 samples
The minimum number of samples needed in this
study are:
n= = 9 (rounded up)
Statistical analysis: Analysis of the data used in
this study consisted of univariate and bivariate analysis.
1. Univariate Analysis: Univariate analysis is the
analysis of the characteristics of the descriptive
variables studied (Hastono, 2007). The
characteristics of the descriptive variables observed
in this study were gestational age, birth weight,
and body weight during the study by calculating
the mean, median, standard deviation (SD), and
minimum and maximum values at a significance
level of 95% (α = 0.05).
2. Bivariate Analysis: This study used a paired sample
t-test which compared two different tests in the
same single group (Siswosudarmo, 2015). Oxygen
saturation and pulse were analyzed by collecting
data on mean, median, standard deviation (SD), and
minimum and maximum values at a significance
level of 95% (α = 0.05). In this study a comparison
of oxygen and pulse saturation in 12 LBW samples
were conducted by using a nest of blankets and
incubator cover made from thin material and nest
made from phlanyl and darco and thick incubator
cover.
Research ethics: All research subjects were treated
according to human ethics guided by the Standards of
Ethical Nursing Research published by the Association
of American Nursing Scholars. Ethical research approval
for the research subjects was examined and approved
by the Health Research Ethics Comission of Health
Polytechnics, the Ministry of Health of Yogyakarta as
stated in the Research Ethics Decree with Registration
Number N0. L.B.01.01/KE-02/XXIX/711/2017, and
written permission statement from parents or legal
caregivers of the research subject.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  97

Results
Effects of Physiological Reactions

Table 1. Oxygen saturation levels (% per minute) and heart rate (times per minute) of LBWB (n-12) in test 1
(before intervention) and test 2 (intervention) during the 20-minute measurement interval.

Average Oxygen Saturation (%/minute) Average Pulse Rate (times/minute)

Test 1 Test 2 Test 1 Test 2
Total Sample (n = 12) Rolled blanket Phlanyl/Dacron Based Rolled blanket Phlanyl/Dacron Based
Nest and thin cloth Nest and thick cloth Nest and thin cloth Nest and thick cloth
incubator covers incubator covers incubator covers incubator covers
LBWB 1 98,1 97,6 143 140,2
LBWB 2 98,2 96,4 133,2 117,7
LBWB 3 75,4 85,6 120,1 138,5
LBWB 4 88,8 93,4 135,3 136,3
LBWB 5 97,4 95,9 109,1 123,7
LBWB 6 96,3 96,9 139,8 152
LBWB 7 97 98,3 124,3 148,9
LBWB 8 92,1 98,2 132,2 148,8
LBWB 9 93,1 98,9 131,9 94,8
LBWB 10 94,3 97,7 104,2 105,8
LBWB 11 93,2 98,5 143,6 158,3
LBWB 12 94,5 98,4 140,2 147,2
Total Rerata 93,20 96,32 129,42 134,35
Low oxygen levels, less High oxygen levels are Low pulse because low High pulse because of
Teory
comfortable more comfortable temperatures high temperature
Not Confirmed the
Result Confirmed the theory Confirmed the theory Confirmed the theory
theory

Effect of nest on oxygen saturation.–Babies were
comfortable-oxygen saturation increased.
Effects of non-test on heart rate — babies became
stressed-their oxygen saturation decreased.
Body temperature drops, oxygen saturation rises.
The thin cloth covering the incubator caused an
increase in the beam of light that hits the baby, increasing
the stress on the baby. Stress in babies causes lower
oxygen saturation.
The thick cloth covering the incubator caused the
light to be reduced to reduce stress on the baby. Thus,
his heart rate decreased.
Pulse frequency is strongly influenced by physical
activity and other situations that can cause the body’s
metabolism to increase such as increases in body
temperature and anxiety or stress4.

Table 2: Normality of oxygen saturation and pulse rate of LBWB (n = 12).

p Value (Asymp. Sig. Value)

Variabel Before Intervention After Intervention Remarks
(Rolled Blanket Nest and thin cloth (Phlanyl/Dacro Based Nest and thick
incubator cover) cloth incubator cover)
Oxygen Saturation 0,375 0,271 Normal
Pulse Rate 0,631 0,689 Normal
98  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
The results of the normality test data show that test in this bivariate analysis. This is evident from the
oxygen saturation and pulse rate in the test group 1 value of p> 5% significant level.
(nesting with roll blanket and incubator cover made of
thin cloth) and test group 2 (nest made from phlanyl Description of physiological reaction data
and dacro and thick incubator cover) were normally comparison of total mean oxygen saturation and pulse
distributed so that paired t test was used as a parametric before and after intervention is shown in Table 3.

Table 3: Total mean oxygen and pulse saturation levels before and after the intervention (n = 12).

Independent Variable
Before Intervention After Intervention
Dependent Variable Rolled Blanket Nest and thin cloth incubator Phlanyl/Dacro Based Nest and thick cloth
cover incubator cover
x Min. Max. SD Varian x Min. Max. SD Varian
O2Saturation 93,20 6,26 75,40 98,20 39,18 96,32 3,70 85,60 98,90 13,70
Pulse Rate 129,42 12,82 104,00 143,00 164,27 134,35 19,76 94,80 158,30 390,54

Table 3 shows the total oxygen saturation level of
group 1 (nesting with roll blanket and incubator cover
made of thin cloth) at 93.20% (SD = 6.26%; variance =
39.18%), while the total mean oxygen saturation level
of group 2 (nest made from phlanyl and dacro and thick
incubator cover) at 96.32% (SD = 3.70%; variance =
13.70%).
Bivariate analysis before and after intervention:
Bivariate analysis was performed to calculate the
difference in the average of total oxygen saturation and
pulse before and after the intervention. Table 9 shows
the total mean oxygen saturation of LBWB before and
after intervention. The total oxygen saturation before
intervention was 93.2% (SD = 6.26%), while the total
oxygen saturation after intervention increased by
96.317% (SD = 3.70%).

Table 4: Total mean of oxygen saturation at LBWB before and after intervention

Mean N SD Std. Error Mean

Before intervention 93,200 12 6,2597 1,8070
Pair 1
After intervention 96,317 12 3,7013 1,0685

The difference in total oxygen saturation before
intervention and after intervention is 3.1167% shown in
Table 10. In Table 10, there were significant differences
in oxygen saturation before and after intervention. This
was observed from the range of confidence values (CI)
not exceeding zero (lower limit =-5,4006; upper limit
=-, 8327; p = 0.012 <real level 0.05). Thus, nest made
from phalyl/dacron and thick incubator cover made a
significant influence on the increase in oxygen saturation
compared to the nest of blankets and thin incubator
covers.

Table 5. Differences in total mean oxygen saturation before and after intervention (n = 12).

Paired sample t-test

Paired Differences
95% Confidence Interval of p-value Sig.
Std. Error T df
Mean SD the Difference (2-tailed)
Mean
Lower Upper
Before Intervention
Pair 1 -3,1167 3,5947 1,0377 -5,4006 -,8327 -3,003 11 ,012
After Intervention
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  99
Discussion
Nurses have an important role in creating a stress-
free care environment. The environment of care can be
created through the treatment of growth and development.
In this study, the care aspects of developmental care
provided included thick-incubators cover to reduce the
lighting and installation of nests with dacron materials
to support the baby’s body in a flexed position, provide
comfort, maintain normality of the torso, and support
self regulation.
Oxygen saturation states the percentage of
oxygenated hemoglobin in the blood. The important
role of hemoglobin is to bind oxygen in each molecule.
Hemoglobin is a protein compound that has four globin
and porphyrin polypeptide chain subunits, each of which
contains heme. Heme itself contains one iron atom in
the form of ferro, so that one hemoglobin molecule has
four iron atoms that will bind four oxygen molecules5-8.
Therefore, if the hemoglobin level in the blood decreases,
it can reduce the value of oxygen saturation. This is
presumed as a temperature factor affecting the increase
in the value of the test pulse 2 (after intervention)
compared to the group before intervention. Body
temperature factors may be expressed as confounding
factors (a confoundeing factor) on comparisons between
groups before intervention and after intervention in this
study. Nevertheless, the average value of total oxygen
saturation after the intervention experienced a higher
increase than the group before the intervention7-10.
Body temperature data 12 LBWB is important
included in the general data above (Table 2). Body
temperature data need to be measured as a confounding
factor which explains why the pulse of the treatment
group is higher even though given nest made from
phlanyl/dacro and incubator cover made from thicker
than before intervention. The body temperature data
on LBWB given rolled blanket nest and thin layer
cover were measured using paired t-test. Effect of body
temperature on the pulse of LBWB given nest made
from phlanyl/dacron and thick incubator cover measured
using paired-t test.
Conclusion
Nest made from phlanyl & dacron and thick
incubator cover proved to be significant in increasing
physiological stability of LBWB judging from the
increase in LBWB oxygen saturation even though it was
not proven to significantly increase the LBWB pulse rate
compared to before intervention. Further research on the
application of nest made from phlanyl and dacron and
thick-coated incubator cover in the Infant Birth Care
Unit is needed in order to support the improvement
of developmental care approach for reducing neonatal
mortality.
Conflict of Interest: None
Ethical Clearance: Obtained from univeristy
ethical committee
Source of Fund: Self
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 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  101

Effectiveness of Flipchart Toimprove Knowledge and Attitude

about Tuberculosison Mandar Etnic in Majene District West
Sulawesi

Madjid Abdul1, Muh Syafar2, Arsunan, A.A.3, IdaLeida Maria3, Muh Tahir Abdullah4,
Syamsiar S. Russeng5, Anwar Mallongi6
1PostgraduateProgram, Epidemiology Department, 2Health Promotion and Education Behavior, 3Epidemiology
Department, Biostatistics Department, 5Occupational Health and Safety Department, 6Environmental Health
4

Department, Faculty of Public Health, Hasanuddin University, Makassar

Abstract
Case detection in the TB control program in Majene Regency is still low. This study aims to increase
active case detection through counseling to housewives using flipchart containing social determinants of
tuberculosis. This study uses a quantitative method with 200 survey respondents selected using the zig-
zag method. Quantitative data were analyzed using the statistic Wilcoxon signed Ranks Test. The results of
the average score of knowledge before 41.86 and after intervention 102.34 with a value of p = 0.000 and
attitudes showed there were differences before and after the intervention where the value of p = 0,000 then
the detections of cases by mothers and cadres were measured after three months of intervention increased by
100%. Discussion and conclusions; knowledge of attitudes and case-detection actions before and after the
intervention increased on average so it can be concluded that the FGD intervention model with counseling
was very suitable to be applied to increase the knowledge of mothers detection TB cases.

Keywords: Case Detections, Social Determinants, Empowerment.

Introduction Majene Regency is the location of the research.

West Sulawesi Province has also implemented
the DOTS strategy as an effort that believed to be
effective in stopping the spread of TB, but the results
have not been able to reduce the incidence of TB in
West Sulawesi Province. Early case detection such
as pulmonary tuberculosis can prevent and break the
chain of transmission by making early detection and
earlytreatment is prevention and treatment efforts that
must be carried out simultaneously (parallel) and is
simultaneous in nature1. At present, the incidence of
tuberculosis is quite high as much as 395 per 100,000
inhabitants (Sulbar TB report. The description of
the high incidence that has not been matched by high
detections demands that the local government look for
the right case detection method and can be scientifically
accountable. The idea of detection a case that links
social determinants with the flow of TB events is in line
with the recommendations of the 2016-2020 RAN for
TB Research 2
This regency is the center of the Mandar ethnic royalty
besides that Majene Regency for 3 years carrying out a
strategy but always showing low TB cases detectionand
never reach the target, seeing that in 2014 the target
was set at 80% but the case detection was only 67%,
and in in 2015 the target was set at 90% but coverage
was only 72%, so in 2016 the target was set at 90% and
achievement was only 75%3.
As explained earlier in this paper, the cause of
tuberculosis is Mycobacterium tuberculosis but the
battery is not enough for someone to become ill. With
the method of focus group discussion (FGD) using a flip
sheet with the concept of Mandar culture as a promotion/
communication media, it can give an idea of the level
of knowledge and attitudes of respondents regarding
TB. Based on the above concept, the researcher tried to
understand the differences in the increase in knowledge
and attitudes of respondents before and after being
given health education regarding TBC with flip sheet
102  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
media with a concept that described the condition of the Table 1. Distribution of Respondents by
Mandar ethnic real estate in the Rangas urban village. Characteristics of Respondents

Materials and Method Variable

Amount
n = 200 %
Location and Research Design: This study was
Gender
carried out in the Rangas urban village, Banggai District, a.  Male 83 41.5
Majene Regency, West Sulawesi in January-November b.  Female 117 58.5
2018. The type of research is operational research, with Age
a quasi-experimental design. a.  <30 years 57 28.5
b.  31-40 years 81 40.5
Population and sample: The population in this
c.  41-50 years 45 22,5
study were all housewives who were in the area of
d.  > 50 years 17 8.5
the Rangas Community Health Center, Banggae Sub-
Education
District, Majene Regency, West Sulawesi. Sampling
a.  Not School 9 4.5
selected usingpurposive cluster sampling with a sample b.  Elementary School 125 62,5
size of 258 people, from the selected sample size refers c.  High School 49 24,5
to 10% of opinions and also refers to SEM modeling, d.  College 5 2,5
an analysis tool that requires a minimum of 100-200 e. Magister (Professional/Postgraduate 6 3,0
samples so that 200 samples were taken in this study. f.  School of Religion 5 2,5
Residing in Rangas Urban Village, and is willing to take g.  Class Literacy 1 0,5
part in this research as a respondent. Occupation
a.  Free-lancer 53 26.5
Data collection Method Data: Datacollection was b.  Farmers 8 4.0
carried out by researchers using questionnaires (age, sex, c.  Civil Servants 4 2.0
education, family income, respondents’ knowledge and d.  Entrepreneur 15 7.5
attitudes about TB, which were carried out before and e.  Fishermen 57 28.5
after treatment in the form of Focus Group Discussion f.  Other 63 31.5
(FGD) with flipchart method. The results of this study Family Income
presented in the form of tables and narratives a.  <Rp.500,000 78 39.0
b.  Rp.500,001-Rp.1,000. 000 86 43.0
Data Analysis: Data analysis performed was c.  Rp.1,000,001-1,500,000 23 11.5
univariate, bivariate analysis with the Wilcoxon signed d.  1,500,001-1 Rp.3,500,000 6 3.0
Ranks Test e.  > Rp.3,500,000 7 3.5

Source: Primary Data, 2018

Results
Sample characteristics: Table 1 shows the results
of univariate analysis, based on sex, showing the highest
number of female respondents was 58, 5%. Age shows
the highest number of respondents in the age group of
31-40, which was 62.5%. The level of education shows
the highest number of respondents at the Elementary
School level, which was 62.5%. Based on the work,
most respondents work as housewives who sell their
husband’s haulwas 31.5%. The family income per
month for most respondents in the group of Rp.500,001-
Rp.1,000,000 was 43.0%.
Based on the research variables, the distribution
of respondents based on the level of knowledge and
attitudes of respondents regarding TB shows that there
were 58.5% of respondents who have a sufficient level
of knowledge about TB, and based on the variable
attitude of respondents regarding TB there are 75.5% of
respondents who have a fairly good attitude, Table 2.
Based on table 2, Ranks have a negative level of
586.0 and the number of positive levels was 18524.0.
In table 3, the value of Z =-11,375 and the value of p =
0,000 <0,05, then Ho is rejected, so it can be concluded
that there was a difference in knowledge of TB before
and after FGD with the flipchart method or it can be
interpreted that there was an effect flipchart method for
increasing knowledge about TB in respondents.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  103
Table 2: Distribution of Respondents by Knowledge of TB

Number of
Variable Pre-Test Post-test
n = 200 % n = 200 %
Seriousness of TBC
a.  Very Seriously 136 68.0 196 98.0
b.  Moderate Serious 29 14.5 2 1.0
c.  Not Too Serious 35 17.5 2 1.0
Causes of transmitted tuberculosis
a.  through handshake 6 3.0 0 0,0
b.  through the air when people with TB coughing/sneezing 127 63,5 196 98,0
c.  Food share 5 2,5 1 0,5
d.  Using the same dishes and food 15 7,5 2 1,0
e.  not know 47 23,5 1 0,5
TB prevention
a.  Avoid sharing dishes 39 19,5 0 0,0
b.  Window Covering 12 6.0 2 1,0
c.  Good Nutrition 73 36,5 2 1,0
d.  Praying 17 8,5 5 2, 5
e.  Don’t Know 56 28,0 1 0.5
f.  Others 3 1,5 190 95.0
Opportunities for Infected with TB
a.  Anyone 179 89.5 193 96, 5
b.  Only Poor people 10 5.0 5 2.5
c.  Only Alcoholics 2 1.0 0 0.0
d.  Smoker 7 2.5 2 1.0
e.  others 2 1.0 0 0.0
Causes of TB
a.  Germs 61 30.5 2 1.0
b.  Virus 112 56.0 2 1.0
c.  Poisoning Food 1 0.5 3 1.5
d.  Curse 1 0.5 0 0.0
e.  Genetics 23 11.5 5 2.5
f.  Other 2 1.0 188 94.0
Main Symptoms of TB
a.  Cough 35 17.5 0 0,0
b.  Phlegm Cough for> 2 weeks 74 37.0 191 99,5
c.  Fever 2 1, 0 0 0,0
d.  Sweating at Night 10 5.0 0 0,0
e.  Blood Cough 64 32,0 9 4,5
f.  Other 15 7,5 0 0,0
TB Can Be Cured
a.  Yes 191 95,5 199 99.5
b.  No 9 4,5 1 0.5
How to Cure TB
a.  Herbal Medicine 6 3.0 1 0.5
b.  Rest at home 1 0.5 0 0.0
c.  Specific Drugs from CommunityHealth Center 51 25.5 2 1.0
d.  OAT Regularly Until Complete 108 54.0 197 98.5
e.  Don’t Know 33 16.5 0 0.0
f.  Other 1 0.5 0 0.0
TB and TB
a.  TB and TB are the same 24 12.0 187 93.5
b.  Unequal TB and TBC 174 87.0 13 6.5
c.  Don’t know 2 1.0 0 0.0

Source: Primary Data, 2018

104  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Table 3. Tests of Normality Knowledge

Kolmogorov-Smirnova Shapiro-Wilk
Statistics df Sig. Statistics df Sig.
Pre post Knowledge TB .137 200 .000 .941 200 .000
Post test Knowledge TBC .474 200 .000 .271 200 .000

Source: Primary Data, 2018

Tables 4 and 5 are the results of the Wilcoxon Signed Ranks Test for respondent’s knowledge of TB
Table 4. Ranks knowledge

N Mean Rank Sum of Ranks

a
Negative Ranks 14 41.86 586.00
b
Positive Ranks 181 102.34 18524.00
poTOT.PTB – prTOT.PTB
Ties 5c
Total 200

Source : Data Primer, 2018

Table 5. Test Statistics Knowledge
poTOT.PTB - prTOT.PTB
Z -11.375a
Asymp. Sig. (2-tailed) .000
Source : Data Primer, 2018
In table 4, Ranks were negative 141.0 and positive
numbers are 2634.0, and in table 5 are Z =-6,879 and p
= 0,000 <0.05, so Ho is rejected, this can be interpreted
as different attitudes before and after FGD with the
flipchart method or it can also be interpreted that there is
the influence of the FGD with the method of flip sheeting
on the attitude of the respondents.
Discussion
The relationship between the level of knowledge and
the incidence of Tuberculosis in the community is very
close. Courtwright and Tumer (2010) suggest that in
addition to increasing knowledge about tuberculosis, it
can change one’s mindset and stigma so that prevention
or treatment for TB patients can work well. According
to the Indonesian Health Profile in 2008, the number of
new positive cases of Acid Resistant Basil TB (BTA) in
the age group 0-14 years in Indonesia amounted to 1861
cases.
Based on the statistical Wilcoxon signed Rank Test
conducted, it was found that there was an increase in
the knowledge of the respondents after the intervention
was conducted in the form of a focus group discussion
using the flip chart method as a promotional media. The
results of this study were also supported by previous
research which suggested that by promoting TB on flip
chart media, or electronic media can increase people’s
knowledge about TB3. According to Deepa Makesh4
also researched the treatment of tuberculosis using two
Method and one of which was used as flip chart media
as a promotional medium, which after the approach was
made through the media, the respondents’ knowledge
increased compared to before.
A similar study carried out in Banyumas-Indonesia,
also stated this, that after counseling and counseling
through media back ships could significantly increase
mothers’ knowledge about pulmonary TB in children5.
Based on some of these researchers, it can be said that
the promotional media in the form of efficient flip sheets
increases the knowledge of respondents regarding TB.
The statistical Wilcoxon signed Rank test showed
that there was an increase in respondent’s attitudes
before and after the intervention in the form of focus
group discussions using flip sheets as a promotional
medium that contained positive and easily understood
things by respondents. Study also explains this, where
flip sheets are used as a communication medium to
improve the attitude of respondents who previously have
also been tested in other pilot locations.
Research that is corresponding obtained by Miller3,
wherein his research also uses flip sheets as one tool
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  105
or media promotion to change or increase the stigma
and attitude of the respondents. Croft et al6conducted
a survey of the level of knowledge and attitudes about
tuberculosis and leprosy in two regions in Bangladesh,
the results showed that there were significant differences
between regions that received a 2-year education
program in the form of day/night mass information
programs run from jeeps using flipcharts, loudspeakers
and two locally developed slide series that show simple
stories about leprosy and TB sufferers who receive
successful treatment.
A person’s attitude and knowledge are interrelated
so that in other studies, it is said that the low level of
knowledge about TB can affect behavior in seeking
patient health and maintaining the transmission of
disease in the community7. The high level of knowledge
a person can cause changes in one’s perceptions and
habits, behavior based on knowledge will last longer
than those not based on knowledge8.
Conclusions
This study concludes that based on the Wilcoxon
signed Rank Test conducted the results showed that there
was an increase in respondents’ knowledge and attitudes
after being given intervention in the form of focus group
discussion (FGD) using promotional media in the form
of a back-note with ethnic Mandar concepts.
Ethical Clearance: Taken from faculty of Public
Health ethical committee
Source of Funding: Self
Conflict of Interest: Nil
References
1. Arsunan, A.A. , Mengalir Melintasi Zaman,
Menebar Ide dan Gagasan Tanpa Batas, P3i Press.
2018.
2. Courtwright, A and Abigail N T. Tuberculosis and
stigmatization: pathways and interventions. Public
health report: 2010. ; 125: 34-42. Available online
at http://www.publichealthreports.org/
3. Miller, J. An Empowerment Approach to Raise
Awareness about and Reduce Stigma around
Tuberculosis among the Indian Community in the
Auckland Region. Multiplying and Dividing, 2008;
62.
4. Makesh, D.. Tuberculosis Tackling with Self-help
Group and Short Film: An Evaluation. In its2010;
(p. 1).
5. Sumiyati, S., Hastuti, P., & Widiastuti, A..
Effectiveness of Health Counseling on Knowledge
and Attitudes of Under-five Mothers About Lung
Tuberculosis in Children in Banyumas Regency.
LINK, 2018; 14(1), 7-13.
6. Croft, RP, & Croft, RA. Knowledge, attitude and
practice regarding leprosy and tuberculosis in
Bangladesh. Leprosy Review, 1999; 70(1), 34-42.
7. Talossa, Daniel. Community Knowledge, Attitude,
and Practices Toward Tuberculosis in Shingle
Town, Somali Regional State, Eastern Ethiopia: a
cross-Sectional Study. BMC Public Health. 2014. ;
1-14
8. Notoatmodjo, S.. Health promotion and health
behavior. Jakarta: RinekaCipta, 2012; 45-62.
9. Ida Leida. M.et.al Determinan Sosialdan
Keteraturan Berobat Terhadap Perubahan Konversi
Pasien Tuberkulosis Paru. 2014.
106  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Accelerative, Effective and Efficient Tuberculosis (TB)

Response to TB Elimination on 2035 in Medan Year 2017

Syarifah1, Tukiman1
1Public Health Faculty of Sumatera Utara University

Abstract
Indonesia includes the rank of two highest TB loads in the world. Incidence rate of TB in the city of Medan
High, the case of TB drug resistance (RO) highest in North Sumatra, low cure rate, high drop out. Research
aims to excavate 1) implementation of the mitigation program TB 2) implementation process 3) community
participation and NGOS in TB countermeasures program. Research, qualitative study of research informant
includes head of health office, head of Puskesmas, manager of TB Private Hospital, physicians of private
Practice and clinic, NGO engaged in the response of TB. Data is gathered through in-depth interviews with
informant. Processing and analysis of data is done through the stages of creating transcripts and analyzed
by content analysis. The results showed that the policy of TB’s handling was appropriate, the implementing
actors were right, all the Puskesmas has been implementing the DOTS strategy, but still many people
who do not know Puskesmas serve TB for free. Hospital support and physicians of private practice in the
reporting of low TB cases resulted in many cases missing, impacting the increased cases of TB MDR so that
government burden in the reduction of TB is getting heavier while TB budget is still Dominated by foreign
donors. NGOS have played a role in the management of TB but the coordination is not maximized, in the
implementation of there are still overlapping reporting activities to the stakeholders is not smooth, Public
Private Mix already exists but has not played a lot. In order to reach the elimination of TB year 2035 the
Municipal health Department of Medan has compiled a regional action plan (RAD) Countermeasures TB
Regulation status of the mayor. It is recommended that RAD should be implanted accordingly, right from
the internal and external environment and the accuracy of the accelerometer, effective and efficient process
to the elimination of TB.

Keywords: Accelerative, effective, efficient, elimination TB 2035, tuberculosis (TB).

Introduction the global target of the latest celebrity milestone of

In North Sumatra the prevalence of TB of 110.666
with a rate of 794/100,000 inhabitants, a TB incident of
68.828 with a rate of 501/100,000 inhabitants and deaths
from TB of 5.714 with a rate of 41/100,000 inhabitants,
case detection rates, issuing form a number of 22.961
(33, 3%)1-3. MDR-TB figures are estimated at 2% of all
new TB cases (2620 cases) and 20% of TB cases with
retreatment (42 cases), with a total of 2662 cases. As
of March 2016 4 changed found 356 TB MDR cases in
Rsup HAM. It is noted that TB MDR increases due to
inadequate countermeasures for TB. It is known that
the treatment of TB MDR is longer and costs much
greater, the effects of adverse reactions are very severe
and can transmit TBMDR in the surrounding people.
Adviesraad’s average celebrity success figure of TB
MDR treatment for the last 4 years is about 37% of
celebrities national TB program.
Although nationally demonstrating increased
developments in the discovery of cases and levels of
healing, achievements at the provincial level still show
disparity between regions. The discovery of the case
of Medan City increased from 5776 cases in 2014 to
6541 cases in 2015.5 The probability of higher TB drug
resistance in hospitals and private sectors that have not
been involved in national TB control program as a result
of high non-compliance and drop out rate of treatment
because it was not prepared High DOTS strategy. Data
from private service providers is not included in the data
on national TB control programs.
While in the hospital in Medan, the new data
available comes from about 41% of hospitals that have
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  107
implemented the DOTS strategy. The number of TB
cases in the city of Medan in 2015 reached 350 cases.
Case of TB proportions child of all cases TB reaches
5.4%. This figure is a partial description of the overall
case of actual TB of children considering the high case
of overdiagnosis in health facilities accompanied by a
low reporting of health care facilities.6
Pengelolaan tuberkulosis (TB) di Indonesia telah
dilaksanakan sejak jaman penjajahan Belanda. Tapi
faktanya menunjukkan bahwa TB masih merupakan
masalah besar dalam kesehatan masyarakat Indonesia.
Pada sebuah pengadilan WHA untuk 67 tahun 2014
menentukan resolusi pada pasca-2015 strategi kontrol TB
global yang bertujuan untuk menghentikan epidemi global
TB di 2035 ditandai dengan: 1. penurunan angka kematian
dari TB oleh 95% dari tingkat 2015,2 tahun. Penurunan
tingkat kejadian TB 90% (untuk 10/100.000 jiwa).
Furthermore, the support by the Government to
expedite the process is seen among others with the
issuance of circular letter from the Ministry of State
with No 440/4838 Bangda, on 26 October 2016 to all the
governor of Indonesia to Provide accelerated TB response
support. Furthermore, in the standard of Minimal service
(SPM) health in 2016 is also more firmly stated in the
12th Standart of health services people with TB.7
It is necessary to do research that aims to: 1) Excavate
the implementation of TB countermeasures program that
has been conducted by the city health agency Medan. 2)
Digging process implementation of TB countermeasures
program. 3) to explore public and NGO participation in
TB countermeasures program.
Method
Research Design: Research is a qualitative study
to explore more in-depth policies implemented in TB’s
countermeasures program in Medan City to obtain an
effective and efficient TB countermeasures strategy.
Qualitative Data was collected to explore the policy
implementation of policy makers in TB program of the
Medan city. Further excavated the role of NGOS and
engaged in TB in the program of TB.
Location: This research was conducted in Medan
because Medan is the capital city of North Sumatra
province with the problem of TB which is quite complex
from the heterogeneous population aspects, health
services both government and private, as well as TB
programs that conducted by NGOS.
Informants: Informant of this research: Head of
Health service, head of P2P section, Head of Infectious
diseases section as a manager of TB policy and NGO
engaged in the response of TB KNCV, JKM, Aisiyah,
Buddha She Chi.
Results
Implementation of TB Countermeasures
program in Medan Health office: DOTS strategy
is a national strategy that has been set in the TB
countermeasures program, data shows that all Puskesmas
in the city of Medan have been executing the DOTS
strategy. However, the difficult practice to implement
this strategy is an independent practitioner (DPM) and
a private hospital. There are pros and cons between
government programs and private physician practices in
this regard, such as informant:
“Doctors of independent practice still uphold
their diagnosis with photo Thorax/Roentgen While the
government is with sputum. In the case of government
treatment with the DOTS system and free but DPM with
paid. When the case comes first to DPM especially with
the low-economic social-then visit only a few times,
Karen is unable to pay, it will be released. Patients
who after this drug will inevitably spread the case to
the surrounding environment so that the incidence of TB
cases is still increasing and more severe when severe
then the case of visiting health care services and there
are those times it has suffered TB RO.
However, funding regulation for TB countermeasures
has been aimed at increasing the role of the Government
by having compiled the regional Action Plan (RAD)
of TB in Medan city which will be strengthened by the
legal status to be the rule of Mayor (PERWAL) . In
RAD, it has been determined that the case of TB is not
only addressed by the Department of Health but must be
addressed with cross-sector related, private, educational
institutions synergize and set targets for access, executor
and funding sources so that when donor assistance
has been reduced, the government burden is ready to
respond.
Coordination and synergy of the program has begun
to be improved both among government health services
and DPM where it is currently in case of notification of
cases in accordance with Permenkes No 67 year 2016
on the response of TB that each physician must make a
report (A mandatory notification) of tuberculosis. It has
been done training activities of MN-TB based Android
108  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
in Medan City, is expected through this network of TB
cases found at DPM can be immediately reported in the
Puskesmas in the working area and expected through
this network no longer exists Loos to follow TB cases.
Communication process in the implementation
of TB countermeasures program in Medan:
Communication process between health centers with
hospitals, clinics and DPM in its working area is less
harmonious especially in terms of reporting. Many cases
of TB from hospitals, clinics and DPM who do not
want to report a case of TB to Puskesmas even though
the notification rules have been in the invitation. To
overcome the loss to follow then inevitably the deputy
Supervisor (Wasor) TB must fetch TB reports by visiting
one by one health facilities, because non-governmental
health services consider them not required to report a
phrase:
“We have to pick up reports to non-governmental
health facilities because they do not feel obliged to
report TB cases to the Puskesmas”
Related to communication between hospital Adam
Malik as a reference to TB case with Puskesmas and vice
versa from Puskesmas to hospital Adam Malik has not
run smoothly which resulted in case of missing or drop
out. This can occur in the case of TB RO which after TB
RO patients submitted to the treatment Puskesmas such
as the expression of an informant of Puskesmas officers:
“TB patients who have undergone treatment
for approximately 2 weeks, do not want to go to the
Puskesmas anymore because of the severe side effects
of the drug so the family decides to bring medication to
DPM and feel it is getting healthier.”
Family patients with emotional tone say: “Why
we have a cure to the Puskesmas when making the body
feel sick, we come medicated because it wants to be
healthy.”
This Data indicates that the communication between
the officers and patients is not maximized where the
officers do not have to support the patient to bring to
the HOSPITAL Adam Malik because the SOP has been
explained that if the problem is experiencing the drug
side effects immediately Consultation with the clinical
expert team (TAK). “The drug given by the officer is the
drug from Puskesmas”
Meanwhile, it is known that there is no TB RO drug
from Puskesmas. The above Data indicatess that both
vertical and horizontal communication have not been
well-done due to the role of the individual and the ability
of the intertiller in accordance with the SOP, it is as the
same as the results of this study.9
Community and NGO participation in TB
countermeasures program
Like the following informant phrases: “JKM
starts from the preparation of community mobilization,
forming a cadre then there TOT. At the same time we
strengthen the community leaders and religious figures
so that there is special training for religious leaders
there are special training for community leaders. Then
there is also training for PMO of the patient’s family.”
The results of previous research conducted
by (9,10) showed that the discovery of cases in NGOS and
Puskesmas officials still scramble because of incentives
given to find different cases between NGOS. Bambang’s
research in Bantul Regency declares the discovery of
cases by officials of formalities and administrations.
As for the training of community leaders according
to the informant that focuses on advocacy as said the
informant:
“Advocacy is done in order to understand TB at
once will be the lower-level advocator. From village
and district level to district and Regency and provincial
level”
Aisyiyah NGO: This organization has been involved
in the response of TB gained funding, training and other
supporting facilities. The organization is engaged in
health but not in the TB program is called to suspend TB
because it has facilities and human resources such as the
following informant phrases :
“Organization: Aisyiyah, formed from Aisyiyah
Center with the establishment of TB CARE Community
Team 2009.”
Gain trust from the government through the GF
program participating in TB program. This Program
was named Community TB HIV Care Aisyah North
Sumatera. Initially the main task in response to TB is
like the following informant phrases:
“Looking for suspect TB and these cadres bring
TB patients to the Puskesmas. Aisyiyah cadres exist in
each sub-district and Kelurahan in Medan. In addition
to searching for Suspeck, the Institute also conducts
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  109
training in drug monitoring (PMO). The essence of the
program is that the patient does not end up with 6 months
of medication.” Almost the same study conducted10
Nevertheless, since the last 2 years, this foundation
has begun to handle the TB RO called the Supporter
Patient (PS), namely
“The healed TB patients were used as supporters
for other TB patients. Currently, this foundation already
has 3 PS, each of the PS accompanying 3 patients. In
addition in the year 2015, this Foundation has also set up
a stopover house to accommodate TB RO patients who
should get treatment in the RS referral Adam Malik.”
Research results of Erna M DKK11 In 2015 indicates
that in the case of the treatment of TB RO still found a
drug that has expired, after confirmed with the officer
that the year 2014-2015 is indeed too much drug in the
drop, but already Stated at that time all drugs should be
withdrawn, apparently there are also circulating.
LSM Buddha Tse Chi: The participation of
NGOS in the TB program actually originated from the
movement of this Organization in the field of social and
health that has been under the center of the institution
in cataract surgery. Subsequently this organization since
2015 began to move in the field of TB, feel called to
handle TB cases because of the high number of TB in
Indonesia.
“Since Indonesia is independent we already handle
TB but why until now still many of the case, because
people can not be overcome, people are uncomfortable
to come to the Puskesmas, no lung doctor, not friendly,
if come to a specialist doctor initially can but Because
expensive finally broke down the drug.”
Based on the facts in the field, the organization
coordinates with the city health office by expressing the
intention to participate in TB countermeasures Program,
no intention to bring religion, and not restrict an area
The head of Medan Health office that welcomes the idea
of the foundation as below:
“The most difficult to enter the health workers are
the Chinese, especially the ones in the area like Rame.”
For this, the foundation began to be interested in
the prevention of TB by establishing TB clinic in the
like crowded Puskesmas. But if further analyzed the
informant to say the embryos in the handling of TB is
actually already a few decades ago :“Cooperation with
NGOS and PPTI, but this activity is not the way, because
there is no doctor Who wants to practice guard in place.
Research on Syarifah 12) need to engage religious figures
in TB response in Medan.”
Conclusion
1. Implementation of TB countermeasures in the city
health office is already referring to the national
strategy but has not been able to run the maximum,
because not all health facilities, especially non-
extrapding health facilities, private clinics and
DPM complies with Established strategies.
2. The process of communication in the
implementation of TB countermeasures program
has not been maximally both vertical and horizontal
communication impacting TB’s tougher response.
3. Already many NGOS are petrified in TB
countermeasures program but the invention of the
case is not maximal, TB insides, TB RO cases, TB
DM, TB HIV and children are still increasing and
need complex countermeasures.
4. The elimination of TB will be achieved if the control
of TB is not only implemented by the Health office
but is addressed along with other related sectors and
refers to the regulation of the mayor of Medan No.
85 year 2017 on the regional action plan Response
of TB City Medan year 2017-2022 (Medan City
News year 2017 number 75).
Acknowledgement: Researchers thanked the
University of North Sumatra who have given funds
through the PNBP of North Sumatera University year
2017. Researchers are also grateful to the Jakarta City
Health Office and the provincial Health office of North
Sumatra which has provided secondary data and helped
expedite the research process. Also to all informants
who have been willing to provide data in accordance
with the facts for the needs of this research.
Ethical Clearance: Taken from University
committee
Conflict of Interest: Nil
References
1. WHO. Global tuberculosis report. Who. ttp://doi.
org/10.1007/s10393-014-0940-0. 2014
2. WHO.. Global Tuberculosis Report 2016. Geneva
3. WHO SEARO.. Tuberculosis control in the South-
East Asia Region, Annual Report 2016
110  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
4. Departemen Kesehatan RI . Pedoman Nasional
Pengendalian Tuberkulosis. Jakarta: Departemen
Kesehatan RI. 2014
5. Departemen Kesehatan RI.. Kebijakan
Pembangunan Kesehatan. Retrieved November
23, 2016, from http://www.depkes.go.id/resources/
download/info-terkini/rakerkesnas_gel2_2016/
Paparan Menkes.pdf
6. Dinas Kesehatan Kota Medan; Data Cakupan TB
Kota Medan diolah dari SP2TT. 2016
7. Departemen Kesehatan RI Permenkes No. 43
tentang Standar Pelayanan Minimal Bidang
Kesehatan . 2016
8. Murti, Bhisma, dkk. “Evaluasi Program
Pengendalian Tuberkulosis dengan Strategi
DOTS di Eks Karesidenan Surakarta” 2009https://
rossisanusi.files.wordpress.com/2013/09/evaluasi-
program-pengendalian-tuberkulosis-dengan-
strategi-dots1.docx (diakses pada 23 Maret 2017)
9. Setyawan, Aditya DB, dkk.“Implementasi Program
Penanggulangan Tuberkulosis di Kabupaten
Semarang Tahun 2013” http://download.
portalgaruda.org/article.php?article=314951
& val=4925 & title=IMPLEMENTASI%20
PROGRAM%20PENANGGULANGAN%20
TUBERKULOSIS%20DI%20KABUPATEN%20
SEMARANG%20TAHUN%202013 (diakses pada
23 Maret 2017)
10. Erna M, Syarifah dkk, Pengembangan Model
Kepatuhan Pasien TB Resistan Obat Dalam
Program Terapi di Kota Medan tahun 2015 Laporan
Penelitian Subdit TB Kemenkes RI. 2015
11. Fitriyah Amiruddin dkk : Implementasi Strategi
AKMS Dalam Penanggulangan Tb Paru Oleh
‘Aisyiyah Muhammadiyah Di Kota Makassar
Akms Implementation Strategies In Pulmonary Tb
Control Of ‘Aisyiyah Muhammadiyah In Makassar
12. Syarifah, Tukiman Pengembangan Model Pelibatan
Tokoh Masyarakat dan Tokoh Agama Dalam
Peningkatan Kepatuhan Pasien TB Resistan Obat
Dalam Program Terapi di Kota Medan. Laporan
Penelitian Lembaga Penelitian USU, 2016
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  111

Behavior of Tuberculosis Pulmonary Disease Prevention

(Tb Paru) South Sulawesi

Herman

Health Polytechnic Ministry of Health of Makassar, Edi Sukamto (Health Polytecnic Ministry of Health of East
Kalimantan), Syahida Djasang (Health Polytecnic Ministry of Health of Makassar)

Abstract
Diseases Tb. Lung is caused by the bacterium Mycobacterium tuberculosis, with the incidence rate in
Indonesia ranks third after China and India and attacks all age groups of society. The purpose of this research
is to know the behavior of disease prevention Tb. Lungs of Makassar City and the influence of disease
prevention knowledge Tb. lung from the aspect of controlling the source of p enyakit Tb. Lungs, aspects
Lung, and the aspect of increased endurance t against the disease Tb. Lungs. The type of research is analityc
survey. The study population is the people who live in the area of Makassar City. Samples of 335 people
obtained by multi stage sampling. Data analysis was performed by simple regression test and multiple
regression . Results of research that g the behavior of disease prevention targets Tb. The lungs of Makassar
City are generally good category . Lung effect on disease prevention behavior Tb. Lungs of Makassar City .
Lung effect on disease prevention behavior Tb. Lungs of Makassa City r . Lung effect on disease prevention
behavior Tb. Lungs of Makassar City . The lungs of the people of Makassar are the knowledge of the source
of the disease Tb. Lungs.

Keywords: Knowledge, Control, Disease Sources, Agent Disease, Body Resistance and Behavior.

Introduction cases found in male type as much as 5,259 cases (59,08%)

The Commitment of the Government in order to
decrease the case of Tb in Indonesia, it has been issued
Decree of the Minister of Health of the Republic of
Indonesia Number 364/Menkes/SK/V/2009 About
TB Control Guidelines referring to Directly Observed
Treatment Short-course (DOTS) strategy and
implemented in all parts of Indonesia. DOTS strategy
consists of 5 key components, namely: 1) Political
commitment, with improvement and sustainability of
funding. 2) The discovery of cases through microscopic
sputum examination of assured quality. 3) Standard
treatment, with supervision and support for patients. 4)
Effective management and availability of OAT systems.
5) A recording and reporting monitoring system capable
of assessing patient treatment outcomes and program
performance. But issue Tb. Lung in Indonesia is still
a serious problem because the case is still high and
attacking all age groups.1 (Ministry of Health RI, Year
2015).
Case incidence Tb. Lung with BTA (+) in South
Sulawesi Province (2013) reported as many as 8,902
and female gender 3,643 (40,92%). Bina field Disease
Prevention and Environmental Health Makassar City
Health Office (2014), the discovery rate of new cases of
TB BTA (+) in 2013 as much as 72.44% (found 1,811
people from 2,500 mark), this number increased from
2012 with a number of 1,324 sufferers of 1,641 targets.
When compared to the 2013 target of 70% then the
achievement rate exceeds the target with the percentage
of achievement of 72.44%.2 (Health Office Makassar,
Health Profile Year 2014).
The results of research related to the interaction
mentioned above are Media Y (2011) reported that the
community of Padang Panjang City has a knowledge
level about Tb is relatively good, but as a still assume
that the cause of TB lung disease is related to things
that ghaib/magic and because of heredity; the public
perception that the disease is a common cough, so that
it relates to people’s lack of concern about the effects of
pulmonary TB disease; and the behavior and awareness
of some people for sputum examination and use of health
service facilities is lacking. U ntuk reduce the incidence
112  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
rate of disease Tb. Lung can be done by controlling the
health behavior of the community . Noatmodjo3, states
that health behavior is a person’s response to stimuli or
objects related to healthy-sickness, illness, and factors
affecting health-sickness (health) such as environment,
food, drink and service health. In other words, health
behavior is any activity or activity of an observable or
unobservable person related to the maintenance and
improvement of health.
Based on the above explanation, the purpose to be
achieved from this research is the description of behavior
about prevention of disease Tb. Lungs of the people of
Makassar , knowledge of disease source control , control
agent p enyakit, and increased endurance of the patient
against disease prevention behavior Tb. Lung and
variable knowledge of dominant influence to behavior
of disease prevention tb. Lungs of Makassa City.
Research Method
Based on the research design that will be used then
the type of research is the analitic survey Population
referred to in this study is all masomism berdomisisli
in the area of Makassar City either healthy or sick or
suffering from disease Tb. Lung that has been diagnosed
by the doctor. Samples referred to in this study are some
of the people who have suffered from TB disease. Lung
and who do not suffer Tb. Lung who is domiciled in the
working area Pusekesmas Makassar as many as 335
people
Sampling in this research is with multi stage
sampling technique that is a way of sampling done by
going through stages. The technique as follows:
a. The first stage, using all the existing districts within
the city of Makassar are as many as 14 districts
b The second stage, determining the number of
samples per kecamatan by way of comparison of
the number of cases Tb. lung to total population of
Tb. pulmonary tuberculosis (+) multiplied by the
number of samples to be studied (335 people).
c. The third stage, from the sub-district determined
Puskesmas which has the number of cases number
Tb. the highest lung as a place of data collection.

Table 1: Number of Research Sample Per Puskesmas in Persons

No Districts Number of Patients Tb. pulmonary tuberculosis (+) Puskesmas Number of Samples
1. Ujung Tanah 66 Pattigalloan 13
2. Tallo 193 Kaluku Bodoa 37
3. Bontoala 85 Layang 16
4. Wajo 43 Tarakan 9
5. Ujung Pandang 50 Makassar 10
6. Makassar 169 Maccini Sawah 32
7. Mamajang 79 Cendrawasih 15
8. Mariso 148 Pannambung 28
9. Tamalate 241 Tamalate 45
10. Rappocini 201 Kassi-kassi 38
11. Panakkukang 182 Pampang 35
12. Manggala 124 Antang 24
13. Biringkanaya 90 Sudiang 17
14. Tamalanrea 85 Tamalanrea 16
1.756 Total sample 335

In this study, the variables to be analyzed consist
of the dependent variable that is tb disease prevention
behavior. Lungs and independent variables ie Knowledge
of disease source control Tb. Lung, Knowledge of
disease agent control Tb. Lung and Knowledge of
increased endurance against disease Tb. Lungs.
Analysis technique in this research, used is simple
regression test and double regression at error rate equal
to 5%.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  113

Research Result
Univariate Analysis

1. Behavior of Makassar City Community in The Prevention of Disease Tb. Lung.

Figure 1 . Distribution of Makassar City Community Behavior in Prevention of Disease Tb. Lung Year 2016

Figure 1 shows that out of 335 respondents in
Makassar City who have Behavior of Communicable
Disease Prevention Tb. Lung categ ori less as much as
6 people (1.79 %); sufficient category as many as 114
people (34.0 3 %); good category as many as 181 people
(54.0 2 %) and very good category as many as 34 people
(10,14 %). Based on these data it can be concluded that
most respondents have TB disease prevention behavior.
Lung category GOOD.
Multivariate Analysis: This analysis aims to
determine the influence of variables Penge Penguan Peng
Sumber Peng yaki t, Knowledge Controller variables i
a n Agent Diseases and knowledge variables Improved
endurance against the variable Behavior Prevention
Infectious Diseases Tb. Lung of Makassar City people
using multiple regression analysis. The results of the
study as follows:
1. The Influence of Knowledge of Disease Control
Control on Behavior Prevention Behavior Tb.

Table 2 . Results Anova Influence Knowledge Control of Source of Disease, Tera dap Makassar Community
Behavior in Disease Prevention Tb. Lungs. Year 2016.

Model Sum of Squares Df Mean Square F Sig.

1 Regression 94647 1 94647 605.094 .000b
Residual 52.087 333 .156
Total 146.734 334

a. Dependent Variable: Behavior

b. Predictors: (Constant), PPSP
114  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Table l Show that p <0.05, The null hypothesis is penyaki berpengaru t h variable Tb Disease Prevention
rejected, and the alternative Hypothesis is accepted. Behavior. Lungs of Makassa City.
This means that the variable Knowledge Source Control

2. Influence of Knowledge of Agent Control of Disease Against Behavior of Disease Prevention Tb.
Table 3 . Paru.Tahun 2016

Model Sum of Squares df Mean Square F Sig.

2 Regression 63.667 1 63.667 255.226 .000 b
Residual 83.068 333 .249
Total 146.734 334

a. Dependent Variable: Behavior

b. Predictors: (Constant), PPAP

Table 3. Show that P <0.05, null hypothesis is Tb. Lung berpengaruh to variable Tb Disease Prevention
rejected and the alternative hypothesis is accepted. This Behavior. Lungs of Makassa City.
means that the Knowledge Controlling Agent of Penyaki

3. Knowledge Influence Improved Body Resistance Against Behavior Prevention Disease Tb.
Table 4 . Results of Analysis Impact Knowledge Improvement of Body Resistance to Community Behavior
Makassar City In Prevention of Disease Tb. Paru.Tahun 2016.

Model Sum of Squares Df Mean Square F Sig.

3 Regression 80420 1 80420 403.831 .000 b
Residual 66.314 333 .199
Total 146.734 334

a. Dependent Variable: Behavior

b. Predictors: (Constant), PPDTT

Table 4 . Show that p <0.05, The null hypothesis Body Endurance berpengaru h to variable Tb Disease
is rejected, and the alternative Hypothesis is accepted. Prevention Behavior. Lungs of Makassa City.
This means that knowledge variable ingkatan Pen

4. Knowledge of Communicable Disease Prevention Tb.

Table 5 . Result Analysis Corrum Recognition Control of Source of Disease, Knowledge of Agent of Disease
Control, and Knowledge of Improved Durability To Behavior of Disease Prevention Tb. Lung Society of
Makassar

VAR.CONDUCT VAR.PPSP VAR.PPAP VAR.PPDTT

Pearson Correlation VAR. CONDUCT 1,000 , 948 , 867 , 900
VAR. PPSP , 948 1,000 , 916 , 940
VAR. PPAP , 867 , 916 1,000 , 975
VAR. PPDTT , 900 , 940 , 975 1,000
Sig. (1-tailed) VAR. CONDUCT . , 000 , 000 , 000
VAR. PPSP , 000 . , 000 , 000
VAR. PPAP , 000 , 000 . , 000
VAR. PPDTT , 000 , 000 , 000
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  115
Table 5 . Show that the Influence of Knowledge
of Disease Control Control on Behavioral Prevention
Behavior Tb. Lung r = 0.948, Effect of Knowledge
of Agent Control of Disease on Behavior of Disease
Prevention Tb. Lung r = 0.867, and Knowledge of
Increased Body Resistance against Disease Prevention
Behavior Tb. Lung r = 0.900. Based on the coefficient of
the correlation, it can be concluded that the knowledge
of disease prevention tb. lungs that have the greatest
influence influence are Knowledge of Disease Control,
followed by Knowledge of Improved Body Resistance,
and the last Knowledge of Agent Disease Control.
Discussion
1. Disease Prevention Behavior Tb.
Figure 1 shows that out of 335 respondents in
Makassar City who have Behavior of Communicable
Disease Prevention Tb. Lung category less as much as
6 people (1.8%); sufficient category as many as 114
people (34.0%); good category as many as 181 people
(54.0%) and good category as many as 181 people
(54.0%). Based on these data it can be concluded that
most respondents have TB disease prevention behavior.
Lung category GOOD.
Community behavior referred to in this research is
to prevent the transmission of germs disease Tb. Lung
is by closing the mouth with tissui or handkerchief at
the time of coughing or sneezing, seeking treatment
to doctors, clinics, Puskesmas if sick, eradicate germs
cause disease Tb. Lung by cleaning the floor of the
house with antibacterial every day, lighting the room
home with enough eye rays, increase endurance by way
of exercise at least 3 times a week, adequate rest at least
8 hours every day, eat a balanced diet, manage stress
with well, do not consume alcoholic beverages, avoid
drugs, avoid cigarettes and so on.5,6
2. Influence of Knowledge of Disease Control
Control Tb.
Based on the results of research on t ab 2 above
it was concluded that the control knowledge s umber
disease Tb. Lung effect on disease prevention behavior
Tb. Lungs in the people of Makassar.
3. Influence Knowledge Control Agent Diseases Tb.
The result of research t abel 3 shows that
Knowledge Control Agent Penyaki Tb. The lung has a
disproportionate attitude to the TB Disease Prevention
Behavior Tb. Lungs of Makassar City.Lungs that are
known by the people of Makassar so that people can
prevent transmission of TB disease.Lungs.
4. Influence of Knowledge Increased Body
Resistance Diseases Tb.
Results of the study showed that t abel 4 Pen
Knowledge ingkatan Body Endurance berpengaru h
against Tb Disease Prevention Behavior. Lungs of
Makassar City.Knowledge of increasing body endurance
is an effort to increase body resistance against disease
Tb.Lung is known by the people of Makassar so that
people can prevent the transmitters of disease Tb.Lungs.
Herda A4 there is a significant relationship
between the level of knowledge with the compliance of
patients with pulmonary TB in Pekakesmas Pekauman
Banjarmasin, South Kalimantan . This means that
the better the level of knowledge of the patient to the
disease, the mode of transmission and treatment of TB
Lung will be the better the compliance, and vice versa.
Lung Glugur community of Medan.This means that the
higher the level of knowledge of drug consumption the
more obedient the patient in drug consumption or vice
versa.
Conclusion
Based on the results of research and discussion
on this study, it can be concluded that g behavior
prevention behavior of TB Tb. The lungs of the people
of Makassar are generally good category , knowledge
of disease source control Tb. Lung effect on disease
prevention behavior Tb. Lung of Makassar City ,
knowledge of disease agent control Tb. Lung effect on
disease prevention behavior Tb. Lung of Makassa city
r, knowledge of body resistance against disease Tb.
Lung effect on disease prevention behavior Tb. Lungs
of Makassar City, a variable that is very influential on
disease prevention behavior Tb. The lungs of the people
of Makassar City are the knowledge of controlling the
disease source Tb. Lung, further knowledge of increased
body resistance against disease Tb . Lung , and finally
the knowledge of agent disease control Tb . Lungs .
Conflict of Interest: None
Ethical Clearance: Obtained from university
committee.
Source of Funding: Self
116  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

References Pekauman Banjarmasin, South Kalimantan. Journal

of Pharmascience 2016; Vol. 3 No.2.
1. Dinkes Prov. Sul-Sel.Health Profile of South
Sulawesi Province. http://www.google.com./search 5. Rahman N. H. A.. Challenges Of National TB Paru
. Retrieved February 10, 2013. Control Program Implementation : The Malaysian
Experience. Elsevier 2015; [Online]. [Accessed
2. Dinkes Prov. Sul-Sel.Health Profile of South
http://www.sciencedirect.Com/Science/Article/Pii/
Sulawesi Province.http://www.google.com./search.
S1877042815004425].
Retrieved February 10, 2013.
6. Rukmini R. Faktor-faktor yang
3. Notoatmodjo S,.Public Health Science & Art.
berpengaruhterhadapkejadian TB parudewasa di
Jakarta: Rineka Cipta. 2013 Herda A.. Knowledge
Indonesia (Analisis Data Riset Kesehatan Dasar
Level Relationships With Compliance In Treatment
Tahun 2010). Buletin Penelitian Sistem Kesehatan,
of Pulmonary Tuberculosis At Pekakesmas
2011; 14(2).
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  117

Children’s Nutrition Status 7-12 Months Based on Age,

Education and Job of their Mother in South Sulawesi

Hastuti1, Hadju Veni2, Citrakesumasari2, Maddeppungeng Martira3, Tanziha Ikeu4, Abdullah Tahir2
1Doctoral Student in Public Health,Hasanuddin University, Indonesia, 1Senior Lecture Departement of Nursing,
Anging Mammiri Nursing of Diploma, Makassar, 2Faculty of Public Health, Hasanuddin University, Indonesia,
3Child Departement, Wahidin Sudirohusodo Hospital, 4Department of Comunity Nutrition, Bogor Agricultural

University

Abstract
The problem of malnutrition and malnutrition is one of the main health problems faced by developing
countries including Indonesia. The incidence of cases of malnutrition is still very high, especially in South
Sulawesi, although it is known until now that there are very many negative effects caused by malnutrition.

Purpose: Knowing the nutritional status description of children aged 7-12 months based on age, education
and employment of mothers in Jeneponto Regency.

Method: This study uses a quantitative descriptive method with a cross-sectional design approach. Sampling
with a total sampling of 131 people. The study was conducted in Jeneponto Regency, South Sulawesi.

Results: Based on the BB/U index, mothers aged 30-34 years had children with poor nutritional status of
1 person (2.7%) but the BB/TB index of mothers aged 25-29 years had children with normal nutritional
status as many as 32 people (94.1%). Based on the BB/U index, mothers with elementary school education
have children with good nutritional status as many as 32 people (97%), and educated mothers who do not
complete elementary school have children with poor nutritional status of 1 person (5%). Based on the BB/U
index, mothers who did not work had children with good nutritional status as many as 100 (90.9%) but based
on the index BB/TB mothers who did not work had children with very thin nutritional status of 2 people
(1.8%)

Conclusion: Mothers aged 30-34 years and mothers with education who did not complete elementary school
had children with poor nutritional status, mothers who did not work had children with very thin nutritional
status.

Keywords: Nutritional status of children, age, education, mother’s work.

Introduction less and worse nutrition 17.7%, while the percentage

Malnutrition in children can cause several negative
effects such as slow growth, prone to disease, decreased
level of intelligence, and mental disruption. So that
serious malnutrition can ultimately cause death1.
According to WHO, 54% of the causes of infant and
toddler deaths are due to poor child nutrition. The risk
of dying from a child who is malnourished is 13 times
greater than a normal child2. In general, the proportion
of malnutrition and undernourishment in toddlers
in terms of body weight according to age (BB/U) is
of nutritional status in South Sulawesi Province has
decreased compared to 2013 even though it is still higher
than national standards3.
In South Sulawesi there are four districts/cities
with the most cases including Bone (16 cases), Pinrang
(15 cases), Wajo (11 cases) and Jeneponto (8 cases)
(Health Profile of South Sulawesi Province in 2008).
In Jeneponto Regency in 2014 it was found that the
percentage of children under five weighed 82.08% of
the 36,127 toddlers available. Of the 29,652 toddlers
118  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
weighed found toddlers with good nutrition as many as Results
28,625 toddlers (97.64%), malnutrition as many as 687
Respondents Characteristic
toddlers (2.32%) and malnutrition as many as 16 people
(0.04%)4 Table 1: Characteristics of Respondents in
Jeneponto Regency
Efforts to improve infant nutrition are based
Variabel n (131) %
on that malnutrition at less than 2 years of age will
Sex
have an impact on decreasing physical growth, brain
Male 68 51,9
development, intelligence, and productivity, and this
impact is largely irreparable5 Micronutrients are needed Female 63 48,1

for brain development during gestation and infancy. This Baby Age (month)
is an important period for brain formation, laying the 7 35 26,7
foundation for the development of cognitive, motor and 8 23 17,6
socio-emotional skills during childhood and adulthood6. 9 21 16,0
10 19 14,5
Based on this phenomenon, the purpose of this 11 15 11,5
study was to determine the nutritional status description 12 18 13,7
of children aged 7-12 months based on anthropometric Mother Age (year)
index BB/U, TB/U, and BB/TB in Bontoramba District 15–19 13 9,9
and Binamu District, Jeneponto Regency.
20–24 30 22,9
25–29 34 26,0
Materials and Method
30–34 37 28,2
The design of this study used a quantitative ≥ 35 17 13,0
descriptive method to determine the description of the Mother Education
nutritional status of children aged 7-12 months, with UnfinishedElementary School 20 15,3
a cross-sectional approach. The total sample was 131 Graduated Elementary School 33 25,2
people in the Bontoramba and Binamu Subdistricts Yunior High School 33 25,2
of Jeneponto Regency. The sampling technique is the
Senior High School 30 22,9
total sampling method. Data on maternal and child
Diploma 15 11,4
characteristics were collected through direct interviews
Mother Job
using questionnaires, while children’s nutritional
Unemployment 110 84,0
status was determined based on anthropometric index
Employment 21 16,0
(Department of Health, 2011), by measuring body weight
according to age (body/age), height/body length by age The highest maternal education in the low education
(TB/U) and body weight according to height (BB/TB). group was 33 elementary school and junior high school
To measure body weight, digital baby scales are used, graduates (25.2%) and the lowest was 15 (11.4%) higher
while length boards are used to measure body length. education (Diploma). Regarding the work of the mother,
there were at most 110 non-working groups (84%) and
those working as many as 21 people (16%).

Distribution of Nutritional Status of Children Based on Mother’s Age

Table 2 Distribution of Nutritional Status of Children Based on Mother’s Age
Mother Age (Year)
Nutritional Status
15-19 20-24 25-29 30-34 ≥ 35 Total
Indeks BB/U n % N % n % n % n % N %
Malnutrition 0 0,0 0 0,0 1 5,3 1 2,7 0 0,0 2 1,5
Poor Nutrition 1 7,7 0 0,0 3 8,8 4 10,8 3 17,6 11 8,4
Good Nutrition 12 92,3 30 100 30 88,2 32 86,5 14 82,4 118 90,1
Total 13 100 30 100 34 100 37 100 17 100 131 100
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  119

Mother Age (Year)

Nutritional Status
15-19 20-24 25-29 30-34 ≥ 35 Total
Indeks TB/U
Stunting 4 30,8 6 20,0 16 47,1 7 18,9 3 17,6 36 27,5
Normal 9 69,2 24 80,0 18 52,9 30 81,1 14 82,4 95 72,5
Total 13 100 30 100 34 100 37 100 17 100 131 100
Indeks BB/TB
Very Thin 0 0,0 0 0,0 0 0,0 0 0,0 2 11,8 2 1,5
Thin 1 7,7 0 0,0 2 5,9 3 8,1 1 5,9 7 5,3
Normal 11 84,6 29 96,7 32 94,1 32 86,5 14 82,4 118 90,1
Fat 1 7,7 1 3,3 0 0,0 2 5,4 0 0,0 4 3,1
Total 13 100 30 100 34 100 37 100 17 100 131 100

Based on the index BB/TB, mothers aged 25-29 years had children with very thin status as many as 2
years had children with normal nutritional status as people (11.8%).
many as 32 people (94.1%) and the age of mothers> 35

Distribution of Children’s Nutritional Status Based on Mother’s Education

Table 3: Distribution of children’s nutritional status based on Mother’s Education

Mother’s Education
Nutritional Unfinished Graduated Yunior High Senior High
Graduated Total
Status Elementary School Elementary School School School
N % n % N % N % N % n %
Indeks BB/U
Malnutrition 1 5,0 1 3,0 0 0,0 0 0,0 0 0,0 2 1,5
Poor Nutrition 1 5,0 0 0,0 4 12,1 2 6,7 4 26,7 11 8,4
Good Nutrition 18 90,0 32 97,0 29 87,9 28 93,3 11 73,3 118 90,1
Total 20 100 33 100 33 100 30 100 15 100 131 100
Indeks TB/U
Stunting 3 15 13 39,4 11 33,3 5 16,7 4 26,7 36 27,5
Normal 17 85 20 60,6 22 66,7 25 83,3 11 73,3 95 72,5
Total 20 100 33 100 33 100 30 100 15 100 131 100
Indeks BB/TB
Very Thin 1 5,0 0 0,0 1 3,0 0 0,0 0 0,0 2 1,5
Thin 1 5,0 1 3,0 3 9,1 0 0,0 2 13,3 7 5,3
Normal 17 85,0 31 93,9 29 87,9 28 93,3 13 86,7 118 90,1
Fat 1 5,0 1 3,0 0 0,0 2 6,7 0 0,0 4 3,1
Total 20 100 33 100 33 100 30 100 15 100 131 100

In table 3, it appears that the nutritional status of
children is based on the BB/U index, so mothers with
elementary school education have children with good
nutritional status as many as 32 people (97%) and
educated mothers do not complete primary school with 1
poor child (5 %). Based on the TB/U index, the mothers
who graduated from high school had 25 children with
normal nutritional status (83.3%) and mothers who
graduated from elementary school had 13 stunting
children (39.4%). Based on the BB/TB index, mothers
with elementary school education had children with
normal nutritional status as many as 31 people (93.9%)
and educated mothers who did not complete elementary
school had children with very thin nutritional status of 1
person (5%).
120  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Distribution of Children’s Nutritional Status Based on Mother’s Work

Table 4: Distribution of children’s nutritional status based on Mother’s Work

Mother occupation
Nutritional Status Unemployment Employment Total
n % N % n %
Indeks BB/U
Malnutrition 2 1,8 0 0,0 2 1,5
Poor Nutrition 8 7,3 3 14,3 11 8,4
Good Nutrition 100 90,9 18 85,7 118 90,1
Total 110 100 21 100 131 100
Indeks TB/U
Stunting 31 28,2 5 23,8 36 27,5
Normal 79 71,8 16 76,2 95 72,5
Total 110 100 21 100 131 100
Indeks BB/TB
Very Thin 2 1,8 0 0,0 2 1,5
Thin 5 4,5 2 9,5 7 5,3
Normal 99 90,0 19 90,5 118 90,1
Fat 4 3,6 0 0,0 4 3,1
Total 110 100 33 100 131 100

Source: Primer Data, 2018

Based on the index BB/TB, mothers who do not education (Diploma).

work have children with normal nutritional status as
many as 99 people (90%) and very thin nutritional status
of 2 people (1.8%).
Discussion
Characteristics of Respondents: A person’s health
status is influenced by four factors, namely behavior,
health services, genetics and environment7. One of the
things related to the environment is culture. Cultural
factors influence a person’s health status according to
the theory of nursing known as Sunrise Model8.
In this study the age of most children at the age of
7 months was 35 people (26.7%) and the least at age
11 months were 15 people (11.5%). This is consistent
with a study that produces findings that age is one of the
things that affects children’s development9.
The highest maternal age at the age of 30-34 as
many as 37 people (28.2%) and the least at age 15-19
years as many as 13 people (9.9%).
The highest maternal education in the low education
group was 33 elementary school and junior high school
graduates (25.2%) and the lowest was 15 (11.4%) higher
Child Nutrition Status based on Mother’s age:
In reality there are still many women who give birth at
<20 years and > 35 years with normal nutritional status
of children. This is due to the seriousness of the mother
in caring for, caring for and raising her child. Adequate
attitudes and knowledge of child nutrition will have an
impact on the pattern of feeding given to children under
five so that it influences the nutritional status of children
under five.10
Short child conditions can be prevented but
cannot be cured so that improvement efforts are more
emphasized on prevention efforts. The improvement
efforts that have been made emphasize the identification
and rehabilitation of children with severe malnutrition.
Whereas the recent improvement efforts have been
emphasized on prevention efforts through a combination
of aspects of nutrition, disease and treatment/treatment11
Child Nutrition Status based on mother’s
education: According to the researchers’ assumptions,
the influence of education on the nutritional status
of children is due to the fact that the education in the
research location is quite good but the education that
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  121
respondents have is still not practiced in everyday life.
The higher the level of education, knowledge, skills there
is the possibility that the better the level of family food
security, the better the care of children, and the more
families use existing health services and vice versa 12.
Someone who just graduated from elementary
school is not necessarily less able to arrange foods that
meet nutritional requirements than other people with
high education. Because even if the education is low if
the person is diligent in listening to nutrition counseling
it is not impossible that his nutritional knowledge will
be better. It’s just that it must still be considered that the
level of education factors also determine whether or not
someone is easy to absorb and understand the knowledge
of nutrition they obtain 13.
A study also showed that there was no relationship
between maternal education level (p = 0.646) and family
income (p = 1,000) with stunting in toddlers14. Although
it is understood that increasing the ability of mothers
through health education can be done to maximize
growth and development of children.
One alternative with health education using the
modeling approach that has been carried out by nurses
is effective in increasing knowledge, practical ability,
mother’s confidence in breastfeeding and stimulating
babies, which in turn can optimize infant growth15.It
was concluded that increasing maternal empowerment
through health education improves baby growth16.
Conclusion
As a health worker especially focusing on public
health, it is very wise to prioritize promotive and
preventive efforts without ignoring curative and
rehabilitative efforts.
Ethical Clearance: Taken from Hasanuddin
University ethical committee.
Source Of Funding: Self
Conflict of Interest: Nil
Refferences
1. Larasati, W.. HUBUNGAN ANTARA PRAKTIK
PEMBERIAN MAKANAN PENDAMPING
ASI (MP-ASI) DAN PENYAKIT INFEKSI
KAITANNYA DENGAN STATUS GIZI
PADA BAYI UMUR 6-12 BULAN (Studi pada
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kerja Puskesmas Boja I Kabupaten Kendal 2010).
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4. Jeneponto, P. K. K.. Profil Kesehatan Kabupaten
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Moringa Leaf Extract in Breastfeeding Mothers
against Anemia Status and Breast Milk Iron
Content. Int J Sci Basic Appl Res (IJSBAR, 2015;
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6. Prado, E. L., Alcock, K. J., Muadz, H., Ullman,
M. T., & Shankar, A. H.. Maternal multiple
micronutrient supplements and child cognition:
a randomized trial in Indonesia. Pediatrics, 2012;
130(3), e536-e546.
7. Hendrik, B.. Planning For Health Development
and Application of Social Change Theory, Human
Sciences Press. New York. 1974
8. Leininger, M.. Culture care theory: A major
contribution to advance transcultural nursing
knowledge and practices. Journal of transcultural
nursing, 2002; 13(3), 189-192.
9. Gunawan, G., Fadlyana, E., & Rusmil, K..
Hubungan status gizi dan perkembangan anak usia
1-2 tahun. Sari Pediatri, 2016; 13(2), 142-146.
10. UNICEF.. The state of the world’s children: Oxford
University Press for UNICEF. 2002
11. Caulfield, L. E., Putnick, D. L., Zavaleta, N.,
Lazarte, F., Albornoz, C., Chen, P., . . . Bornstein, M.
H.. Maternal gestational zinc supplementation does
not influence multiple aspects of child development
at 54 mo of age in Peru. The American journal of
clinical nutrition, 2010; 92(1), 130-136.
12. DepKes, R.. Profil Kesehatan Indonesia Tahun
2004. KESEHATAN, K.(ed.). 2006
13. Departemen Kesehatan, R.. Keputusan Menteri
Kesehatan Republic Indonesia. Nomor 1995/
Menkes: SK/XII/2010 tentang standar antropometri
penilaian status gizi anak.2011
14. Anindita, P.. Hubungan Tingkat Pendidikan Ibu,
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dengan Stunting (Pendek) pada Balita Usia 6-35
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Bulan di Kecamatan Tembalang Kota Semarang. praktek dan percaya diri ibu dalam menstimulasi
Jurnal Kesehatan Masyarakat Universitas tumbuh kembang bayi 0-6 bulan. Tesis Fakultas
Diponegoro, 2012; 1(2). Ilmu Keperawatan Universitas Hasanudin. 2014.
15. Saleh, A., Nurochmah, E., As’ad, S., & Hadju, V.. 16. Hadju, V. Baby Nutritional Status Improvement
Pengaruh pendidikan kesehatan dengan pendekatan Through Mother Empowerment in Baby Care in
modelling terhadap pengetahuan, kemampuan South Sulawesi Indonesia. 2017
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  123

The Effect of Health Social Determinant on the

Life Quality of Pregnant Mother

Muhammad Anwar1,2, Saifuddin Sirajuddin3, Ridwan Amiruddin4,

Ridwan Thaha5, Toto Sudargo6, Anto J. Hadi7
1Doctoral
Student Program, Faculty of Public Health, Hasanuddin University, Makassar, 2
Faculty of Public Health, Universitas Al Asyariah, Majene, 3Departementof Nutrition,Faculty of
Public Health,HasanuddinUniversity, Makassar, 4Departementof Epidemiology, Faculty of Public
Health,HasanuddinUniversity, Makassar, 5Departemen of Health Promotion,Faculty of Public Health,
HasanuddinUniversity, Makassar, 6Departemen of Nutrition, Universitas Gajah Mada, Yogyakarta, 7Faculty of
Public Health, Helvetia Health Institute, Medan, Indonesia

Abstract
Objective: This research aims to determine the social determinant factor related to the life quality of pregnant
women in Polewali Mandar district.

Method: The research was conducted in July to December 2018 using a cross sectional study design.
Sampling by sampling proportional random sampling with 399 peoples distributed in 3 districts and it is
analyzed with multivariate logistic regression by backward elimination method.

Results: Mother aged 20-35 years (Adjusted Odds Ratio (AOR): 1.75 [1.15-2.66]), income over or equal
to Regional Minimum Wage (Rp. 2.017.780) (AOR: 1.66 [1.01-2.73]) adequate information access (AOR):
1.89 [1.22-2.94]), domiciled in urban areas (AOR: 1.95 [1.27-2.99]) and those who have health insurance
(AOR: 2.42 [1.417-4.126]) tend to have a better quality of life.

Conclusion: Life quality of pregnant women is influenced by maternal age, income, access to information,
domicile and health costs. Therefore, women should be pregnant at an age that is not at risk and to maintain
and improve the life quality of pregnant women, it is very important for pregnant women to be given adequate
access to information, a good socio-economic environment and health insurance. This is a responsibility of
family and needs to be supported by government policy.

Keywords: Social determinant, quality of life, pregnant mother, access to information.

Introduction with a low-ANC globally; only 64% of women receive

four or more antenatal (prenatal) treatments during their
In the world, WHO estimates that there are 303.000
pregnancy. Though this ANC can reduce and prevent
women died due to pregnancy causes, 2.7 million babies
high maternal mortality rates. Therefore, we need
die during first 28 days of life. This condition is associated
quality health care for pregnant women.1 Pregnancy
care requires equal and affordable health resources,2but
Correspondence Author: in reality it is not evenly distributed and not affordable.
Muhammad Anwar
Doctoral Student Program, Faculty of Public Health, The life quality of pregnant women is related to
education, income, but based on data from the Central
Hasanuddin University, Makassar, Indonesia, Faculty
Statistics Agency of West Sulawesi in 2015 shows
of Public Health, Universitas Al Asyariah, Majene,
the low level of education as seen from the number of
Indonesia
school dropouts aged 16-18 or not yet school 36%, and
Handphone: 081281329973
dependency is still high (56.74%)3. The life quality of
e-mail: anwarpsuh2014@gmail.com
124  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
mothers and children is largely determined by early Table 1. Characteristics of respondent
and comprehensive efforts. Health-related quality of
life (HRQOL) has become increasingly recognized as Variable Category Amount %
an important result of medical care over the past two <20 yrs 36 9.0
decades.4 In this research, the quality of life includes Ages 20-35 yrs 306 76.7
relativity and it is influenced by various factors such as >35 yrs 57 14.3
expectations, life attitudes, physical, psychological and Never school 8 2.0
social effects, adequate and appropriate care, sufficient Not Elementary School 25 6.3
information, accessing health facilities and equal Elementary Scholl 101 25.3
Education
adequacy sources.5 Junior High School 92 23.1
Senior High School 114 28.6
Until now, maternal mortality is still high,
Academy/College 59 14.8
it is estimated 830 women died everyday due to
Housewives 351 88.0
complications of pregnancy or childbirth around the
Trader 16 4.0
world. As much 99% of all maternal deaths occur in
Private Employee 2 .5
developing countries. Almost all of these deaths are Occupation Public Servant/Army/
related to low resources, and most can be prevented.6 11 2.8
Police
Inequality as occur in West Sulawesi based on HDI
Others, Voluntary/
in 2017, 64.3 ranked 31 after West Papua, Papua and 19 4.8
Honorarium
NTT. While, the lowest HDI by district is Polewali Bugis 64 16.0
Mandar are 62.35. This condition raises problems as a Java 2 0.5
social determinant of health, especially for maternal and Mandar 303 75.9
child health. As a result the maternal mortality rate is
Ethnic Pannei 2 0.5
still high7. Several studies related to the life quality of
Patinjo 1 0.3
pregnant women have been conducted, but with different
Pattae 20 5.0
determinant and especially in Indonesia it is rarely done.
Toraja 7 1.8
This research was aimed to determine the health social
Status of Anemia 104 26.1
determinants associated with the life quality of pregnant
anemia Not anemia 295 73.9
mother in Polewali Mandar district.
Quality of Low 193 48.3
Method Life High 206 51.6

This research was conducted in July to December Table 2 shows that mothers aged 20-35 years
2018 by using a cross sectional study design. Sampling (Adjusted Odds Ratio (AOR): 1.75 [1.15-2.66]), income
by cluster proportional random sampling. The sample over or equal to Rp. 2.017.780 (AOR: 1.66 [1.01-2.73])
was 399 pregnant mother distributed in 3 sub-districts in adequate access to information (AOR): 1.89 [1.22-2.94]),
Polewali Mandar, namely Polewali, Pambusuang, Bulo. domiciled in urban areas (AOR: 1.95 [1.27-2.99]) and
Data analysis uses multivariate logistic regression. have health insurance (AOR: 2.42 [1,417-4,126]) tends
to have a better quality of life.
Result
Table 2. Analysis of the Effect of Social Determinant
Table 1 shows the characteristics of respondents. Factor on the Life Quality of Pregnant Women in
Most respondents at not risk on ages (20-35 years) Polewali Mandar District
(76.7%), more high school education (28.6%), generally
they were not working or only housewives by 88.0. Multivariate Logistic Regression
Furthermore, the dominant ethnic is Mandar (75.9%) Variable Adjusted Odds Ratio
P value
and in general pregnant women do not have anemia (AOR) 95% CI
(73.9%). The quality of pregnant mother tends to be Age (Year)
almost equal in number between those who have high < 20 and ≥30 Ref.
0.008
and low quality of life. 20-35 1.754(1.16-2.66)
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  125

Multivariate Logistic Regression most of women die are laborers or farming workers
Variable Adjusted Odds Ratio in other countries. Some of them are migrant workers
P value
(AOR) 95% CI and even work until the last month of their pregnancy.
Income (IDR)* Economically, employment is able to empower women
Low (less than IDR to take responsibility for their health and facilitate access
Ref.
2.017.780)** to health facilities15. Therefore, income as comes from
0.004
High (IDR 2.017.780
1.66(1.01-2.73)
mother can affectthe life quality of pregnant women16.
and higher) The results of research indicate that most pregnant
Access to information women do not work and only as housewives. As a
Low Ref. result, they do not have authority in obtaining health
0.005
Adequate 1.89(1.22-2.94) services, so the quality of life is below as expected. They
Domicile with high levels of education will increase maternal
Rural Ref. knowledge, increase self-confidence and also increase
0.002
Urban 1.95 (1.27-2.99) awareness related with the use of health resources in the
Health Cost community for maternal health17. However, it is found
Do not have health different in this study in which education does not affect
Ref.
insurance 0.001 the life quality of pregnant women. It can occur due to
Have health insurance 2.42 (1.417-4.126) other important factors.
*IDR=Indonesian Rupiah (1 IDR=0.000072 USD on 11th Juli Health education media are all means or efforts
2018), ** Regional Minimum Wage : IDR 2.017.780
to show messages or information to be conveyed by
Discussion communicators, both print media, electronic and outdoor
media, so that the target can increase their knowledge
The problem of physical and psychological health and ultimately it is expected can change their behavior
for pregnant mother, childbirth, post-partum and towards positive health18. One cause of efforts to control
breastfeeding were included as risks in pregnancy and anemia in pregnancy must begin by providing health
childbirth that may arise and have a significant effect on education for pregnant women and their partners, which
the life quality of mothers8. The social determinant of reinforces mother statements during antenatal care19. As
health is a condition in which people live and work, and results of distributing leaflet media as information can
this condition affects their chances to live in a healthy increases the understanding of pregnant women about
life. In March 2005, WHO established the Commission high-risk pregnancies such as obstetric complications,
on Social Determinants of Health9. The commission bleeding and preeclampsia. Therefore, it is necessary
records determinants such as child development, sex, to develop promotional media to increase high-risk
urbanization, employment, health systems, measurement knowledge20. Coupled with the development of social
and evidence, globalization, and social exclusion, as media is very useful to change health behavior21.
centers for addressing health inequalities as prevail in Some pregnant mother states that general complaint of
the world10. Most respondents give birth at age 20-35 pregnancy as a barrier to accessing health information.
years which is very good for mother. Therefore, the age Several complaints that are often noted by respondents
of pregnant mother determinetheir quality of life111213. such as nausea and vomiting that can disrupt their daily
WHO emphasize to avoid four tooin a pregnancy routine activities. Some pregnant women also state that
namely too young (pregnancy <20 years), too old fatigue, and sleep problems and followed by lethargy
(pregnancy> 35 years), too many children (over 4) and throughout the day, so they do not have time to access
too close (pregnancy distance <2 years).As many 78 of information. Similar results were also found in this
124 of women who died were very young, less than 25 research, high media access tend to be a good quality of
years old. Furthermore, 26 of them were aged between life than opposite.
16 and 20 years and nearly 40% of women died during Life quality of pregnant women in urban areas is
their first pregnancy and another 38% during the second better than rural areas. Generally, the rural women are
or third pregnancy. At the other end of the spectrum are considered to have poor health and higher mortality.
older women with a history of several pregnancies14. This is because rural areas have poor access to perinatal
In additionbeing responsible for their daily household, care. In general, health resources are concentrated in
126  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
densely-populated urban areas, while rural women tend
to suffer from both their health and lifestyle. As result of
Nasem’s(2011) research found that role limitations due
to physical problems, perceptions of general health and
alsodue to emotional problems had a significantly lower
score in rural women compared to urban women22. In
this research, domicile has relation with the quality of
life, mothers who live in remote areas often experience
severe vulnerability. The availability and utilization of
reproductive and child health services varies widely
from country to country. It is important to understand
the extent of poor and non-poor gaps in urban areas
across the country apart from their urban poverty23.
The level of public policy and financing, according
to Egan et al.,(2008) that social protection mechanisms
and national health insurance schemes targeting
marginalized populations, so that all groups can be
reached. If a health system develops organically
without government supervision, they can even provide
services or support facilities for urban health services
in remote rural areas. In this research, they had health
financing both independently and those receiving aid24.
Also, in this research the available financing is related
to quality of life. For the life quality of mothers to be
better,it is expected to improve prenatal care, one of
them by considering insurance factors that still need
to be improved, as happened to low-income African-
American women. It is intended to reduce limitations in
obtaining health services25.
Conclusion
As result and discussion mentioned earlier, it can
be concluded that the life quality of pregnant women
is influenced by maternal age, income, access to
information, domicile and health costs. Therefore,should
be the women to become pregnant at not risk age (20-
35 years) and to maintain and improve the life quality
of pregnant women, it is very important for pregnant
women to be given adequate access to information, a
good socio-economic environment and health insurance.
This is a family responsibility and needs to be supported
by government policy.
Source of Funding: Ministry of Research and
Technology for Grant Program of Dissertation.
Interest Conflict: Nil
Ethical Clearance: This study was approved by the
Research Ethics Committee of the Faculty of Medicine,
Hasanuddin University.
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128  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Implementation of Partnership betwen Midwives and

Traditional Birth Attendants in Kotabaru District

Anggrita Sari1, Adriana Palimbo1,3, Angga Irawan1, Sukamto2, Isda Herlina4

1Lecturer of Sari Mulia University, Banjarmasin, Indonesia, 2Senior Staff South Kalimantan Provincial Health
Office, Banjarmasin, 3Student Doctoral of Public Health, Hasanuddin University, Makassar, Indonesia, 4Lecturer
Public Health Center of Berangas, Kotabaru

Abstract
Background: Maternal and infant mortality ratio, in the Kota Baru high enough, one of them because of
labor that much by the Traditional Birth Attendants (TBA).Midwives offer fewer deliveries and coverage
has not reached the 95% target and fewer midwives than TBA.

Objectives: This study aims to know the implementation of the partnership program between midwives
and traditional birth attendants in Kotabaru District.

Method: This study use da qualitative approach to the design of case studies, with purposive sampling
technique. The number of the main informant as much as 3 people and informant triangulation 6 people.
This research was conducted for 1 month consists of content analysis and data processing.

Results: The results show human resources are still lacking, inadequate facilities and funding partnership
that is often paidlate. Midwive sand TBA is not made a written agreement, and over the role of the TBA will
not be in accordance with there gulations. The support from the village head and community leader that there
is no information and the number of TBA partnering is still less.

Conclusion: Our findings conclude the importance of cross-program coordination and involvement in the
District Health Office and across sectors at the District Government level. This participation is urgently
needed from local stakeholders playing a major role in the successful implementation of maternal and child
health programs.

Keywords: Midwives; traditional birth attendants;implementation of partnerships.

Introduction to 40 days. TBA’s knowledge of pregnancy and birth

Traditional Birth Attendant’s (TBAs), ”dukun
beranak” in Indonesia, has been around for a long time,
and are still practicing labor and childbirth, where most
deliveries occur at home and are not assisted by skill birth
attendant such as midwives. This situation increases the
risk of death for the mother and her baby.1 TBA is a
trusted employee in the family and community in all
matters relating to women’s reproductive problems and
their work is obtained from generation to generation.2
Indonesia, which has a variety of tribes, customs, and
cultures in the community, they are considered capable
of providing emotional comfort and security to mothers
during pregnancy check-ups, assisting mothers and
caring for their mothers and babies after birth for up
is so lacking that if complications arise they are unable
to overcome them even realize it.3 However, in addition
to providing technical assistance, TBA also practices
unsafe abortion and contraception at high risk and
threatening the life of the pregnant woman.4
Trained TBAs are family TBAs who have received
short training courses through the modern health care
sector to improve their skills.5-6 So, starting in 2007, the
government initiated a partnership program by village
midwives and traditional birth attendants aimed at
reducing maternal and child mortality and morbidity.7
This is because the traditional birth attendants do not
have enough ability and knowledge to handle obstetric
complications and emergencies (EMOC) that occur during
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  129
and after labor.8Then, between midwives and doulas,
they offer physical, emotional, and ongoing support
while simultaneously encouraging patient autonomy.
However, disagreements between them also occur from
the Middlemiss (2015) study in the UK, differences in
the role of doulas and midwives and identify potential
for conflict if the role of doulas is misunderstood.Some
experts have identified antagonistic attitudes towards
doulas that create challenges for midwives,9and lead
to inter-professional conflicts in the dynamics between
midwives and doulas.10 In Canada, this misconception,
midwives and nurses fear that doulas will take over their
roles and “grass” jobs.11-12
Death that occurs in a hospital is a referral for labor
handled by TBA. Furthermore, in some cases TBAs
called on midwives when their mother’s condition was
severe. At this time, there are 329 TBAs in Kotabaru
District. Their presence is spread in 21 sub-districts.
Meanwhile, only 220 midwives served.. The coverage
of childbirth assistance by health workers is 68.2%
which has not increased and has not reached target
95%from 2014 to 2017.13 Based on this problem, this
research is intended to know the implementation of the
partnership program between midwives and traditional
birth attendants in Kotabaru District.
Materials and Method
The study design uses an explorative qualitative
approach. A total of 9 participants consisted of 3 village
midwives and 6 triangulation informants. This study
was conducted at the Berangas Public Health Center
in Kotabaru District, South Kalimantan Province.
The selection of research locations was taken through
considerations, among others: First, coverage of delivery
assistance by health workers in the last 3 years had not
met the District target of 95%. Second, their have the
highest number of traditional birth attendants from the
number of midwives. And, third, their has an ongoing
partnership program indicator.
Data collection uses in-depth interviews, and
semi-structured interview guides. Processing data
with content analysis. The aspects studied include the
system of implementing partnerships, namely 1) Human
Resources, funding, facilities, and data collection and
mapping of traditional birth attendants; 2) Fostering
of traditional birth attendants; Written Agreement for
Midwives and TBA; and the role of TBA; and 3) Support
of Village Heads and Community Leaders.
Results
Characteristics of Participants: Characteristics
explained the main informants were 3 midwives in each
village in the Puskesmas area. And the triangulation
informant consisted of 6 people selected based on
competency and representatives who were aware of the
partnership program.(Table 1).

Table 1: Characteristic of Participant

Code Sex of Education

No Age Work Status Period of Work
Informant Gender Background
Main Informant
1 IU 1 28 Female Midwifery Diploma Midwife of Berangas Six years
2 IU 2 28 Female Midwifery Diploma Midwife of Sungai Limau Three years
3 IU 3 29 Female Midwifery Diploma Midwife of BatuTunau Seven years
Triangulation Informant
1 BK 39 Female Midwifery Diploma Coordinating Midwife 21 years
2 DB 55 Female No school TBA Partnered Five years
3 DT 70 Female Primary School TBA Not Partnered 30 years
4 TM 47 Male High School Community Leader 20 years in village
5 KD 49 Male High School Village Head Three years
6 M 29 Female Primary School Mothers is served by Midwives and TBA Second Labor

Sources: Health Office Report, 2017

130  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Analysis of Results
Human Resources: From the interviews,
information was obtained that 1 midwife served 2 to 3
villagesat a time,because othervillagesthat did not have
midwives to cover all villages in their work area.
“..Serving three villages, meaning one village has
three regions: Rampa Kapis, Batu Tunauand the Coal
Mining Company.” (IU2) “Each place only has a few
empty villages” (IU1, IU 3)
Interview for six triangulation informants, we
obtained a statement that three midwives were still not
living in the village but were willing to come at any time
if needed.
“..do not live in the village every day, if called they
are willing” (KD, M) “there is no residence in Berangas
village, but if anyone wants to give birth, they are ready
to come” (BK)
Half of the midwives, residing in districts and
villages, have areas with a geographical area that vary
by a distance of 25-30 km.
“I live in urban areas for about 30 minutes from
Berangas Village because my children go to school in
there” (IU3) “..back and forth to the village, but don’t
stay overnight” (BK, M)
Facilities and Infrastructure: They are complete
but some people are giving birth at home even though
they are near to Puskesmas. Most of them do not have
adequate electricity and clear water. Access and difficult
terrain is also an obstacle. It must be taken on foot.
Medical equipment is very unnoticed, so they add unsafe
ingredients to the baby’s umbilical cord.
Funding Source: Specific funds for partnerships
do not exist. Companion funds come from Health
Operational Assistance (BOK). The funds according to
them are insufficient because they are considered too
little. Disbursement of funds is not routine every month
but has to wait a long time. This is related to TBA not
making an Accountability Letter (SPJ) and there are no
reports on labor and childbirth period referrals.
Written Agreement for Midwives and TBA:
Information from two people revealed never made
a written agreement. Only an oral request to call the
midwife if there is something
“..nothing.. we just talked..” (IU1, IU2)
Even they do not know the information about the
partnership. the coordinating midwife stated that the
agreement had not been made, it was still in the planning
stage and had not been implemented.
“..up to now has not been implemented, because
many other health programs take precedence” (BK)
TBA will call the midwife, if the baby has been born
and delivery has been completed just to cut the baby’s
umbilical cord.
“..because I am not allowed to cut the umbilical
cord with a knife and concoctions” (DB)
Fostering of TBAs: Fostering shamans only through
refreshing once a year and not all of them are invited.
Midwives provide guidance on useful knowledge.
“Guidance and refreshing shamans have been
carried out ..This year is only once, this year just once”
(BK, TM)
Different from the 3 other triangulate informants
who claimed to have never known and were never
invited to refreshing the shaman.
“..never really meetings, try to be invited to
meetings” (DB, DT, KD)
The Role of TBAs: Only one midwife informant
who collaborated and applied the transfer of roles with
TBAs.
“..if at my place, TBA tells me that pregnant women
will give birth.. we usually join together to help until
parturition “ (IU1) “they usually massage, make herbal
concoctions, and midwives care.” (IU2)
Other different information TBAs are not partners,
refuse cooperation and complete change of role. Only
ever accidentally help together give birth.
“..Ever..she only held the abdomen, if part of the
birth ..of course midwife”(IU3)”..Postpartum mothers
still visited by midwives.” (BK,DB, M)
Midwives and TBAs seem to compete and look less
harmonious. “..they (midwives) hold mother’s full ..if her
signs of birth appear, you call me, I better go home” (DT)
it can be concluded that TBA not partnered still
does not work together so that their role is still helping
birth and the baby independently. In fact, they consider
midwives to be powerful over patients.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  131
Support of Village Heads and Community
Leaders: Real support was provided from the village
head and community leaders, but information about the
partnership program was not yet optimal. During this
time they made requests to give birth with midwives at the
health center. Their support is in the form of regulations,
financial assistance, supporting facilities, and invitations
to midwives and traditional birth attendants to work
together.
Discussions
Human Resources: Resources hold an important
influence in the implementation of health care systems,
especially partnerships. Resources include implementing
personnel, infrastructure, service facilities, and funding.
Midwives are competent health workers who are
stationed and should reside 24 hours in the work area
of the puskesmas.14One of the factors that caused the
community to choose to be assisted by a dukun is the
distance between the community’s house and the dukun
in the adjacent village and the TBA is always 24 hours.
While many of the midwives reside in areas farthest
from the reach of the community.1,7
Facilities and Infrastructure: Based on research
by Pramono & Sadewo (2012),that geographical
conditions make it difficult to call midwives so that
pregnant women choose TBA who are domiciled around
their homes.15To be able to realize the partnership,
childbirth must be assisted by midwives, the government
must be able to facilitate adequate health facilities and
ensure the availability of quality midwives in each
village and easy access to services.16Therefore, through
a Government Regulation states that childbirth can only
be done outside health care facilities if difficult to reach
by the community.17
Funding Source: The availability of a budget plan
for the Birth Waiting Home (RTK) which is a temporary
residence for pregnant women who will give birth until
the postpartum period including their babies and their
companions (husband/family/cadre)6For Childbirth
Assurance, the Health Allocation Fund (DAK) can be
used to cover: operational costs, health workers and
companions in RTK or official travel from home to RTK
or from RTK to health service facilities. Of the 10%
of the Village Fund Allocation (ADD) used to work
on maternity guarantee programs, including the Health
Operational Assistance (BOK) fund for promotive and
preventive activities and funding for midwife and TBA
partnership funds
Written Agreement for Midwives and TBA: A
written agreement between the midwife and the dukun
is made together, in accordance with the implementation
manual which contains information on the mechanism of
reference for pregnant women, the referral mechanism
for labor cases, the mechanism for distributing labor
costs and the schedule for regular meetings. In line with
the results of research by Rochmayanti, the partnership
did not go according to expectations and targets despite
having a memorandum of agreement between them.18
Fostering of TBAs: TBAs are also not equipped
with knowledge of detection of danger signs in pregnant
women, maternity, postpartum and newborn babies as
well as ways of referring midwifery.So the TBA only
has some knowledge to carry out his partnership role.
In fact, for the treatment of the umbilical cord, TBAs
still use herbs that are not useful and not clean. In terms
of benefits, some TBAs want to follow the call so that
they don’t help their own deliveries anymore. But the
appeal is not optimal so that they are still many who help
deliveries unsafe.19
Support of Village Heads and Community
Leaders: According to the research of Budiono, et al.
(2012), the support of community leaders is needed
in collaboration between midwives and TBAs. This
support includes socialization and direction through
village meetings, mediation between midwives and
TBAsand helps influence other parties such as posyandu
cadres, village officials, and TBAs to take an active role
in the partnership.
CONCLUSIONS
Some obstacles in implementing the partnership
program are midwives and TBAs on the utilization
of SBA and strengthening the role of each available
resource. Funding management from Jamkesmas, DAK
and other fund allocations needs to be maximized so that
the community realizes that safe delivery with midwives
and in health facilities is accompanied by TBAs, not
obstacles or concerns from families and communities.
Training of skilled TBAs needs to be considered as a
refresher in the skills of their childbirth practices under
the supervision of the District Health Office, the priority
of areas that are difficult to reach.
Conflict of Interest: None
Ethical Clearance: Obtained from university
committee
Source of Funding: Author him self
132  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
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 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  133

Socio-Cultural Transformation through the Process of

Internalizing Values in Early Childhood Education in
Makassar City (An Ethnographic Study of Education)

Juwanita Sahid1, Nurul Ilmi Idrus2, Hamka Naping2, Munsi Lampe2

1Anthropology Doctoral Study Program, 2Senior Lecturers of Hasanuddin University, Makassar, Indonesia

Abstract
The global idea of child education was declared through the Educational For All movement for the first
time in 1990 in Thailand and then confirmed in the Dakkar Declaration in 2000. The study aim to examine
in depth about the children value for PAUD institutions and the process of socio-cultural transformation
through the process of internalization value to children. This research uses an ethnographic approach. Primary
data obtained through in-depth interviews, and participant observation. The data was analyzed through a
qualitative analysis procedure. The results of the study that changes in the application of the curriculum not
only on one “Islamic value” but also universal values through child-friendly learning nuances of “Islamic”.
There are nine indicators of basic Islamic values that are structurally internalized to children involve the
three pillars of education (parents, educational institutions and the community), synergy and influence each
other. There are supporting and challenges factors in implementing Islamic values in TK WU.

Keywords: Early Childhood Education, Transformation, Islamic values, ethnography.

Introduction A number of other relevant studies explain the

The global idea of children’s education was
declared through the Educational For All movement for
the first time in 1990 in Thailand and then confirmed in
the Dakkar Declaration in 2000. At the level of early
childhood education (PAUD), the role of educational
institutions is very strategic to internalized moral values,
cultural values and nationality value to the children.
Now education faces the substance of the problems of
globalization and the transmission of external values in
national life. The orientation of new values has alienated
city people from their roots, original culture. In a good
and respectable family, their children can become foolish
and unexpected, because the determinant of formation is
no longer only parents, but the media, peers, education
and even markets1. Socio-cultural changes to education
when children no longer belong to families, but belong
to educational institutions and the environment. The
development of communication technology, has totally
changed the world culture. Global culture is known as
MC Donald2 culture.
In 2011, the Indonesian government launched the
PAUD program, one village one PAUD program. PAUD
is an instrument to overcome the deficit in the role of
family or parents in children’s education.
position of this research, for example Baki3 study;
Badruddin4; Rosdiana5; Priwardhani6; Amini7 and a
number of other studies on education are portrayed using
the perspective of anthropology, sociology, education,
religion and so on. Despite the diversity of studies on
early childhood education have been conducted by a
number of researchers referred to, but there has not been
a specific look at the transformation process in early
childhood education.
The study of this transformation is a very relevant
study using the anthropological approach. Spindler8
believes education as a whole process of development
and adaptation, leading to the process of cultural
transmission, including skills, knowledge, attitudes,
values and beliefs and certain behavioral patterns.
The study of how the reality of education in PAUD
institutions in its development has also undergone a
transformation, to capture the meaning of reality in the
world of education using the ethnography as a method
also experiences development. The views of Laksono et
al.9 agree with the view of George Sprindler, that the
ethnography of education is not only the ethnography of
schools, but more extensive studies.
134  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
This research tries to reveal the process of
transformation of values in “Kindergarden of WU” and
how the strategy, the process of achieving educational
achievement becomes an interesting reality revealed
using the “ethnographic” approach. This research
takes place in Kindergarden of WU as an educational
institution with strong Islamic characteristics and this
research locationis an effort of resilience to current
developments.
The general objective of this research is to examine
in depth the phenomenon of transformation or socio-
cultural processes working through the process
of internalization in early childhood. The specific
objectives, as follows:
1. In-depth study of the value of children for PAUD
institutions in WU Kindergarden.
2. In-depth study of the process of socio-cultural
transformation through the process of internalization
of value in children.
Method
This research uses an ethnographic approach10. The
research involved informants such as parents of students
(mothers), grandmothers, teachers, school principals,
foundation administrators, and baby sisters. Primary data
obtained through in-depth interviews, and participant
observation11. Qualitative data analysis through three
processes (1) data reduction, (2) categorization, (3) data
interpretation
Results and Discussion
Child Friendly Learning Based on Islamic
Values: Efforts to integrate the curriculum based on
Islamic values and eight PAUD Standards in Indonesia.
The level of development achievement includes basic
competencies and indicators of religious and moral
values, motor, cognitive, language, socio emotional and
arts. The character or personality of the child becomes
the main achievement of education initiated by WU.
Basic Competencies are elaborated in daily activities
based on the Koran and Hadith.
There are four principles of child-friendly learning
indicators initiated by kindergarden of WU, namely 1)
teachers as learning media12, 2) learning and playing, 3)
creating learning spaces, and 4) schools are part of the
daily lives of students.
There are at least five important aspects of child-
friendly learning in WU Kindergarden, namely:
a) The teacher knows how to teach children with
diverse backgrounds and abilities.
b) All children have the right to learn, regardless of
physical, intellectual, social, emotional, linguistic
or other differences,
c) In a friendly learning environment, everyone shares
a vision of how children should learn, work and play
together.
d) They believe that education should be inclusive, fair
and non-discriminatory, sensitive to all cultures, and
relevant to children’s daily lives.
e) A friendly learning environment, teaches life skills
and a healthy lifestyle, so students can use the
information obtained to protect themselves from
disease.There is no violence against children and
physical punishment.
Meanwhile, child-friendly learning has significant
benefits, such as benefits for children, teachers, parents
and the community.
Internalization of Islamic Values of Students in
Kindergarden of WU
The social structure internalized in TK WU is
formulated in nine points,namely:
a) Children are able to memorize a minimum of 20-30
short suras to a maximum target of juz 30.
b) The child is able to read, write, count and
communicate simply in Indonesian.
c) Children are equipped with Islamic moral character
education.
d) Children have discipline and independence.
e) The education system is integrated between religious
and general sciences.
f) Extracurricular activities vary, planned, directed
and systematic.
g) Islamic environment, safe and pleasant.
h) Teachers and human Resources who are friendly,
dedicated and professional.
i) Facilities and Infrastructure support teaching and
learning process activities.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  135
The Internalization of Islamic values to children
is divided into three, namely the value of monotheism,
morals, and worship which is carried out in the initial
semester for three weeks, using the method of reciting
surahs in the Koran and the Hadith with the aim of being
a process of habituation to students.
In addition to the family, school and teachers are
important determinants of internalizing Islamic values
to children. Schools are the second most significant
institution in shaping children’s personality.
Factors that determine the internalizing Islamic
values in early childhood are the environment, such
as friendship. In this context, children tend to be more
independent, innovative and experience the process of
sorting good and bad subjectively. Bun, 27 years old,
one of the parents stated:
“... actually what determines good or bad children is
not just parents. Teacher or the meaning of school and
the environment of his friends is also a big influence.
Now what needs to be understood is, which children
are more dominantly affected. These parents must
understand, in order to balance. For example, don’t let
the kids be locked up in the house all the time, or be told
to play outside or continue to take care of school. Just be
balanced. But many conflict. “
Early childhood has unique characteristics, both
physically, socially, morally and so on. According to
Aisyah, et al13 characteristics of early childhood include;
has a great curiosity, is a unique person, likes to fantasize
and imagine, the most potential time to learn, shows
egocentric attitude, has a short span of concentration
power, as part of social beings.According to Bredekamp
and Coople13, some aspects of early childhood
development such as physical, social, emotional, and
cognitive aspects of each other are closely related. Child
development and learning are children’s interactions
with various contexts through play. The Internalization
process here takes place through the play process.
All of these characteristics are very clearly
seen in kindergarten ofWU. Thus, each stakeholder
(parents, teachers and community) is very important
to pay attention to the characteristics of this early age.
According to Piaget14, children have 4 levels of cognitive
development namely sensory motor stages (between 0-2
years), pre-concrete operations (between 2-7 years),
concrete operations (between 7-11 years), and formal
operations (11 years and above).
After school, the family has the main functions
of socialization and education, namely as the first
institution in children’s education that designates the
role of the family in shaping the child’s personality,
through social interaction within the family. Children
learn patterns of behavior, attitudes, beliefs, ideals and
values in society in the context of the development of
their personality. Internalizing values in children is an
important process in children’s development. The role
of the school (teacher or educator), family (parents and
siblings) and the friendship environment must have a
positive connection.
Integrated Education: Parent and Teacher
Involvement: The form of parental involvement in
this research is relevant to the Overlapping Sphere of
Influence theory proposed by Epstein.15 There are six
types of parental involvement, namely (1) parenting
education, (2) communication, (3) volunteering (4)
learning at home, (5) making decisions and (6) in
collaboration with the community.
Parental involvement in education is very much
needed at every level of education especially in PAUD
institutions, where children are just starting to form
character through the development of moral, religious,
social and emotional values16. The development of
these values can only be achieved maximally with the
existence of continuity between education at home and
at school, not apart from the participation of parents16.
Research Park et al17 that parental involvement has a
contribution to the development of cognitive aspects of
children and other aspects of development.
The activities of the school committee are to provide
education to parents of students through tarbiyah
every Friday to harmonize the Islamic values given to
children so that parents make habituation routed in their
respective homes.
Hand over the role of children’s education to other
parties, such as care for the maid or baby sister, then
formal education is fully delegated to the school. The
role of parents is also often replaced by other family
parties, both siblings and grandparents. Child care
patterns tend to distance between parents and children,
because parents are busy working.
PAUD and Internalization of Islamic Values:
The education system developed by TK WU is the
integration of formal education based on curriculum
with internalization of Islamic values. Education gives
136  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
a very big influence and contribution to children’s self
development. An action done by an educator (teacher),
parent or social environment of the child in order to
achieve better goals for children.
The basic values of Islam18,19 consist of (a) Faith and
devotion, (b) Appreciation of human existence with all
its potential, (c) Promoting the principles of freedom and
independence, and (d) Social responsibility. universalism
of Islamic teachings contains basic principles regarding
social relations, including democracy.
In general, early childhood education, especially
in the kindergarden of WU is to build individuals with
Islamic personality based on the Koran and Hadith. from
this goal individuals are formed with akhlakul kharimah,
and have emotional and spiritual intelligence (religious),
consistency (istiqamah), humility (tawadhu), totality
(kaffah), balance (tawazun), integrity and perfection
(ihsan). The need for value education, through the
internalizing Islamic basic values in early childhood
urban families, has been carried out by the kindergarten
of WU.
Changes in children’s behavior are getting better
at school and at home after getting invested in basic
humanist religious values. Changes in children’s
behavior at school include: (a) behavior in aqidah, (b)
behavior in morals, (c) behavior in worship, (d) behavior
in social, emotional, and independence dimensions.
Changes in children’s behavior at home shown by: (a)
pay more attention and listen to the words of parents,
(b) can say and answer greetings in Islam correctly, (c)
can distinguish clothes cover the genitalia and not cover
genitalia, (d) can pray alone.
Most early childhood education, oriented to the
achievement of children’s independence. Independence
is considered as the most basic foundation in the stage
of child development. Not only in WU Kindergarten,
children’s independence is really an important
achievement even more priority than reading and writing.
Bordieu20 views on the theory of Habitus, field and
Capital. Habitus is a product of internalization carried out
by structures (agents that influence children) born from
the background of parents, the orientation of parents’
values in choosing schools, orientation of educational
institutions (organizational values). The struggle or
efforts made by parents and educational institutions in
conducting coaching (socialization functions) carried
out by educational institutions and family institutions
are synergized with the three pillars of education.
Habitus20 as a determinant component in the process
of transformation consisting of cultural values, religious
values, and social values that are owned and practiced
by children. Based on the Cultural Analysis framework
described by Muller21, Habitus is at the mentality level.
Transformation or change occurs in the field of education
and children are at the level of social structure
Conclusions
Indicators of Values that are structurally internalized
to children are (1) loving the Qur’an and Hadith from
an early age by being able to memorize a minimum of
20-30 short surahs to a maximum target of juz 30, (2)
Children are able to read, write, count and communicate
in Indonesian. (3) Children are equipped with Islamic
moral character education, (4) Children have discipline
and independence. (5) The education system is
integrated between religious and general sciences. (6)
Extracurricular activities vary, planned, directed and
systematic. (7) Islamic environment, friendly, safe and
pleasant. (8) Teachers and human resources who are
friendly, dedicated and professional. (9) Facilities and
infrastructure support teaching and learning activities.
These values are internalized to students involving
the three pillars of education (parents/family, educational
institutions and the community/environment) that work
together and influence one another.
Supporting factors for implementing values: (1)
friendly and competent teaching staff (2) integrated
curriculum (Islamic values and universal values); (4)
Parental involvement and child-friendly environment.
(5) Availability of learning facilities and media
(6) Consistency and Commitment of organizers to
educational achievements in accordance with the vision
and mission of the PAUD institution.
Challenges factors faced: (1) The innate character
of students varies (children are unique), (2) Parents
of students have not synergized with school programs
because parents are busy working; (3) Lack of parents’
understanding of the concept of PAUD as a playground
for children, (4) limited facilities for learning and
playing space for children; (5) limited teaching staff with
adequate qualifications and competencies.
Source of Finance: Self
Conflict of Interest: None
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  137
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Utama
138  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11

Risks Assessment of Silica Contamination on the Communities

Living Surround the Cement Industry, Pangkep Indonesia

Anwar Mallongi1, Stang2, Syamsuar Manyullei1, Muhammad Fajar Natsir1,

Ratna Dwi Puji Astuti3, Annisa Utami Rauf3
1Lecturerof Department of Environmental Health, 2Professor of Department of Biostatistics,
3Postgradute PhD Program of Faculty of Public Health, Hasanuddin University, Makassar Indonesia

Abstract
This study focused on the assessment of the potential risks of silica on the ecology and the estimated weekly
intake due to the consumption of traditional cake, water and mixed fruits. Soils and traditional cakes were
collected from the concerned area where water was collected from the river and drainage basin. Silica
potentially toxic elements were analyzed in terms of concentration, potential ecological risk, and human
health risk. The highest concentration of Silica pollutant around the Tonasa Cement Industry Pangkep were
on well water with (16.18 mg/l), river water (18.12 mg/), sediment (41.11mg/l), surface soil (7,92%) and air
particulate (2.74%), respectively. In addition, the highest concentration of Silica (SiO2) around the Tonasa
Cement Industry Pangkep on mixed fruits with (14.17mg/l), followed by traditional cake (7.26 mg/), and
drinking water with (0.52mg/l), respectively. The potential ecological risks posed by silica on all those
environment were considerable and moderate, respectively. Estimated weekly intake indicated that non-
carcinogenic risks all fell below threshold values. The total carcinogenic risks due to silica was within the
acceptable range for communities. This conclusion provides a scientific basis for the control of potentially
toxic element pollution and environmental protection of the ecology and food for communities who are
living surround the Cement Industry, Pangkep.

Keywords: Potentially silica toxic element; pollution level; well water; sediment; surface soil; ecological
risk and weekly intake.

Introduction negatively impact human health5. Therefore, the main

The transformation and migration patterns of silica
and others elements potentially toxic in the aquatic
environment are complex and a long processes. The
rapid urbanization and industrialization activities, toxic
contaminants are continuously and increasingly entering
the urban soils, water and leading to environmental and
health problems1‑4. Urban soils and water are certainly
regarded as an important component of the urban
ecological system, and excessive amount inputs of toxic
element pollutants may deteriorate the water and soil
ecological environment and change the physical and
chemical properties of soils, as a resuls agricultural and
food may get the bad effect3,4.
A more serious problem is that these pollutants may
travel from urban water and soils to humans through
various pathways (e.g., direct ingestion,inhalation,
and via skin contact or called absorption) and lead to
purposes of our study were to test the following three
hypotheses: (a) trace metals accumulate in the water and
soils; (b) the potential ecological and human health risks
from trace silica metals intensify in the water and soils
of developing Pangkep districts; (c) human activities are
the main sources of silica trace metals.
Silica exposure is associated with a wide series of
effects, including many neuro developmental outcomes,
mortality (mainly due to cardiovascular disease),
decreased renal function, hypertension, impaired fertility
and adverse consequences on pregnancies. Typically,
the majority of released metals/metalloids accumulate
in the surficialsedimentinaquatic systems via adsorption,
chelation, and sedimentation processes6, and about
10% of them exist in the water column in the dissolved
form7,8, or are associated with suspended particles.
 Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11  139
Furthermore, the sediments also play very Table 1: Ecological risks assessment of Silica around
important roles in the aquatic safety and in assessing the the Tonasa Cement Industry Pangkep, Indonesia
potential ecological risk of the pollutants in the aquatic
environment. Although several studies were conducted Ecological Risks Assessment Silica
about Silica concentrations in food, however to our Stations Well River Surface Air
Sediment
water water Soil particulate
knowledge, up to now few studies have investigated
silica concentrations in traditional cake, soils where 1 0.75 3.55 0.26 3.47 3.73
2 0.81 4.01 0.22 4.10 3.30
silica released from cement industry were supposed to
3 0.60 3.63 0.29 7.92 2.94
be less available.
4 0.67 9.06 0.41 6.90 3.36
5 0.95 3.56 1.52 4.15 3.91
Materials and Method
6 0.75 3.09 0.19 2.88 7.43
This analytic observational research applied 7 0.88 4.16 0.23 4.28 4.43
quantitative approaches and cross sectional research 8 1.08 5.71 0.39 5.40 7.30
designs. The purpose of this study is to find out the 9 0.81 4.72 0.22 10.15 9.13
relationship between the independent variable and the 10 0.93 6.09 0.31 9.90 3.93
dependent variable, and to assess the ecological risks
Table 1 described the potential ecological risks of
and to estimate weekly intake. The population in this
silica where the highest risks value were in surface soil
study is the people who live around the Semen Tonasa
with 10.15 then followed by on air particulate with 9.13
Industry, Pangkep Indonesia. The sample in this study
and river water 9.06, respectively. The Ecological risks
amounted to 50 people. Data were collected using a
assessment of Silica in surface soil was significantly
questionnaire given to respondents, measurement of
higher than those in well water and air particulate.
dust exposure, measurement of lung vital capacity, and
direct observation. Analysis of the data used in the form Estimated weekly intake traditional cake and
of univariate and bivariate analysis using chi square test. drinking water and mixed fruits: Tolerable weekly
Silica levels were determined in samples using graphite intake estimates the amount per unit body weight of a
furnace and cold vapor atomic absorption spectrometry. potentially harmful substance or contaminant in food or
water that can be ingested over a lifetime without risk of
Results adverse health effects9.
Ecological risks assessment of Silica: Common
Silica concentrations in the traditional cake, drinking
Method suitable for potential ecological risk assessment
water and mixed fruits were assessed for human risks
of soil heavy metal pollution include the geo-
uses according to provisional tolerable weekly intake.
accumulation index methodand the potential ecological
table 4.
risk index method, In this study, we attempted to use
these two Method to evaluate the ecological risk of soil Table 2. Estimated weekly intake traditional cake
heavy metals in the study area, and we summarized the and drinking water and mixed fruits around the
results of the two Method to find the general law of the Tonasa Cement Industry Pangkep, Indonesia
problem.
Estimated Weekly Intake of Silica
The potential ecological risk was assessed by on the Stations Traditional Drinking
Mixed Fruits
well water, river water, sediment, surface soil and air cake water
particulate. Table 1 presents the calculated results silica 1 0.003 0.040 0.047
on the environment. 2 0.003 0.062 0.054
3 0.006 0.052 0.049
4 0.006 0.034 0.074
5 0.001 0.064 0.048
6 0.003 0.020 0.036
7 0.003 0.016 0.060
8 0.019 0.032 0.055
9 0.006 0.096 0.095
10 0.003 0.104 0.041
140  Indian Journal of Public Health Research & Development, November 2019, Vol. 10, No. 11
Table 2 indicated the results of EWI results
calculation for Silica, which show that the highest of
EWI in drinking water (0.096) followed in mixed fruits
(0.095) and in traditional cake (0.019). All of the EWI
values were still < than 1.
Discussion
Ecological risks assessment of Silica: This study
revealed that the potential ecological risks of silica. The
highest value risks value were in surface soil with 10.15
then followed by on air particulate with 9.13 and river
water 9.06, respectively. These value indicated that the
level of risks at those environment was in the level of
medium risks. The reasons for higher Silica contents in
surface soil are complex. Greater Silica in air are mostly
due to high Silica concentrations released in to the
atmosphere by the cement industry.
Based on the results of evaluation and potential
ecological risk valuation, it showed that the potential
ecological risk of air and water in the study are a is
generally at a moderate level, also and it is feasible to
carry out reclamation.
Estimated weekly intake traditional cake and
drinking water and mixed fruits: The provisional
tolerable weekly intake (PTWI), recommended by the
Joint FAO/WHO Expert Committee on Food Additives
(JECFA), show appropriate safe exposure levels and is
used to estimate the amount of contaminants, ingested
over a lifetime without appreciable risk11-13.
The excessive amounts of silica in in food chain can
cause health problems for humans and ecosystem. Such
as traditional cake and drinking water and mixed fruits is
an important food in human diet10. Many countries were
infected to water and soil pollution crisis to heavy metals
including silica. Human beings cause this contamination
type through different ways.
Table 2 indicated the results of EWI results
calculation for (SiO2), which show that the highest
of EWI in drinking water (0.096) followed in mixed
fruits (0.095) and in traditional cake (0.019). All of the
EWI values were still < than 1.The estimated values
of all metals in samples in this study were below the
established values. Therefore, it can be concluded that
those silica in these three variables posed no health
problems for consumers,
Conclusion
The conclusion of this study showed the roll of food
and beverage on transferring silica from soil, water and
food to humans. Of the obtained result it’s concluded that
water and is contaminated with silica. Therefore, more
attention should be given and remediation action should
be set to minimize the concentration and ecological
impacts of silica in the study area. Further research
should be conducted on human health impact of silica in
all aspect of life.
Acknowledgement: The researchers would like
to thank the Directorate of Research and Community
Service (DRPM) for funding the research. The
researchers would also like to thank the Chancellor and
Head of LP2M of Hasanuddin University who provides
facility support for the research; Head of Makassar
Health Office. Authors also highly appreciate to Pangkep
Municipality, who have given a very kind cooperation
during the research commencement. Hence, we thank to
laboratory members of Health Laboratory (Balai Besar
Laboratorium Kesehatan) Makassar, Indonesia for their
samples analysis in accordance.
Conflict of Interest : The authors declare that they
have no competing interests.
Source of Fund: Directorate of Research and
Community Service (DRPM) for funding the research.
Ethical Clearance: Obtained from the faculty of
public health ethical clearance committee.
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 Positive Deviance Against Malaria Events in Majene District

Arsunan, A. A.1, Indra Dwinata1, Januar Ariyanto1, Muhammad Akbar Nurdin1, Aisyah2
Department of Epidemiology, Faculty of Public Health, Hasanuddin University, Makassar
1

2
Department of Agribusiness at the State Agricultural Polytechnic of Pangkajene Kepulauan, Pangkep

Abstract
Essentially behavioral factors are actions or activities of human beings themselves which results in an
imbalance between agent, host and environment that affects human health status, including the incidence of
malaria caused by one of the factors which is good human activity that can be observed directly or indirectly.
So this study aims to determine the effect of positive deviance on malaria incidence in Majene District. This
research was conducted in Manyamba Village, Majene Regency, West Sulawesi Province, July - September
2018. This study used a mixed-method research design. Quantitative data is used to explain the relationship
between the variables of the study and the incidence of malaria and qualitative data is used to determine
positive deviance behavior using the focus group discussion method. The data obtained will be processed
using SPSS V. 24. Based on the data obtained in the field there are several variables related to the incidence
of malaria, namely positive deviance (p = 0.039), knowledge (p = 0.018) and work (p = 0.035). Multivariate
analysis to see the effect on malaria, obtained results that the job variable has the strongest relationship to
the incidence of malaria, with a value of p = 0.001. The results of the data obtained from the FGD obtained
that there were 4 positive deviance behaviors in the community of Manyamba Village, Tamerodo District,
Majene District; plant the toga, keep the lead head fish, burn the egg rack and bring it to the paranormal.
Positive deviance behavior in the community can be used to prevent the occurrence of malaria through the
active role of health cadres by forming healthy communities in the community.

Keywords: malaria, positive deviance, work, knowledge

Introduction shifts2. Malaria transmission can be associated with the

Malaria is one of the diseases that causes the most
suffering and death to date. Disease caused by the
Protozoa of the Genus Plasmodium, which is transmitted
through mosquito bites, attacks almost all regions or
regions on the surface of the earth. This disease has also
been detected since ancient times. Various efforts that
have not been done by humans to overcome this disease
both through Preventive and Curative actions1. Behavior
is the biggest factor that leads to a person’s health. Health
behavior is formed from individual characteristics
such as knowledge, experience, attitudes and actions
to interact with the environment. Another work factor
that causes malaria transmission is the division of work
most activity carried out by someone by considering
where the person is doing daily activities. This is the
basis for seeing the relationship between one’s work
and the incidence of malaria. Of all respondents in all
provinces in Indonesia who work in agriculture and
fishermen by 18.5%. As many as 41% of respondents
affected by malaria were people with jobs as fishermen
and farmers3.
Knowledge factors are often associated with
increased malaria incidence in several places. As was
the case in Uganda, only 68% of people took their
children to health facilities when they had a fever. Lack
of knowledge about the behavior of clean and healthy
people living by choosing an open source of water rather
than a closed one4. Increased knowledge of malaria
manifestations and controls is an important role in
controlling malaria incidence5. Based on the background
above, the researcher is interested in studying positive
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  143

deviance in Manyamba Village, Tamerodo District, Graduate senior high school 5 3.5
Majene District, West Sulawesi. Occupation
Risks 53 37.1
Materials and Method
Not risks 90 62.9
This study uses a mixed-method research design. Illness history
Quantitative data is used to explain the relationship Yes 41 28.7
between the variables of the study and the incidence of No 102 71.3
malaria and qualitative data is used to determine positive Knowledge
deviance behavior using the focus group discussion Enough 116 81.1
method. The population in this study were the people of Less 27 18.9
Bussu Hamlet, Manyamba Village, Tammerodo District, Attitude
Majene District, West Sulawesi. The sampling method for Enough 143 100
quantitative data uses Total Sampling with a total of 143 Action
respondents. While the FGD participants were carried Enough 49 34.3
out by community leaders, religious leaders, health Less 94 65.7
cadres and people in Bussu Hamlet. Data were analyzed Total 143 100
using bivariate test with Chi-Square Test. Furthermore,
multivariate test using Logistic Regression. Furthermore, the highest age variable is the early
adolescent age group as many as 32 Respondents
Research Result (22.4%) then continued with the lowest age frequency,
Based on table 1, it shows that the highest frequency namely the elderly age group as many as 4 respondents
is Positive Deviance as many as 114 Respondents (79.7%) (2.8%). Then the highest frequency based on sex was
and Positive Deviance is 29 respondents (20.3%) of the female gender as many as 74 respondents (51.7%) and
total respondents as many as 143 respondents (100%). the lowest was male gender as many as 69 respondents
(48.3%) of a total of 143 respondents (100%).
Number
The level of education in table.1 is known that. the
n %
highest level of education is never schooling as many
Positive deviance
as 44 respondents (30.8%) while based on the lowest
Yes 114 79.7
level of education level is high school equivalent to
No 29 20.3
5 respondents (3.5%). For the highest respondent
Age
frequency job variable based on risky work as many as
Baby under 5 year 8 5.6
53 respondents (37.1%) and the lowest frequency based
Children 29 20.3
on non-risky work as many as 90 respondents (62.9%).
Early Teenagers 32 22.4
And the frequency of malaria occurrence based on the
Advance teenagers 19 13.3
highest history of malaria incidence is that of non-
Early adults 21 14.7
malaria as many as 102 respondents (71.3%) while the
Advance adults 15 10.5
lowest frequency of malaria incidence is positive malaria
Early elder 9 6.3
as many as 41 respondents (28.7%).
Advance elder 6 4.2
Elderly 4 2.8 Based on the results of the FGD, 3 (three) out of 8
Sex (eight) informants informed that burning an egg rack can
Male 69 48.3 repel mosquitoes to prevent mosquito bites. As quoted in
Female 74 51.7 the following FGD:
Education level
“Ma ‘baka I know, e tellu (burning egg racks)” (RS,
Never school 44 30.8
33 years) Meanwhile 1 (one) of 8 (eight) informants
Not graduate basic 29 20.3
informed that planting lemongrass leaves can repel
Graduate basic 51 35.7
mosquitoes so that they avoid mosquito bites. As quoted in
Graduate junior school 14 9.8
the following FGD:”If I plant Sarre leaves near my house”
144  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

(ID, 35 years). There were 3 (three) out of 8 (eight)
informants using mosquito nets to avoid mosquito
bites during sleep. As quoted in the following FGD:
“Installing mosquito nets with the usual burn is an egg
rack” (JA, 27 years old) In addition, 1 (one) of 8 (eight)
informants requested help from a seaman in the form of
a spell so as not to contract Malaria.
Table 2. shows the results of cross tabulation
between dependent variables and independent variables.
Which is known that the positive deviance variable
has a significant relationship with p = 0.039. Then
other variables related to the incidence of malaria in
Manyamba Village, Tammerodo Subdistrict, Majene
Regency are knowledge and jobs with p value of 0.018
and 0.035 respectively.

Table 2. Results of cross tabulation between dependent variables and independent variables

Malaria occurrence
Total
Yes Not
Positive deviance
Not 13 (44.8%) 16 (55.2%) 29 (100%)
p=0.039
Yes 28 (24.6%) 86 (75.4%) 114 (100%)
Age
Not Productive 18 (28.1%) 46 (71.9%) 64 (100%)
p=1.000
Productive 23 (29.1%) 56 (70.9%) 79 (100%)
Sex
Male 22 (31.9%) 47 (68.1%) 69 (100%)
p=0.462
Female 19 (25.7%) 55 (74.3%) 74 (100%)
Education level
Low 39 (28.3%) 99 (71.7%) 138 (100%)
p=0.625
High 2 (40%) 3 (60%) 5 (100%)
Occupation
Risks 21 (39.6%) 32 (60.4%) 53 (100%)
p=0.035
Not risks 20 (22.2%) 70 (77.8%) 90 (100%)
Knowledge
Less 13 (48.1% 14 (51.9%) 27 (100%)
p=0.018
Enough 28 (24.1%) 88 (75.9%) 116 (100%)
Action
Less 28 (29.8%) 66 (70.2%) 94 (100%)
p=0.846
Enough 13 (26.5%) 36 (73.5%) 49 (100%)
Total 41 (28.7%) 102 (71.3%) 143 (100%)

The data in table 3 shows the statistical test using logistic regression shows the smallest p value is a job with a
value of p = 0.001.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  145
Table 3. Regression logistic test results
Variables in the Equation
B S.E.
Positive deviance -.723
Knowledge -1.567
Step 1a
Occupation 1.732
Constant 1.008
Which means that the job variable has the strongest
relationship with malaria incidence in Manyamba Village,
Tammerodo District, Majene District, South Sulawesi.
Discussion
Positive Deviance with Malaria
The location of the area in the mountains and the
absence of a permanent road. Makes the area isolated
and certainly makes it difficult for people to access
daily needs, including mosquito repellent. To avoid
mosquito bites, people use insect repellent. But when
insect repellent was no longer available, the informant
tried to find other alternatives, such as egg shelves. One
end of the egg rack was burned to smoke. This smoke is
then used by residents to repel mosquitoes. Although the
smoke produced is quite thick and makes people around
shortness of breath. Egg shelves are still chosen as an
alternative mosquito repellent because they are easy to
find and also practical6.
In addition, there were informants who planted
lemongrass. This lemongrass plant is seen on residents’
yard. Lemongrass planting is not preceded by the motive
of preventing mosquito bites. But it is just a fulfillment of
kitchen needs. Lemongrass leaves contain essential oils
can repel mosquitoes. Lemongrass essential oil consists
of cytral compounds, cytronella, geraniol, mirsena,
nerol, farnesol methyl heptenol and dipetana. Cytronella
compounds have dehydration (desiscant) toxicity. The
toxin is a contact poison that can cause death due to
continuous fluid loss. Insects exposed to this poison will
die from lack of fluids7. This is what makes informants
free from mosquitoes.
Informant beds are equipped with mosquito nets.
This mosquito net is rarely released from the bed. So
Wald df Sig. Exp(B)
.624 1.342 1 .247 .485
.669 5.495 1 .019 .209
.498 12.086 1 .001 5.653
.713 1.995 1 .158 2.739
that every time you sleep, this mosquito net stays
installed. The use of mosquito nets is an effective and
safe way to avoid mosquito bites8. When one family
member suffers from malaria. The informant first took
him to the shaman. This is because the distance from
the place of residence to the health facility is quite far
and the cost of transportation is high compared to the
treatment in the seaman. The treatment of the shaman
comes from supernatural powers. Shamans use white
water as an intermediary medium. Water will be given
a mantra or recitation of the Holy Qur’an according to
the illness. The informant does not only ask for spells
for healing. But also to prevent malaria transmission.
The role of positive deviance behavior in the community
of Manyamba Village, Tamerodo Subdistrict, Mejene
Regency, West Sulawesi has a statistically significant
relationship with the incidence of malaria, in line with
research conducted in rural areas in the country of
Senegal9 by Ndiaye et al reported that positive deviance
increases found in the community can improve health
in general. Positive deviance is a new strategy in an
effort to improve health promotion and approach to
the community10. This was achieved when there was
an extraordinary case of malaria in Thailand in 2014.
Support for positive deviance was also found in research
conducted in Cambodia, that positive deviance is one
tool that can be used to control the incidence of malaria
in an area by strengthening the community11.
Knowledge with Malaria Events
Knowledge of the community has an important role
in malaria transmission in an area. The level of knowledge
of the community in the Manyamba Village is dominant
in the category of sufficient malaria knowledge, although
education in the community of manyamba is dominant in
the category of low education. The results of this study
146  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
indicate that there is a significant relationship between
people’s knowledge and the incidence of malaria.
Individual knowledge is one of the important
factors to cut the chain of malaria transmission in
each family, especially the knowledge possessed by
women as a mother12-14 . Although the community’s
knowledge of malaria is sufficient, there is still a need
for a kind of community formation consisting of cadre
cadres to provide more knowledge related to malaria
in the community15. In addition, knowledge about how
to transmit malaria, people need to be educated about
preventing mosquito bites that can cause malaria by
using insecticide-treated mosquito nets16-18.
Work with Malaria
The geographical condition found in the research
location in the form of mountains is one of the places
of vector breeding. In villages affected by extraordinary
events there are rivers near residential areas that are
breeding places for mosquitoes. With such geographical
conditions, the livelihoods of the majority of the
population are gardening and farming. This is also one of
the causes of malaria because when they do the work of
the plantation area, unconsciously mosquitoes carrying
malaria attack. Suharmasto states there is a significant
relationship between work with malaria incidence and
people whose occupations are at risk of 2.82 times risk of
developing malaria compared to people whose jobs are
not at risk. Meanwhile, according to research by Aisy18
stated that there was no significant relationship between
work and the incidence of malaria. Various activities or
human work often result in changes in environment that
benefit malaria transmission19,20.
Conclusion
Positive deviance, work and knowledge are variables
that have a significant relationship with the incidence
of malaria. Work is a variable that has the strongest
relationship with the incidence of malaria in Manyamba
Village, Tammerodo District, Majene District, West
Sulawesi. Positive deviance behavior in the community
can be used to prevent community events through active
role of health cadres by forming healthy communities in
the community.
Conflict of Interest: None
Source of Funding: Authors
Ethical Clearance: Obtained from Faculty Ethical
Committee
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Influencing Of Malaria Insident In Indonesia (
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Kesehatan, 2010; 9(Juni), pp. 1207–1218.
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knowledge, attitudes, practices and predictors of
malaria incidence in a cohort of Ugandan children’,
Tropical Medicine and International Health,
2003; 8(8), pp. 685–692. doi: 10.1046/j.1365-
3156.2003.01060.x.
5. Dike, N. et al. ‘Influence of education and
knowledge on perceptions and practices to control
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Annual Parasite Incidence Malaria di Kabupaten
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Soedirman, 2014.
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Larva Aedes Aegypti pada Tempat Penampungan
Air. Poltekes Kemenkes Pontianak, 2017.
8. Masruroh, L., Wahyuningsih, N., E., & Dina, R.,
A. Hubungan Faktor Lingkungan dan Praktik
Pemberantasan Sarang Nyamuk (PSN) dengan
Kejadian Demam Berdarah Dengue (DBD)
di Kecamatan Ngawi. Semarang: Universitas
Diponegoro, 2016.
9. Ndiaye, M. et al. ‘Impact of a positive deviance
approach to improve the effectiveness of an iron-
supplementation program to control nutritional
anemia among rural Senegalese pregnant women.’,
Food and nutrition bulletin, 2009; 30(2), pp. 128–
136. doi: 10.1177/156482650903000204.
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10. Lyttleton, C. ‘Deviance and resistance: Malaria
elimination in the greater Mekong subregion’, Social
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144–152. doi: 10.1016/j.socscimed.2015.12.033.
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in malaria control and elimination: Methodology,
qualitative assessment and future potential’, Malaria
Journal. BioMed Central, 2016; 15(1), pp. 1–15.
doi: 10.1186/s12936-016-1129-5.
12. Tarimo, D. S. et al. ‘Mothers’ perceptions and
knowledge on childhood malaria in the holendemic
Kibaha district, Tanzania: Implications for malaria
control and the IMCI strategy’, Tropical Medicine
and International Health, 2000; 5(3), pp. 179–184.
doi: 10.1046/j.1365-3156.2000.00537.x.
13. Nganda, R. Y. et al. ‘Knowledge of malaria
influences the use of insecticide treated nets but
not intermittent presumptive treatment by pregnant
women in Tanzania’, Malaria Journal, 2004 ; 3, pp.
1–7. doi: 10.1186/1475-2875-3-42.
14. Mubyazi, G. et al. ‘Intermittent preventive treatment
of malaria during pregnancy: A qualitative study of
knowledge, attitudes and practices of district health
managers, antenatal care staff and pregnant women in
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4-31.
15. Hlongwana, K. W. et al. ‘Community knowledge,
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16. Adongo, P. B., Kirkwood, B. and Kendall, C. ‘How
local community knowledge about malaria affects
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10(4), pp. 366–378.
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‘Knowledge of malaria, risk perception, and
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A. Understanding the perspectives of village leaders
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2017; 14: 49-57.
Genetic Identification of Aplocheilus Panchax from the Waters
of West Papua Using Molecular Approach for Preventing the
Spread of Malaria

Lutfi1, Hermawaty Abubakar2, Marhan Manaf1, Ida Lapadi1, Muhammad Dailami3

Department of Fishery, Faculty of Fishery and Marine Science, University of Papua. Jl. Gunung Salju
1

Amban - Manokwari, West Papua Province, Indonesia, 2Department of Biology, Faculty of Mathematics and
Natural Science, University of Papua. Jl. Gunung Salju Amban - Manokwari, West Papua Province, Indonesia,
3
Department of Chemistry, Faculty of Mathematics and Natural Science, University of Papua. Jl. Gunung Salju
Amban - Manokwari, West Papua Province, Indonesia

Abstract
Aplocheilus panchax domesticated as candidates of broodstock is genetically identified in order to be
cultivated and restocked. This research is aimed at identifying the gene of Aplocheilus panchax from the
waters of West Papua. Samples were collected from several locations. In Sorong only seven samples were
obtained due to the decrease of population of A. panchax, because increase population of predator. The
length of the total genomes of A. panchax which were isolated ranged 20 and 30 kb. Their amplicon length
was approximately 400 bp. The quality of DNA was excellent with high level of brightness, brighter than
the DNA bands in the DNA marker. Cyt b sequences from the samples of KT_MKW_01 with forward and
reverse primers were aligned and manually proof read to ensure that DNA sequences corresponded to the
peak of electropherogram. The results of BLAST sequence obtained from real sequences from Cyt b gene
of A. panchax had 99% similarity with GenBank and alignment indicated that point of polymorphism was
not found. All the sequences had exactly similar nucleotide sequences, that the amplified Cyt b gene was a
greatly conserved gene and 34 samples were grouped into the same haplotype based on fragment of Cyt b
gene.

Key words: Cyt b gene, Kepala timah (Aplocheilus panchax), malaria, molecular genetics and waters of
West Papua.

Introduction by more than 10 per 1000 population. There are several

Papuagovernment encounters difficulties in
protecting its natural wealth and most importantly
human beings that inhabit the area. The inhabitants of
Papua cannot be separated from a terrible bogeyman,
i.e. malaria. Furthermore, malaria is the number one
killer in Papua with the incidence of cases in 2012
that about 231 thousand people suffered from malaria
with an incidence rate of 96 cases per 1000 births. In
addition, Papua according to news daily Republika
ROL Online1 has the highest Parasitical Annual Index
(API) in Indonesia by more than 20 per 1000 population,
which is far from the MDGs target of about one or less
than one. This is also supported by high disparity value
of API between regions, especially in eastern Indonesia
challenges in controlling malaria including: limited
access to health care, continuity of coverage, quality
of (microscopic) diagnosis and case management,
cross program and cross sector synergies and increased
potential risk factors for malaria. This makes malaria
control very difficult due to disease-transmitting vector,
i.e. mosquitoes existing in nature and is not easy to deal
with. In addition, environmental aspects facilitate the
reproduction of mosquitoes and drugs lead to resistance2.
Understanding the geographical distribution of
melecular within a species is paramount to any attempts
to conserve major genetic lineages, if such variance
exists in the wild4,5. Kepala timah Aplocheilus panchax
Hamilton inhabits the waters of Papua in both freshwater
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  149
and brackish waters that can be used as a bio-indicator
of pollution of any water body. Aplocheilus panchax
has a habit of eating mosquito larvae in nature5. This
makes Kepala timah serving as a natural pest controller
(biopesticide), that it has the ability to eat malaria
mosquito larvae, a terrible bogeyman for most of the
people who live in Papua.
A well-maintained and unique nature that is different
from other Indonesian regions. This is not only due to
the number of species, but also its genetic diversity. It
is associated with the complex formation of the islands
(biogeography) and the isolation of certain places, which
lead to high speciation6. In regard to the aforementioned
problems and potential, this research attempts to identify
the genetics of Kepala timahfrom West Papua waters
which can be domesticated as a candidate superior
parents to be cultivated and restocked to nature in order
to assist the local government program in the form of
policy to prevent malaria transmission in West Papua.
This research aims to identify molecular genetics
of Kepala timah from West Papua waters (Manokwari,
Sorong and Oransbari) that in the next research will be
domesticated to support the restocking efforts to nature,
in order to assist the local government in controlling
malaria in West Papua.Meanwhile, this research is
beneficial to obtain a genetic data of Kepala timah from
West Papua waters, which has the advantage of feeding
on mosquito larvae in controlling malaria transmission
in West Papua.
Materials and Method
Place and Time
The research was conducted for eight months
from January to August 2016. It attempted to obtain
genetic data of Kepala timah (Aplocheilus panchax)
from West Papua waters that feed on mosquito larvae and
is resistant to adverse environmental conditions so that it
is able prevent malaria transmission in Papua.
The research was conducted in the sub-laboratory of
Genetics and Molecular, Faculty of Fisheries and Marine
Sciences, University of Papua. It included sample
collection, sample extraction, samples in PCR and data
analysis of sequence results that previously the samples
had been sent to obtain the data of the sequence results.
Tools and Materials
Tools used in the research were aquarium equipment
complete with aeration sets to temporarily raise fish
samples taken from several locations or districts in West
Papua. The tools for taking samples in locations included
battery aerator, scoop or net and five liter jerry cans as
temporary containers from the locations and plastic
bags equipped with dissolved oxygen were used for
transporting live fish from the locations to Manokwari.
Meanwhile, the tools used collecting genetic samples
were: analytical balance, micro pipettes, tube PCR,
PCR machine (Thermal Cycler Type 1148), hot
block, UV transluminator, microcentrifuge eppendorf,
sample bottles, PCR tube rack, a set of electrophoresis
equipment, erlenmeyer flask, freezer, measuring cups,
goblets, bunsen lamp, magnetic stirrer, vortex machine,
stationery, polaroid digital camera, MEGA 5.0 software.
The materials used in this research were: oxygen
given when packaging living samples for the purpose
of transporting the samples. Materials for preparing
DNA samples were DNA extraction kits, proteinase K,
isopropanol, ethanol 70%. Materials used when running
at PCR were Cyt b primer, primers, dream Taq, dNTP
mix, DMSO, nuclease-free water, tissue, hand glove,
microtube and tips. Materials used for electrophoresis
were : agarose, TAE buffer, blue/orange loading dye,
ladder, deion/ molecular grade water and aluminum foil.
Research Methodology
In regard to genetic aspects of Aplocheilus panchax,
research methods consisted of the following stages:
sample collection, DNA extraction, amplification,
electrophoresis, Exo/Sap, cycle sequencing,
precipitation and data analysis (Figure 1).
DNA extraction
Samples of Aplocheilus panchax were collected
from three districts/locations in West Papua
(Manokwari, Sorong and Oransbari). Samples were
taken randomly numbering ten individuals from each
location. Afterwards, they were stored in 70% ethanol
until they were used. DNA extraction employed a
standard protocol of Geneaid kit (Geneaid, 2013).
Mitochondrial DNA Analysis
Mitochondrial DNA Analysis of Cytochrome b gene
aimed to identify nucleotide diversity, haplotype and
kinship between populations. Mitochondrial DNA used
150  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
was Cytochrome b gene. Amplification aimed to copy Oreochromis niloticus in Sorong area was presumably
genes existing in mtDNA. The amplification process the cause of the small number of Aplocheilus panchax
was performed using PCR, namely Gold program (Saiki obtained11. All samples were preserved in 96% ethanol
et al. 1988) in accordance with a modified protocol of and stored in the collection of sub-Laboratory of
standard gold (Lourie 2005). The amplification firstly Genetics and Molecular, Faculty of Fisheries and Marine
made a mixture between 1 mL of sample extraction Sciences, University of Papua. Photos of some of the
and 24 mL of master mix (MM) consisting of ddH2O, collected samples were presented in Figure 1.
10X PCR buffer (Gold), dNTPs, MgCl2, primers and
Table 1. Data of Aplocheilus panchax sample
Taq enzyme. The amplification process was performed
collection
in the (PCR) Thermal Cycler machine and using Taq
Gold DNA polymerase as an enzyme in denaturing
conditions of 94°C for 10 minutes, annealing of 50°C GPS Sample
Location sample Total Sample
Position id.
for 30 seconds and chain elongation of 72°C for 10
minutes, as many as 38 cycles. Primers were designed
using Geneious Software (Biomatter) with PCR product S:
Amban Pantai, 00o49’06,3” KT_
≥400 base pairs (bp). Sequences were downloaded from 10 Individuals
Manokwari E: Mkw
GenBank (http://www.ncbi.nlm.nih.gov). Phylogeny 134o04’53,0”
tree was constructed using Neighbor Joining method
S:
(NJ) (MEGA 5.2) with 1000 replication.
SP7 Masni, 00o48’00,0” KT_
10 Individuals
Manokwari E: Msi
Results and Discussion 133o43’51,6”
Genetic analysis of Aplocheilus panchax S:
Oransbari, 00o19’48,8”
KT_Ob 10 Individuals
Genetic analysis of Aplocheilus panchax in this Manokwari E:
134 13’15,5”
o
research aimed to identify genetic diversity of some
S:
populations of Aplocheilus panchax from of waters 00o50’00,1”
Manokwari District, South Manokwari District Sorong KT_Sr 7 Individuals
E:
and Sorong Municipality in West Papua Province. 131o14’29,7”
Information of genetic diversity is very important in
Total Genomic DNA Isolation
determining the origin of parents to be used8. The higher
the genetic diversity of a population is, the better the Total genomes of Aplocheilus panchax samples in
resilience of the population from the disease will be 9. this research were isolated with a length of between
The genetic analysis in this research was carried out 20-30 kb (Geneaid, 2013). The success of the genome
through several stages, namely: a. Collection of tissue isolation of was characterized by the appearance
samples, b. Isolation of total genome, c. amplification of DNA bands on agarose gel stained with ethidium
CYT B gene, and d. sequencing of Cyt B Gene10. bromide. The electrophoresis results of agarose gel from
all samples are shown in Figure 1.
Collection of tissue samples
Genom of A. panchax from Manokwari (Amban
Samples of Aplocheilus panchax used in this research
Pantai) Genom of A. panchax from Manokwari
were collected from several locations in the province of
(Oransbari)
West Papua as shown in Table 1. Ten samples were taken
from each location to represent the population in the Genom of A. panchax from Manokwari (Masni)
location. In Sorong, only seven samples were obtained Genom of A. panchax from Sorong
because the population of Aplocheilus panchax was
decreasing. The researcher believes that the population
of Channa striata, Trichogaster pectoralis and
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  151
Genom of A. panchax from Manokwari (Amban Pantai)
Genom of A. panchax from Manokwari (Masni)
Figure 1. Electrophoresis Results of Aplocheilus panchax Genomes from Manokwari District, South Manokwari District and
Sorong Municipality, West Papua Province. Photo: Lutfi.
In general, the quality of the genome obtained was
very good, which could be seen from the presence of a
thick band at the upper part of the gel and a thin smear
band elongated at the lower part. This elongated smear
band could be due to DNA which was cut during the
process of genome isolation, or the result of the remains
of short RNA molecules. The less good quality of the
genome could be seen at samples from Manokwari (id:
KT_Mkw_15 and KT_Mkw_17). In this sample, the
DNA band that appeared was only a smear band from
the middle to the lower part of the gel. However, this
condition was still good enough to be used as a template
in PCR to amplify Cyt B gene. This was because the
target genes of Cyt B to be amplified using primers
L14841 and H15149 (Kocher et al. 1989) only had a
length of approximately 300 - 400 base pairs.
Cytochrome b (Cyt B) Gene Amplicon
Cytochrome b gene amplification was performed
Genom of A. panchax from Manokwari (Oransbari)
Genom of A. panchax from Sorong
in vitro using polymerase chain reaction (PCR). The 1
kb DNA marker was used as a marker. The length of
amplicon obtained had a size of approximately 400 bp.
The quality of DNA was very good with high levels of
brightness, brighter than the DNA bands in DNA marker
which had a concentration of 70 ng/uL for the brightest
band of DNA marker (Thermoscientific 2012). This
means that the concentration of DNA amplicon was
higher than 70 ng/uL. This concentration was sufficient
to be used in the sequencing stage. The electrophoresis
results of PCR products are shown in Figure2 .
Amplicon Gen Cyt B sample from Manokwari
( Amban Pantai) Amplicon Gen Cyt B sample from
Manokwari (Oransbari)
Amplicon Gen Cyt B sample from Manokwari
(Masni) Amplicon Gen Cyt B sample from Sorong
152  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

Amplicon Gen Cyt B sample from Manokwari ( Amban Pantai) Amplicon Gen Cyt B sample from Manokwari (Oransbari)

Amplicon Gen Cyt B sample from Manokwari (Masni) Amplicon Gen Cyt B sample from Sorong

Figure 2. Electrophoresis results of PCR products of Cyt B Gene of Aplocheilus panchax from Manokwari District, South
Manokwari District and Sorong Municipality. Photo: Lutfi.

Cytochromeb (Cyt B) Gene Sequence (http://www.ncbi.nlm.nih.gov) by using BLAST (basic

local alignment search tools). The results of BLAST.
Sequencing reaction (nucleotide sequencing) in
The results of BLAST by Satiamarga13indicated that
vitro with Sanger’s dideoxy termination method using
the sequences obtained were correct sequences of cyt
labeled nucleotide (Dideoxynucleotide triphosphates).
B genes from Aplocheilus panchax with 99% similarity
Sequencing reactions was conducted by 1st Base of
to sequences from GenBank with the access code
Singapore, through PT. Genetikas Sains. The sequencing
AB373005.1.
results were electropherogram in AB1 file format that
was sent via email. This file could be read using MEGA5 Until September 2016, sequencing had been
software12. Each sample was sequenced using two carried out for 37 samples from Manokwari Amban
primers, namely forward and reverse primers. Pantai (10 samples) and Masni (10 samples); Oransbari
(10 samples); and Sorong (7 samples). All samples
Cyt B sequences of KT_Mkw_01 samples with
had a very good quality of electropherogram, except
forward and reverse primers were aligned to be manually
3 samples from Masni with the ID numbers (KT_
proof read in order to ensure that the DNA sequences and
Msi_12, KT_Msi_15, KT_Msi_18). The alignment
its peak of electropherogram had matched. Sequencing
to 34 samples was carried using clustalW contained
this sample has a very good quality. The proof reading
in MEGA 5 software (Appendix 1). The results of the
process of these sequences was performed using MEGA5
alignment did not indicate any point of polymorphism.
software. Forward and reverse primers were aligned
All the sequences had the exact similarity of nucleotide
with the sequences and cut on the limit. The result of
sequences. This suggests that the amplified Cyt B gene
combination of the two sequences. The total length of
was a very conserve gene (having a very low mutation
nucleotides obtained was 358 bp.
rate). Therefore, the 34 samples could be grouped into
In order to ensure that Cyt B sequences obtained the same haplotype based on Cyt B gene fragment in
were correct Cyt B sequences of Aplocheilus panchax, this research.
a comparison was performed with GenBank database
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  153
Conclusions
The results of the alignment do not show any point
of polymorphism. All the sequences have the exact
similarity of nucleotide sequences. This suggests that the
amplified Cyt B gene is a very conserve gene (having a
very low mutation rate).
34 samples can be grouped into the same haplotype
based on Cyt B gene fragment.
This research suggests that genetic diversity
analysis should be performed using RAPD (Random
Amplification of Polymorphic DNA).
Conflict of Interest : None
Source of Funding : Incentive Research Insinas
grant (RT-2016-0245), Ministry of research, technology
and higher education of the Republic of Indonesia.
Ethical Clearance : Obtained from University of
Papua
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 The Effect of National Health Care and Motivation of
Maternity Mothers in Health Care Facilities in the Working
Area of Bantilang Health Center East Luwu Regency in 2018

Nilawati Uly1, Suhra Surdin1

1
Institute of Higher Health Education, Mega Buana Palopo. Indonesia

Abstract
Social Security Organizing Agency (BPJS) is organized through a social insurance mechanism and the BPJS
membership is all Indonesian citizens without exception. Objective: To determine the effect of nasuonal
health care and motivation of mothers giving birth in health care facilities in the work area of Bantilang
Health Center East Luwu District in 2018 Method: This study used a cross sectional method. The population
in this study were all obstetric patients at the time of the study. The sample in this study were some obstetric
patients both from Maternity Mothers Care (KIA) and Family Planning (KB) Polyclinics and the delivery
room (Inpatient) at the time of the ongoing study who were willing to become respondents using purposive
sampling technique. Data collection using questionnaire research instruments and processed using SPSS
program and distribution with distribution tables and bivariate analysis tables. Results: Univariate analysis
looked for frequency distribution while bivariate analysis looked for the influence of each variable where
National Health Insurance (JKN) variable (p = 0,000) and motivation (p = 0.003). Conclusion: There is an
effect of nasuonal health care and motivation of mothers to give birth at health care facilities in the work area
of Bantilang Health Center East Luwu District in 2018

Keywords: Maternity Mothers, Health Care Facilities, National Health Insurance and Motivation

Introduction Based on the PWS KIA report on the Bantilang

Health is the basic right of every person, all citizens
have the right to receive health services, including the
poor1. In 2014, the government implemented a National
Health Insurance (JKN) program organized by the
Social Security Organizing Agency (BPJS)2,3. This
BPJS is expected to meet the needs of citizens for health
services. Based on data from the East Luwu Health
Service, the number of JKN participation in the District.
In 2016, East Luwu was 1,722,111 people, while in 2017
there were 2,597.53 people. KIA annual report, namely
coverage of assistance by health workers as many as
5,671 maternity mothers from the target target of 6,234
mothers giving birth.
Corresponding author;
Nilawati Uly
Institute of Higher Health Education, Mega Buana
Palopo. Indonesia
Health Center in East Luwu Regency, the number of
maternity mothers at home or non health facilities in
2015 was targeted for 119 maternity mothers where there
were 108 maternity facilities at 11 maternity facilities
and a target in 2016 as many as 131 women giving birth
in health facilities as many as 115 mothers giving birth
while non-health facilities as many as 16 people and
in 2017 the target of maternity mothers is 148 women
giving birth in health facilities as many as 130 women
giving birth while non-health facilities are 18 person. In
a previous study conducted by Melina4 that the results of
analysis with the chi square test obtained a significance
value of 0,000, because the significance value (p-value)
was obtained at 000 smaller than, 05 (p <, 05), the
statistics show that there is a relationship between the
use of national health insurance and the achievement
of coverage of target services for pregnant women at
Banguntapan II Health Center, Bantul Regency in 2016.
From the results of Zahruddin’s5 study, it was shown that
half of the respondents in Jrangoan Community Health
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  155

Center considered that subjective norms were very
instrumental in supporting the delivery community to
health facilities. There are three aspects assessed in this
regard, namely community support, husband support
and parental support. Based on the description above,
the researchers are interested in conducting research
with the title “The Effect of National Health Insurance
and Motivation of Maternity at Health Service Facilities
in the Bantilang Community Health Center Working
Area in East Luwu Regency in 2018”.
Materials and Method
Based on maternal facilities at Bantilang Community
Health Center in East Luwu Regency in 2018 was highest
in health facilities as many as 44 people (89.8%) while
the lowest was in non-health facilities with 5 (10.2%).
National Health Insurance (JKN)
Table 2 Frequency Distribution Based on
National Health Insurance at Bantilang Community
Health Center, East Luwu Regency in 2018
National Health
Insurance
Number Percentage

Research design Yes 45 91.8

This research is a quantitative research with No 4 8.2

analytical survey method using crossectional research
Total 49 100
design where the independent variable and dependent
variable data are taken at the same time to identify
Distribution based on national health insurance in
factors related to JKN role on maternal motivation in
the East Java Community Health Center in 2018 has the
health care facilities in Bantilang Health Center, East
highest JKN of 45 people (91.8%) while the lowest in
Luwu Regency in 20186.7
not having JKN with 4 (8.2%).
Location and Time of Research 1. Research Sites
Motivation
Research locations in Bantilang Health Center, East
Luwu Regency 2. Research Time Time of study from Table 3 Distribution Mother’s Motivation in
March to September 2018 Bantilang Community Health Center, East Luwu
Regency in 2018
Population and Samples

The population in this study were all women giving Motivation Number Percentage
birth at the time of the study that took place with a Good 44 89.8
population of 98 people. The sample in this study was
Less 5 10.2
that some women gave birth at the time of the study that
were willing to be respondents with a total sample of 49 Total 49 100
people. By using yairu purposive sampling technique.
The results of this study are presented in the form of Distribution based on maternal motivation in
frequency distribution tables as follow. Bantilang Community Health Center in East Luwu
Regency in 2018 was the highest in good motivation
Results with 44 people (89.8%) while the lowest in motivation
was 5 people (10.2%).
Univariate Analysis
Bivariate Analysis
Maternity Facilities
National health insurance
Table 1 Distribution of Frequency Based on
Maternity Facilities at Bantilang Community Health
Center, East Luwu Regency in 2018

Maternity Facilities Number Percentage

Health Facility 44 89.8
Non Health Facility 5 10.2
Total 49 100
156  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Table 4. Influence of JKN with Maternity in Health Facilities with in Bantilang East Luwu Regency in
2018.

Maternity Health Facilities

No National Health Insurance Non Health

Health Facility
Facility Total P
n % n % n %

1 Yes 44 89.8 1 1.2 45 100

2 No 0 0 4 100 0 0 .000

Based on the results of statistical tests using SPSS version 20 with the chi-square statistical test, it can be seen
that the chi-square values obtained are 000, which means <value of α, 05 which means Ha is accepted which means
there is an influence of national health insurance with maternity at the service facility health in the working area of
the Bantilang Community Health Center in East Luwu Regency in 2018

Motivation

Table 5. Effects of Motivation with Maternity in Health Facilities with Bantilang Health Center East
Luwu Regency in 2018.

Maternity Health Facilities

No Motivation Non Health

Health Facility
Facility Total P
n % n % n %

1 Good 44 100 0 0 44 100

2 Less 0 0 5 10.0 5 100 .000

Table shows the highest percentage with good
motivation to choose maternity in health facilities as
many as 44 people (100%) while the lowest percentage
with less motivation by choosing labor in non-health
care as much as 5 people (100%) of the total respondents
as many as 49 people. The chi-square statistical test​​
obtained are 000 which means <value α, 05 which means
Ha is accepted which means there is an influence of
motivation with maternity at health care facilities in the
working area of ​​Bantilang Community Health Center,
East Luwu Regency in 2018.
Discussion
National Health Insurance
The results of this study indicate that JKN is a
community need for national health insurance which is a
necessity for basic and high levels. Basic level needs are
needs that can be satisfied from the outside, for example
physiological needs and the need for security. While
high level needs are needs that can only be satisfied
in the person concerned, for example the need for
appreciation and self-actualization8,9. To certify the JKN
program the role of all cross-sectors is needed to provide
understanding and information to the public about the
benefits of JKN so that the community can be motivated
and can increase the coverage of universal and universal
health services. The results of the above research indicate
that the National Health Insurance (JKN) is part of the
National Social Security System (SJSN). The National
Social Security System is organized through a mandatory
social health insurance mechanism based on Law No. 40
of 2004 concerning the National Social Security System.
The aim is that all Indonesian citizens be protected in the
insurance system, so that they can meet the basic needs
of proper public health10-12. The results of the study are
in line with the research conducted by Melina (2016.
The results showed that pregnant women who used JKN
whose achievement of coverage coverage for pregnant
women reached 38 people (73.1%) and achieved the
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  157
target coverage of services for pregnant women as many
as 14 people (26,9%).
Contingency coefficient values ​​are C = 0.502 Thus
it can be concluded that the closeness of the relationship
of the contingency coefficient is moderate (0.40-0.599).
The maintenance guarantee factor is one of the important
factors for the community today where having a health
care guarantee the community feels more protected if
one day they are stricken with an illness because having
health insurance they can be freed from medical expenses
Mothers who have not become BPJS members have
reasons that different. The results showed that pregnant
women were not yet members of the BPJS because they
did not know how to take care of it, were in the process
of being managed. Even though the Minister of Health of
the Republic of Indonesia announced in 2019 the entire
Indonesian community has been included as a member
of the BPJS. One guarantee of maternity is the guarantee
of childbirth. Collateral guarantee is a guarantee of
funding for delivery services which includes prenatal
care, delivery assistance, postpartum care, including
postpartum family planning services and newborn
services1. In the process of implementing the National
Health Insurance Program (JKN) to provide health
protection in the form of health care benefits in order to
meet basic health needs given to everyone who has paid
contributions or fees paid by the government10,11.
Motivation
Based on the results of statistical tests using SPSS
version 20 with the chi-square statistical test it can be seen
that the chi-square values ​​obtained are 000 which means
<value α, 05 which means Ha is accepted which means
there is an influence of motivation with maternity at
health care facilities in the working area of ​​the Bantilang
Community Health Center in East Luwu Regency in
2018 The research above shows that motivation is an
internal drive that causes the person to carry out certain
activities in order to achieve a goal13. Expectations for
Health facilities are health service facilities used for
carry out individual health care efforts, both promotive,
preventive, curative and rehabilitative organized by the
Government, Regional Government and or Society 2,3.
The results of this study are in line with the research
by Zahruddin14 showing that half of the respondents
in Jrangoan Health Center considered that subjective
norms were very instrumental in supporting the delivery
community to health facilities. Whereas based on the
results of multiple linear regression tests, it was shown
that the normative beliefs of giving birth to health
facilities and the motivation to deliver to health facilities
had a significant effect on subjective norms. Subjective
norms are formed by two components, namely the
normative belief in giving birth to health facilities and
the motivation to deliver to a health facility. There are
three aspects assessed in this regard, namely community
support, husband support and parental support. The
influence of motivation to health facilities is influenced
by the most influential aspect in this case is the support
of parents on the sub-variables of normative beliefs
and community support in the sub-variables of labor
motivation to health facilities. This result means that in
deciding to implement or not deliver to a health facility,
pregnant women and postpartum mothers are influenced
by their social environment (significant others), namely
the support of parents and support from the community
or someone who becomes a preference. The absence
of support from parents and the motivation of the
community to give birth to health facilities causes the
low desire of pregnant women to give birth to health
facilities14-17
The role of cross-sector in increasing motivation to
Health Facilities in order to carry out individual health
care efforts, both promotive, preventive, curative and
rehabilitative organized by the Government, Regional
Government, and or Community2. First Level Health
Facilities, hereinafter abbreviated as FKTP, are health
facilities that carry out non-specialist personal health
services for the purposes of observation, promotion,
prevention, diagnosis, care, treatment, and / or other health
services (BPJS, 2016). People as users of health services
will provide an assessment that quality health services
as a form that can meet the needs because it is organized
by: 1) Courteous and polite, timely, responsive, 2) Able
to cure illnesses, 3) Able to prevent the development or
the spread of the disease suffered to other people or the
disease gets worse. For health care providers linking
quality health services with: 1) Equipment independence,
2) Work producer or protocol, 3) Professional freedom
in carrying out every health service in accordance with
the latest health technology and, 4) How is the outcome
or outcome of health services implemented, 5) For
funders of health services To be able to improve public
health, there are many things that need attention. One of
them which is considered to have a quite important role
is to provide health services. What is meant by health
158  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
services is every effort that is held alone or jointly in
an organization to maintain and improve health, prevent
and cure diseases and restore the health of individuals,
families, groups and / or communities. Requirements
for good health services can at least be distinguished
from 13 types, namely available, comprehensive
(comprehensive, integrated), continuous, equitable,
sustainable, appropriate. acceptable (acceptable),
accessible (affordable), affordable (effective), effective
(efficient), and quality18
Conclusion
1.There is an influence of national health insurance
with maternity at health service facilities in the working
area of ​​Bantilang Community Health Center, East Luwu
Regency in 2018. Statistical test results using SPSS
version 20 with chi-square statistical test can be It is seen
that the chi-square value is obtained, 000, which means
<value of α, 05 which means Ha is accepted. 2. There is
an influence of motivation with maternity at health care
facilities in the working area of ​​Bantilang Community
Health Center, East Luwu Regency in 2018. The results
of statistical tests using SPSS version 20 with the chi-
square statistical test can be seen that the chi-square
value is obtained which is 0,000 which means < value α,
05 which means Ha is accepted.
Conclict of Interest : None
Source of Funding : Institute of Higher Health
Education, Mega Buana Palopo. Indonesia
Ethical Clearence : Obtained from Institute of
Higher Health Education, Mega Buana Palopo.
References
1. Yuliah, R & Yuswanto, A, T. Community midwifery
care. Issue 2. Jakarta, K. Salemba Medika. 2014
2. BPJS. Practical Guide to Midwifery and Neonatal
Services. Jakarta: J. 2015.
3. BPJS. Health Social Security Organizing Agency
Regulation Number 4 of 2016 concerning Technical
Guidelines for the Implementation of Benefit
Coordination in the National Health Insurance
Program. Jakarta. 2016
4. Melina. Relationship between the Use of National
Health Insurance and the Achievement of Targeted
Coverage of Pregnant Women in Banguntapan Ii
Health Center, Bantul Regency in 2016
5. Zahruddin. Recommendations to Increase Delivery
to Health Facilities in the Jrangoan Community
Health Center Working Area in Sampang Regency,
2015.
6. Sulistyaningsih, Midwifery Research Methodology.
Yogyakarta, Y: Graha Ilmu. 2012Syafruddin. Ilmu
Kesehatan Masyarakat. Jakarta Tumur, JT : CV
Trans Info Media 2015.
7. Nasir, A, et.al ,. Health Research Methodology.
Yogyakarta, Y: Nuha Medika. 2011
8. Nottmodjo, S. Health Promotion Theory &
Application. Jakarta, J: Rineka Cipta. 2010
9. Ministry of Health R.I. Republic of Indonesia
Minister of Health Regulation Number 28 of
2014 concerning Guidelines for Implementing the
National Health Insurance Program. Jakarta. 2014
10. Ministry of Health R.I. JKN Socialization
Handbook. Jakarta. 2015
11. Ministry of Health R.I. Indonesia Health Profile
Jakarta. 2016
12. Mubarak, I, W. Public Health Sciences Concepts
and Applications in Midwifery. . Jakarta, J: Salemba
Medika. 2014
13. Zahruddin. Recommendations for Increasing
Delivery to Health Facilities in the Jrangoan
Community Health Center Working Area in
Sampang Regency. 2015
14. Budiani, N.N., Somoyani, N.K., Marhaeni, G.A.,
(...), Erawati, L.P.S., Mallongi, A., Administration
of tempehethanol extracts on prenatal until weaning
inhibitory period the ovary follicles developing of
little wistar rats. Indian Journal of Public Health
Research and Development. 2018.
15. Anwar Mallongi, Ruslan La Ane and Agus Bintara
Birawida. Ecological risks of contaminated lead and
the potential health risks among school children in
Makassar coastal area, Indonesia. J. Environ. Sci.
Technol., 2017; 10: 283-289.
16. Rosmala Nur, Nikmah Utami Dewi, Khairunnisa
and Anwar Mallongi, Golden standard feeding and
the risk of 25-60 month-old underweight children
in Central Sulawesi, Indonesia. Asian J. Clin. Nutr.,
2017; 9: 104-110.
17. Saifudin B, A. Practical Handbook for Maternal
Neonatal Health Services. Jakarta, J: PT Bina
Pustaka Sarwono Prawihardjo. 2010
 The Effect of Granisetron and Ondansetron on Hemodynamic
During Cesarean Section Under Spinal Anesthesia

Syafri Kamsul Arif1, Ahmad Nur Islam 2, Alamsyah A.A.1, Muh. Ramli Ahmad1,
Syafruddin Gaus1, Hisbullah1
1
Staff, 2Resident, Department of Anesthesiology, Intensive Care and Pain Management Hasanuddin University,
Faculty of Medicine, Makassar, Indonesia

Abstract
Spinal anesthesia is the most popular technique of anesthesia for Caesarean section (Cs) which is frequently
associated with hypotension and bradycardia. Hypotension is harmful for maternal and fetal outcome.
The Bezold–Jarisch reflex (BJR) is one of the mechanisms which explain the occurrence of hypo tension
after spinal anesthesia through serotonin-mediated vasodilatation. These receptors located peripherally as
cardiac chemoreceptors on the cardiac vagal afferent and centrally in the chemoreceptor trigger zone. The
aim of our study was to evaluate the effect 5-hydroxytryptamine 3 (5-HT3) receptor antagonists between
Granisetron and Ondansetron on hemodynamic in parturients undergoing Cs with spinal anesthesia. Forty
patients underwent Cs under spinal anesthesia randomly divided into two groups (20 parturients in each
group). Group G received intravenous 0.03 mg/kg Granisetron 30 min before spinal anesthesia, group O
received intravenous 0.1 mg/kg Ondansetron. Mean Arterial Blood Pressure (MABP), Heart Rate (HR),
and vasopressor used were assessed. MABP changes was higher in group O compared to group G (p<0.05),
although this result was not statistically significant (p>0.05). However, incidence of nausea and vomiting
was significantly decreased in group G (p<0.05). Granisetron and Ondasetron have similar effect in prevent
hemodynamic changes during Cs under spinal anesthesia.

Keywords: Granisetron, Ondansetron, hemodynamic, Caesarean section, spinal anesthesia.

Introduction explain the development of hypotension after spinal

Spinal anesthesia is the most popular technique of
anaesthesia for Cs, which is frequently associated with
hypotension and bradycardia. Hypotension is harmful for
maternal and fetal outcome. Hypotension resulted from
the decrease in systemic vascular resistance and central
venous pressure due to sympathetic block. Sudden
bradycardia may occur from shift in cardiac autonomic
balance toward the parasympathetic system.1,2
Ondansetron and Granisetron are selective 5-HT3
receptor antagonists. These receptors located peripherally
as cardiac chemoreceptors on the cardiac vagal afferent
and centrally in the chemoreceptor trigger zone. On the
other hand, the BJR is one of the mechanisms which
anesthesia through serotonin-mediated vasodilatation.
Stimulation of cardiac chemoreceptors in the heart due
to decreased in venous return increases parasympathetic
activity, while decreases the sympathetic activity
resulting in hypotension and bradycardia.2,3 From
systematic review and meta-analysis, Heesen et al.
in 2016 suggested 5-HT3 receptor antagonist were
effective in reducing the incidence of hypotension
and bradycardia.1 The effect are only significant in
patients undergoing Cs, therefore in this study, we
evaluated the effect of Granisetron and Ondansetron
on the hemodynamic and side effects following spinal
anesthesia in women undergoing elective Cs.
Materials and Method
This study was conducted at Mother and Child
Hospital in Makassar, Indonesia between February and
March 2018. Institutional ethical committee approval
160  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
and informed written consent were obtained from all distributed were compared between groups by Student’s
patients. Participants were evaluated one day before independent samples t-test with p<0.05 was statistically
surgery by an anaesthesiologist. Obstetric patients with significant.
ASA Physical Status (PS) II, between 20 and 45 years old,
and undergoing an elective CS were included. Patients
Results
who refused to participate, had any contraindications Forty patients were recruited: 20 parturients in
to spinal anesthesia, history of hypersensitivity to local each group. No significant differences were observed in
anesthetic agent, bleeding disorder, hypertensive and patients demographic (age, BMI, and ASA PS) between
cardiovascular disorders in pregnancy were excluded. the two groups (p>0.05). The incidence of nausea and
For eligible patients, demographic information was vomiting significantly reduced in group G (see Table 1).
collected and a physical examination was performed.
Age, BMI, and ASA PS class were recorded and MABP and HR were observed in the two groups.
analyzed. The difference in time of measurement in each group
was observed. MABP changes was higher in group
In the pre-anesthesia room, baseline value recorded, O compared to group G (p<0.05), although this result
non-Invasive blood pressure (NIBP) and HR were was not statistically significant (p>0.05) (see Figure 1).
recorded and a peripheral 18-Gauge i.v. cannula was There was no difference of HR changes between the two
inserted. Patients were randomly assigned to receive 0.1 groups (p>0.05) (see Figure 2).
mg/kg Ondansetron (group O) or 0.03 mg/kg Granisetron
(group G) 30 min before spinal anesthesia, where each Table 1. Demographic details and side effect by
group consists of 20 parturients. All patients received each group
i.v 50 mg Ranitidine and preloading with 10 mL/kg
Ringer’s lactated solution given over 15 min. The spinal
Group G Group O p value
technique was performed at L3-4 or L4-5 with the patient
in the left lateral decubitus position. The 10 mg 0.5%
hyperbaric bupivacaine with adjuvant 25 mcg fentanyl
(n=20) (n=20)
was administered after confirmation of cerebrospinal
fluid through a 25- or 26-Gauge Quincke spinal needle.
Patients were immediately placed in the supine position
Age (years) † 28.95±4.45 28.55±6.32 0.818
with 15o left tilt. The second anesthesiologist was
blinded to the study solution, measured hemodynamic
parameters and recorded the presence of nausea and BMI (kg/
25.38±2.24 25.88±2.74 0.532
vomiting. m2) †

HR and MABP were recorded before spinal

anesthesia and at 2-min intervals up to 15 min, followed ASA PS‡ 20 (100) 20 (100) 1.000
by 30-min intervals until the end of surgery. Rescue
i.v. bolus doses of 10 mg ephedrine were given if the
Nausea/
parturient had hypotension (hypotension was defined as Vomiting §
0(20) 5(20) 0.047*
a decrease in SBP <90 mmHg or in MABP more than
20% from the baseline). Decrease in HR to less than Vasopressor
0 0 -
50 beat/min was treated with 0.5 mg atropine sulphate Use §
intravenous.
Data presented in number of patient (n) or mean±SD.
The Statistical Program SPSS (SPSS Inc., Chicago, .*:p<0.05, analyzed with Fisher’s exact test. †: analyzed
Illinois, USA) for Windows, version 25, was used with Student’s independent samples t-test, ‡: analyzed
for data entry and analysis. Data were expressed as with Chi-square test. § : analyzed with Fisher’s exact
number and mean ± SD for quantitative variables. test.
Categorical variables were analyzed using Chi-squared
test or Fisher’s exact test. Numerical variables normally
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  161
Figure 1. Comparison MABP (mmHg) changes in group G
and group O
Figure 2. Comparison HR (bpm) changes in group G and
group O
Discussion
Sympathetic blockade from spinal anesthesia
decreases systemic vascular resistance and induces
peripheral pooling of blood leading to hypotension.
In response to hypovolaemia, stimulation of cardiac
sensory receptors in the left ventricle induces the BJR
and results in reflex bradycardia, vasodilation and
hypotension. Chemoreceptors are activated in response
to decreased blood volume by serotonin. Activation of
5-HT3 receptors, which are G protein coupled, ligand-
gated fast-ion channels, results in increased efferent vagal
nerve activity which frequently producing bradycardia.
However, bradycardia occurs less frequently than
hypotension following spinal anaesthesia.6,7,8
Ondansetron and Granisetron, although both of
them from the same category and have same mechanism
of action, may be due to the action of Ondansetron on
mixed receptors and the high selectivity of Granisetron
on 5-HT3 receptors, but it has minimal affinity for other
5-HT receptors, adrenergic, histaminic, dopaminergic,
or opioid receptors.10,11
In the present study, two 5-HT3 antagonists,
Ondasnetron and Granisetron, as they block the BJR
and may successfully treat postspinal hypotension, were
used prophylactically and given 30 min before spinal
anesthesia. The important finding in this study is that,
despite the reduction in MABP changes in Ondasetron
group higher than Granisetron group, there were no
statistically difference in MABP changes in the two
groups.
Our findings is consistent with study by Mahmoud
and Shaaban in 2017 showed that prophylactic
intravenous 4 mg Ondansetron or 1 mg Granisetron
compared to saline as placebo were significantly
reduced the severity of hypotension induced by spinal
anesthesia.6 In our study, we gave prophylactic 0.03
mg/kg Granisetron and 0.1 mg/kg Ondansetron 30
min before spinal anesthesia. It showed there were no
difference in hemodynamic changes and there was no
incidence vasopressor use in each group.
This study showed that Granisetron and Ondansetron
have protective effect on hemodynamic response
during Cs. Our results indicated that Ondansetron
and Granisetron prevented the serotonin-induced BJR,
suppressed venodilatation, augmented venous return to
the heart and resu lted in lesser reductions in MABP.10
Limitations of this study were small sample size,
used one dose of each drugs only, and amount of blood
loss was not recorded in this study, which may influence
the hemodynamic profile of parturients. We recommend
further studies with larger sample size and large doses of
Granisetron and Ondansetron to evaluate the effect on
hemodynamic.
Conclusion
Granisetron and Ondansetron has similar effect
on preventing hemodynamic changes during Cs under
spinal anesthesia.
Acknowledgement: Author thanks to staff and
resident Department of Anesthesiology, Intensive Care,
and Pain Management, Faculty of Medicine, Hasanuddin
University for the ideas, supporting, and advising this
study. Thanked to Mother and Child Hospital staffs and
all of participants of this study.
Conflict of Interest : None
Source of Funding : Authors their selves
162  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Ethical Clearance: Obtained from medical faculty,
Hasanuddin University
References
1. Michael H, Markus K, Sanne EH, Rolf R. Prevention
of spinal anesthesia-induced hypotension during
Caesarean delivery by 5-hydroxyptamine-3 receptor
antagonist: a systematic review and meta-analysis
and meta-regression. Anesth Analg 2016;123:977-8.
2. Klöhr S, Roth R, Hofmann T, Roscaint R, Heesen
M. Definitions of hypotension after spinal
anaesthesia for Caesarean section: literature search
and application to parturients. Acta Anaesthesiol
Scand 2010;54:909-21.
3. Campagna JA, Carter C. Clinical relevance
of the Bezold-Jarisch reflex. Anesthesiology
2003;98:1250-60.
4. Pollard JB, Warner ME. Cardiac arrest during spinal
anesthesia: common mechanisms and strategies of
prevention. Anesth Analg 2001;92:252-6.
5. Kinsella SM, Tuckey JP. Perioperative bradycardia
and asystole: relationship to vasovagal syncope
and the Bezold‑Jarisch reflex. Br J Anaesth
2001;86:859‑68.
6. Sayed AEDM, Ahmed S. Ondansetron versus
granisetron effect on hemodynamic instability
during spinal anesthesia for Caesarean section. Euro
J Pharm Med Res 2017;4(6): 758-65.
7. Sahoo T, SenDasgupta C, Goswami A, Hazra A.
Reduction in spinal-induced hypotension with
ondansetron in parturients undergoing Caesarean
section: a double-blind randomised, placebo-
controlled study. Int J Obstet Anesth 2012;21:24-8.
8. Sussan SM, Somayeh M, Alireza S. Efficacy of
granisetron on attenuation of hemodynamic response
of parturients undergoing elective Caesarean
delivery under spinal anesthesia. Anesthesiol Crit
Care 2017;5(4): 375-7.
9. Owczuk R, Wenski W, Polak-Krzeminska A,
Twardowksi P, Renata M, Anna DS, Magdalena AW,
et al. Ondansetron given intravenously attenuates
arterial blood pressure drop due to spinal anesthesia:
a double-blind, placebo-controlled study. Reg
Anesth Pain Med 2008;33:332-9.
10. Dasgupta M, Biswas BN, Chattarjee S, Mazumder
P, Bhaja CM. Randomized, placebo controlled trial
of granisetron for control of nausea and vomiting
during Caesarean delivery under spinal anesthesia. J
Obstet Gynaecol India 2012;62(4):419-23.
11. Rashad MM, Farmawy MS. Effects of intravenous
ondansetron and granisetron on hemodynamic
changes and motor and sensory blockade induced
by spinal anesthesia in parturients undergoing
Caesarean section. Egypt J Anesth 2013;29:369-74.
12. Aapro M. Granisetron: an update on its clinical
use in the management of nausea and vomiting.
Oncologist 2004;9:673-86.
 The Accessibility of Health Services for Multiethnics
Community Towards Universal Health Coverage in Samarinda
City : A Qualitative Study

Ratno Adrianto1, Amran Razak2, M. Alimin Maidin3, Darmawansyah4

Department of Administration and Health Policy, Faculty of Public Health, Mulawarman University; 2
1

Department of Administration and Health Policy, Faculty of Public Health, Hasanuddin University; Department
of Hospital Management, Faculty of Public Health, Hasanuddin University, 4Department of Administration and
Health Policy, Faculty of Public Health, Hasanuddin University

Introduction
Since January 1, 2019, Indonesia has entered the era of Universal Health Coverage (UHC) that is sustainable.
This success is considered an innovation in the coverage of almost all communities to be able to access
available health services. In some districts / cities, the membership of the National Health Insurance System
(NHIS) does not cover 100 percent, such as Samarinda. This has an impact on the low universal coverage of
NHIS, so that citizens experience obstacles to accessing the health services they need.

Methods: There are four focus group discussions (FGD), which are made according to large ethnic groups
in Samarinda, namely the Banjar, Javanese, Bugis and Dayak ethnic groups. The discussion participants
were almost all housewives, they were considered to have a high level of concern for their household health
problems, and eight main informant interviews. Content analysis was used to explore the phenomena that
emerged in this study.

Results: Findings show that approachability dimensions (distance traveled, travel time, and transportation
costs), including health insurance coverage, are a problem for some multi-ethnic communities. Although
there was no discrimination in vulnerable groups such as the elderly and pregnant women, it was revealed
that other patients felt different treatment when receiving services. Available health facilities are considered
adequate. However, the number of health workers (doctors and paramedics), is considered lacking. The low
level of government attention and lack of socialization from the Social Security Agency of Health (SSAH)
are considered as obstacles to achieving UHC in Samarinda City.

Conclusion: There are still obstacles to access for ethnic groups who are located far from the city center.
Revealed the existence of ‘discrimination’ patients when using health care facilities.

Keywords: accessibility, multiethnic community, universal coverage, samarinda city.

Introduction NHIS management carried out by the Social

The National Health Insurance System (NHIS) is
a part of the National Social Security System (NSSS)
which was implemented since 2014, using a mandatory
social health insurance mechanism based on Law
Number 40 of 2004. The law is concerning the NSSS
with the aim of meeting the basic needs for decent public
health, given to everyone who has paid contributions or
fees paid by the government.1
Security Agency of Health ( SSAH) based on Law
Number 24 of 2011, aims to realize the implementation
of guarantee, fulfillment of basic needs for a decent life
for each participant and/or family members.2
Decentralization of government since 2001 has
increasingly increased health system heterogeneity
and worsening equity disparity.3 The UHC system in
Indonesia initiated in 2014 focused on accommodating
164  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
diversity with flexible and adaptive implementation
features and quick evidence-driven decisions based on
changing needs. UHC is one way to reduce disparity in
access to health services.4
Since January 1, 2019, Indonesia has entered an
ongoing era of UHC. This success is assessed as an
innovation in the coverage o f almost all communities
to be able to access available health services.3 Some
districts/cities in Indonesia, SSAH membership
coverage has not reached 100 percent including Kota
Samarinda.5 This has caused people experiencing
difficulties in accessing health services that they need.
This study employed qualitative research on
the accessibility of health services to multi-ethnic
communities, in Samarinda City supporting UHC.
This study aims to explore dimensions that affect the
accessibility of multi-ethnic communities to support
UHC and the achievement of Sustainable Development
Goals (SDGs) 2030.6
Theoretical framework
The theoretical concept of the five accessibility
dimensions of Levesque, et. al.7 was modified as a
conceptual framework for this study. Access is defined
as an opportunity to achieve and obtain appropriate
health services in situations that are deemed necessary
for care.8 Access is seen as a result of interactions
between the characteristics of people, households,
physical and social environment and characteristics of
health systems, organizations and providers.9
The concept of five dimensions of service
accessibility includes Approachability; 2) Acceptability;
3) Availability and accommodation (Availability and
accommodation); 4) Affordability; 5) Appropriateness.
Conceptual definition used
In this study, the concept of five dimensions of
health service accessibility was modified to explore the
dimensions of accessibility of health services to multi-
ethnic communities in the city of Samarinda to utilize
health facilities.
1) Approachability is the distance to get health
services in the form of mileage, travel time, and travel
costs (geographical access), including health insurance
coverage.
2) Acceptability is that services provided do not
conflict with customs, needs, beliefs, public trust, there
is no discrimination in providing services, especially
for vulnerable groups (not capable) and how people
perceive service quality.
3) Availability and accommodation is that all types
of health services needed by the community are not
difficult, as well as their presence in the community at
any time needed (availability of infrastructure, adequate
health equipment, pharmaceuticals (medicines) and
health human resources (doctors, midwives and nurses).
4) affordability is the financial capacity of the
community to utilize health services (description of
community work, socio-economic status and income
picture).
5) Appropriateness is the need for health services
with services provided in accordance with community
demand; and community perceptions in accordance with
services provided by providers (health care providers)
This dimension of accessibility allows individuals or
households to plan, choose, utilize and feel satisfaction
with the health services they obtain.
Materials and Method
Selection of participants
The selection of Focus Group Discussion (FGD)
participants was purposive sampling with the following
criteria; they have or are currently using health facilities;
always be alert and responsive to maintaining the health
of his family; influential in making decisions on the
utilization of health facilities; and willing as a participant.
Key informants are selected purposively based on their
relevance to health service policies; community leaders,
and traditional leaders.
    The target population for this study was 4 ethnic
communities (Banjar, Javanese, Bugis, and Dayak
etnhic groups). The number of discussion participants
was 8 people each group (n=32). Key informants were
4 people from service providers, and 4 people from
community leaders and traditional leaders (n=8).
Data collection and analysis
Accessibility of Health Services in the Multi-
Ethnic Community Towards UHC in Samarinda City
was explored through 4 Focus Group Discussion
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  165
(FGD) groups and 8 key informant interviews.
FGDs are conducted in open spaces and halls where
communities usually gather. In-depth interviews were
conducted at the office or at the key informant’s home.
FGDs and in-depth interviews were conducted after
obtaining informed consent from participants and key
informants. Interviews and discussions focused on
the 5 dimensions of accessibility of health services
including: approachability, acceptability, availability
and accommodation, affordability and appropriateness.7
Data analysis used content analysis10 to analyze the
phenomena found in the study.
Results
Focus group discussions of 32 participants (n=32),
as many as 30 people (93.75%) were women. Therefore,
almost all participants were housewives. There were 8
key informants of which 4 key informants were heads of
the community health center and 4 other key informants
were community leaders and traditional leaders (n=8).
This study uses the accessibility model of Levesque
et.al. which has been developed according to the context
of local communities and the policies of the Indonesian
government. There are 5 dimensions of accessibility
including approachability, acceptability, availability and
accommodation, affordability, and appropriateness.
Approachability
Accessibility of proximity includes distance, travel
time, transportation costs and ownership status of health
insurance.
Mileage to health care facilities, especially hospitals,
each ethnicity is different depending on its geographical
location, but can be accessed by public transportation
or private vehicles, and motorbikes. For ethnic
communities that are close to urban areas (Javanese,
Banjar and Bugis), they are relatively not constrained
by the distance. Unlike the Dayak ethnic group, having
difficulty accessing health center and hospitals, it takes
around 30 kilometers.
Travel time to health service facilities for ethnic
communities domiciled around Samarinda city
(Javanese, Banjar and Bugis ethnic group) between
6-18 minutes using a motorcycle or car. Whereas with
the Dayak ethnic group, it took almost 1 hour to get to
the hospital.
 In focus discussions, participants argued that travel
costs were perceived as an economic obstacle due to
extra expenses, although these costs varied according to
the distance traveled and transport facilities used. For
the Banjar, Javanese and Bugis ethnic group, because
they live around the center of Samarinda, the average
cost is Rp. 10,000, up to Rp. 20,000, - one way. Unlike
the Dayak ethnic group who have to spend around Rp.
50,000, one way.
Regarding the ownership status of NHIS, in 4
discussion groups it turned out the participants were
very diverse. Those who have been included as NHIS
participants, most feel happy to have used their cards to
meet their medical needs. Unlike the participants who
have not been included in NHIS membership, they feel
the cost constraints if they want to use health services.
Regarding the ownership status of NHIS, in 4
discussion groups it turned out the participants were
very diverse. Those who have been included as NHIS
participants, most feel happy to have used their cards to
meet their medical needs. Unlike the participants who
have not been included in NHIS membership, they feel
the cost constraints if they want to use health services.
On the other hand, the population of Samarinda City
itself, the coverage of NHIS participation has not yet
reached the Universal Health Coverage (UHC) target,
still 81 percent.5
Acceptability
Acceptance accessibility includes perceptions of
service quality and discrimination in health services.
Public acceptance of the presence of modern health
services is quite good. There are no significant obstacles
to enjoying the medical needs of all ethnic group,
both indigenous and immigrant ethnic group. Dayak
ethnic group who still take good care of their culture
and customs, have apparently relied on modern health
services.
In the discussion it was revealed that participants
were almost totally not familiar with the treatment
system and care of their ancestors. Knowledge and
traditional medicine systems are no longer an option,
except occasionally using herbs such as betel leaves
for the efficacy of reducing certain diseases. Even so,
several cases of childbirth were handled by TBAs.
Actions carried out by TBAs such as umbilical cord are
166  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
given powder, umbilical cord given coffee which finally
festering.
Availability and accommodation
Some key informants from the service providers,
stated that the condition of the infrastructure, the
completeness of health equipment, the availability of
medicines and the number of health workers (doctors and
paramedics), were adequate. However, they admit that
they still need an increase in the quantity and capacity of
the availability of health facilities to be able to provide
quality services.
Affordability
Accessibility of the user›s ability can be observed
from the description of the work and income of the
family head.
Job descriptions for the Javanese ethnic group
are generally building coolies, Bugis ethnic group as
fishermen and farmers, Dayak ethnic group as a farmers
and Banjar ethnic group as farmers and traders.
The income picture of the multi-ethnic community
is closely related to the type of work, so it is very varied,
daily workers such as construction workers are around
Rp. 75,000 / day or Rp. 180,000 per month. Fishermen
can reach Rp. 100,000, - per day or Rp. 3,000,000, - while
farmers are around Rp. 5,000,000 / month. Farmer’s
income is around Rp. 3,000,000 per month. Those who
work as traders earn an average of Rp. 4,000,000 per
month.
Appropriateness
Accessibility in the form of suitability of demand
with health services; and perceptions of services
provided in accordance with health service providers.
The comments of several discussion participants
stated that the service provided was good enough,
hopefully this will continue. They do not doubt the
professionalism of health workers who provide services.
Meanwhile, several key informants said that they were
in line with the operational standards of the minister of
health regulations
Discussion
Affordability of health care facilities for multi-ethnic
communities in Samarinda City is closely related to the
problems of distance, travel time, and transportation.
This will effect the economic burden of the household,
due to the costs that must be spent from their pockets
to access the health services. The transportation costs
comes from their daily expenses. This obstacle has an
effect on the delay in achieving UHC. Potentially, health
service needs are influenced by distribution, distance,
and means of transportation.12-13
This study revealed the complexity of managing
and utilizing NHIS, among participants who were not
the member of NHIS, they chose to pay for themselves
because they did not want to be involved in the
complexity due to uncertainty waiting for NHIS cards to
arrive, and other administrative problems.
The emergence of ‹discriminatory› treatment
when receiving health services. This will cause patient
discomfort. Participants for this study argued that every
health problem should be treated equally. Experience
in Cape Coast, Ghana showed that the main obstacles
to subscribing to health insurance include; long queues
and waiting times, and negative attitudes of service
providers. 14
In East Kalimantan province alone, there have been
5 districts/cities won UHC awards.15 This is different
from Samarinda city which has not yet reached the UHC
target.6 Whereas the city government of Samarinda has
improved the SSAH management counter facilities in
each sub-district and sub-district, socialization of SSAH
to all levels of society and every citizen who comes to
the location must be informed, as well as door to door
socialization. The ineffectiveness of SSAH outreach
was also revealed in discussions that participants were
still not covered by NHIS, there were also dropouts. The
multi-ethnic approach model as carried out in this study
can be used to help in socializing UHC achievements in
Samarinda City.
One sensitive issue that emerged among discussion
participants, i.e. the health service users still had to pay
from their pocket when receiving the services, this would
be an economic burden.16 Many patients purchased
drugs in the private pharmacy because they were not
available at the health facilities, especially for those who
are not easy to have cash. The same case occurred in
Addis Ababa when the beginning of the Economic Basic
Health Insurance (EBHI) implemented.17 This condition
shows that there are still obstacles to the use of health
services.
This study emphasizes the need for intensive
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  167
socialization to foster positive perceptions of SSAH
management. This is expected to increase the
participation of NHIS, thus supporting the achievement
of UHC in Samarinda City. Health center as the leading
gate-keeper of health services is expected to optimize the
Mobile Health Center as an effort to glue the imbalance
of health services due to obstacles to geographical access
especially to ethnic Dayak communities.
Conclusion
The accessibility of health services to multi-ethnic
communities in Samarinda City was adequate. Although
there was no discrimination in health services for
vulnerable groups, other patients felt different treatments
when receiving health services. The overall coverage
of NHIS participation had not yet become a barrier to
achieving UHC in Samarinda City.
Conflict of Interest : None
Source of Funding : Authors self
Ethical Clearance: Obtained from Public health
faculty
References
1. Republic of Indonesia. Law Number 40 of 2004
concerning National Social Security, 2004.
2. Republic of Indonesia. Law Number 24 of 2011
concerning the Implementation of National Social
Security, 2011.
3. Agustina, Rina et.al. Universal health coverage in
Indonesia: concept, progress, and challenges, Lancet
2019; 393: 75–102, Published Online December 19,
2018. http: // dx. doi.org/
4. Alegria, M., Lin, J., Chen, C. N., Duan, N., Cook,
B., & Meng, X. L. The Impact of Insurance
Coverage Diminishing Racial and Ethnic Disparities
in Behavioral Health Services. Health Services
Research, 2012: 47 (3), 1322-1344.
5. Kaltim Post. Kaltim.Prokal.co. Total Participation
Below Target. http://kaltim.prokal.co/ ead / news
/ 339258-number-participation-under-target.html,
accessed February 20, 2019
6. United Nations Sustainable Development Goals
(SDG’s), New York, 2015. https: // sustainable
development.un. org / sdgs, accessed January 29,
2019
7. Jean-Frederic Levesque, Mark F Harris and Grant
Russel. Patient-centered access to health care:
conceptualizing access at the interfaces of health
systems and populations, International Journal For
Equity in Health 2013, 12:18
8. Haddad S, Mohindra K: Access and community:
ingredients for health equity in the South. Paper
presented at the Public Health and International
Justice Workshop. New York: Carnegie Council on
Ethics and International Affairs; 2002
9. Penchansky R, Thomas WJ: The concept of access:
definition and relationship to consumer satisfaction.
Med Care 1981, 19: 127–140.
10. Creswell, J. W. Research Design: Qualitative,
Quantitative and Mixed Approaches. Fourth Edition,
Yogyakarta: Student Library, 2018.
11. Ministry of Health, R.I. Minister of Health
Regulation of the Republic of Indonesia Number 75
concerning Public Health Center, Jakarta, Ministry
of Health R.I, 2014.
12. John K Ganle, Michael Parker, Raymond Fitzpatrick,
& Easmon Otupiri. Inequities in Accessibility to and
Utilization of Maternal Health Services in Ghana
After User-Fee Exemption: A Descriptive Study.
International journal for equity in health, 2014: 13
(1), 89.
13. Ruishan Hu, Suocheng Dong, Yonghong Zhao,
Hao Hu, & Zehong Li. Assessing China’s Potential
Spatial Accessibility of Health Services: A Case
Study of Donghai County. International journal for
equity in health, 2013: 12 (1), 35.
14. Kumi-Kyereme et al. Barriers and motivations for
health insurance subscription in Cape Coast, Ghana:
a qualitative study, Archives of Public Health (2017)
75:24
15. Tribunkaltim.co. JKN-KIS Participation Reaches
98 Percent of Kukar Kaltim Regency Government
Receives UCH Award, http: // kaltim. tribunnews.
com/2019/10/28/kepesertaan-jkn-kis-capai-98-
persen-pemkab-kukar-kaltim-terima-uhc-award
accessed 20 February 2019
16. Razak, Amran et.al. Economic Burden of Cancer
Patients at Hasanuddin University Teaching
Hospital, Makassar: A Qualitative Study, Indian
Joernal of Public Health Research & Development,
December 2018, Vol. 9, No. 12, pg 1438-1443
17. Obse, et.al. Knowledge of and preferences for health
insurance among formal employees in Addis Ababa:
a qualitative study, BMC Health Services Research
(2015)
The Role of Estrogen and Progesterone Hormons Imbalance in
Premenstrual Syndrome of Female Adolescent

Suriani Bahrun1,2,Yunita Suriani Suardi2, Yanti Mustarin2, Kusumawardani Bakri3

Postgraduate Doctoral Program, Faculty of Medicine, Hasanuddin University, Makassar, 2Nursing Program,
1

STIK GIA Makassar, Makassar, 3Midwifery Program, STIK GIA Makassar, Makassar

Abstract

Background: Teenagers with menstrual cycle still experience one or more symptoms of Premenstrual
Syndrome (PMS). High estrogen levels and imbalance of estrogen and progesterone cause PMS symptoms.

Research objective: Identifying the role of estrogen and progesterone hormone imbalance on PMS in
female adolescent.

Research method: using a non-experimental design, using a cross sectional approach with 40 samples.

Conclusion: The imbalance of the estrogen and progesterone hormones plays a role in the degree of
premenstrual syndrome. The high imbalance of the hormones estrogen and progesterone will cause a low
degree of premenstrual syndrome.

Keywords: estrogen, progesterone, premenstrual syndrome, female adolescent

Introduction begins. These symptoms are physical and psychological

Menstruation is one sign of puberty in women.
At present the average age of menstruation is getting
earlier. The youngest age for menstruation is 8 years
while the oldest age is 17 years. The better nutritional
conditions accelerate the body’s readiness to start
menstruation in girls. In addition, information about sex
that is more easily obtained from various media today
can also trigger the brain to immediately activate sexual
hormones. So that when it reaches the age of 17 years
old, a woman has not yet experienced menstruation, she
must immediately see a doctor because it indicates a
disruption in reproductive function1.
disorders, physical complaints such as breast pain or
swelling, flatulence or pain, headache, joint pain, back
pain, nausea, vomiting, diarrhea or constipation, and the
appearance of skin problems such as acne. Psychological
problems include depression, sensitivity, irritability,
sleep disorders, fatigue, weakness, and sometimes very
rapid mood swings2.
The prevalence of PMS is quite high, which occurs
in around 70-90% of women of childbearing age and is
more often found in women aged 20-40 years. Women
who have given birth will be at higher risk of suffering
from PMS. The exact cause of PMS is unknown3.

The symptoms that arise before the menstrual
period are expected to be a disruption to daily activities
in adolescent girls during menstruation. According to
Dickerson et al (2005), about 85% of young women
who still get the menstrual cycle experience one or more
symptoms of Premenstrual Syndrome (PMS)2.
It is estimated that 13-19% of reproductive-
age women experience PMS, 3-8% even experience
premenstrual dysphoric disorder (PMDD)4. Ashraf
(2014) even stated that the prevalence of STDs reached
48% and the highest prevalence was in Asia and the
lowest in Europe5.

PMS or pre-menstrual syndrome is a condition The results of a study conducted in Iran found that
where a number of symptoms occur just before 98.2% of students aged 18-27 years experienced at least 1
menstruation, symptoms usually occur 7-10 days mild or moderate degree of premenstrual syndrome. The
before menstruation and disappear when menstruation overall evidence suggests that premenstrual syndrome is
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  169

a form of disorder commonly experienced by teenagers
in Asia6. Another study conducted by Locklear, 2010
found results that Justicia pectoralis Jacq. which has
estrogenic, progestagenic and anti-inflammatory effects
can be beneficial in menopausal women and PMS7.
Frank in Rimma stated that high estrogen levels and
balance disorders of estrogen and progesterone cause
PMS symptoms8.
To get in-depth information about the role of
estrogen and progesterone hormone imbalance with
PMS, an assessment of estradiol, progesterone, and PMS
degrees was carried out.
The sample size in the study was obtained based on
the sample formula for correlative analytical research,
as follows:
Based on the calculations above, the sample size
taken was 40 samples that were in accordance with the
inclusion criteria10.
Inclusion criteria and exclusion criteria
Inclusion criteria, namely:
1. Women of childbearing age who are in the
luteal phase

Research purposes 2. Menstrual cycle 28-35 days

To identify the role of imbalance of estrogen and Exclusion Criteria, that are :
progesterone hormones with PMS in female adolescent.
1. Using hormonal therapy
Research Method
2. Alcoholic history
The design of this study uses a non-experimental
3. History of reproductive system disorders
design, with a cross sectional approach that is the
observations are only conducted once according to the 4. Do not sign informed consent
time determined by the researcher by looking at the
relationship between the dependent and independent 5. Not cooperative
variables9. 6. Not obese
   This research was conducted at STIK GIA Research Materials and Tools
Makassar and the Laboratory of Molecular Biology and
Immonology at the Faculty of Medicine, Hasanuddin 1. Form of Food Frequency Questionnaire
University.
2. Stationery
The population in this study were female adolescent
3. Spoit 10 cc
who experienced PMS (STIK GIA MAKASSAR
students). 4. Blood sample
Sampling in this study using nonprobability 5. Commercial kit: DIAsource E2-EASIA
sampling with purposive sampling technique that is
sampling with certain considerations. 6. CYP17 gene primer, PCR System 7300
(Applied Biosystems, USA) with SYBR Green
(𝑍𝑍𝑍𝑍+𝑍𝑍𝑍𝑍)
n{0,5In[(1+𝑟𝑟)/(1−𝑟𝑟))]
= } ² +3
(1,28+1,28)
{0,5In[(1+0,4)/(1−0,4))]
= } ² +3
2,56
= {0,5In[2,33]} ² + 3
= 36,6+3
= 39,6
= 40
170  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

Research Result
Table 1. Charachteristic Distribution of Young Women respondents.

Charachteristic Frequency %

Age
18-21 26 65
22-24 14 35

Menstrual cycle
28-30 days 21 52.5
31-35 days 19 47.5

Menstrual period
3-5 days 24 60
6-7 days 16 40

Body mass index

Normal 15 37,5
Moderate depletion 22 55,0
Severe depletion 3 7,5
Estrogen rate
Low 10 25
High 30 75
Progesterone level
Low 10 25
High 30 75
Estrogen-Progesterone combination
High Estrogen, low progesterone 10 25
Low Estrogen high progesteron 10 25
High Estrogen and progesterone 20 50
Low Estrogen and progesterone 0 0

PMS level
Severe PMS level 5 12.5
Moderate PMS level 28 70.0
Mild PMS level 7 17.5

Total 40 100.0

Table 1 shows that majority of respondents are in
the age of 18-21 years old (26 respondents or 65%), and
22-24 years old (14 respondents or 35%). According to
the menstrual cycle, respondents mostly have the 28-30
days cycle (21 respondents or 52,5%) and some have
31-35 (47.5%).
Based on the menstrual period, respondents mostly
have 3-5 days (24 respondents or 60%) and some have
6-7 days (16 respondents or 40%). Based on the Body
Mass Index, they mostly have moderate depletion (22,
respondents or 55%), and minority of them have severe
depletion (3 respondents or 7.5%).
Based on the characteristics of estrogen level,
most of the respondents are on the higher category (30
people or 75%) and 10 of them are on lower category
(25%). Based on the progesterone level, mostly they are
on higher category (30 people or 75%) and 10 of them
are on lower category (25%). Based on the estrogen-
progesterone combination, mostly they have high level
of estrogen and progesterone (20 people or 50%),
10 people have high estrogen and low progesterone
(25%), the other 10 people have low estrogen and high
progesterone, and no respondents has low estrogen and
progesterone.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  171

Table 2. The role of estrogen and progesterone hormones imbalance towards the level of premenstrual
syndrome on female adolescent

PMS level
p
Mild n %
Severe level Moderate level r
% % level of %
of PMS of PMS
PMS

Imbalance of estrogen and

progesterone hormones

High estrogen, low progesterone 2 20 7 70 1 10 10 100

0.02
Low estrogen, high progesterone 2 20 8 80 0 0 10 100 -0.33

High estrogen and progesterone 1 5 13 65 6 30 20 100

Low estrogen and progesterone 0 0 0 0 0 0 0 0

Based on table 2, the combination of high estrogen,
low progesterone, the majority experienced moderate
grade PMS (7 people or 70%). For the combination
of low estrogen and high progesterone, the majority
had moderate degrees of PMS (8 respondents (80%).
The combination of high estrogen and progesterone,
the majority experienced moderate degree of PMS (13
respondents or 65%). There were no respondents who
had a combination of low estrogen and progesterone
levels. The table also shows that there is a role for
imbalance of estrogen and progesteronee hormones with
PMS degrees. The direction is negative and weak.
Discussion
The results of the research showed that there was
the role of the imbalance of estrogen and progesterone
hormones towards the degree of premenstrual syndrome.
The higher the imbalance of estrogen and progesteronee
hormones, the lower the degree of PMS. Respondent
who had high estrogen and progesterone levels was
only one, with severe degree of PMS. This is due to the
imbalance of the estrogen and progesterone hormones
is not a single factor in PMS. Low calcium intake is
one of the causes of PMS. From the data obtained, the
respondents never consumed milk and spinach which
are sources of calcium.
Meanwhile, respondents who had an imbalance
of estrogen and progesterone (both high estrogen, low
progesterone as well as low estrogen, high progesterone)
have 2 respondents with severe PMS. This is partly due
to low food intake (banana, papaya) which contains
vitamin A which is a predisposition factor for PMS.
Conclusion
The imbalance of the estrogen and progesterone
hormones plays a role in the degree of premenstrual
syndrome. The high imbalance of the hormones estrogen
and progesterone will cause a low degree of premenstrual
syndrome.
Suggestion
Further research is needed regarding to the role of
calcium, bananas, and papaya towards PMS.
Ethical Clearance: Taken from medical research
ethics committee at the faculty of medicine, University
of Hasanuddin, Makassar
Source of Funding: leading scholarship for
Indonesian lecturers -domestic
There is no Conflict of Interest
References
1. Astuti, Ari Puji., The effect of premenstrual syndrome
on the productivity of female workers in the factory
of Pematang Siantar, Thesis, Postgraduate School
172  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Health Masters Program, University of North
Sumatra, Medan. 2007.
2. Elvira, S.D., Normal pre-menstrual syndrome?
Jakarta: Faculty of Medicine, University of
Indonesia. 2010.
3. Evy., Descriptive Statistics in the fields of Health,
nursing, medicine. Yogyakarta: Fitramaya, 2009.
4. Kiesner, J., & Granger, D. A. A lack of consistent
evidence for cortisol dysregulation in premenstrual
syndrome/premenstrual dysphoric disorder.
Psychoneuroendocrinology, 2016; 65, 149–164.
https://doi.org/10.1016/j.psyneuen.2015.12.009
5. Sattar, K. Epidemiology of Premenstrual
Syndrome, A Systematic Review and Meta-
Analysis Study. Journal of Clinical and Diagnostic
Research, 2014; 10–13. https://doi.org/10.7860/
JCDR/2014/8024.4021
6. Delara, M., Ghofranipour, F., Azadfallah, P.,
Tavafian, S. S., Kazemnejad, A., & Montazeri, A.
Health related quality of life among adolescents
with premenstrual disorders: a cross sectional study.
Health and Quality of Life Outcomes, 2012;. 10(1),
1. https://doi.org/10.1186/1477-7525-10-1
7. Locklear, T. D., Huang, Y., Frasor, J., Doyle, B. J.,
Perez, A., Gomez-Laurito, J., & Mahady, G. B..
Estrogenic and progestagenic effects of extracts of
Justicia pectoralis Jacq., an herbal medicine from
Costa Rica used for the treatment of menopause and
PMS. Maturitas, 2010. 66(3), 315–322. https://doi.
org/10.1016/j.maturitas.2010.04.001
8. Rimma Rosenfeld, Dana Livne, Ori Nevo, Lior
Dayan, Victor Milloul, Shahar Lavi, G. J. .
Hormonal and Volume Dysregulation in Women
With Premenstrual Syndrome. Hypertension,
2008’ 51, 1225–1230. https://doi.org/10.1161/
Hypertensionaha.107.107136
9. Sugiyono.. Business Research Methods. Alfabeta:
Bandung, 5-13,30-31,49-59. 2009
10. Dahlan, M. Sopiyudin.. Sample Size and Method of
Sampling. SalembaMedika: Jakarta, page. 20. 2010
 Factors That Influenced The Use of Family Planning (KB) In
Padang Hulu District of Tebing Tinggi 2018

Namora Lumongga Lubis1, Hasnida2

1
Department of Public Health, University of North Sumatera, Jalan Universitas No. 21 Medan, Indonesia,
2
Department of Psychology, University of North Sumatera, Jalan Dr. Mansyur No.7 Medan, Indonesia

Abstract
As developing country, Indonesia still has to struggle with various problem. One of the main problem faced
by Indonesia today is the growing number of population. The purpose of this research is to analyse the
factors that influence the male use of family planning in Padang Hulu sub-district, Tebing Tinggi 2018. This
research is using analytical observational with case control study design. The sample of this study consisted
of 60 cases group and 60 control group. The case group sample was the male family planning acceptor and
the control group sample including the male non family planning. Based on multivariate results that age
and support of wives are predicators of male family planning. It is suggested for health workers to improve
the promotion of vasectomy services, through the provision of education, knowledge and the use of family
planning vasectomy in the form of counselling and family approach concerning the importance of family
planning vasectomy and for men family acceptor is expected to be role model to his peers so that the other
men would participate in family planning, especially vasectomy.

Keywords: Use of Male Family Planning, Possible Factors, Strengthning Factors.

Introduction Regency. Male participation in the practice of modern

Male participation rates in contraceptive use in
Indonesia are still very low at only 2.1% family planning
and they generally use condoms. The percentage is lower
compared to other countries, such as Iran 12%, Tunisia
16%, Malaysia 9-11%, even the percentage in the United
Stated reached up to 32%. Based on BKKBN 2012 the
participation of male using contraception is only 1.3%
consist of condom user (0.9%) and vasectomy (0.4%).
Therefore the socialization of family planning programs
among men should be improved1,2.
The ease and availability of service family planning
facilities has a positive impact on the use of contraception.
Men became less motivated to use contraception due
to the low accessibility of information about family
planning3. According to 4 the cause of husband’s less
participation in family planning is the limitation of
knowledge about reproductive health and paradigm
associated with patriarchy in which the role of husband
is greater than women. Based on the research showed
that wife support associated with husband’s involvement
in family planning (condom and vasectomy) in Bantul
family planning methods in Indonesia is influenced by
socio-demography that includes knowledge, wife’s age,
husband’s education, number of surviving children and
attitudes toward family planning programs5-8.
Tebing Tinggi, is one of the city in North Sumatera
which inhabited by 147,771 people with a total of
23,550 couples with reproductive age. Active family
planning participants in 2013 reached up to 17,450
people which consist of 200 males using vasectomy
(1.15%) and 610 males using condom (3.50%) at the
group age of 30-45 years old. The largest coverage of
family planning acceptors was found in Rambutan sub-
district consist of 52 people (1.23%) from the total 5,578
reproductive couples. In Bajenis sub-district there were
49 people (1.23%) from the total of 5.081 reproductive
couples, Tebing Tinggi Kota 48 people (1.85%) from the
total of 3,539 couples, Padang Hilir sub-district is 33
people (0,97%) from 4,697 couples, and Padang Hulu
sub-district is 18 people (0,51%) from 4,655 couples
(BKKBN 2013)9.
174  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Material and Method
This study is an analytic observational study with
case control method. Analytical observational case
control study is a design to determine the relationship
between variables by comparing case group and control
group based on their status10. The sample were consisted
of 60 control groups and 60 case groups. Data were
analyzed using simplex logistic regression and multiple
logistic regression test.
Univariate Analysis
Description of the respondents in the study showed
that the most of respondents in the case group had
entrepreneurial jobs it consist of cases of 38 people
(63.3%). Based on the research , the Muslim respondents
in the case group consist of 55 respondents (85%). And
there were 58 Muslims (96.77%) in control group. The
majority of respondent were Javanese consist of 28
people (46.7%) from case group and 35 people (53.8%)
from control group. 47 people (78.3%) from case group
had 1-2 children and in control group there were 52
respondents (86.7%) had ( > 3) more 3 children’s.
48 respondents (80%) respondents in case group an
55 respondents (91,7%) in control group had income
1-2 million. 27 respondents (61,7%) wife in the case
group were within in control group above 35 years.
43 respondents (71.7%) in control group were within
the age group above 35 years (> 35). 32 of respondent
(53.3%) from the case group and 40 respondents (66.7%)
from control group had more than 12 years the length of
marriage.
Bivariate Analysis
Simple Logistic Regression Test Results
The analysis results of simple logistic showed that
there is a significant influence between age to male
KB use. The results of analysis using simple logistic
regression test showed that there is no significant influence
between education on the use of family planning in men.
The results of analysis using simple logistic regression
test showed that there is no significant influence between
knowledge on the use of family planning in men. The
results of analysis using simple logistic regression test
showed that there is no significant influence between the
availability on the use of family planning in men.
The results of analysis using simple logistic
regression test showed that there is no significant
influence between the support of wife to the use of
family planning. The results of analysis using simple
logistic test showed that there is no significant influence
between culture on male family usage.
Thus, based on bivariate analysis using simple
logistic regression test, age variable and wife support
have p value <0, 25 so it can be include in multivariate
analysis model and conducted by multiple logistic
regression test with “enter” method.
Multivariate Analysis Results
Based on the results of multiple logistic regression
test showed that risk factors influencing the use of
contraceptive in men in Padang Hulu sub-district of
Tebing Tinggi after being adjusted with other variables
were p = 0,034, OR = 2,384 95% CI (1,068-5,320), wife
support p = 0,042 ; OR = 2,428 95% CI (1,033-5,708).
Results and Discussion
The Relationship Between Age and Contraceptive
Use in Men
The result bivariate analysis shows that there
is significant influence between age with the use of
famili planning in men with p value = 0,014. The
result of multivariate analysis also showed that age had
significant effect on male KB use p = 0,034; OR = 2,384
95% CI 1,068-5,320. This means that men > 40 years
old are 2.3 times more likely than men to use vasectomy
contraception compared with men aged ≤ 40 years. Age
can affects the one’s psychic, young age often cause
tension, confusion, anxiety and fear that can affect one’s
behavior11. The results of this study is in line with the
previous research that there is a spesific relationship
between age and men’s participant in family planning12.
The results is also accordance with the research
conducted by13 showing the significant relationship
between respondent’s age and their participants in
family planning.
The Relationship Between Education with The
Contraceptive Use in Men
Based on the results of simple logistic regression,
that there is no influence between education on
contraceptive use in men. This is evidenced from the
calculation of simple logistic regression test can be seen
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  175
that the value p = 0.999 which means greater than α =
0.05, then Ho accepted.
Conforming to Nurliana & Subiyatun states that
14
there is no relationship between husband education
with the use of contraceptives in the hamlet Tekik
Bangunharjo Bangunkerto Turi Sleman, which proved
the value with the value p = 0.185 (p> 0.05). In contrast
to research indicating that of 291 husbands in Sumber
Agung Jetis Bantul, most husbands were educated at
junior high school 150 (51.5%), and the least husband
who had high education was 14 (0.5%). From the results
of analysis it can be said most of the husband educated
junior high. The results of this study revealed there is an
influence between educational factors on the use of male
contraceptive methods15.
Less educated people will be more likely to respond
new ideas with emotion. Because the new things might
be shock the people or change what they have done
in the past. The level of education not only affects the
willingness to use family planning, but also the selection
of a method.
The Relationship Between Knowledge with The
Contraceptive Use in Men
Based on the results of simple logistic regression
test, that there is no influence between knowledge on
contraceptive use in men. This is evidenced from the
calculation of simple logistic regression test can be seen
that the value p = 1,000 which means greater than α =
0.05, then Ho accepted.
Knowledge and attitude associated with husband’s
participation in family planning, husbands’ knowledge
about family planning can be influenced by geography
location, the respondents live closer to the city has
the better knowledge about family planning than that
of respondents who live in the village, because the
geography location close to the city can facilitate more
information about family planning to society17.
The Relationship Between Knowledge with The
Contraceptive Use in Men
Based on the results of simple logistic regression
analysis, there is no influence between the availability of
male family planning services to the use of contraception
in men. This is revealed from the calculation of simple
logistic regression test can be seen that the value p =
0.650 which means greater than α = 0.05, then Ho
accepted.
This results of this study is contradict with previous
research states, that factors that cause male family
planning participation in various areas tend to be low
are: First, information access is very limited. Men’s
knowledge of contraception, such as type, side effects,
effectiveness, mode of use, where to get contraceptives,
benefits and others is still very low. Second, access to
services is still limited18.
In accordance with the situation in the District of
Padang Hulu Kota Tebing Tinggi, it was found that there
was no relationship between the availability of male
contraceptive services with the use of contraception in
men. Although this study was not statistically significant
but in terms of OR values, the availability of male family
planning services has a tendency of 1.526 times to affect
men in using contraception.
The Relationship Between Wife Support with
Contraceptive Use in Men
Based on the results of simple logistic regression,
there is a relationship between the wife support with the
use of contraception in men. It is revealed from the result
of simple logistic regression test with the value p = 0.017
which means smaller than α = 0.05, then Ha is accepted.
The result of multivariate analysis was dominant
influential factor which showed that wife support had
significant effect on contraception use in men p = 0,042;
OR = 2,428 95% CI 1.033-5,709 This means that men
who get wife support 2.4 times more the estimate of men
willing to use vasectomy contraception in men than men
who do not have the support of the wife.
This is conforming to previous research stated, that
the support of wife to the contraception use is a positive
attribute of the wife to family planning, if couples have
a positive attitude toward family planning then they
tend to use contraception. Other research also stated
that there is a relationship between the support of the
wife and the participation of the husband in the family
planning program19.
The Relationship Between Culture with
Contraceptive Use in Men
Based on the results of simple logistic regression
test, there is no influence between the culture on the use
of contraception in men. This is revealed from the simple
logistic regression test showed that the value p = 0.855
176  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
which means greater than α = 0.05, then Ho is accepted.
A study states that, there is no socio-cultural
relation on family planning men’s acceptor with men’s
participation in family planning14. In some studies,
cultural standards are identified as barriers to male
involvement in participating family planning programs.
All respondents believe that the reasons for involving
men in family planning programs include that men play
a dominant role in family decision-making. Another
reason expressed by the majority of participants is that
men are the head of the family and give much influence
to women’s decisions20-22. Men often assume that family
planning services are designed and provided for women,
so men are embarrassed to join the family planning
program.
In contrast to other research, which states that
respondents who are positive social culture as much as
86% participate actively in the vasectomy program21.
This is different from the situation in Padang Hulu
Subdistrict, Tebing Tinggi in 2018, found that there is
no connection between culture and contraceptive use in
men. Although this study was not statistically significant
but in terms of OR values, cultures had a tendency of
0.935 times to influence men in using contraception.
Conclusion
Based on the results of research on the use of factors
that affect the use of male Family Planning in Padang
Hulu District Tebing Tinggi in 2018, the conclusions are
stated as follows:
There is an effect between age, education,
knowledge, cultural, on the use of family planning, then
the availability of male contraceptive service on male
family planning use as well. However, There is an effect
of wife support on the use of family planning Based on
multivariate test results, the dominant variable affecting
the use of male KB is the support of the wife
Conflict of Interest : None
Ethical Clearance- Taken from University of
North Sumatera committee
Source of Fund: Self
References
1. BKKBN, PelayananKontrasepsi. Jakarta: BKKBN.
Available from [03 Mei 2018]. 2011.
2. Ernawati, S. Faktor yang Memengaruhi Keluarga
Berencana (KB) Pria dengan Paritisipasi Pria dalam
Keluarga Berencana di Wilayah Kerja Puskesmas
Sedayu II. Jurnal Ners dan Kebidanan Indonesia,
2016; (4)2, 109-116. Available from [26 April 2018]
3. Sariyati, S, Hati, F, S, & Fatimah. Motivation
Variable to Use Contraceptive among Male in
Yogyakarta. Kesmas: National Public Health
Journal, 2016; (2)11, 74-78. Available from: [10
Juni 2018]
4. Rosmala Nur, Anwar Mallongi, Indah P. Kiyai
Demak, Fadliah , Elli B. Yane, Nurhaya S. Patui,
Marselina, H. Muhammad Rusydi, Muhammad
Asep Dwitama and R. Erina Thursina, Early-Age
Marriage and the Impact of Health Reproduction
Women. Journal of Engineering and Applied
Sciences, 2019; 14: 981-986.
5. Posmaningsih, D.A., Aryasih, G.A.M., Hadi, M.C.,
Marwati, N.M., Mallongi, A.. The influence of media
booklet in behavior change of waste management
in elementary school students, South Denpasar,
Bali. Indian Journal of Public Health Research &
Development. 2018.
6. Ambartana, I.W., Mallongi, A., Gumala, N.M.Y.,
Kencana, I.K., Widarti, I.G.A.A. The effectiveness
of nutritions ergogenic modified to the local
endurance of Pamong Praja Police personnel in
Denpasar. Indian Journal of Public Health Research
and Development. 2018.
7. Pulubuhu, D.A.T., Evans, K., Arsyad, M., Mallongi,
A. Understanding the perspectives of village leaders
and institutions in transforming social conflict into
peace and health.  Indian Journal of Public Health
Research & Development, March 2018, Vol. 9, No.
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8. Tasnim Tasnim, Gouranga Dasvarma, Lilian
Mwanri., Housing conditions contribute to
underweight in children: An example from rural
villages in southeast Sulawesi, Indonesia. Journal
of Preventive Medicine & Public Health. 2017; 50.
(5),328-335
9. BKKBN, 2013, Survei Demografi Kesehatan
Indonesia Jakarta: BPS, BKKBN, Kemenkes dan
ICF International. Available from [03 Mei 2018].
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10. Murthi, B Prinsip dan Metode Riset Epidemologi.
Yogyakarta: Gadjah Mada University Press. 2003.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  177
11. Notoatmodjo, S, Promosi Kesehatan dan Ilmu
Perilaku. Jakarta: Rineka Cipta; 2011
12. Rozi, Utami, & Lasri. Hubungan Antara Tingkat
Pengetahuan Terhadap Motivasi Penggunaan Alat
Kontrasepsi Pria Pus Di Desa Mulyorejo Kecamatan
Ngantang Kabupaten Malang. Nursing News, 2017;
(3)2, 407-417. . Available from: [10 Juni 2018]
13. Butto, D., & Mburu, S Factors Associated with
Male Involvement in Family Planning in West Pokot
County, Kenya. Universal Journal of Public Health
2015; 3(4), 160-168.
14. Nurliana, DH & Subiyatum, S, Hubungan
Tingkat Pengetahuan Suami dengan Pemakaian
Alat Kontrasepsi di Dusun Tekik Bangunharjo
Bangunkerjo Turi Sleman, Yogyakarta. 2011
15. Setyaningrum, N & Melina, F. Faktor-Faktor Yang
Berhubungan Dengan Keikutsertaan Suami Menjadi
Akseptor Kb Di Desa Sumber Agung Jetis Bantul.
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dalam Ber-KB di Kelurahan Catur Tunggal
Kecamatan Depok Sleman DIY. Universitas Respati
Yogyakarta. 2012,
17. Robby Kayame, Anwar Mallongi., Relationships
between smoking Habits and the Hypertension
occurrence among the Adults of Communities in
Paniai Regency, Papua Indonesia. Indian Journal of
Public Health Research & Development, January
2018, Vol. 9, No. 1
18. Sutinah. Partisipasi Laki-Laki dalam Program
Keluarga Berencana di Era Masyarakat
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19. Bintarayani, C., Kharisto, M., & Shofiyah, S.
Hubungan Dukungan Istri dengan Partisipan Suami
dalam Program Keluarga Berencana, Midwifery
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2016; 12(1), 78-85. Available from [26 April 2018]
20. Bayray, A Assessment of Male Involvement in
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21. Mallongi, A. and Herawaty, 2015. Assessment of
Mercury Accumulation in Dry Deposition, Surface
Soil and Rice Grain in Luwuk Gold Mine, Central
Sulawesi. Res. J. Appl. Sci., 10: 22-24.
22. Rizkitama, A., A., & Indrawati, F. Hubungan
Pengetahuan. Persepsi, Sosial Budaya dengan
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Efficacy of Topical Cream of Garlic Extract (Allium sativum) on
Wound Healing in Experimental Mice using Aa Acute Wound
Modeling: Determination of Expresión of Tumor Necrotic
Factor (TNF-α)

Zaenal1, Rini Mustamin2, Rusli Taher3, Anwar Mallongi4

Islam Makassar University, Makassar, South Sulawesi Province, Indonesia, 2Nusantara Jaya School of Health
1

Sciences, Makassar, South Sulawesi Province, Indonesia, 3Graha Edukasi School of Health Sciences, Makassar,
South Sulawesi Province, Indonesia, 4Department of Environmental Health, Faculty of Public Health, Hasanuddin
University, South Sulawesi Province, Indonesia

Abstract
Garlic (Allium sativum) is one of the ethnomedicinal plants used by people in the tropical region. Its bulb is
commonly utilized as traditional medicine for wound healing, particularly in the developing world. This study
analyzed the efficacy of topical cream of garlic extract (Allium sativum) on the expression of tumor necrotic
factor (TNF-α) and wound closure as the parameters of wound healing in the experimental mice using an
acute wound modeling. The research design was a randomized post test control group design. The study
was conducted at 4 labolatories, i.e., Biofarmaka Laboratory at the Center for Health Education Research
at the Hasanuddin University for the preparation of topical cream of garlic bulb extract, Animal Laboratory
of the Medicine Faculty of the Hasanuddin University for the care and treatment of the experimental mice,
Histopathology Laboratory of the Research Center for Veterinary Sciences in Maros for the preparation of
histopatological slides. A total of mice were 54 mice (Rattus novergicus) of wistar strain by making circular
excision wound on dorsal with the diameter of 8 mm using punc byopsi. The experimental mice were divided
into 3 groups that include the negative control group by treating 0.9 % NaCl, the positive control group by
treating 3 % oxytetracycline and the treatment group by treating 10% topical cream of garlic extract. Wound
tissues of mice were microscopically observed on day 3, day 7 and day 14 respectively. Results of the study
proved that wound healing by using topical cream of garlic extract (Allium sativum) showed the highest
effect in reducing the expression of tumor necrotic factor (TNF-α) and the lowest diameter of wound in the
experimental mice compared to the control groups.

Keywords: Garlic, TNF-α, wound healing.

Introduction
In view of the modern concept, wound healing
involves dynamic reciprocity between cytokines, cells,
and the extracellular matrix during four overlapping
phases1. In cellular phase, wound healing process
involves several types of cells working together to mount
an inflammatory response, synthesize granulation tissue,
and restore the epithelial layer.  The second phase, the
inflammatory phase, is characterized by the infiltration
of inflammatory cells that secrete cytokines and growth
factors, while assisting in the removal of apoptotic
cells and debris. The third phase, the proliferative
phase, involves the stage of tissue regeneration that
is initiated in response to stimulatory factors initially
produced during the inflammatory phase. Angiogenesis
is central to wound healing and involves the growth of
new capillary blood vessels2. Finally, the remodeling
phase encompasses the regression of capillaries, the
reorganization of the extracellular matrix, and further
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  179
maturation of the tissue that ensures the structural and
mechanical stability of the dermoepidermal junction3.
Until 21st century, the prevalence and impact
of wounds are likely to increase due to the growing
epidemic of noncommunicable diseases and longer life
expectancy. As indicated in a survey of the MedMarket
Diligence in 2013, the estimated prevalence rates
based on the wound categories worldwide in ascending
order were surgical wounds (114,271 cases), traumatic
wounds (1,627 cases), laceration wounds (20,645 cases),
burn wounds (10,221 cases), chronic wounds (40,400
cases), carcinoma wounds (618 cases), melanoma
wounds (103 cases), and skin cancer wounds (103 cases)
consecutively.
In view of the national level in the developing
world, the survey data derived from the National Basic
Health Research4 reported that the proportions of types
of wounds in Indonesia were dominated by bruised/
chafed wounds (70.9 %), and it was followed by sprained
wounds (27.5 %) and tear wounds (23.2 %). Viewed in
terms of gender, 70.6 % wounds were observed in male
and 71.2 % wounds were found in female, whereas, 26.6
% tear wounds were found in male and 17.8 % were
observed for female respectively.
Based on the problem background as stated
above, this study aims to inquire about the efficacy of
garlic extract (Allium sativum) on wound healing in
experimental mice using an acute wound modeling for
developing this ethnomedicinal plant.
Materials and Method
Location of the study
This study was conducted at 4 labolatories, i.e.,
Biofarmaka Laboratory at the Research Health Center
of the Hasanuddin University for the preparation of
topical cream of garlic extract, Animal Laboratory of
the Medicine Faculty of the Hasanuddin University
for the care and treatment of the experimental mice,
Histopathology Laboratory of the Center for Veterinary
Sciences in Maros for the preparation of histopatological
slides.
Samples and animal care
The mice were caged in groups with free access to
laboratory pellets and tap water and maintained under
standard conditions (12/12 h light-dark cycle, and
ambient temperature 22 ± 1 °C). All animals used in this
study were cared for and treated humanely according
to the Principles of Laboratory Animal Care5. Ethical
clearance for the treatment of the experimental animals
were reviewed and approved by the Medicine Research
Ethics Committee of the Medicine Faculty of the
Hasanuddin University as stated in the Recommendation
Letter of Research Ethics issued in the registration
number: 2264/H4.8.4.5.31/PP36-KOMETIK/2015.
Preparation of garlic extraction
10% garlic extract was prepared in this study.
Samples of garlic bulbs were chopped into small pieces,
and then they were let stand for a while until dry.
Afterward, dried bulbs were crushed by using a blender
until formed refined garlic bulbs and they were then
added with 70% ethanol solvent. Sonification was done
to the mixture for 1 hour and it was then filtered. After
the evaporation of the solvent, the extracted remaining
materials were freeze-dried until formed the extract
powder of garlic6.
Preparation of topical cream
Procedure for the preparation of topical cream
referred to the study of Bergtorm & Strobber7. The steps
of topical cream procedure are described below.
Weighing the following materials
Materials Weight (g)
Stearic acid 1.5
Cetyl alcohol 2
Stearyl alcohol 1.5
Glycerin 5
Propylene glycol 10
α-Tokopherol 0.05
Metyl paraben 0.2
Propyl paraben 0.02
Novomer 1
Aquadest Up to 100 gr
Preparation of cream base
The materials used to prepare cream base including
stearic acid, cetyl alcohol, and stearyl alcohol as well
as propyl paraben. These materials were weigthed and
then they were mixed and heated up to 70oC (oil phase).
Glycerin, propylene glycyl, MP, and water were heated
up to 70o C (liquid phase).
180  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Oil phase and liquid phase were mixed together and
heated up to 70o C while stirring the mixture by using
the homogenizer until the mixture achieved reduction of
heat up to 40OC. The mixture was then added with the
novomer and α-tokoferol until formed cream base.
Determination of tumor necroting factor-α (TNF-α)
Determination of tumor necroting factor-α (TNF-α)
was conducted at the Center for Health Education
Research at the Hasanuddin University.
Materials and Instruments for the determination of
tumor necroting factor (TNF-α)
Materials and laboratory instruments used in this
study including laboratory cloths, goggles, protective
mask, gloves, micro pipette, Eppendorf, multichannel
pipette, Bio-Rad, microplate reader 680, Bio-Rad, Maxi
mix II, Thermolyne, Incubator, Memmert, Elisa Kit,
human TNF-α (tumor necrosis factor alpha) ELISA kit,
Elabscience, Pipet tip 10 µL, 100 µL, 1000 µL, distilled
water (ddH2O), reagent reservoir, test tubes of 1.5 mL,
15 mL and 50 mL.
Procedure of acute excision wound model
Each mouse was put into the anesthetizing box and it
was anesthetized with ether solution with a dose of 0.5-
1.0 cc by inhalation. After then, the dorsal area of each
mouse was aseptically cleaned with hair removal cream
(Veet). Subsequently, disinfection was done with 0.5%
chlorhexidine in 70% alcohol. Acute injury was made
with wound diameter of 0.8 cm (8 mm) by excision at
the left and right bilateral areas of the dorsal.
Measurement of wound area
The wound area was measured by immediately
placing a sheet of transparent paper over the wound
and tracing its perimeter; the area of this impression
was calculated using graph paper and a ruler in mm
dimension. Observation of experimental mice after
incision was conducted on day 4, 7 and 14 respectively.
Design of the study
This study was a purely experimental design by
using randomized post test control group using mice of
Wistar strain as the study samples. A total of samples
were 54 mice divided into 3 experimental groups that
include the negative control group, the positive control
group and the treatment group. The negative control
group was treated with 10% NaCl (placebo).
Statistical analysis
The experimental results were expressed as mean
± standard error, and analysis was done using SPSS
version 20. Statistical correlations among three groups
of mice were analyzed with Spearman’s correlation test.
Statistically significant test was carried out by by means
of one-way analysis of variance (ANOVA) in which p <
0.05 was statistically considered significant.
Results
1. Expression of tumor necrotic factor (TNF-α)
Results of one-way Anova test in the negative
control group showed that the expression of TNF--α
showed statistically significant correlations on day 3
until day 14 (p: 0.058), whereas, the positive control
group did not show statistically significant correlations
in the10 % garlic topical cream group on day 3 until day
14 (p: 0.001) and day 7 until day 14 (p: 0.007). Results of
Spearman’s correlation test showed that the expression
of TNF-α was statistically significant correlations
among all the mice groups, the negative control group
(p : 0.048 and r : -0.682), the positive control group (p:
0.007 and r : -0.876) and the 10 % garlic topical cream
group (p: 0.002 and r : -0.779) respectively. Based on
a two-way correlation, all experimental groups showed
negative orientation of correlation. This means that
the expression of TNF-α gradually reduced along with
longer day in the process of wound healing. Spearman’s
correlation test was highest in the positive group and the
treatment group of garlic extract, whereas it was lowest
in the negative control group.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  181

2500 Negative Control Group

One-way Anova:
2322.86 Day 3 -14 (p: 0,058)
Day 7-14 (p: 0,484)
Day 3-7 (p : : 0,202)
2000

1617.76 1648.57 NegativeNegatif

Kelompok Group
1500 Positive Control Group
1386.99 One-way Anova:
1286.24 Positive Group Day 3 -14 (p:: 0,154)
Kelompok Positif Day 7-14 (p: 0,145)
Day 3-7 (p : : 0,971)
1000
824.13
Ekstrak bawang
10% Garlic putih
Extract
500 575.87 10% Group 10%Garlic extract
386.91 One-way Anova:
307.95 Day 3 -14 (p:: 0,001)
Day 7-14 (p: 0,003)
Day 3-7 (p : : 0,243)
0
Day 0 HariDay
Ke33 HariDay
Ke77 Hari
DayKe
14 14

2.
2. Wound
Wounddiameter
diameter Spearman’s correlation test in wound diameter showed
statistically significant difference among the three
Resuts of Resuts one-way Anova Anova
of one-way test indicated that that wound diameter in the negative control
test indicated groups that include the negative control group (p: 0.032
wound diameter in the negative control group showed
group showed statistically significant difference dan r: -0.506), the positive control group (p: 0.000 and
statistically significant difference on day 3 until day 14 on day 3 until day 14 (p: 0.028) and day 3
r: -0.876) and the10 % garlic topical cream group (p:
until
(p: 0.028) anddayday7 3(p: 0.045).
until day 7The positiveThe
(p: 0.045). control group showed statistically significant difference
positive
0.000 and r : -0.779) based on the analysis of values of
control on
group
dayshowed
3 until statistically significant
day 14 (p: 0.000) and difference
day 7 until day 14 (p: 0.005) and daytest
3 until day 7the
(p:highest value
Spearmen’s correlation in which
on day 3 until day 14 (p: 0.000) and day 7 until day 14
0.003) was observed in the positive control group and the
(p: 0.005) and asdaywell as inday
3 until the10
7 (p:%0.003)
garlic as
topical cream
well as in group on day 3 until day 14 (p: 0.001) and
lowest value was in the negative control group.
the10 %day 7 until
garlic topicalday 14 (p:
cream 0.009).
group on dayResults of Spearman’s
3 until day 14 correlation test in wound diameter
(p: 0.001) and day
showed 7 until day
statistically 14 (p: 0.009).
significant Results
difference of the three groups that include the negative
among
control group (p: 0.032 dan r: -0.506), the positive control group (p: 0.000 and r: -0.876) and
Negative Control Group
the10
mm % garlic topical cream group (p: 0.000 and r : -0.779) based on the analysis of values
(One-way Anova)
Day 3 -14 (p: 0.028)
Day 7-14 (p: 1.108)
of Spearmen’s correlation test in which the highest value was observed in theDay
positive
3-7 (p : 0.475)
Spearman’s Corelation p : 0.032
Negative GroupNegative Group r* : -0.506
control group and the lowest value was in the negative control group.
PositiveGroup
Positive Group
Positive Control Group
Oneway Anova:
Day 3 -14 (p: 0.000)
10% Garlic
Garlic ExtractExtract
10% Day 7-14 (p: 0.005)
Day 3-7 (p : 0.003)
Group Spearman’s Corelation p : 0.000
r* : -0.876

10%Garlic extract
One-way Anova:
Day 3 -14 (p: 0.001)
Day 7-14 (p: 0.009)
Day 3-7 (p :: 0.339)
Spearman’s Corelation p : 0.000
Day 0 Day 3 Day 7 Day 14 r* : -0.779

Table 1. Correlation between the expression of TNF-α and wound diameter.

Day 3, 7 and 14
Groups
p r*
TNF-α – Wound Diameter
Negative Control 0.737 0.085
Positive Control 0.062 0.448
182  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Table 1. Correlation between the expression of
TNF-α and wound diameter.
Day 3, 7 and 14
Groups
p r*
TNF-α – Wound Diameter
Negative Control 0.737 0.085
Positive Control 0.062 0.448
10 % garlic topical cream 0.004 0.639
As shown in Table 1, results of correlation between
the expression of TNF-α and fibroblast showed
statistically significant correlation in the 10 % garlic
topical cream group (TNF-α with wound diameter at
p: 0.004).
Discussion
The effect of garlic topical cream on the expression
of tumor necrotic factor (TNF-α)
Mean value of the expression of TNF-α for all
the three groups showed the same pattern in which its
expression decreased along with longer days on day 3,
day 7 and day 14. This is in line with previous studies
concerning the application of garlic ethanol topical
cream that could accelerate wound healing process as
antibacterial and anti-inflammatory reaction.
Inflamation is an initial reaction when the body is
injured. This phase immediately occurs after injury and it
may last up to 4-6 days. TNF-α is a sign of inflammation in
the process of tissue restoration. Previous studies showed
significant association between TNF-α and wound
healing process. The decrease of TNF-α level indicates
the inflammatory control and adequate process in wound
healing. TNF-α stimulates synthesis of MMPs. High
level of proteases in wounded areas lead to degradation
of protein matrices and growth factor as the significant
factors in wound healing process8. In addition, TNF-α
suppress tissue growth factor-β (TGF-β) in which TGF-β
induces proliferation of myofibroblast to form essential
proteins in reorganization of extracellular matrices such
as α-smooth muscle actin (α-SMA), collagen type 1A,
and fibronectin9.
As reported in the study of Nagori et al.,10 wound
infection is the barrier of wound healing. The most
important orgainsmes including Staphylococcus
aureus, Streptococcus pyogenes, Corynebacerium
sp, Escherichia coli and Pseudomonas aeruginosa.
Garlic bulb is an anti-mikrobial agent. It has capability
in inhibiting growth of microbes, including viruses,
bacteria, protozoa, and fungi.
In a study conducted by Nidadavolu11, garlic
ointment inhibits biofilm formation by bacterial
pathogens from burn wounds. When thermal injury
damages the skin, the physical barrier protecting
underlying tissues from invading microorganisms is
compromised and the host’s immune system becomes
supressed, facilitating colonization and infection of
burn wounds with microorganisms. At a wounded
area, bacteria often develop biofilms, which protect the
bacteria from the immune response and enhance their
resistance to antibiotics. Their study utilized the in-vitro
wound biofilm model to examine the antibiofilm activity
of garlic (Allium sativum).
The effect of garlic extract topical cream on the
reduction of wound diameter
Mean value of wound diameter among the three
groups showed similar pattern in which its expression
decreased along with longer days on day 3, day 7 and day
14. Wound diameter was lowest on day 3 in the negative
control group (3.8333 ± 1.16905) and was highest in
the positive control group (5.3333 ± 1.03280), whereas,
the highest diameter of wound was observed in the10%
garlic ethanol topical cream on day 7 (3.6667 ± 1.50555)
and was lowest on day 14 (3.0 ± 063) in the10% garlic
ethanol topical cream (1.1667 ± 0.75277).
All previous studies as stated above are consistent
with our study results concerning the efficacy of
garlic extract (Allium sativum) on wound healing in
experimental mice using an acute wound modeling for
developing this ethnomedicinal plant.
Conclusions
Garlic (Allium sativum) extract topical cream with
10% concentration has better effect in wound healing
compared to the contol groups groups and showed the
lowest level of tumor necrotic factor (TNF-α) and the
lowest wound diameter compared to the control groups.
Ethical Clearance- Taken from Islam Makassar
University committee
Source of Funding- Self
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  183
Conflict of Interest – Nil
References
1. Orgill D.P., & C. Blanco (2009). The
Pathophysiologic Basis for Wound Healing and
Cutaneous Regeneration. Biomaterials for Treating
Skin Loss. Elsevier. pp.  2–.  ISBN  978-1-84569-
554-5.
2. Folkman, J (2007). Is angiogenesis an organizing
principle in biology and medicine? J :25,p. 9-18.
Pediatr Surg 42:1–11.
3. Yamaguchi Y & Yoshikawa (2001). Cutaneous
wound healing: an update. J Dermatol 28:521–534.
4. National Basic Health Research (2013). National
Institute of Health Research and Development.
Ministry of Health of the Republic of Indonesia.
Jakarta, Indonesia.
5. OECD (2001). Guideline for Testing of Chemicals:
Acute Oral Toxicity-Fixed Dose Procedure (420).1-
14. Available on http://www.oecd-ilibrary.org
(Accessed on January, 15th 2019).
6. Zuber M, Rajesh V, Anusha K, Chitteti, Reddy R,
Ajimera, Tirupathi (2011). Wound healing activity
of ethanolic of allium sativum alloxan induced
diabetetic rats family. International Journal of
Science Intervention Today IJST.volume 2, issue 1.
7. Bergtorm K.G & Strobber B.E (2008). Principles
of topical therapy in Wolff K, Goldsmith LA,Katz
SI, Gilccherst BA,Paller AS,Leffel DJ. Edited by
Fitzpatrick’s Dermatology in general medicine, 7th
Edition, New York: McGraw Hill; 2008 P.2091-6.
8. Li,J., Chen, J., Kirsner, R. (2007). Pathophysiology
of acute wound healing. Clinics in Dermatology. Vol
9. Keller, U., Kumin, A., Braun, S., Werner, S. (2006).
Reactive Oxygen Species and Their Detoxification
in Healing Skin Wounds. Journal of Investigative
Dermatology Symposium Proceedings. Volume 11.
10. Nagori B.P., Renu S, Neha S (2010). Natural
Healing Agent: Garlic, An Approach to Healthy
Life. International Journal in Ayuverda & Pharmacy
1(2), Nov-Dec 2010.
11. Nidadavolu P, Amor W, Tran P.L., Dertien J,
Colmer-Hamood J.A., Hamood A.N (2012). Garlic
ointment inhibits biofilm formation by bacterial
pathogens from burn wounds.J ournal of Medical
Microbiology (2012), 61, 662–671 DOI 10.1099/
jmm.0.038638-
 Structural Intervention Problematic of Condom Usage in
Makassar City, Sulawesi Selatan Indonesia

Hairuddin K
Universitas of Megarezky, Makassar Indonesia

Abstract
The issue of the larger risk of sexually transmitted infections (STIs) requires all stakeholders of health
development to work together to reduce the risk of STIs. This research focuses on regulation problematic of
condoms usage in Makassar city. It used qualitative research method. This research found that the problem of
regulation was in determinants of lack of community leaders’ knowledge that have strong political influence
so that there was hesitation among decision makers. As the result, the effectiveness of community protection
programs against the high risk of unhealthy sex did not run as it should be. Practical condom usage programs
should be backed up by strong regulations, They finally were only personal alertness both the level of
sexually transmitted workers and their customers.

Keywords: Advocacy, STIs, Commercial Sex Workers

Introduction
The spread of sexually transmitted diseases (STIs) is
a consequence of sexual behavior problem Sharma and
Nam1, Lack of awareness and knowledge of healthy sex2-
4
, sexual intercourse before marriage, Muula5, Patriarchal
system by Cain D. et al,6 and social stigma of condom
usage7. Various Determinants show that the awareness of
healthy sex is very complex. However, some researchers
have not yet explained the influence of the determinants
of political consequences for making regulation which
can basically make healthy sex programs with condom
usage in effective prostitution areas. Regulation that
support the effectiveness of condom usage can protect
society from the risk of transmission of sexually
transmitted infections (STIs)
The Directorate General of P2P Ministry of Health
of the Republic of Indonesia 2018 (2018: 139) stated
that: There has been an increase of the new numbers of
HIV cases in 2015 to 2017. There were 30,935 people
infected with HIV in 2015 and there was an increase
of 33,660 people in 2017. While there were 700 people
in 2015 to 1,089 people in 2017 in South Sulawesi as
sufferers. In 2017 AIDS cases amounted to 4,555 cases in
Indonesia which can be specified as follows: causing of
injection as many as 109 cases. AIDS cases amounted to
220 people and syringe cases were only 6 cases in South
Sulawesi. This fact shows that the etiology of AIDS due
to unhealthy sex is 4,445 for the national scale and 214
for South Sulawesi region. Etiology of unhealthy sex is
awareness in using condoms8-13.
This fact shows that etiology is due to a lack of
awareness of condoms usage. Therefore, it is needed a
preventive action to change the people’s mindset about
healthy sex through the use of condoms, especially they
work as commercial sex workers.
Materials and Method
The type of research used qualitative research to
obtain information about government advocacy on
condom usage in CSWs in preventing STIs cases in
Makassar City. This research described the commercial
sex workers’ level of understanding and behavior with
other related parties. Data sources were not only from
female sex workers (WPS) but also from government
parties. Data were collected by conducting in-depth
interviews.
Results and Discussion
The result of this research elaborated data from
informants who were in the field of STIs prevention,
several figures from agencies engaged in health sector
and supported by government institutions as policy
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  185
makers both of executive and legislative. Whereas the
commercial sex workers (CSWs) themselves are workers
who serve a lot and having profession as sex workers.
The fact in the field indicated that the problem of
condom usage was not only due to lack of knowledge
and weak supervision from government but there were
problems with policy interventions so that program
accentuation was not running optimally14-18. As a result,
the quantity of cases of sexually transmitted infections
was still worrying. As the results of the following
interview:
It is true what was said by the health office, that
the report provided was a fact, and even the latest data
showed that it had risen to 214 sufferers in addition to
injecting drug cases or IDUs that were also incomplete
using the right condom ”(AIA’s statement)
The AIA’s statement showed that the similarity
of the etiology of STIs with data from the Directorate
General of the P2P Ministry of Health in 2018 which
confirmed these two determinants. Where from 214
cases, the etiology due to injecting drug cases was only
the remaining 6 cases due to the problem of condom
usage.
The facts above are strengthened by the testimony
of informants who were engaged in community
empowerment, especially public health. Informant Ail
explained his activities to find solution to the problem of
condom usage so that the risk of the spread of STIs did
not increase. :
“If the system that we apply here, there was a
program that carried out in the field with outrising
systems or outreach in the immediate field, then
outreach in some locations where we conduct monthly
discussion activities” (to do interview with Ail)
The activities of non-government organizations
(NGOs) showed that they fill in the actual space if it
was implemented by government through regulations,
so the problem of condom usage could be solved. They
provided continuous assistance. Based on the results of
the research we conducted that all provide assistance for
HIV cases, because the program was done every day.
Most of them worked with government institutions that
directly deal with public health problems. dSw, as an
informant, explained:
“Usually we are together with NGOs specifically
for CSWs; we do have NGOs friends to collaborate
with Community Health Centre ‘Puskesmas’ (dSw as
informant).
The fact in the field indicated that health and
medical interventions were the most commonly found
with the aim of getting an overview of the incidence
and prevalence of STIs and HIV / AIDS among certain
communities while also observing patterns of trends
and factors affecting the AIDS epidemic. In sex workers
who are at risk for the program carried out by offering, if
workers want to be tested it will be linked to a VCT clinic
for testing. In particular the counselling process can be
done after or post test to see if he is positively affected or
not, counselling is still done. If it is found to be positive,
the counselling is how he lives with PLWHA. This is as
expressed by one NGO informant who has long worked
as a companion for PLHIV in Kra AIDS South Sulawesi,
Zla, that:
“If it was stated positive by the laboratory, he was
said to have positive false and he was negative said
negative, so he was directed to use condoms (Zla’s
statement).
Based on the research conducted that has been
carried out planning by partnering with the government
by creating Pokja, with the aim of being based on the
segmentation of potential areas of transmission. This
segmentation is based on targets that were carried out
previously even though there were new ones. The target
of the working group (Pokja) is nightclubs, even though
there is no prostitution, but there are behaviors that
result in HIV / AIDS, as revealed by one of the informants
from an NGO in the city of Makassar, that....... so we
partnered with the government by creating a working
group, our target is THM even though they did not say
there was prostitution but there was risky behavior .......
(Zla’s statement).
But the structural intervention problematic is
actually an additional obstacle to intervention that will
make the condom usage program much more effective.
There are problems of religious and anthropological
conceptions found in the following information from
informants:
We did it, it was secretly not to be loose in public
places, to avoid friction with cultural figures and
religious leaders, so that if it is used only to get condoms,
186  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
but if it really required, then there was a silent program
(just silent). .......... (Zia’s Statement)
So there are religious and anthropological problems
especially in social construction of condoms which
causes entrusted politicians to make policies not to
complete their duty. Fear of religious risk for condoms
usage policy interventions is expressed by a legislator
as follows:
“Actually, I really disagree with giving condoms,
it’s called a solution to encourage people to commit
adultery ...” (AdS’s Statement).
These non-technical issues cause structural
intervention of policy making to solve the problem of
condom usage un running optimally. The result is felt
directly by them that actively promoting sexual health.
There is no feeling of government support such as our
interview with policy informants stated that ... ... there is
no regional regulations... “(AHi’s Statement).
Regarding condom usage, the government of
Makassar city has not dared to provide a guarantee for
the implementation of the policy. The reason cannot be, it
is still constrained by the problem of the unpreparedness
of the religious parties and people who still do not fully
understand the condoms. As the result of our interview
that:
“I didn’t want to talk about condoms, later NGOs.
Did You know that what troubled condoms are”(AHi’s
Statement)
The variety of obstacles cause of disparity between
the appeal of the decision maker (government) and its
implementation at the grassroots level (commercial sex
workers). Based on the result of our interview with one
of the CSWs that:
“As long as I became a sex worker, I had never
heard of it. The government came to tell us. We usually
used it to avoid illness”(Era’s Statement).
Personally, sex workers had already known about
unprotected sex or sexual intercourse without condoms
usage. Regulations that are expected to provide legal
guarantees for the provision of ‘ATM’ Condoms or
Condom Vending Machine in nightclubs are not prepared.
This means that awareness programs on condom usage
are more emphasized in personal awareness. Warner
L, Newman DR, Kamb ML, et al in The Society for
Adolescent Health and Medicine17 stated
: “The effectiveness of condoms for prevention of
non viral STIs, especially gonorrhea and Chlamydia, is
well-documented. A multisite prospective study found no
incident infections with consistent and correct condom
use”.
In a personal perspective, awareness of sex workers
has been formed. But there are problems structurally.
The effort to eliminate misunderstanding about healthy
sex programs, especially condom usage, it is still being
carried out by the aim of community leaders. Dsw, that:
“But we have worked together with AIDS Prevention
Commission #KPA of City to provide understanding to
the MUI, that condoms are not to justify protection, but
it suppresses HIV / AIDS, there has been clear for that
now” (Dsw’s statement)
The phenomenon above can be described in the
flowchart of awareness of condom usage, according to
Coombes et. Al (2017: 10)18 can be described as follows:
Looking at the fact of the research, the main
problem of structural intervention was in absence of
policies that are considered to accelerate the collective
awareness of widespread condom usage. Policy makers
still awkwardly maximize the program by intervening
in a legal basis for the procurement of Condom Vending
Machine or condoms ‘ATM’. The lack of maximum
effort to make regulations has resulted in not being able
to maximize funding to support every program both
government and private sector or NGOs. In the end,
market development condoms and market management
condoms are not integrated.
Conclusion
The structural intervention problematic in this
research is the reluctance or fear of policy makers to
make regulations that are considered to maximize the
effectiveness of condom usage and to cause widespread
collective awareness of the importance of condoms. The
determinant is misunderstanding of some community
leaders both religiously and anthropologically.
Ethical Clearance- Taken from Mega Rezky
University Committee
Source of Funding- Self
Conflict of Interest – None
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  187
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Data and Information Jakarta. Indonesian Ministry
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9. Hairuddin K. Social Behavior of Condom Usage
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Antenatal Care Documentation Information System Integrated
with Web-based Government Employed Midwife
Performance Index (Seindah Lutra)

Elviana Datulinggi1, Ansar Suyuti2, Mardiana Ahmad3, Syarifuddin Syarif4, Samrichard5, Azniah Syam6
1
Midwifery Study Program, Post Graduate School Hasanuddin, University Makassar, 2Faculty of Electrical
Engineering Hasanuddin University Makassar, 3Midwifery Study Program, Post Graduate School Hasanuddin
University Makassar, 4Faculty of Electrical Engineering Hasanuddin Engineering Hasanuddin University
Makassar, 5Pelamonia Hospital Makassar, 6Nani Hasanuddin Health College

Abstract
Introduction: One of the reasons behind the difficulty to analyze Antenatal Care is the weakness of
its documentation. To address this drawback, one of the methods is by designing an adopted antenatal
documentation information system with web-based credit assessment for the midwifes.

Method: Antenatal care documentation information system integrated with web-based government employed
midwife performance index (Seindah Lutra) Design with System Development Life Cycle (SDLC) method.
The prototype of Seindah Lutra is designed by using Php MyAdmin, MySQL data base and Apache web
server.

The output is in the form antenatal patients database, midwifes’ work shift recap, electronic antenatal
documentation (subjective data, objective data, case analysis, management cases : physiologic, problematic
physiology, pathology, pathology with accompanying illness, urgency )of with the recap of midwifes’ credit
point for performance index, valid and ready-to-use antenatal performance report and monthly antenatal
report which is directly linked with the superior. The system validation of this research involves some experts
in midwifery documentation, midwife’s credit rate for performance index, obstetritian and gineocologist,
and information technology system. The system reliability test was conducted in a Community Health
centers in Masamba sub- district, North Luwu district for a month using measuring test method. The system
reliability test used the alpha cronbach with the score r11= 0.776, the strong reliability of the coefficient.

Conclusion: Seindah Lutra created antenatal database which is complete and continuous, with prompt
access and clear performance assessment for the midwives, precise and measured value for the policy maker
to analyze in order to improve the quality of antenatal care to reduce the risk of stillbirths and pregnancy
complications and give women a positive pregnancy experience

Keywords: Information System, Antenatal Documentation, Midwife performance index

Introduction
Corresponding author:
Elviana Datulinggi, The documentation of antenatal assessment is still
S.ST, Midwifery Faculty deemed as too weak that it is difficult to analyze for
Post Graduate School Hasanuddin University Makassar the improvement of antenatal care (1). The Antenatal
Makassar, 90245, HP : 08114250144 Documentation at public clinics is still carried out
Email: elviana.datulinggi@gmail.com manually (paper-based), resulting in data redundancy,
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  189
low data completion, reading difficulties, weak and well-measured data base with quick and continuous
accessability and inconsistency in the accuracy of the access among the medical practitioners throughout the
data information, time consuming risk screening, and villages, local public clinics and policy makers will be
inaccurate data analysis which caused slow pregnancy created through monitoring and evaluation in order to
management (2,3). improve the quality antenatal care.

Due to post-workshift exhaustion, lack of energy, Resources and Method

unstandardized documentation, lack of format, the
The antenatal care documentation information
midwives’ demeanor and overlapping job caused the
system integrated with web-based government employed
midwives’ inability to carry out the documentation well
midwife performance index (Seindah Lutra) design uses
(4, 5)
. Despite this shortcoming, midwives had sufficient
System Development Life Cycle (SDLC) method with
knowledge on midwifery documentation. However,
the stages of problem identification, opportunity and
implementing punishment to the midwives who failed to
direction analysis, determining the necessity analysis,
do the documentation process is suggested (6) to address
designing recommended system, one-month system
said process’ poor practice because the accuracy of
trial at the a Community Health centers in Masamba
the documentation deteremines the service quality in
sub- district, district North Luwu. The system includes
assessing and evaluating the medical condition of the
hardwares such as laptops with internet connection, as
pregnancy and the next childbirth (7,8,9). Antenatal care
well as softwares such as browser, Apache web server,
documentation is also used to assess the performance
data base with MySQL, PhP MyAdmin as Graphic User
of the midwifes with the status of civil servant (10). It is
Interface.
still currently difficult for midwives to prove their credit
point and the process could take a lot of time and may Result
result in inaccurate value for performance index (11,12),
thus the necessity to design an information system which Designing information system
is efficient in term of time, budget and energy to solve
SEINDAH LUTRA is a web-based information
the documentation issues (2,3, 13-16).
system designed as antenatal electronic documentation
By integrating midwifery documentation with credit which usage includes assessing the performance of the
point in an information system for government employed midwifes in the line of antenatal care.
midwife performance index, a complete, comprehensive,

1. Initial Menu Interface

Figure 1. Star Page design (Seindah Lutra’s Home)

The initial menu interface (Figure 2) shows the system logo which is the web address (www.bidannetd.unhas.
ac.id), log-in with username and password, and menu option.
190  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Midwives’ Workshift

Figure 2. Workshift Menu

This menu shows the workshift for the midwives who will input their attendance everytime they are on duty.

3. Antenatal Patients Data Base and Documentation

Figure 3. Antenatal Patients Data Base and Content of Antenatal Documentation

 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  191
The patient data base shows the medical record
number of the patients who have done the antenatal
check-up.This menu shows the Antenatal documentation
which includes input questions for subjective data;
objective data which includes the physical (head-
to-toe) and laboratory check-up and will detect
the check-up result if there are any abnormalities.
Documentation analysis: this system provides assistance
in analyzing 10 items of diagnosis enforcement. In
the next check-up, midwives will choose the case in
which the result is included (physiologic, problematic
physiology, pathology, pathology with accompanying
illness, urgency). Management: The menu shows the
management based on the case chosen by the midwives,
completed with informed consent menu dan referral
letter. This electronic documentation is based on the
flow of antenatal care and the authority of the midwife.
(1, 10, 17-26)
.
Antenatal Care Monthly Check-up and Performance
Recap Daily and monthly per-patient credit point Report
192  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
The antenatal monthly report as shown in Figure
4 shows the recapitulation of antenatal check-up in
Community Health centers of Masamba sub- district,
Luwu Utara district . The items of the report includes the
number of Antenatal visits with the type of physiologic
case, problematic physiology, pathology, pathology with
accompanying illness, urgency, contacs with a health
provide access, Remidial contact on the second and third
trimesters, body mass index (BMI) with classification,
mean arteri pressure (MAP), Roll Over Test (ROT),
number of patients with HIV/AIDS, malaria, anemia,
sexually transmitted infections case, hepatitis, protein
and sugar (+), Grievances information, education,
communication, Informed Consent, medical delivery
letter.This recap will be checked at the end of the month
to show the result of antenatal check-up.
Table 1. System validation
NO Designing points
1 Login System
the attendant’s workshift list
3 The patients’Data Based
4 The Data of the pregnancy first contact
5 The Data of the pregnancy revisitation
6 Subjective data documentation
7 Obejective data : physical dan laboratory check-up
8 Analysis (10 reinforcement diagnosis) with cases types
The implementation :
9 Accepted
Grievances information, education, communication, Informed Consent, medical delivery letter.
10 The recap of the government employed midwife performance index Per patient, Per day dan Per month
11 The recap of monthly antenatal report
The system reliability
The system reliability test was conducted in a
Community Health centers in Masamba sub- district,
North Luwu district for a month using measuring test
method. The system reliability test used the alpha
cronbach with the score r11= 0.776, the strong reliability
of the coefficient ( ± 0.60 - ± 0.799 )
Conclusion and Suggestion
Antenatal care documentation information system
The system points out the details of the credit rate per
patient which is showing the details of the credit rate per
patient, perday, and per month based on cases rate and
the position owned by the midwife. Each treatment and
nurture given to the patients are counted by the system.
At the end of the month, the midwife will print the recap
of the credit rate as the proof of the working performance
of antenatal care. This system proves that the midwife
performance is tangible, clear, and measurable. (10,20).
The system validation
The system validation of this research involves
some experts in midwifery documentation, midwife’s
credit rate for performance index, obstetritian and
gineocologist, and information technology system.
note
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted
integrated with web-based government employed
midwife performance index (Seindah Lutra) is designed
to: 1) produce the source of information about the
complete health record data of the pregnant women
quickly and continuously 2). Be used by the midwives
and the policy makers to analyze the problems and make
the decision in order to improve the quality of antenatal
care to reduce the risk of stillbirths and pregnancy
complications and give women a positive pregnancy
experience 3). Evaluate and monitor antenatal care and
the government employed midwife performance index
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  193
which is tangible, clear, and measurable.
It is highly suggested that antenatal care
documentation information system integrated with
web-based government employed midwife performance
index (Seindah Lutra) should be tried in a broader area.
Ethical Clereance: Ethical clereance number :
1071 / H4.8.4.5.31 / PP36-KOMETIK / 2018 issued by
the Health Research Committee Hasanuddin Makassar
University
Financial Resources: Financial Resources are
fully borne by the researcher
Conflict of Interest : There is not conflict of interest
in the my research.
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Masa Sebelum Hamil, Masa Hamil, Persalinan,
Dan Masa Sesudah Melahirkan, Penyelenggaraan
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elele , rivers state , Nigeria’, International Journal
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s-0035-1547297. 2015.
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‘Making midwifery work visible : The multiple
purposes of documentation’, Women and Birth.
Australian College of Midwives. doi: 10.1016/j.
wombi.2017.09.012. 2017.
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Bidan dan Angka Kred itnya’. 2008.
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Dan Kesejahteraan Sosial Kabupaten Klaten. 2007;
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Pejabat Fungsional Kesehatan Pada Dinas Kesehatan
Kota. 2017;1521–8.
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Records and their Role in Care Coordination’,
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14. Azizi, V., Lotfi, M. and Jalali, F. ‘Designing of
Electronic Health Record Software in the Nursing
and Midwifery Faculty of Tabriz’, RDME, 2012;
1(1), pp. 17–20. doi: 10.5681/rdme.2012.005.
15. Wang, N., Hailey, D. and Yu, P. Quality of nursing
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Advanced nursing, 2011; 67, pp. 1858–1875. doi:
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PENYELENGGARAAN PRAKTIK BIDAN 23. Dkk, B. I. Asuhan Kehamilan berdasarkan Bukti.

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W. Eny meiliya. Jakarta: EGC. 2009.
 Correlation of HbsAg, HBeAg and HBV DNA Viral
Load in Chronic Hepatitis B Patients

Asvin Nurulita1, Uleng Bahrun1, Umi Intansari2, Budi Mulyono2

Department of Clinical Pathology, Medical Faculty, Hasanuddin University, Wahidin Sudirohusodo Hospital,
1

Makassar, 2 Department of Clinical Pathology, Medical Faculty, Gadjah Mada University, Sardjito Hospital,
Yogyakarta

Abstract
Introduction: The high incidence of Hepatitis B infection worldwide causes this to be a universal problem.
Diagnosis and monitoring of HBV infection therapy currently uses HBsAg, HBeAg, anti HBe, anti HBc and
HBV Viral Load tests. Limitations of the tools and costs of HBV DNA Viral load test causes monitoring of
patients with chronic HBV infection is difficult. This study aims to look at the correlation between HBsAg,
HBeAg and HBV DNA Viral Load in patients with Chronic Hepatitis B.

Method: Chronic Hepatitis B patients who meet the criteria consisted of 232 samples. HBsAg, HBeAg, anti
HBe, and HBV DNA Viral Load data were analyzed using the Spearmans Correlation Test and Chi Square
Test. There is a significant correlation and relationship if the test p value is <0.05.

Results and Discussion: Correlation test results showed a significant positive correlation between HBsAg
and HBeAg against HBV DNA, with a role of 28.8% and 60% respectively. There is a significant relationship
between HBsAg and HBeAg with HBV DNA. The percentage of subjects with high HBV DNA was found
to be higher in subjects with HBsAg and HBeAg who were also higher than in subjects with low HBsAg,
HBeAg and anti HBe.

Conclusion and Suggestion: In this study, it is concluded that there is a significant positive correlation
between HbsAg and HBeAg with HBV Viral Load. HBeAg has the greatest role in HBV DNA.

Keywords: Chronic Hepatitis B, HBsAg, HBeAg, HBV Viral Load.

Introduction highest percentage of hepatitis B in the age group 45-

The Hepatitis B virus (HBV) is a universal health
problem, estimated at 240 million people have been
infected worldwide. The highest endemicity rates in
countries with HBV carriers (East Asia, sub-Saharan
Africa and the Amazon basin) are around 8%, then East
European countries 2 to 8% and West European and
North American countries < 2%.1,2
Basic Health Research Results in 2007 showed
that clinical hepatitis was detected in all provinces in
Indonesia with a prevalence of 0.6% (range: 0.2% -
1.9%). The prevalence of hepatitis in 2013 (1.2%) was
twice as high as in 2007. Five provinces with the highest
prevalence of hepatitis were East Nusa Tenggara, Papua,
South Sulawesi, Central Sulawesi, and Maluku. The
49 years (11.92%), age >60 years (10.57%) and age
10-14 years (10.02%), then HBsAg positive in the male
and female groups almost same (9.7% and 9.3%). This
shows that 1 in 10 of Indonesia’s population has been
infected with the Hepatitis B virus.3
Diagnosis of HBV infection now uses serological
marker examination and HBV DNA Viral Load.
Detection of Hepatitis B surface antigen (HBsAg),
Hepatitis B envelope antigen (HBeAg) and anti Hepatitis
B core (anti HBc) is the initial foundation of diagnosis
of chronic HBV infection, followed by HBV DNA
Viral load examination for diagnosis and monitoring of
therapy.4 HBV DNA Viral Load test is a very important
marker for observing viral activity.4,5
196  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Various studies show that the high number of viruses
plays an important role in the emergence of complications
of chronic hepatitis B. Low virus counts are associated
with a lower risk of hepatocellular carcinoma when
compared with a high number of viruses. The number of
HBV DNA viruses varies depending on various factors,
so repeated checks are needed for monitoring disease
course and treatment. Limitations of the tools and costs of
HBV DNA Viral load test causes monitoring of patients
with chronic HBV infection is difficult. Clinicians need
other tests / markers to estimate the number of HBV
DNA viruses with a faster, easier and cheaper method
than HBV DNA Viral Load testing.5
HBV serology markers are currently growing
rapidly. The HBsAg level test is the basis for diagnosing
HBV infection. The HBsAg level test correlates with
the amount of cccDNA HBV in the liver so that it is
considered a marker of infected cells. HBeAg level
test is an active viral replication indicator. the high
number of HBV DNA viruses in pregnant women has a
significant correlation with HBeAg levels. Anti HBe is
an antibody formed in HBeAg. The formation of anti-
HBe is a marker of seroconversion and is associated
with inactive HBV. 5,6
An easier and cheaper test to predict the number
of HBV DNA viruses is very important for monitoring
Chronic Hepatitis B. Research on HBsAg, HBeAg and
anti HBe tests against HBV DNA Viral Load tests is
still very lacking, especially in Makassar. This study
was conducted to see the correlation between HBsAg,
HBeAg, anti HBe and HBV DNA viral load levels in
patients with Chronic Hepatitis B. This study aims to
look at the correlation of HbsAg and BHeAg level against
HBV DNA Viral Load in patients with chronic hepatitis
in dr. Wahidin Sudirohusodo Hospital, Makassar.
Materials and Method
This study was a cross sectional study conducted
at the Clinical Pathology Installation of dr. Wahidin
Sudirohusodo Hospital Makassar and the Makassar
Center for Health Laboratory. The study was conducted
from January 2016 until the number of samples was
sufficient.
The study sample was all adult patients with
hepatitis B more than 6 months who were diagnosed as
Chronic Hepatitis B Patients based on history, physical
examination and laboratory results that showed HBsAg
and anti-HBc reactive and normal SGPT levels (<45 IU
/ mL). Levels of HBsAg and HBeAg were examined
using the Chemiluminescence Immunoassay (CLIA)
method. HBV DNA Viral Load is examined using the
realtime PCR method.
Statistical Analysis
Test data for HBsAg, HBeAg and anti HBe levels
against HBV DNA Viral Load levels were tested using
the Kolmogorov-Smirnov test for the normality of
numerical data. Data distribution is not normal if the test
p value is <0.05. The Spearmans Correlation test was
used to assess the correlation of HBsAg, HbeAg and
Anti HBe levels with HBV DNA Viral Load. There is
a significant correlation if the test p value is <0.05. The
role of each test on HBV DNA Viral load is obtained
from the rank correlation coefficient multiplied by
100%. Chi Square Test, to assess the relationship of
HBsAg, HbeAg and Anti HBe levels in the category of
HBV DNA Viral Load. There is a significant relationship
if the test p value is <0.05.
Results and Discussion
The study involved 273 patients, of whom 41 were
excluded due to hemolysis samples or insufficient sample
volume. A total of 232 chronic hepatitis B patients were
analyzed, consisting of 123 patients (53%) and 195
patients (84%) in the age group of young adults (19-44
years), as seen in Table 1.
Table 1. Characteristics of samples
Variables Number (n=232)
Sex
Male 121 (52%)
Female 111 (48%)
Age
19-44 years old 195 (84 %)
45-59 years old 34 (15 %)
> 60 years old 3 (1 %)
Source : Primary Data
The results of the Ministry of Health’s Basic Health
Research show that the incidence of positive HBsAg in
men and women is almost the same, this was also found
in this study, where men were 52% and women were
48%.3 This difference could be due to men’s lifestyles
such as smoking, which can inhibit the response to the
hepatitis B vaccine.7 The highest incidence is found in
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  197

the age group 19-44 years, this is probably due to the
number of patients involved in this study were less
than 40 years old. Chathuranga (2013) found that there
was no significant difference between age and immune
response to hepatitis B.8
Table 2. Correlation of Mean HBsAg, HBeAg,
and Anti HBe against HBV Viral Load
The role of HBeAg levels on HBV Viral Load DNA
is greater than the role of HBsAg and anti HBe levels,
which is 60.0% (Figure 2), while the role of anti HBe is
only 47.7% (Figure 3). In this study also found a very
strong correlation between HBeAg levels (r = 0.77)
against HBV DNA Viral Load versus anti HBe which
correlated strongly (r = 0.69)

Coefficient of
Variable Mean SD Correlation p
(r)

HBsAg Level 102.5 IU/

63.3 0.54 0.00
Test mL

HBeAg Level 31 PEIU/

51 0.77 0.00
Test mL

Source : Primary Data

There was a positive correlation between HBsAg,

HBeAg and anti HBe levels against HBV DNA Viral
Load with p <0.00, wherein higher HBV Viral Load,
the higher HBsAg, HBeAg and anti HBe levels. The
correlation between HBV DNA and HBsAg is a strong
correlation (r = 0.54) but with HBsAg role in HBV DNA
Viral Load only 28.8% (Figure 1).
Figure 2. Correlation of HBeAg and HBV DNA
Da Silva (2009) found a very strong correlation of
HBeAg levels with HBV DNA Viral Load, a simultaneous
decrease in HBV DNA Viral load and HBeAg levels
after Lamivudin therapy, so that HBeAg levels in the
initial week of therapy can be used as predictors of
antiviral responses.11 HBeAg occurr coincided with the
production of DNA polymerase virus, therefore HBeAg
showed more replication of the virus.4 Previous studies
found a positive correlation between HBeAg and HBV
DNA, 84.6% of patients with positive HBeAg had high
HBV DNA viral load.12,13

Conclusion and Suggestion

Figure 1. Correlation of HBsAg level and HBV DNA Viral
Load
Gupta (2012) concludes that HBsAg correlates with
HBV DNA in Chronic hepatitis B patients and can be
used to predict the number of viruses in HBV DNA.9
Belopolskaya M in 2015 also found a correlation between
HBsAg and HBV DNA levels in pregnant women, but
HBsAg levels height does not always correlate with
the high number of HBV DNA viruses.5 Zhu found that
patients with high HBsAg levels also had high HBV
DNA viral load.10
This study concludes that there is a positive
correlation between HbsAg and BHeAg level against
HBV DNA Viral Load in patients with chronic hepatitis
B. HBeAg level has the greatest role and strongest
correlation to HBV DNA Viral load.
This study suggests the use of HBeAg level test to
predict the number of HBV DNA either for diagnosis
or monitoring the treatment of patients with chronic
hepatitis B.
Ethical Clearance- Taken from Medical faculty
ethical clearance committee
Source of Funding- Self
198  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Conflict of Interest – None
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load correlation with focus on pregnancy, in Annals
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 ITGB2 (CD18) mRNA Expression in Hirschsprung-
Associated Enterocolitis (HAEC)

Nita Mariana1, Andi Asadul Islam2, Muhammad Nasrum Massi3, Warsinggih2,

Mochammad Hatta3, Ilhamjaya Patellongi3
Division of Pediatric Surgery, Departement of Surgery, Faculty of Medicine, Hasanuddin University,
1

Departement of Surgery, Faculty of Medicine, Hasanuddin University, 3Post Graduate of Medical Science,
2

Faculty of Medicine, University of Hasanuddin, Makassar, Indonesia

Abstract
Background: HAEC is a condition of inflammatory bowel which has clinical characteristics such as fever,
abdominal distension, diarrhea, foul-smelling stools and sepsis. At Hirschsprung Disease autopsy that
has HAEC, crypt abscesses, mucous ulcerations, and transmural necrosis are seen. In the pathogenesis of
inflammatory bowel disease, intestinal flora may also play a key role in the pathogenesis and development
of HAEC. CD18 leukocyte disorders and T cell regulation can be associated with genetic predisposition
(ITGB2) for HAEC.

Aim : The aim of this study was to investigated the ITGB2 (CD18) mRNA expression in a cohort of patients
with Hirschsprung-associated enterocolitis (HAEC)

Method : Screening for ITGB2 (CD18) mRNA expression was performed on DNA extracted from colonic
tissue samples of 30 HAEC patients from the Makassar, South Sulawesi, Indonesia population. Polymerase
chain reaction amplification was performed, followed by heteroduplex single-strand conformation primer
analysis and bidirectional semiautomated DNA sequencing analysis.

Results : From 30 HAEC patients; 25 (83,3%) male patients, 5 (16,7%) female patients. 13 (43,3%), aged
≤ 1 year, 3 (10,0%) aged 4-5 years. The value (p-value <α) or (0.038 <0.05) can be concluded that there is
a relationship between ITGB2 mRNA expression (CD18) and Genesis HAEC, it can be concluded that the
lower the ITGB2 mRNA expression (CD18) then the HAEC event will be increase.

Conclusions: There is a relationship between ITGB2(CD18) mRNA expression and the occurrence of
HAEC, the lower of ITGB2(CD18) mRNA expression, the higher histopathological severity degree of
HAEC.

Keywords: Hirschsprung’s-associated enterocolitis (HAEC), mRNAITGB2(CD18), Hirschsprung’s disease

Introduction Although couples of aetiologies have emerged,

Hirschsprung-Associated Enterocolitis (HAEC)
was first known at the end of the 19th century by
HaraldHirschsprung who also described congenital
megacolon. HAEC is a condition of inflammatory
bowel which has clinical characteristics such as fever,
abdominal distension, diarrhea, foul-smelling stools and
sepsis. At Hirschsprung Disease autopsy that has HAEC,
crypt abscesses, mucous ulcerations, and transmural
necrosis are seen.
the biological mechanisms underlying HAEC are still
poorly understood. HAEC is the cause of morbidity
and mortality of Hirschsprung sufferers. The incidence
of HAEC around the world ranges from 6% to 58%.
While the mortality rate at HAEC is still quite high from
6% to 30%. The non-specific clinical manifestations of
HAEC cause frequent diagnosis of gastroenteritis, so the
diagnosis of HAEC is missed or late.
200  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
At present, the pathogenesis of HAEC is still unclear. The researcher used the SPSS version 23 computer
Recent studies have shown that injuries to the intestinal program for Windows.
mucosal barrier, abnormal immune responses in the
intestinal tract and infections due to certain pathogens
Research Result
may play an important role in the pathogenesis of Table 1: Characteristics of Patients by Sex
HAEC.1 Enteric pathogens can attack the bloodstream
through damaged intestinal mucosal barrier and then Gender Frequency Percentage
induce an inflammatory response such as a waterfall.2 In
Male 25 83.3
addition, histology and immunological studies show that
persistent inflammation and decreased immune function Female 5 16.7
in the intestinal tract of the baby causes repeated
Total 30 100
HAEC.3 In the pathogenesis of inflammatory bowel
disease, intestinal flora may also play a key role in the Table 2: Characteristics of Patients by Age
pathogenesis and development of HAEC.4
Age Frequency Percentage
Zhi Cheng reports that from a HAEC trial in mice,
≤ 1 year 13 43.3
it shows genetic deficiency of endothelin B receptor
images, abnormal immunophenotypes characterized by 2 - 3 years old 10 33.3
small lymph size, lymphopenia in B and T cells, and 4 - 5 years old 3 10.0
abnormal images from colon histopathology occur.5
> 5 years old 4 13.3
Sam reports that CD18 leukocyte disorders and T cell Total 30 100
regulation can be associated with genetic predisposition
(ITGB2) for HAEC. This allows a genetic link for the Table 3: Description of HAEC Degree Frequency
selection of HAEC patients, by identifying the potential Distribution
molecular targets.2
Degree HAEC Frequency Percentage
Research Objectives
There are no
0 2 6.7
This study aims to determine the relationship of abnormalities
ITGB2 (CD18) mRNA expression to the occurrence of Crypt dilatation and
I 6 20.0
HAEC in Hirschsprung patients. mucus retention

Research Methods Cryptitis or two

II 7 23.11
cryptic abscesses
The design of this study was a cross sectional study Multiple crypt
III 6 20.0
with simple random sampling in patients of Hirschsprung abscesses
Diseaseto determine the relationship of ITGB2 (CD18) Fibrinoprulent debris
mRNA expression to the occurrence of HAEC. Colon IV 7 23.11
and mucous ulceration
preparations of Hirschsprung Diseasepatients were
Transluminal or
assessed histopathologically according to HAEC V 2 6.7
perforated necrosis
severity that is based on the classification of Teitelbeum.
RNA extraction uses the Boom method. The quality test Total 30 100
of mRNA was using fluorometer, and quantification of
the ITGB2 (CD18) gene mRNA was using RT-PCR. Table 4: The Mean Score of ITGB2 (CD18)
mRNA in HAEC sufferers
Data Analysis
Group Mean ± SD
Statistical analysis of the data was using the
Spearman Rank test, the conclusion for the statistical mRNA ITGB2(CD18)2 11.037 ± 1.229
analysis test based on the significance value of p, if the
value of p<0.05 then the research hypothesis is accepted.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  201

Table 5: Frequency Distribution of HAEC sufferers based on ITGB2 mRNA expression (CD18)

mRNA ITGB2(CD18) Expression Frequency Percentage

High 12 40.0

Low 18 60.0

Total 30 100

Table 6: Relationship of ITGB2 (CD18) mRNA Expressions with HAEC Events

Correlations
ITGB2(CD18) Derajat HAEC
Spearman’s rho ITGB2(CD18) Correlation Coefficient 1,000 ,348*
Sig. (1-tailed) . ,032
N 29 29
HAEC Degree Correlation Coefficient ,348 *
1,000
Sig. (1-tailed) ,032 .
N 29 30
*. Correlation is significant at the 0.05 level (1-tailed).
Source: Calculation Results of SPSS 23.0, 2018

Discussion The results of this study found that the highest

From this study, the data obtained showed that
there were more male than female, that is 25 (83.3%)
compared to 5 (16.7%). Similar to the study of Philip
et al. (2018) who also reported in his study that of 116
HAEC sufferers, 99 (85.34%) of them were male and
the remaining 17 (14.66%) were female. Likewise the
research conducted by Joseph et al.6, out of 110 sufferers,
the ratio of male to female was 3.6:1.
From the description of the age of HAEC sufferers
found in this study, most were under 1 year old of age
(13 children or 43.3%) and only 4 or 13.3% who were
over 5 years old.
Philip K et al7 reported that failure to recognize
Hirschsprung Disease in the initial prenatal period could
place children at greater risk for HAEC, they get 18%
- 50% experiencing HAEC in the pre-operative period.
Surana et al also reported that the incidence of HAEC
in infants was higher in the first week of life (24% were
diagnosed with Hirschsprung Disease) compared to
those diagnosed more than the first week (11% were
diagnosed). In addition, the delay of meconium also
affects the occurrence of HAEC (53 hours : 44 hours).
Delayed diagnosis of Hirschsprung Diseasealso affects
the occurrence of HAEC in children (16.6 : 4,6 days).8
degree of HAEC was histopathology II and IV (cryptitis
or abscesses of two crypts and fibrinoprulent debris and
mucosal ulceration) each constituted 7 patients or 23.3%.
While the fewest were patients with histopathological
degrees 0 and V (there were no abnormalities and
transluminal or perforated necrosis), which were 2
patients or 6.7% each. The high pathological score
of HAEC from all three segments increases the risk
of enterocolitis. The high pathological degree in the
transitional segment is significant for postoperative
HAEC events.9
Teitelbaum et al. reported that 88% of patients
with HAEC III degree and above, and 83% without
HAEC with II grade and lower. They use the degree of
enterocolitis in patients with Hirschsprung Disease to
predict the development of HAEC after definitive pull-
through surgery for III degree and above.
Clinical assessment of the degree of enterocolitis
may prove to be a useful method for early detection of
infants at risk of HAEC. There was a significant change
in intestinal mucin with an increase in neutral mucin and
a decrease in sulfomucin acids identified in HAEC tissue
specimens. The organisms attached to enterocytes are
seen in 39% of HAEC tissue specimens.10
202  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
The results of this study found that the mean of acute inflammation), for example chronic inflammation
ITGB2 (CD18) mRNA in HAEC patients was 11,037 that occurs in fat tissue. Acute inflammation that does
and SD was 1,229. The description of HAEC sufferers not heal is usually caused by: failure of neutrophils to
based on ITGB2(CD18) mRNA expression, as many eliminate pathogens, the presence of foreign elements,
as 18 children or (60.0%) were patients with low autoimmune diseases and unclear causes.
ITGB2(CD18) mRNA expressions and the remaining 12
The same was reported by Moore et al. that variations
children (40.0%) were patients with high ITGB2(CD18)
in ITGB2(CD18) gene immunomodulatory (CD18) were
mRNA expression. From the correlation coefficient, the
found in 66% of patients with Hirschsprung Disease,
value ​​obtained was (p-value <α) or (0.038 <0.05) so it
and 59% of these patients suffered HAEC. More than
can be concluded that there is a relationship between
one variation of the ITGB2(CD18) gene is associated
ITGB2(CD18) mRNA expression and the incidence of
with more severe HAEC. Further research on genetic
HAEC, the lower the ITGB2(CD18) mRNA expression,
variation in HAEC may explain its pathogenesis.12
the higher number of HAEC occurrence. The lower the
ITGB2(CD18) mRNA expression, the higher the degree Chronic inflammation mediated by immune diseases
of histopathology in HAEC patients. (eg. Rheumatoid arthritis (RA)), psoriasis, multiple
sclerosis, and inflammatory bowel disease (IBD)
Proinflammatory cytokines also trigger the
are characterized by the recruitment of unregulated
production of local chemokines which will deliver
leukocytes. Neutrophils, which are short-lived outside
leukocytes from the circulation to the location where
the circulation, migrate to the site of inflammation and
PAMPs or DAMPs are located, to carry out its effector
undergo apoptosis, while monocytes remain in inflamed
function. The leukocyte effector function is to kill
tissue for several days, where other monocytes become
pathogens and to clean tissue from dead cells. The entry
permanent occupants. The leukocytes migrate to the site
of many neurophils into the tissues is a sign of acute
of inflammation throughout the walls of post-capillary
inflammation. Whereas chronic inflammation that may
venules by involving specific molecules expressed on
appear later is dominated by the deposition of monocytes
special endothelial cells. Endothelial molecules function
and lymphocytes into the inflammatory area.11
as mechanical anchors and to provide network specificity
After leukocytes meet with inflammatory agents for the recruitment process .13
and the remains of dead tissue, the neutrophils
The type of β subunit which is present in each
and macrophages will actively eliminate them by
heterodimer defines a discrete integrin subtype, which
phagocytosis. To carry out this function, on the surface
displays a unique pattern of structure, network specificity,
of phagocytes there are a number of receptors and other
and function. The integrin families β2, α4 and β7 play
molecules used to carry out their functions. Cytokine
the most prominent roles during immunological and
and chemokine receptors in menbran phagocytes are
inflammatory conditions, because they are leukocyte-
triggered by cytokines for the production of ROS, NO
specific. The β2 / CD18 integrins combine with different
and lysozyme and inflammatory mediators (metabolism
α chain ligands to produce four β2-heterodimers.
of arahidonic acid and cytokines) for amplification of the
Their cellular distribution varies between different
immune response.
heterodimers and several such as CD11c which is
The presence of leukocyte-1 adhesion deficiency now generally seen as a monocyte lineage cell marker.
will occur in the leukocyte system, the recruitment of Essential information for the functional importance of
granulocytes which is not effective in responding to β2 integrins is obtained from clinical and immunological
bacterial invasion, which ultimately results in recurrent phenotypic studies of mice or humans that contain
bacterial infections. This is what causes the increased mutations of each gene. In particular, lymphocytes and
incidence of HAEC and the severity of HAEC in patients neutrophils mainly express CD11a/CD18(LFA-1). LFA-
with Hirschsprung Disease. 1 binds to ICAM-1 and ICAM-2 which is expressed
in endothelial cells and mediates migration, antigen
Chronic inflammation can arise from acute
presentation, and cell proliferation.14
inflammation that does not heal or indeed a chronic
inflammation from the beginning (not preceded by
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  203
Recent genetic studies explain the important role of
CD18 integrins in innate immunity. Where, 26 human
and 21 rats, carry zero or hypomorphic mutations in the
ITGB2(CD18)2 gene (which encodes the β2 (CD18)
integrin subunit) resulting in genetic abnormalities of
leukocyte-1 (LAD-1) adhesion deficiency. This condition
is characterized by recurrent bacterial infections. The
pathophysiological disorder underlying the clinical
phenotype is the recruitment of granulocytes that are
ineffective in responding to bacterial invasion.15
Intestinal-related lymphoid tissue, gut-associated
lymphoid tissue (GALT) is the largest lymphoid organ
in the body and is responsible for protecting against
various antigens that may enter the body, including food
particles, pathogenic bacteria and their toxins. Peyer’s
patches (PP) are the main inductive for intestinal
mucosal immunity. PP is a collection of immune
cells, follicles that are similar to lymph nodes and are
located along the intestinal anti-mesenteric surface. In
circulation, T-naive lymphocytes and B-lymphocytes,
α4β7 integrins and L-selectin, migrate from PP through
binding of MADCAM-1 (mucous cell 1 cell addressin
adhesion molecules), which is expressed in high
endothelial venules in PP. Above the PP mucosa contains
M cells, a special epithelium for transporting antigens
from the intestinal lumen to PP, which is presented
for naive lymphocytes, such as dendritic cells (DC).
Activated lymphocytes then enter efferent lymphatic
channels to travel to “mesenteric lymph nodes” (MLN).
From MLN, activated lymphocytes travel through the
thoracic duct into the systemic circulation. The travel
of activated lymphocytes to the lamina propria (LP),
through the main effectors of mucosal immunity, occurs
through coordinated action of a number of cellular
adhesion molecules, cytokines and chemokines. After
being in LP, T lymphocytes produce Th-2 cytokines pro-
inflammatory interleukin-4 (IL-4) and pro-inflammatory
IL-10 to stimulate the production of immunoglobulin A
(IgA) with terminal differentiated B lymphocytes, called
plasma cells. IgA, the most widely immunoglobulin
isotype produced in the body, is then actively transported
to the mucosal surface in the form of dimers by polymer
immunoglobulin receptor (pIgR). 16
In addition, they also observed a decrease in
marginal zone B lymphocytes, suggesting impaired
development of B lymphocytes. Both groups showed
changes in lymphocyte population, similar to those
experiencing stress (such as HAEC). In an effort to
describe the contribution of the EdnrB - / - genotype to
the HAEC phenotype, Frykman, et al. performed bone
marrow transplantation from EdnrB - / - animals to
Rag2 recipients - / - and, separately, induced intestinal
obstruction in experimental animals. They concluded
that stress due to obstruction produced lymphocyte
changes seen in the HAEC model. In addition, in the
EdnrB - / - model, animals undergoing surgery and
continuous intestinal blockages will have a 40% risk of
HAEC .17
Conclusion
There is a relationship between ITGB2(CD18)
mRNA expression and the occurrence of HAEC, the
lower of ITGB2(CD18) mRNA expression, the higher
histopathological severity degree of HAEC.
Ethical Clearance- Taken from Medical faculty
ethical clearance committee
Source of Funding- Self
Conflict of Interest – None
References
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 Women Participation in Fast Food Control in
Kendari City, Indonesia

Tasnim Tasnim1, Maria Inge Lusida2, Anwar Mallongi3

1
Public Health Department, STIKES Mandala Waluya, Kendari, Sulawesi Tenggara, Indonesia,
2
Institute of Tropical Disease, Airlangga University, Surabaya, Jawa Timur, Indonesia,
3
Department of Environmental Health, Faculty of Public Health, Hasanuddin University. Makassar

Abstract
Background: Kendari City Health Government faced fast food trader issue which affected to public health
status. The prevalence of diseases which were caused by food continued to increase. Community participation
in fast food control was needed because of limited health workers in health centres. Therefore, this study
aimed to indentify affectivity of women participation in fast food control to food traders in Kendari city,
Southeast Sulawesi, Indonesia.

Materials and Method: This study applied Quacy Experiment with the one group pretest-posttest design.
The study was conducted in 3 villages in Kendari City because they have many temporary food traders.
The sample of temporary food traders ware 39 traders and 17 women. The hypothesis of this study is that
community involving in control to the temporary food traders will be effective to improving the fast food
processing which will affect to the quality of sold food. Data analysis used Linier Regression.

Results: women could control the fast food traders to increase food hygiene and sanitation. The
distance of the cadre’s home to the fast food trader significantly influenced to the fast food processing
which eventually affected to the quality of the sold food.

Conclusions: women can a representation of a civil society to control food for traders in Kendari effectively
because they are closed with food traders.

Keywords: Women, Participation, Food, Disease

Introduction
Kendari city health government in Southeast
Sulawesi Indonesia faced the unsanitary huge fast food
sellers. This has contributed to increasing the number
of communicable and non communicable diseases
such as diarrhoea and hypertension in Kendari city. In
2015, there were about 63.28% of diarrhoea and about
14.83% of hypertension. Those were higher than other
district such as in North Konawe (6,64%) and Wakatobi
Corresponding Author:
Dr. Tasnim,
SKM, MPH, Mailing: Jl.H.A.Nasution no.G-37
Kendari, Sulawesi Tenggara Indonesia,
E-mail: tasnim349@gmail.com,
Phone:+6282237658472
1
(15,87%) of the prevalence of diarrhoea . While the
prevalence of hypertension were also higher compared
1
to 7.15% of Bau-Bau city . The Health Department
in Kendari City implement several strategies. The
strategies include collaborated programs between the
producers, governments, non-government organization
and communities2. However, community involvement
was still unclear. While the number of unsecure
fast food sellers continued to rise. Health department has
involved cadres or community volunteers involve in the
village comprehensive health services. However, cadre’s
involvement in the fast food controller has never been
done until now. Therefore, this study aimed to identify
the model of cadres’ involvement in controlling to the
fast food traders to reduce the foodborne diseases in
Kendari city of Southeast Sulawesi Province.
206  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

Material and Method each variable such as communities’ characteristic who

involved in, the form, the mechanism of the fast food
a. Research Design controlling. The inferential analysis was to analyse the
This quantitative method study used a quasy relationship between the distance of cadre’s house to the
Experiment approach with The one-Group fast food traders and the quality of the food hygiene and
sanitation. The statistical analysis used linier Regression.
Pretest-posttest Design as described below.
Results
Pre-test Treatment Post-test a. Characteristic of women who involve in the
01 X 02
fast food control

notes: Women who were involved in this study were 17

: Pre-test people. All women aged 41.5 on the average and 7.3 of
01
: treatment from communities as standard deviation. The majority of the age of cadres
X
controller and educator was between 40-44 years old (41.2%). There were only
02 : Post-test 5,9 % of cadres who aged more than 50 years. 29.4%
of them aged 35-39 years old and 11.8% of them aged
Figure-1. The Quacy-Experiment method with 30-34 years old and 45-49 years old. Some of them
The One-Group Pretest-posttest Design passed from senior high school (52.9%), while they
who passed from diploma/Bachelor/Post Graduate were
b. The Study Site and Time 23.5%. Other cadres passed from Junior High School
This study was conducted in three villages in Kendari (17.6%) and 5.9% of Primary School. There were about
city of Southeast Sulawesi province Indonesia namely 70.6% of cadres who did not have job. Another cadres
Andonohu, Rahandauna and Wundumbatu villages. This work as traders (17.6%), teachers (5,9%) and civil
study was conducted from March to July 2018. servant (5.9%). 94.1% of cadres were married, while
1 cadre was widow. The majority of cadres have two
c. The Population and Samples children (41.2%), 23.5% have three and five children.
5.9% of cadres have one and four children. They have
Population
been a cadre more than 1 years. They have had many
All fast food traders were population in this study experiences to do social activities and trainings. Detail
namely about 119 traders. of the cadres who involved in controlling the fast food
traders was presented in this table below.
Sample and sampling technique
Table-1. Women’s experiences in the social
The samples of this study were 39 fast food traders activities
who were selected with using the purposive sampling.
The inclusive criteria of sample were active cadre b. The Relationship between the distance of
available in the village and there many fast food traders. women’s house to the fast food traders and the
quality of food hygiene and sanitation
d. Data collection
Women have various type when they controlled the
Data was collected through interview and food traders. Some of them used motor cycles (82.4%),
observation. The interview was purposed to the fast food while others were on food (17.6%). The duration of
sellers and cadres in three villages. This study recruited reaching the food traders were also verity as presented
17 women a controller to the fast food traders. in the below table.
e. Data analysis

Data was analysed into two ways, namely

descriptive and inferential analysis. Descriptive analysis
was to understanding percentage and distribution of
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  207
Table-2. The distance of Women’s house to the fast food traders

The distance between women’s home to the

766.2 ±657.0
food seller: (meter): mean (±) 1 SD*

< 100 2 11.8

100 – 499 5 29.4

500 - 999 2 11.8

1000 – 1499 5 29.4

1500 – 1999 1 5.9

> 2000 2 11.8

Duration of time to the food seller (minute):

6.7 ±3.2
mean (±) 1 SD*

<4 4 23.5

5–9 8 47.1

10 – 14 3 17.6

15 – 19 1 5.9

20 1 5.9

SD*= Standard Deviation

This study found out there was significant association between the distance of women’s house to the fast food
traders and the quality of food hygiene and sanitation as showed in table 3.

Table-3. The relationship between the distance of women’s house to the food traders with the quality of
food hygiene and sanitation based

Unstandardized Standardized 95% confidence

coefficients Coefficients Interval for B

Model t Siq Lower Upper

B Std.error Beta Bound Bound

The Distance of
21.428 .616 34.796 .000 20.181 22.676
cadre’s house
.001 .001 .192 1.190 .241 .000 .003
(meter)

Discussion of important factors of the individual behaviour besides

This study found out that women or community
health volunteers could control fast food traders because
of many reasons. They have gotten training from Health
Department and form Primary health care services 3, as
showed about 9.2 times. They have become a volunteer
more than 6 years. Therefore, they have had huge
experiences, particularly in community engagement
and Mobilization. They have also gotten their family’s
support such as husband or parents. Family support is one
the individual knowledge, belief and infrastructures
4. As presented above, the cadres passed from Senior
High School (52.9%). Thus, they could synthesize
health information which they got5. Cadres with more
higher educational level tends to have awareness
5
about science and information . The several previous
studies also found that cadres’ knowledge influenced
6
to success in their social responsibility . Moreover,
motivation is also the essential factor of successful for
cadres. Motivation has significant relationship with
208  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
human basic needs7. The human basic needs include
physiological, safety, love, esteem and self-actualization
needs7. This is true that cadre’s involvement in the fast
food control in this study because they want to get new
experiences and self-actualization. This is based on
Depth interview with cadres. Another thing, they hope
to get an incentive from Primary Health Care Centre or
from their village leader. Some of cadres (70.6%) do
not have job. They are wives who do domestic chores
only. If they got incentive such as a few money, there
will be increasing their family income. Additional
household income will give significantly impact for
their children nutrition because they will increase their
purchasing power for food8. Increasing in the household
income also can improve their household facilities such
as water and latrine facilities. The housing condition
also influence significantly to their under-five children’s
nutrition status9. Some of cadres have under-five years
old children. Also, they can buy gasoline for their motor
cycle because there are about 82.4% of them used
motor cycle when they supervise the fast food sellers.
This means that incentive includes in intrinsic factor
which motivate the human to involve in the activity
like involving in the fast food control. Other previous
study also argued that cadre’s motivation was important
factor for them to be active in the social activities in their
village6.
Other important factor why cadre were effective to
involve in the fast food control is they
have lots of free time. As above mentioned that
there were about 70.6% of cadres were no job. Thus,
they had lots of time to involve in the fast food control.
This activity took about 6.7 minutes only. Even some
of cadres (29.4%) who had a job, they still could use
their free time to involve in this activity. The distance
between the cadre’s home and the fast food seller is
about 766 meters in average. Cadres have 3 children in
the average. Therefore, they do not have heavy burden
between their responsibility in their home and in this fast
food control. As we known, the wives in this culture have
responsibility to child rearing including the domestic
chores.
Furthermore, cadre’s experiences in the previous
activity could do the best approach and communication
with the fast food traders. Thus, they could also give
health promotion to the sellers during supervision. The
cadres were about 41.5 years old in the average. They
included in the adult people who changed their interest
and responsibility towards socialist people10. With the
simple instrument of control the fast food quality, the
cadres could show their ability to involve in the fast food
control. The form includes several aspects such as about
environment, the trader’s behaviour towards the food
hygiene and sanitation. Thus, they could give health
education for the food sellers during supervision10-13.
The number of assessment (0-10) of the quality
of the food hygiene and sanitation is easier for the
cadres. The number of 5 becomes the basic to determine
the good or poor because this number was agreed as a
middle number.
Conclusions
Women volunteer in the village who can help health
worker to control the fast food traders because they have
gotten lots of trainings and had huge experiences in the
health promotion program. Therefore, they can influence
the fast food traders to improve their food management.
The process of controlling is simple and needs short time
only.
Acknowledgement: I would like to thank to
Ministry of Research, Technologi and Higher Education
of Republic of Indonesia in financial support of this
study. I am grateful to College of Mandala Waluya
Health Sciences who give permission to take this study.
My sincere goes to women volunteer and food traders in
Kendari city for your participation.
Conflict of Interest: The authors have no conflict
of interest associated with the material presented in this
paper.
Source of Funding: This study was supported
in financial by Ministry of Research, Technologi and
Higher Education of Republic of Indonesia in 2018-
2019.
ORCID: Tasnim Tasnim, http:..orcid.org/0000-
0002-5322-082X.
Ethical Clearance- Taken from institution of
Mandala Waluya Ethical committee
References
1. Health Department of Southeast Sulawesi Province.
Southeast Sulawesi Health Profile in
2015. Kendari: Health Department of Southeast Sulawesi
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  209
Province; 2016.
2. Bureau of Food and Drug Control of Kendari
City. Strategic Plan of Bureau of Food and Drug
Control in Kendari in 2015-2019. Kendari: Bureau
of Food and Drug Control of Kendari City; 2015.
3. Ministry of Home Affairs Republic of Indonesia.
Ministry Regulation of Home Affairs no.19 in
2011 about guideline of integration of the basic
social service in comprehensive service. Jakarta:
Ministry of Home Affairs Republic of Indonesia;
2011.
4. Ryan RM, Patrick H, Deci EL, Williams GC.
Facilitating health behaviour change and its
maintenance: Interventions based on self-
determination theory. The European Health
Psychologist. 2008;10:2-5.
5. Setyatama IP. The relationship between cadre’s
knowledge and motivation with cadre’s roles in
olderly health care service in Kangkung Village
of Mranggen Sub-district in Demak District.
Dinamika Kebidanan. 2012;2(2):1-7.
6. Nugroho HA, Nurdiana D. The relationship
between Cadre’s knowledge and motivation
with active Cadre in Village health care service
in Dukuh Village Central Ketanggungan Sub-
district of Brebes District. Jurnal Keperawatan.
2008;2(1):1-8.
7. Ryan RM, Deci EL. Intrinsic and extrinsic
motivations: Classic definitions and new
directions. Contemporary Educational
Psychology. 2000;25:54-67.
8. Tasnim T. Determinants of malnutrition in
children under five years in Developing Countries:
A systematic review. Indian Journal of Public
Health Research & Development. 2018;9(6):333-
338.
9. Tasnim T. Housing conditions contribute to
underweight in children: An example from
rural villages in Southeast Sulawesi, Indonesia.
Journal of Preventive Medicine & Public Health.
2017;50(1):328-335.
10. Wardana, W D Alzarliani, Suriadi, M Arsyad, M
Salam, D A T Pulubuhu, and A A Unde. Effect
of App utilization on the agricultural efficiency of
rural communities. IOP Conf. Series: Earth and
Environmental Science 235 (2019) 012101.
11. Ambartana, I.W., Mallongi, A., Gumala, N.M.Y.,
Kencana, I.K., Widarti, I.G.A.A. 2018. The
effectiveness of nutritions ergogenic modified
to the local endurance of Pamong Praja Police
personnel in Denpasar. Indian Journal of Public
Health Research and Development 
12. Anak Agung Nanak Antarini, Ni Putu Agustini, I
Gusti Putu Sudita Puryana, Ni Komang Wiardani,
Anwar Mallongi 2018. Identification of
Microbes, Chemical, and Organoleptic
Characteristics towards Teh W o n g
during Fermentation. Indian Journal of Public
Health Research & Development, April-June
2018, Vol.9, No. 5
13. Simanjuntak M. Characteristic of demography
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performance in the comprehensive village health
care services. Jurnal Wira Ekonomi Mikroskil.
2012;2(1):49-58.
 Calculation of Potential Risks Assessment of Escherichia coli
and Total Coliform in Communities Well Water of Puty Village,
Luwu Regency

Anwar Mallongi1, Herlianti 1, Hasnawati Amqam1, Dwia Aries Tina Pulubuhu2, Muhammad Arsyad3, Muh.
Saleh Jastam4, Muhammad Rachmat5
1
Environmental Health Department, Faculty of Public Health, Hasanuddin University, 2Faculty of Social and
Political Sciences, Universitas Hasanuddin, Makassar, Indonesia, 3Faculty of Agriculture, Universitas Hasanuddin,
Makassar. Indonesia, 4Lecturer in Public Health Faculty, Universitas Islam Negeri, Makassar Indonesia,
5
Department of Health Promotion and Behavioral Science, Faculty of Public Health Hasanuddin University,
Indonesia

Abstract
This study aims to determine total coliform present in water and to determine the health risk to the people
who consume water contaminated by bacteria. The research was a cross observational study with microbe
risk analysis conducted in Puty Village of Bua District, Luwu Regency. The sample consisted of 15 drilling
wells and 34 respondents who owned drilling wells selected using purposive sampling method. The data
was analyzed using MRA method and Excel programs. The results of the research indicate that the average
concentration of total coliform in drilling water among 15 samples is 130-160.000000 MPN / 100 ml water.
Meanwhile, for E. coli the average concentration in water exceeds the standard of drinking water quality, i.e
23-24000 .000 cells/100 ml while the standard drinking water quality should be 0/100 ml water. The amount
of risk for public who consume water contaminated by bacteria is in a high risk on average. The results
of risk analysis indicate that the highest Probability of infection (P_inf/day) of Escherichia coli bacteria
contamination in water among 15 samples is sample 5, i.e 2.40E-04. Probability of infection/year (P_inf/
year is 874E-2, while probability of illness (P_ill) is 1.28E+2). Therefore, this is in a high risk category which
means that it is risky of a disease.

Keywords: Microbial Risk Analysis, Escherhicia coli, total coliform

Introduction Data by Riskesdas2, the use of clean water that is most

Average water needs by Indonesia people is 60
liters per capita, include: 30 liters for bathing purposes,
15 liters for drinking purposes and the rest for other
purposes1. The presence of this group of bacteria used as
an indicator of a product has been contaminated by fecal
matter, namely bacteria residing with feces or feces. This
is due to the natural habitat of these bacteria group is in
the feces of humans and other warm-blooded animals.
Corresponding author:
Anwar Mallongi
Email: anwar_envi@yahoo.com;
anwarmallongi@unhas.ac.id
widely used for domestic purposes is protected dug wells
amounted to 27.9% and boreholes or pump by 22.2%.
Whereas, for the purposes of drinking water is the most
widely used is protected dug wells amounted to 24.7%
and boreholes or pump by 14%. These wells, if not
addressed properly, has the potential to be contaminated
with Escherichia coli.
Many risk factors are thought to cause diarrhea in
Indonesia. One risk factor is often studied environmental
factors including microbiological quality of water, the
presence of pathogenic bacteria in the water, such
as the bacterium Escherichia coli the most dominant
risk. Factors contribute to diarrheal diseases are water,
hygiene and sanitation (availability and ownership of
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  211
latrines, trash), the transmission through food, waste
water and air2.
A study of risk factors for the incidence of diarrhea
by Natsir et, al.,3, found that poor sanitation relationship
with the incidence of diarrhea which gained frequency
distribution of clean water a bad category of 199 (90.5%)
of 220 respondents; Poor handling of waste by 171
(77.7%); bad excreta disposal facilities by 124 (56.4%).
While the frequency distribution of bacteriological water
quality examination showed that of 218 (99.1%) positive
water samples E. coli. The World Health Organization
(WHO)4 reported the disease caused by the bacterium
Escherichia coli that hit Germany and 11 other countries
in Europe up to now has reached 2,260 cases and
resulted in the death of 22 people. Until June 5, 2011,
Germany has reported the incidence of 1,536 cases of
EHEC (Escherichia coli entorohemoragik) which is an
increase of 108 cases from the previous day and resulted
in the deaths of six people.
Assessment approach associated with the procedure
MRA can assist the risk assessment to characterize
the source of exposure, the causative agent associated
with symptoms, and other factors that contribute to the
emergence of disease MRA has become a method is
growing rapidly that systematically combines available
information on exposure and dose-response to produce
estimates the burden of disease associated with exposure
to pathogens5. MRA expressed great risk in the value P
infection (P inf) or P illness (P ill). This study aims to
determine the risk of contamination of Escherichia coli
and total coliform in wells water to public health.
Materials and Method
Research Methods
This study used an observational study design
with the approach of microbial risk analysis (MRA) to
determine the health risk that would occur if infected by
bacteria in the water.
Research Sites
This research was conducted in the village of Bua
Puty districts during 2 months from May to June.
Population and Sample
The human population in this study are all people
who consume water from well. For human sample in this
study were 34 people who have dug well water samples
was 15 samples. Sample is determined by purposive
taken one time. Bacteria that become research object
were Total coliform and Escherichia coli bacteria that
present in water wells in the test laboratory. Sample
Environmental health techniques for determining the
amount of the concentration of bacteria in the water
wells. Concentration results in analysis with Quantitative
Approach Microbial Risk Assessment (QMRA) to
determine how much the probability of Escherichia coli
bacteria can cause infection (P infection) or disease (P
illness) in the community.
Data Collection
Primary data obtained from the test results
laboratories ie the number of E. coli and total coliforms
in secondary Makassar. Data BTKL-PP obtained from
recording data related to the community of Bua district
office, health office and health center Luwu Bua about
10 highest diseases and the number of facilities 2014
clean water.
Data analysis
Data were analyzed using Analysis of Quantitative
Microbial Risk Assessment (QMRA) which cover
of Hazard Identification, Exposure Assessment, the
analysis of dose response Risk characterization), and
Risk Management. Presentation of data in tabular form
accompanied by narration.
Research Results
Results showed that the number of E. coli
and total coliform bacteria in wells water in the
village Puty that used as sources of drinking
water are not eligible for direct consumed.
It present concentration of bacterium of Escherichia coli
and total coliform. The result of temperature, and pH
of the water wells test and analysis were also not meet
requirement at all. The concentration of total coliform
bacteria in water (Table 1) shows that water samples
from 15 wells tested were not safe for consumption
without treatment, the highest sample Total coliform at
sample 5 with 160 million cells / 100 miles of water,
and the lowest total coliform samples was at 130 cells
/ 100 miles of water at well number 15. In the sample
(Table 2) shows the concentration of bacteria E.coli
from 15 well water were tested all the samples showed
no feasible and highest sample Escherichia coli bacteria
212  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

was on 5 sample that is 24 million cells / 100 miles of water and a sample of the bacteria Escherichia coli lowest 20
cells / 100 miles of water.

Table 1. Laboratory Test Results Total Pollution Total coliform in dug well water in Bua District, Luwu
Regency in 2015

Samples Location Total Coliform/100 ml Maximum Allowance Feasibility Method

1 RW 1 9200 Base of the regulation Not Feasible APHA 2005.9221 B

RW1 PERMENKES RI NO.416/MEN.
2 5400 KES/PER/IX/1990 Not Feasible
RW 1
3 230 50 for water air non pipe Not Feasible
4 RW 11 24.000.000 /IX/1990 Not Feasible
5 RW 11 160.000.000 Not Feasible
6 RW III 1.600.000 Not Feasible
7 RW III 3500 Not Feasible
8 RW IV 1600 Not Feasible
9 RW IV 220 Not Feasible
10 RW V 470 Not Feasible
11 RW V 54000 Not Feasible
12 RW VI 9200 Not Feasible
13 RW VI 5400 Not Feasible
14 RW VII 1700 Not Feasible
15 RW VII 130 Not Feasible

Table 2 Laboratory Test Results Number of Escherichia coli Pollution in dug well water in Bua District,
Luwu Regency in 2015

Sample Location MPN E. Coly/100 ml Maximum Allowance Feasibility Method

1 RW 1 23 0 for drinking water Not Feasible APHA 2005.9221 F

2 RW1 1700 Not Feasible
3 RW 1 78 Not Feasible
4 RW 11 23.000.000 Not Feasible
5 RW 11 24.000.000 Not Feasible
6 RW III 23000 Not Feasible
7 RW III 240 Not Feasible
8 RW IV 9200 Not Feasible
9 RW IV 20 Not Feasible
10 RW V 220 Not Feasible
11 RW V 250 Not Feasible
12 RW VI 400 Not Feasible
13 RW VI 23 Not Feasible
14 RW VII 45 Not Feasible
15 RW VII 130 Not Feasible
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  213

Table 3. Results of Quantitative Calculations Microbial Risk Assessment Source of Drinking Water in
Puty Village, Bua District, Luwu District, 2015

Quality of Pathogen Infection

Bacteria Bacterial Exposure Infection Probability Probability of
Sample in water Concentration to Probability Per year Gastrointestinal Notes
Cr) in Drinking Drinking Per Day (Pinf) Disease (Pill )
Water (Cd) Water (E) (Pinf.Y)

1 23 0.0023 0.0023 -2.30E-10 -8.39E-08 1.28E-05 High Risks

2 1700 0.17 0.17 -1.70E-08 6.20E-06 9.48E-04 High Risks
3 78 0.0078 0.0078 -3.37E-08 2.84E-07 4.35E-05 High Risks
4 23.000.000 2300 2300 2.30E-04 8.38E-02 1.28E+01 High Risks
5 24.000.000 2400 2400 2.40E-04 8.74E-02 1.34E+01 High Risks
6 23000 2.3 2.3 2.30E-07 8.39E-05 1.28E-02 High Risks
7 240 0.024 0.024 2.40E-09 8.75E-07 1.34E-04 High Risks
8 9200 0.92 0.92 9.19E-08 3.35E-05 5.13E-03 High Risks
8 20 0.002 0.002 2.00E-10 7.29E-08 1.12E-05 High Risks
10 480 0.022 0.022 2.20E-09 8.02E-07 1.23E-04 High Risks
11 220 0.025 0.025 2.50E-09 9.11E-07 1.39E-04 High Risks
12 250 0.04 0.04 4.00E-09 1.46E-06 1.90E-04 High Risks
13 400 0.0023 0.0023 2.30E-10 8.39E-08 1.09E-05 High Risks
14 23 0.0045 0.0045 4.49E-10 1.64E-07 2.51E-05 High Risks
15 45 0.013 0.013 1.30E-09 4.74E-07 7.39E-05 High Risks

Figure 1. Graph of State Temperature and pH of well water dug as a source of drinking water.

Figure I shows temperature and pH in the wells as a
source of drinking water with an average of pH between
6.9 -9.2 while the normal limit of the pH is 6-8, meaning
the highest pH value there is in the sample 14 are in RW
7 marks that it is on the water because the acid levels
over the limit. Whereas highest pH in the sample 14
is 9.2 with the sampling time at 15:40 on the exposure
limits with low pH 6.5 and the highest 9.0. pH or acidity
pH ranges of drinking water 5-8. While the value of
water quality standards 31.6 where temperature ever on
the samples 2 to 15 and 30.9 on the sample 6, and 3 on
the sample 5 is the maximum allowed 30.1 (BMA) water
quality standards (26-29 0C).
Quantitative Microbial Risk Assessment on wells
as a source of drinking water.
Quantitative calculation results in microbial risk
analysis aims to determine the dose response of the
214  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
probability of infection and the risk characteristics of the
population of the village society Puty. Table 3 shows the
probability of infection per day based om P inf. d = 1- (1
+ E / β) ^ (- α) that people who consume water every day
/ 1 liter contaminated with bacteria E.coli then he will be
infected with about 23954E-4 bacteria then categorized
as high risk, while the probability of infection per year or
infection due to consumption of water contaminated with
bacteria during the year by the formula (P inf. d y = 365)
was = 8,74327E-2 can be categorized high. And the risk
for probability of gastrointestinal disease or (Pill = P inf.
year x S x I = 13.3771209E-1 if the resulting percentage
is the risk of clinical disease 50% the risk of disease is a
high risk. Of the 15 samples of the lowest concentrations
of the bacterium Escherichia coli is a sample 9 as 20/100
miles. For P inf.d = 1- (1 + E / β) ^ (- α) 2.00E-10. For (P
inf x P inf.d y = 365) was 7,29E-10 while for (Pill = P
inf.y x S x I = 1.12E-5.Bahwa (Pinf.d or Pill) ketch more
than 10-6 ie examples of the highest concentrations of
bacteria are Pinf.yx S x I = 13.3771209E-1 is a high risk.
Of the 15 samples of water in the village Puty with test
results analysis P inf.y x S x I all smaller than 10-6 then
all categorized as high risk.
Discussion
Results of the analysis of the content of total
coliform bacteria in water samples dug research region
ranged 130-160000000 MPN / 100 ml indicates that the
water has been contaminated by human or animal feces
that can cause gastrointestinal diseases. All samples
were above the threshold of water quality standards
are allowed to water intended for drinking water which
should not be any bacteria that is 0/100 ml of water and
for its designation as clean water ≤50 MPN / 100 ml.
This study shows that the number concentration of E.
Coly between 23-24.000.000 ranges coli cells / 100 ml
water. In 100 ml drinking water should not be on the
content of the bacterium Escherichia coli. The presence
of E. coli in drinking water indicates poor water quality.
Bacteria indicator bacteria E. coli are sanitation and also
be pathogen that frequently causes various diseases6.
In this study of the results of the risk analysis of
the sample greatest risk is 12,82016452E-1 with a
concentration of 23 million cells of E. coli / 100 ml of
water is on the sample 4 and sample 5 is 13,3771209E-1
with concentration E. coli bacteria in the water 23 million
cells / 100 ml of water. This is a relatively high risk even
as the highest mortality burden in the future. The high
concentration of bacteria in the water as probable with
the results of measurements of water temperature past
the normal limit water quality standard yaitu31,6 ie on
the samples 2 to 15 and 30.9 on the sample 6, and to 3 on
the sample 5 is the maximum allowed 30.1 (BMA) water
quality standards (26-290C but total coliforms are found
under the maximum limit. It shows that the temperature
conditions conducive to the growth of total coliforms. It
is possible there are other factors such as levels of waste,
as well as other things that cause could grow maximum
of coliforms in the water7.
Risk characteristics that (P inf/day or P ill) ketch more
than 10-6 is an example of the highest concentrations
of bacteria are P inf/year x S x I = 13.3771209E-1 is
a high risk. Of the 15 water samples with assay results
of analysis P inf/y x S x I all smaller than 10-6 then all
risks are categorized high. A study previously done by
Kroli8, shows that the level of risk is lower (1.36E-07
for fig. 1 and 1.45E-07) showed that cater to the health-
based targets. Taking the average contamination in the
distribution, the risk is much higher (5.26E-04 for 1998
and 2.92 E-04 for 1999). Gastrointestinal infections
arising as a result of this attack Escherichia coli bacteria
to the intestinal wall causing movement of the solution
in large quantities and damage the membrane electrolyte
balance in mucus. It can cause water absorption in the
intestinal wall decreases and causes diarrhea9-13.
Conclusions
Probability Risks of infection (P inf/d) from
Escherichia coli bacteria contamination in drinking
water of 15 samples were highest in samples 5 was 2.40
E-4. Then, probability of infection / year (P inf / year)
1.34E+1 or the probability of illness (Pill) is the category
in the high risks 1.34E+1.
Ethical Clearance- Taken from Faculty of Public
Health committee
Source of Funding- Self
Conflict of Interest – Nil
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 Effect of Knowledge and Attitude Factors on
Tuberculosis Incidents in Mandar Ethnic in the District of
Majene West Sulawesi

Abdul Madjid1, Syafar Muhammad1,ArsunanArsin Andi1, Ida Leida Maria1, Thahir Abdullah1,
Burbahar1, Rustia Russeng1
1
Faculty of Public Health, Hasanuddin University, Makassar, Indonesia

Abstract
Tuberculosis is still one of the diseases that cause health problems in the community. Tuberculosis (TB) is
an infectious disease caused by the bacterium Mycobacterium tuberculosis. Indonesia is ranked third in the
world with the highest burden in the world for TB cases, this can be influenced by several factors. This study
aims to determine the factors that influence the level of knowledge and attitudes regarding the prevention and
spread of TB in the ethnic Mandar of the Rangas village, Banggai District, Majene Regency, West Sulawesi.
This study used an observational analytic design. 200 respondents were selected by purposive sampling.
Data collected included gender, age, family income, education, knowledge about TB, and the attitude of
respondents. Data was processed using SPSS for univariate analysis and path analysis to understand the
relationship of variables. The results showed that there was a significant relationship between the knowledge
and attitudes of respondents with a value of 2,521.

Keywords : Tuberculosis, Incidents ,Path Analysis, Knowledge, Attitude

Introduction the incidence of TB. Early case discoveries such as

Tuberculosis (TBC) is a direct infectious disease
caused by Mycobacterium Tuberkulosi. Until recently,
TB is still a worldwide health problem where WHO
reports in 2017 there are 14 countries in the world that
experience a double burden of TB such as TB sensitive,
MDR TB and TB / HIV, this condition is worse than
the previous years globally estimated estimates > 300 /
100,000 residents of new TB cases occur in developing
countries such as southern Africa in Indonesia and India1.
The incidence of TB cases in Indonesia varies
according to numbers and absolute if seen from the
figures, Java is recorded as <400 / 100,000 population
but if based on absolute numbers the highest incidence
of TB cases is> 100,000 cases occur on the Java island
and in the next report shows a map of TB cases based on
the Province differ from one another2.
West Sulawesi Province, implemented the DOTS
strategy as an WHO recommended strategy that is
believed to be effective in stopping the spread of
TB, but the results have not been able to reduce
pulmonary tuberculosis can prevent and break the
chain of transmission by making early detection and
immediate treatment is prevention and treatment efforts
that must be carried out simultaneously (parallel) and are
simultaneous3.
West Sulawesi currently has a high incidence rate
of 395 per 100,000 inhabitants. The description of
the high incidence that has not been matched by high
findings demands to find the right case finding method
and scientifically accountable the idea of ​​case finding
that connects social determinants with the TB incident
flow in tune with the recommendations of the 2016-2020
RAN TB Research2,4.
The research location is Majene Regency where this
district is the center of the Royal Mandar ethnic and this
district has a high incidence based on data obtained at
Totoli puskesmas for three years showing a increasing
trend of incidents from 2016 recorded 43 new cases, in
2017 there were 56 new cases and in 2018 there were 62
new cases in this district for 3 years TB control always
showed that low case discovery rates never reached the
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  217
target, reflected in the 2015 target is set at 80 % but only
case discovery is 67% in 2016 the target was set at 90%
but coverage was only 72%, so in 2017 the target was set
at 90% and achievement was only 75%4.
A high incidence rate should be followed by high
discovery rates as well, based on the concept of social
determinants that illustrate how to understand the factors
that determine the incidence of TB disease. As explained
earlier in this paper that the determinant of tuberculosis
is mycobacterium tuberculosis but it is not the only one
caused someone to become sick with TB, but it is still
necessary to know the determinants outside themselves
which are also called risk factors for TB disease known
as determinants social TB. Based on the concept above,
the researcher tried to describe the condition of the
mandar ethnic real in the Rangas sub-district analyzed
by age, sex, level of education, and income towards
knowledge and attitudes regarding the prevention and
spread of TB in the community.
Materials and Method
Location and Research Design
This study was carried out in the Rangas village,
Banggai District, Majene Regency, West Sulawesi in
January - November 2018. The type of research used was
operational research, with a quasi experimental design.
Population and sample
The population in this study were all residents
residing in the health center area of ​​Rangas Village,
Banggae Sub-District, Majene Regency, West Sulawesi.
Sampling technic using selected purposive cluster
sampling with number sample size of 258 people, from
the selected sample size refers to 10% of opinions
and also refers to SEM modeling, an analysis tool that
requires a minimum of 100-200 samples, so that 200
samples were taken in this study. Residing in Rangas
Village, and is willing to take part in this research as a
respondent.
Data collection method
Data collection was conducted by researchers using
questionnaires (age, sex, education, family income,
knowledge and attitudes) of respondents about TB. The
results of this study are presented in the form of tables
and narratives and applied path analysis.
Results
Characteristics of the sample
Table 1 shows the results of the univariate analysis,
by sex showed most respondents were female that equal
to 58.5%. age showed most respondents in the age group
31-40 was 62.5%. the level of education showed most
respondents at the elementary school level that is equal
to 62.5%. Based on the work the most respondents
work as housewives who sell their husband’s catch
which was equal to 31.5%. Family income per month
the most respondents were in the group of Rp.500,001-
Rp.1,000,000 which was by 43.0%
Based on the research variable, the respondent
distribution n based on the level of knowledge and
attitudes of respondents regarding TB, it shows that
there we re 58.5% of respondents who have sufficient
level of knowledge about TB, and based on the variable
attitude of respondents regarding TB there are 75.5% of
respondents who have a fairly good attitude.
Path Analysis
In picture 1 the results of path analysis variable
have a significant correlation between the knowledge
and attitudes of the respondents (2,521) and there is no
significant association between age, sex, family income,
recent education with the respondents’ knowledge and
attitudes to tuberculosis prevention.
Discussion
This study used a questionnaire as a measure of the
level of knowledge about tuberculosis prevention and the
attitude of respondents to TB patients in the community
of Rangas, Banggai District, Majene Regency, West
Sulawesi. Basically the level of public knowledge about
TB disease in the research location is quite good. Even
some people who became respondents already knew
about the TB treatment procedure which requires a
long time which is around 6 months. However, people’s
knowledge about the causes of TB is still high, because
there are still people who think that TB is caused by
viruses or magical powers.  
The path analysis results showed that there was a
significant relationship between the level of knowledge
about TB and the respondent’s attitude towards TB
with a score of 2.512. The results of this study were
also supported by the study of Daniel Tolossa5 which
218  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
suggests that the low level of knowledge about TB can
affect behavior in seeking health care and maintaining
transmission of disease in the community. Similar results
were also found in studies conducted in Bangladesh,
which suggested that the main reason for the poor early
detection of TB in children is due to the low level of
knowledge about TB among children by health workers6.
The high level of knowledge a person can cause
changes in one’s perceptions and habits, behavior based
on knowledge will last longer than those not based on
knowledge7. However, there are also studies that are not
in tune with those conducted by Mohammad RN8 who
say that there was no significant relationship between
knowledge and attitudes towards the prevention and
spread of TB in the community.
Path analysis result also showed that there was
no correlation between age and level of knowledge and
attitudes regarding the prevention and spread of TB. The
results of this study were in tune with research conducted
by Hilma P. Lubis et al9 which states that there was no
relationship between age and duration of work with
the level of knowledge and attitudes of midwives at
community health centre in Medan (p = 0.191; p = 0.478
and p = 0 , 22; p = 0.649). The result happen because the
knowledge was come from prior knowledge, personal
experience, and other people and several other factors
that can shape a person’s knowledge for a long time and
knowledge will last until old. But this was different from
the research of Urasa et al.10 who said that there was a
significant relationship between the age of nurses and
knowledge (p = 0.027) where nurses’ knowledge was
better at a young age of 87.5%.
In his theory, age influences the development of
capture power and one’s mindset, the older a person is,
the better the processes of mental development, but at a
certain age, the increase in mental development process
is not as fast as when he was a teenager. Increasing one’s
age can influence the increase in knowledge gained by
Ar-Rasily and Puspita11.
The results of path analysis showed that there was
no relationship between the level of knowledge and
attitudes with education (p = 1.586 and p = 0.497). This
result, similar to the results of a study conducted by Urasa
et al.10 and Hilma P. Lubis et al9 which showed that there
was no significant relationship between knowledge and
attitudes regarding the causes of cervical cancer with
education level. This can happen because knowledge
was not absolutely obtained from formal education, but
can also be obtained from non-formal education. In fact,
a person with a high level of education does not mean
having a good level of knowledge, and vice versa. As
with one’s attitude, a low level of education does not
mean having a bad attitude.
The results of the path analysis conducted
also showed that there was no significant relationship
between sex with the level of knowledge and attitudes (p
= 0.644 and p = 1.146). This research was in tune with
the research conducted by ERWandwalo and O. Morve12,
where he said that knowledge was not significantly
affected by gender or place of residence.
In this study also found that there was no
association between income per month and the level
of knowledge and attitudes towards the prevention
and spread of TB. In tune with this, Portero Navio J.,
L et al13stated that respondents who did not seek health
services in TB cases were significantly correlated with
low family monthly income. This can happen because
not everyone with low income cannot provide special
facilities to obtain knowledge and information regarding
the prevention and spread of TB. In addition, knowledge
and examples of attitudes can also be obtained from
anywhere.
However, this study was not in tune with previous
studies conducted in Nigeria by KE Agho et al14 which
showed that the probability of having bad knowledge
and negative attitudes towards TB was consistently
significant with the poorest households in the region.
This finding was also in tune with the national household
survey conducted in the Philippines, Pakistan, and India,
which shows that higher knowledge of TB was present
among urban residents15-17. This might reflect the fact that
respondents who live in rural areas and come from low
socioeconomic backgrounds may feel embarrassed and
stigmatized because they suffer from tuberculosis18-22.
Conclusions and Suggestions
This study concludes that based on path analysis
conducted the knowledge level variable has a meaningful
relationship with the attitude of the respondents, while
the variables of age, sex, education, and income do
not have a meaningful relationship with the level of
education and attitudes about the prevention and spread
of tuberculosis. Therefore, the local government can
intervene as counseling on the prevention and spread of
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  219
TB in the community, so that people can be consistent in the prevention of tuberculosis

Table 1 Distribution of Respondents by Age, lighting, and Lactic Acid Employee PT PLN (Persero) Region
Sulselrabar

Number
Variable
n = 200 %

Gender
Male 83 41.5
Female 117 58.5

Age
<30 years 57 28.5
31-40 years 81 40.5
41-50 years 45 22.5
> 50 years 17 8.5

Education
Not School 9 4.5
Elementary 125 62.5
High School 49 24.5
College 5 2.5
College (Professional / Postgraduate 6 3.0
School of Religion 5 2.5
Literacy Class 1 0.5

Family Income
<Rp.Rp.
500,000500,001
78 86 23 6 7 39.0 43.0 11.5
Rp.1.000.001-1.500.000
1500001-Rp.1.000.000-Rp.3.500.000>
Rp.3.500.000

Knowledge of TB is
moderate 117 58.5
bad 83 41.5

Attitudes towards tuberculosis is

moderate 127 63.5
bad 73 36.5

Source: Primary Data, 2018

220  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Figure 1. Results of Variable Age Analysis, Gender, Income, Education Against Level Knowledge and Attitudes About TB Spread
Prevention
Ethical Clearance- Taken from Faculty of Public
Health Ethical committee
Source of Funding- Self
Conflict of Interest – Nil
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 Proinlammation and Anti Inflammation in Contrast Induced
Nephrophaty Patient after Administration of Contras Media;
Analysis of Interleukin 18 and Interleukin 37 Levels

Uleng Bahrun1*, Yuyun widaningsih1, Rahmawati Minhajat3, Andi Nilawati Usman4, Wira3
Clinical Pathology Department, 2Clinical Pathology Department, 3Internal Medicine Department,
1

Hasanudin University, Indonesia, 4Public Health Department, Mandala Waluya College, Indonesia

Abstract
Background/Objective : Contrast induced nephrophaty is potential side effect of contrast administration.
A good marker is required in order to synergize with the creatinine marker so that CIN can be handled
more quickly. This study aimed to compare the levels of interleukin 18 as a marker of inflammation and
interleukin 37 as an anti-inflammatory marker in patients with CIN after administration of contrast media.

Material and Method: It was as crossectional study, subject of study were were all affordable populations
who underwent Percutaneus Coronary Intervention (PCI) at the Cardiac Installation Center of Wahidin
Sudirohusodo Makassar (as many as 30 patients). Healthy people used as control of study (10 people) and
also AKI patients (10 people).

Results: Data indicated that both Non CIN and CIN groups had statistically significant IL-18 increases
but decrease IL-37 even unsignificantly Data after media contrast administration showed that IL-18 of the
control group differed significantly with CIN and AKI groups and did not differ significantly with non-CIN
groups. After media contrast administration also showed that the IL-37 of control group differed significantly
with AKI groups only and did not differ significantly with non-CIN and CIN groups.

Conclusion: Proinflammation activity, marked by IL-18 increased significantly after contrast administration
but anti-inflammatory, marked by IL-37 decrese even unsignificatnly.

Keywords: Contrast, Contrast Induced Nephrophaty, IL-18, IL-37

Introduction
Contrast Induced nephrophaty (CIN) is side effect
of giving contrast media that has become one of the
main causes of kidney failure and causes a critical
condition in patients 1-3. It has been a major determinant
of Acute Kidney injury (AKI) and its incident has varied
time after contrast media delivery, there are fast only 2
days and there are up to 30 days4, 5. Athough a recent a
meta-analysis study found that no significant difference
between renal of patients given and those not given
contrast many studies has indicated different result 6.
Marker of CIN traditionally still used increasing of
creatinine serum within 24-48 hours after exposure but
some studies have tried used inflammatory reponse as
biomarker because delayed response of creatinine serum
could reach 30 days and it was too late for patients to
treat and prognostic will deteriorate 7. A good marker
is required in order to synergize with the creatinine
marker so that CIN can be handled more quickly even
if the serum creatinine condition is still under normal
conditions
Pathophysiology of CIN-AKI is still being studied to
gain a good understanding and consensus on prevention
is not present yet 8. Inflammatory processes are involved
in the CIN mechanism that occurs after the administration
of contrast media, some studies use C-reactive protein
(CRP) levels as an inflammatory marker and predictor
9-11
. Proinflammation cytokine, interleukin 18 (IL-18)
has been one of the early detection of AKI events, it can
be detected at 24 hours and 48 hours after exposure. It
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  223
suppose as strong biomarker and moderate diagnostic
IL-18 also has potential as a biomarker for CIN events
12-14
. after contrast has a serum creatinine increase of ≥ 0.5
Before being used as a biomarker in CIN events,
it must first be ascertained whether there is indeed a
difference in IL-18 levels in CIN and non-CIN patients
and should also be comparable to patients with AKI.
Response to inflammation by antiinflammation cytokine
should be considered to be biomarker together with
proinflammation cytokine. One of the most infrequently
studied but important anti-inflammatory cytokines
is interleukin 37 (IL-37). Clinicians need an early
biomarker of CIN diagnostic and also an appropriate
decision regards inflammation.
Interleukin-18 stimulates infiltration and activation
of T lymphocytes and Natural killer (NK) and interferon-
production. Interleukin-18 is released into the urine 6
hours after the onset of a kidney injury 15. Interleukin 37
(IL-37) is a family of IL-1 that has a close relationship
as well as a natural inhibitor for Interleukin 18 (IL-18),
this cytokine is also a suppressor for TNF-α that induces
neutrophil activation 16.
This study aimed to compare the levels of interleukin
18 as a marker of inflammation and interleukin 37 as
an anti-inflammatory marker in patients with CIN after
administration of contrast media. This study will also
compare between IL-18 and IL-37 in patients with CIN
and AKI patients.
Materials and Method
Design and Subject
It was as cross sectional study, subject of study were
all affordable populations who underwent Percutaneus
Coronary Intervention (PCI) at the Cardiac Installation
Center of Dr. Wahidin Sudirohusodo Makassar and meet
the inclusion criteria.
Inclusion criteria were serum creatinine levels
were normal before contrast administration, adults aged
30 and above and willing to participate in research
by signing Informed consent. Criteria of control were
healthy young adults 20-40 years old who are not getting
contrast and have no history or are not suffering from
kidney disease and other illnesses based on serum
history and serum creatinine. Subject was drop out
when the patient’s condition worsened, patients refuse
blood collection after 24-48 hours after contrast medium
delivery. Patient categorized as CIN when a patient who
mg / dl or an increase of 25% from baseline within 24-
48 hours.
The contrast agent in this study was a type of iodine
contrast, nonionic with Low-Osmolar Contrast Media
(LOCM) or Iso-Osmolar Contrast Media (IOCM) and
injected into the patient’s body either through an artery
or vein.
Ethic
Each action was conducted by the consent and
knowledge of the patient who was sampled by the
informed consent sheet and stated to fulfill the ethical
requirements to be implemented from the Medical
Research Ethics Committee of Hasanuddin University
Medical Faculty. Ethical clearance has been accepted
before study from Medical Research Ethics Committee of
Hasanuddin University Medical Faculty (UH16080614).
Procedures
Procedure conducted was:
1. Record the identity of patients who meet the
inclusion criteria and provide a full explanation
of what will be done to them and if agreed they
will fill out and sign the informed consent.
2. The subjects who met the inclusion criteria
were taken venous blood sampling before
and after contrast administration as many as
3 ml. The serum was obtained after the tube
containing the blood was allowed to freeze for
30 minutes at room temperature and centrifuged
for 20 minutes at a rate of 3000 rpm. Samples
are stored at -80 ° C until sufficient samples,
at most 12 months, when the sample will be
diluted at 25 ° C before analysis.
3. Serum level of IL-18 and IL-37 examination
was performed at the Biomolecular Laboratory
and Immunology of the Faculty of Medicine,
Hasanuddin University based on Human ELISA
KIT Instruction.
Statistics Analysis
Data presented with table using mean, deviation
standard (SD), mean difference and probability value
224  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

(p-value). Analisys of pre and post administration of contras data used paired T test and comparison of group used
independent T-test for normal distribution data and Mann Whitney U for data have not normal distribution. Level
of significance was 0.05.

Results
Interleukin 18

Data indicated that both Non CIN and CIN groups had statistically significant IL-18 increases (p-value=0.000),
although the increase in the CIN group was much higher than in the non-CIN group (86.11 pg/ml versus 127.15 pg/
ml) (Table 1).

Table 1. Level of IL-18 before and after contrast administration

IL-18 (pg/ml) level based on time

administration of contrast
Group Frequency (n) Mean difference P-Value
Mean±SD

Pre Post

Non CIN 20 114.422±10.972 200.532±24.065 86.11 0.000a

CIN 10 89.410±9.254 216.560±35.071 127.15 0.000a

*Paired T-test

Data after media contrast administration showed that the control group differed significantly with CIN and AKI
groups and did not differ significantly with non-CIN groups . Analysis of the differences between the groups showed
that the largest difference in the control group was with the group experiencing CIN even higher when compared
with patients with AKI but AKI and CIN group did not differ significant (Table 2).

Table 2. Comparison Level of IL-18 between healthy and AKI subjects After Contrast Administration

Comparison of Frequency IL-18 (pg/ml) level Mean

P-Value
group (n) Mean±SD difference

Control vs 10 154.744±50.954

Non CIN 20 200.532±24.065 45.788 0.039a

CIN 10 216.560±35.071 61.816 0.015a

AKI 10 204.503±90.455 49.759 0.045a

AKI vs 204.503±90.455

Control 10 10 154.744±50.954 49.759 0.045a

Non CIN 20 20 200.532±24.065 3.971 0.967b

CIN 10 10 216.560±35.071 12.057 0.701b

Mann Whitney U test

a

b
Independent T-test
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  225

The data show that both non cin group and cin group had decreased levels of IL-37 although not statistically
significant (table 3). Decreased levels of IL-37 group cin is higher than non-cin group (2.151 pg/ml versus 5.372 pg/
ml).

Interleukin 37

Table 3. Level of IL-37 before and after contrast administration

IL-37 (pg/ml) level based on time

Group Frequency (n) administration of contrast Mean difference P-Value
Mean±SD

Pre Post

Non CIN 20 85.152±25.837 83.001±34.841 -2.151 0.313a

CIN 10 79.825±27.949 74.453±20.896 -5.372 0.386a

*Paired T-test

Data after media contrast administration showed that the IL-37 of control group differed significantly with AKI
groups only and did not differ significantly with non-CIN and CIN groups . Analysis of the differences between the
groups showed that the largest difference in the control group was with the group experiencing AKI and AKI group
has significant difference with other group (Table 4).

Table 4. Comparison Level of IL-37 between healthy and AKI subjects After Contrast Administration

Comparison of Frequency IL-18 (pg/ml) level Mean

P-Value
group (n) Mean±SD difference

Control vs 10 85.243±35.003
Non CIN 20 83.001±34.841 2.242 0.930a
CIN 10 74.453±20.896 10.790 0.545a
AKI 10 240.366±145.463 155.123 0.000a

AKI vs 240.366±145.463
Control 10 10 85.243±35.003 155.123 0.000a
Non CIN 20 20 83.001±34.841 157.365 0.000a
CIN 10 10 74.453±20.896 165.913 0.000a
Mann Whitney U test
a

b
Independent T-test

Discussion research because this study only provides basic data of

An increase in inflammatory activity characterized
by elevated pro inflammation cytokine interleukin 18
appears to suggest that inflammatory activity may be a
predictor and at the same time as a diagnostic for CIN
incidence for patients who get contrast administration.
Although this still needs to be continued with further
significant differences.
The pathogenesis of CIN is very complex. Several
previous studies have shown that inflammation is
important in the prevention of renal impairment. Immune
cells of both the natural immune system and the immune
system include Dendritic Cells (DC), Natural Killer T
226  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
cells, T lymphocytes, B lymphocytes, neutrophils, and
macrophages are known to participate in the early stages
of injury. Thus, control of inflammation can reduce
kidney damage significantly 17, 18.
Inflammation is mediated by the adhesion of
leukocytes to injured endothelial cells. There is increased
escalation of leukocyte adhesion molecules such as
ICAM-1, P-Selectin and E-Selectin in endothelial
cells in response to injury. Increased chemoatractant
factors such as fractalkine (CX3CL1) can be expressed
when kidney injury occurs and promote macrophage
infiltration. This leads to the activation of leukocytes,
capillary obstruction and increased production of
proinflammatory cytokines 19, 20.
Data also showed that IL-37 level did not increase
but decrease even not significantly. It is shown that
contrast administration has high risk to develop be acute
kidney injury. Immune response should increase IL-37
to prevent severe inflammation but it did not happen 21, 22.
Study related IL-37 are still very rare, especially
those associated with CIN, this study provide a basic
data to develop. Increased proinflammatory cytokines,
IL-18 and decreased anti-inflammatory cytokines, IL-37
have the potential to be predictors and diagnostics with
further study.
Conclusion
Proinflammation activity, marked by IL-18
increased significantly after contrast administration but
anti-inflammatory, marked by IL-37 decrease even
unsignificatnly.
Conflict of Interest : None
Source of Funding : Self
Ethical Clearance: Obtained from Medical Faculty
committee member
References
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Intervention at Wahidin Sudirohusodo Hospital in
Makassar, South Sulawesi. 2017. 2017;33(1):6.
2. Eng J, Wilson RF, Subramaniam RM, Zhang A,
Suarez-Cuervo C, Turban S, et al. Comparative
Effect of Contrast Media Type on the Incidence
of Contrast-Induced Nephropathy: A Systematic
Review and Meta-analysis. Annals of internal
medicine. 2016;164(6):417-24.
3. Bhatt S, Rajpal N, Rathi V, Avasthi R. Contrast
Induced Nephropathy with Intravenous
Iodinated Contrast Media in Routine Diagnostic
Imaging: An Initial Experience in a Tertiary
Care Hospital. Radiology research and practice.
2016;2016:8792984.
4. Araujo GN, Wainstein MV, McCabe JM, Huang PH,
Govindarajulu US, Resnic FS. Comparison of Two
Risk Models in Predicting the Incidence of Contrast-
Induced Nephropathy after Percutaneous Coronary
Intervention. Journal of interventional cardiology.
2016;29(5):447-53.
5. Houben IPL, van Berlo C, Bekers O, Nijssen EC,
Lobbes MBI, Wildberger JE. Assessing the Risk
of Contrast-Induced Nephropathy Using a Finger
Stick Analysis in Recalls from Breast Screening:
The CINFIBS Explorative Study. Contrast media &
molecular imaging. 2017;2017:5670384.
6. Aycock RD, Westafer LM, Boxen JL, Majlesi N,
Schoenfeld EM, Bannuru RR. Acute Kidney Injury
After Computed Tomography: A Meta-analysis.
Annals of emergency medicine. 2018;71(1):44-53.
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7. Khatami MR, Nikravan N, Salari-Far M, Davoudi S,
Pahlavan-Sabbagh MR. A comparison of definitions
of contrast-induced nephropathy in patients with
normal serum creatinine. Saudi journal of kidney
diseases and transplantation : an official publication
of the Saudi Center for Organ Transplantation,
Saudi Arabia. 2016;27(1):94-100.
8. Ozkok S, Ozkok A. Contrast-induced acute kidney
injury: A review of practical points. World journal of
nephrology. 2017;6(3):86-99.
9. Kwasa EA, Vinayak S, Armstrong R. The
role of inflammation in contrast-induced
nephropathy. The British journal of radiology.
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10. Guan XF, Chen QJ, Zuo XC, Guo R, Peng XD,
Wang JL, et al. Contrast Media-Induced Renal
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11. Lazaros G, Zografos T, Oikonomou E, Siasos G,
Georgiopoulos G, Vavuranakis M, et al. Usefulness
of C-Reactive Protein as a Predictor of Contrast-
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M, Brar R, et al. Urinary, Plasma, and Serum
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 Influence of Teeth Brushing Behavior, Saliva Flow Rate,
Salivary Hydration, Saliva Viscosity and Saliva PH on Risk of
Caries Occurrence in Adolescents in Gianyar, Bali, Indonesia
(Research conducted at SMAN 1Ubud-Gianyar District Bali)

Anak Agung Gede Agung1, Regina Tedjasulaksana1, Maria Martina Nahak1

1
Dental Hygienist Department-Polytechnic of Health-Ministry of Health - Denpasar-Indonesia

Abstract
Background: Objective: The purpose of this study was to determine the effect of brushing behavior,
salivary flow rate, salivary hydration, salivary viscosity and saliva pH on the risk of caries occurrence
in adolescents at SMAN 1Ubud Gianyar. Method: This research is cross sectional study, with 235
samples selected by purposive random sampling. All samples were measured DMF-T, salivary flow rate
and salivary hydration, followed by saliva collection 2 hours after eating last meal during the day for
analysis of viscosity and salivary pH, followed by an assessment of toothbrushing skill with the guidance
of toothbrushing rubric. The collected data were analyzed by chi-square statistic test. Result: there was a
significant correlation between toothbrushing behavior with caries incidence rate with p = 0.00 (P≤0.05),
whereas flow rate, hydration, viscosity and salivary pH did not significantly affect caries incidence rate with
p≥0.05. Conclusion: Toothbrushing behavior significantly affects caries incidence rate when compared with
physical and chemical properties of saliva.

keywords: tooth brushing behavior, saliva, caries, adolescent

Introduction varies considerably between countries, depending on

Dental caries occurs due to the interaction of the four
factors of the host (teeth and saliva), microorganisms,
substrate and time duration, which is the length of the
interaction process between these factors.1 The process
of caries occurrence begins with the fermentation of
substrates containing carbohydrates by bacteria in
plaque on tooth surfaces that can lower plaque pH below
5 within 1-3 minutes. The decrease in plaque pH of
plaque will lead to demineralization on the surface of
the enamel. The process of neutralization by saliva can
increase salivary pH, and the process of remineralization
takes place. Caries results from a larger demineralization
process than remineralization.2
According to Rosenberg (2010), caries ranks
second after the common cold.3 The caries experience
Corresponding author:
Anak Agung Gede Agung
E-mai: lagungsyojkgdps@yahoo com;
Mobile: +6281999098894;
behavioral factors, age, socio-economic circumstances
and the pattern of life and diet of the community.4 Caries
prevalence in developing countries tends to increase
with increasing consumption of foods that contain lots
of sticky processed sugar and inadequate coverage
of dental services. Basic Health Research Results of
(RISKESDAS) 2013 showed that there was an increase
in dental caries prevalence from 2007 to 2013, and
the highest increase at age 12 years was 13.7%. The
prevalence of active caries in children aged 12 years
reaches 43.4%.5
Adolescence is a period of transition from childhood
to adulthood and in the process, there is development of
physical, psychological and social maturity. According
to Hurlock (2001), in general, adolescence is divided
into three parts: the beginning of adolescence lasts
from the age of 12-15 years, middle adolescence lasts
from the age of 15-18 years and the end of adolescence
begins from 18-21 years which is legal mature age.
Adolescence is characterized by biological, cognitive
and socio-emotional changes that influence self-care
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  229
behaviors including keeping the teeth and mouth clean.
According to Notoatmodjo (2012), behavior is
an activity or activity of a highly complex organism,
among others: behavior in speaking, dressing, walking,
perception, thought and emotion. Brushing behavior
is one of the important and effective health behaviors
for the maintenance of oral and dental health and
prevents plaque buildup in teeth7. According to Sihite
(2011), tooth brushing behavior is influenced by several
factors: brushing, brushing, brushing time and tools and
ingredients to brush teeth.8 Notomatodjo in Sihite (2011),
explains that the risk of caries and periodontal disease in
society, one of which is the behavioral factor that is the
attitude of neglecting tooth and mouth hygiene.8
Saliva is also one of the factors that contribute to
caries risk. Saliva is a secretory secretion of various
glands in the oral cavity and plays an important role in
maintaining balance in the oral cavity. Adequate salivary
function, important in defense against caries attacks.9
Saliva contains certain organic and inorganic materials
which, if excessive or decreased, can cause salivary
imbalances. Saliva function is as a lubricant, buffer,
cleanser, anti-solvent and anti-bacterial. Chemical
composition, flow rate, viscosity, salivary hydration,
acid-base properties (pH) and antibacterial properties of
saliva are associated with the risk of caries occurrence
in a person.10
Caries risk is a person’s chances of having a carious
lesion over a period of time. The risk of caries differs
from person to person, and may even vary in the same
individual, depending on how to maintain oral hygiene
and the salivary buffer function.11,12 Assessment of caries
Table 1: The relation between Teeth Brushing Time with Experience of Caries (DMF-T) at Student of
SMAN 1Ubud Gianyar Regency 2017
Caries experience / DMF-T
Tooth brushing time
High % Medium
Correct 2 2.13 6 6.383
Wrong 50 35.5 61
Total 52 22.1 67
risk in a person is necessary because caries can affect
anyone regardless of age, gender, race or socioeconomic
level. Caries can affect children, adolescents, adults and
geriatrics. Information on caries risk assessment can be
used as a strategy in planning the precautions.13
High school students belong to adolescence which
is in late adolescence, susceptible to dental caries
because at this time biological, cognitive and socio-
emotional changes that affect self-care behaviors include
maintaining oral hygiene.14 The average age of high
school students ranging from 15-19 years is the right age
to measure the salivary flow rate.15
Materials and Method
This research is cross sectional with survey design.
The sample size is 235 students, selected by purposive
random sampling. Intraoral examination was conducted
first to measure DMF-T respondents and observed
salivary flow rate and salivary hydration. The salivary
collection was performed 2 hours after the last meal
and conducted on the afternoon, conducting a salivary
analysis including: salivary viscosity and salivary pH
concluded with an assessment of tooth brushing skill
with guidelines for tooth brushing rubric.
The collected data were then analyzed using
bivariate analysis to find out the correlation between
caries risk factor and caries incidence with chi-square
statistic test.
Results
The results of analysis of tooth brushing time with
caries experience score (DMF-T) can be seen in table 1
below:
total %
% Low %    
86 91.5 94 100
43.26 30 21.3 141 100
28.51 116 49.4 235  
230  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

The table above shows that 91.5% of respondents
who brushed their teeth at the correct time has a low
DMF-T score. While 35.5% of respondents who brush
their teeth at the wrong time have high DMF-T numbers.
The result of analysis with chi-square obtained value P
= 0,00 (<0.05) or there is significant correlation between
tooth brushing time with caries experience.
The results of the relationship analysis of tooth
brushing techniques with caries experience (DMF-T) are
seen in Table 2 below:

Table 2: The Relationship between Tooth Brushing Technique with Experience of Caries (DMF-T) at
Student of SMAN 1 Ubud Gianyar Regency 2017

Caries experience / DMF-T total %

Tooth brushing technique
High % Medium % Low %    

Correct 3 9.09 3 9.091 27 81.8 33 100

Wrong 49 24.3 64 31.68 89 44.1 202 100

Total 52 22.1 67 28.51 116 49.4 235 100

Table 2 above shows that of 235 respondents were examined, 33 people (14.04%) brushed their teeth with the
correct technique and out of these, 81.8% had low caries category. Other 202 people (95.96%), brushing teeth with
the wrong technique and from that amount, 49 people (24.3%) experienced caries with high category. The result of
analysis with chi-square obtained value P = 0,00 (<from 0.05) or there is significant relation between tooth brushing
technique with caries experience.

The effect of salivary flow rate on DMF-T is shown in table 3 below:

Table 3: Effect of Saliva Flow Rate on Caries Experience (DMF-T) at Student of SMAN 1 Ubud, Gianyar
Regency 2017

Caries experience / DMF-T total %

Saliva flow rate
High % Medium % Low %    

Low 0 0 1 33.33 2 66.7 3 100

Normal 4 30.8 5 38.46 4 30.8 13 100

High 48 21.9 61 27.85 110 50.2 219 100

Total 52 22.1 67 28.51 116 49.4 235 100

Table 3 above shows that 219 samples (93.19%) there is no significant relationship between saliva flow
have high salivary flow rates but have a high caries rate with DMF-T number.
experience rate as well, compared with those with low
The effect of salivary hydration on DMF-T is shown
salivary flow rates. The result of analysis with chi-
in table 4 below:
square obtained p-value = 0.602 (p> 0.05), which means
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  231

Table 4: Effect of Saliva Hydration on Caries Experience (DMF-T) at students of SMAN 1 Ubud Gianyar
Regency 2017

Caries experience / DMF-T total %

Saliva hydration
High % Medium % Low %    

Low 3 15 6 30 11 55 20 100

Normal 22 25 27 30.68 39 44.3 88 100

High 27 21.3 34 26.77 66 52 127 100

Total 52 22.1 67 28.51 116 49.4 235 100

Table 4 shows that most respondents had high salivary hydration. From127 respondents who have high hydration
there are 27 respondents or 21.3% who have high caries. The chi-square test showed no significant relationship with
p = 0.757 (p> 0.05) or no significant effect of salivary hydration with caries experience.

The result of saliva viscosity analysis on dental caries / DMF-T incidence is seen in table 5 below:

Table 5: Effect of Saliva Viscosity on Caries Experience (DMF-T) in students of SMAN 1 Ubud Gianyar
Regency 2017

Caries experience / DMF-T total %

Saliva viscosity
High % Medium % Low %    

Very thick 9 25.7 8 22.86 18 51.4 35 100

Thick 40 23 51 29.31 83 47.7 174 100

Clear 3 11.5 8 30.77 15 57.7 26 100

Total 52 22.1 67 28.51 116 49.4 235 100

Table 5 above shows that most of the respondents (74.04%) had viscosity saliva with thick category, but 47.7%
of these had low caries experience. Results of chi-square analysis showed no significant relationship between
salivary viscosity with caries experience with p = 0.757 (p> 0.05).

Saliva pH analysis result on dental caries incidence (DMF-T)is seen in table 6 below:

Tabel 6: Effect of Saliva PH on Caries Experience (DMF-T) at SMAN 1 Ubud Students Gianyar
Regency 2017

Caries experience / DMF-T total %

Saliva pH
High % Normal % Low %    

Acidic 11 21.6 16 31.37 24 47.1 51 100

Normal 31 21.5 38 26.39 75 52.1 144 100

Alkaline 10 25 13 32.5 17 42.5 40 100

Total 52 22.1 67 28.51 116 49.4 235 100

232  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Table 6 above shows that most respondents had
normal and alkaline pH saliva. Of the 51 respondents
(21.70%) who had an acidic pH of only 11 people
(21.6%) and had high caries. The result of statistical
analysis with chi-square showed that there was no
significant relationship between salivary pH and caries
experience with p = 0.839 (p> 0.05).
Discussion
The results showed that there is a significant
correlation between tooth brushing behavior and DMF-T
number in adolescent at SMA Negeri 1 Ubud with p =
0.00 (p <0.05), so tooth brushing behavior was a risk
factor for caries occurrence. Brushing behavior is one of
the most effective health behaviors for the maintenance
of oral health because it prevents plaque buildup in
teeth. Brushing teeth skillfully at the right time can
prevent caries (Sihite, 2011). According to Princess, et
al. (2010), tooth brushing is the act of cleaning the teeth
and mouth of food scraps and debris that aims to prevent
the occurrence of disease in the network hard and soft
on the mouth.16
The results also showed that salivary flow rate,
salivary hydration, salivary viscosity and salivary pH
did not significantly affect the risk of caries occurrence
in adolescents. Most students have a high salivary flow
rate but have a high DMF-T number as well. Salivary
hydration in most students is high but has a high DMF-T
number as well. The saliva viscosity of most students is
relatively thick, but has a low DMF-T. The saliva pH of
most students is normal and has a low DMF-T number
as well.
Saliva flow rate shows how much saliva is
continuously secreted to protect and coat the oral cavity.
Salivary flow rate at rest is 0.3 ml / min17. Zunt (2010),
wrote that the average saliva flow of a normal person
is 0.5-1.5 liters/day.18 When salivary flow is stimulated
below 0.7ml / min, it can increase a person’s caries risk,
but it also depends on other interacting factors.19 Salivary
viscosity is the viscous viscosity that is closely related
to the glycoprotein composition. If salivary viscosity is
increased, it indicates that saliva in the saliva decreases,
so saliva becomes thick, and the individual is at high risk
for periodontal tissue disease.20 A person is said to be
at high caries risk if it has a low salivary flow. Salivary
deficiency can cause dry mouth, thus increasing the risk
of caries occurrence. Multiple salivary secretions, dilute
viscosity and normal salivary pH will facilitate control
of dental and mouth disease.13
Saliva is not the only factor that contributes to the
caries incidence rate, as other factors contribute to the
risk of caries. The risk of caries is a person’s chances
of having multiple carious lesions over a period in the
future. The risk of caries in each person is different, not
even permanent for life in the same person. Caries risk
may change if the patient performs a caries prevention
action either by himself or the dentist.11
Conclusion
Tooth Brushing behavior is significantly associated
with caries experience in adolescents at SMA Negeri 1
Ubud, but Saliva flow rate, salivary hydration, salivary
viscosity and salivary pH are not significantly related to
caries experience in students, so it can be concluded that
behaving correctly in tooth brushing will prevent caries.
Conflict of Interest : None
Ethical Clearance: Obtained from the University
Committee and Respondent agreement
Source of Funding: Indonesian Ministry of Health
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chapter%20II.pdf.(3Agustus 2015
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 Role of Genetic Polymorphisms of Angiotensin Converting
Enzyme to Cardiovascular Endurance in Men
Ages 13-14 Years After Fartlek Training for 3 Months

Fatoni1,2, Haerani Rasyid1, Rosdiana Natsir1, Ilhamjaya Pattelongi1, Andi Ihsan²,

Adam Mappaompo², Sudirman²
¹Faculty of Medicine, Universitas Hasanuddin, Indonesia, ²Faculty of Science, Universitas Negeri Makassar,
Indonesia

Abstract
Physical ability is influenced by two factors, namely environmental and genetic factors. Environmental
factors that influence are exercise intensity, nutritional intake, and age. Another factor that is not less
important in influencing cardiovascular endurance is genetic factors. One of gene variation that is
considered to determine the athlete’s potential is the variation in the ACE gene symbolized by I and D.
The ACE gene insertion / deletion polymorphism (I / D) has an important relationship with cardiovascular
fitness with genotype II which shows a lower level of cardiorespiratory fitness with VO2max than the Non
II genotype (ID and DD). The purpose of this study was to assess how the role of the ACE gene in male
cardiovascular endurance aged 13-14 years. This study provides a three-month fartlek training program and
conducts cardiovascular endurance tests before and after taking a three-month fartlek training program.
In group II genotype subjects showed the results of increased cardiovascular endurance compared to the
Non II genotype subject group. Research can conclude a strong relationship between the variation of the
angiotensin converting enzyme gene II genotype against male cardiovascular age 13-14 years.

Keywords: ACE gene, cardiovascular endurance, fartlek training

Introduction ACE gene is an important factor that needs to be

Efforts to improve sports performance cannot be
separated from physical conditions, because the physical
condition supports when practicing or competing to
show the best performance by displaying techniques
and tactics effectively and efficiently. Good physical
condition is one of the absolute requirements to achieve
optimal performance. Sports training strategies focus on
athletes’ interests and achievements. Genetic potential
of individuals must be considered to get high achieving
athletes, because with the appropriate genetic variation
there is a greater chance of producing accomplished
athletes than athletes who have inappropriate genetic
variations if they receive the same training intervention
and motivation. This research concentrates on finding the
right genetic profile to contribute to sports performance.
One of the main objectives of this research is to help
trainers to identify and guide individuals with genetic
potential to become elite athletes.
considered. The results of this study proves that human
physical performance is influenced by genetic profiles1.
Allele I was found to have a beneficial effect on
higher maximum oxygen uptake values. Characteristic
distribution of genotypes was found, where allele II was
more common in individuals doing aerobic exercise
and DD alleles in individuals who were disciplined in
anaerobic exercise2.
The role of ACE gene polymorphism with
cardiovascular response with irregular resistance
training in women. The subject of DD alleles is greater
in post-exercise hypotension, While the allele I showed
a greater increase in heart rate after endurance training3.
the integration of several genes added to environmental
factors, identification of talents and prescription of
training programs that maximize the athlete’s individual
potential based on genetic variable characteristic,
will be able to make a revolution in sports science.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  235
polymorphism gene ACE II which states higher ACE
activity has a correlation with the ability for sports that
require endurance, while DD polymorphisms and higher
ACE activity are related to sprint ability4. Variations
in the Angiotensin Converting Enzyme gene which
were interacted with resistance showed differences in
changes in endurance results, namely genotype II which
was better than the variation of DD genotype, with an
average increase of 11.57ml / kg / minute, while the DD
genotype decreases by an average of -8ml / kg / minute5.
There is an individual variability characterized
in response to endurance training, and some research
results suggest that this part of the variation is genetically
regulated6. In addition, the results show that genetic
variation. The ACE gene can affect blood pressure
response to exercise, although more research is needed
to confirm this finding7.
Research results of Myerson S, et al.8 His analysis
showed a linear tendency to increase the frequency of
allele I with running distance. The allele I ACE gene
is associated with improved endurance performance.
In addition, the insertion / deletion (I / D) type
polymorphism of the ACE gene also influences the
process of performance in the heart as the results of the
study. Aziza, L., et al.9 which states that the insertion
/ deletion (I / D) type polymorphism of the ACE gene
affects ACE concentration in the blood and affects
blood pressure. Blood pressure changes are affected by
changes in angiotensin II, aldosterone or active vaso
substances10.
This relatively new approach needs to be considered
by sports institutions in determining the right strategies
to foster the seeds of young athletes to improve sports
performance. So, research can be utilized by considering
the variation of the genotype II of the ACE gene in the
search for potential talent for Indonesian endurance
athletes. If the genetic information of prospective young
athletes obtained earlier, is expected to have a significant
influence on the effectiveness of sports training in
general.
Research Methods
This type of research is a retrospective cohort study
using a cross-sectional design or approach to describe
the correlation between factors and effects. Research
in October 2018 January 2019 in South Sulawesi. The
population in this study were SMP N 3 Sungguminasa
students with a age range of 13-14 years, amounting to
78 people to be the number of samples in this study but
those who completed until the end of the study were 59
samples. Data were analyzed using SPSS version 24.
The results are displayed in the form of narratives and
tables.
Measurement Procedure
The 12-minute run test designed by Cooper is a field
test that is relatively easy and inexpensive, because it
requires enough running track or can also use public
roads and time measuring devices (watch or stopwatch).
The cooper test (running 12 minute) is used to determine
endurance. The implementation of the 12-minute run
test requires a rather complicated procedure, in which
participants are required to stop when the 12-minute
time has been exceeded, then they need to give a sign
where the stop is, to immediately measure the distance
the result is taken. If there are many test participants,
it needs carefulness to measure it. The distance reached
is then confirmed in the physical fitness category table
to determine the fitness status of the sample. The test
categories are distinguished by sex and age group. In the
implementation the 12-minute run test requires a running
track even though it can be carried out on the streets.
Test implementation
1) Beginning attitude
2) Participants stand behind the start line
3) Movement:
a. In the “READY” command, the participants took
a stand, ready to run
b. On the “YES” command the participants ran as
much as possible until the time showed 12 minutes
c. After reaching 12 minutes the stopwatch is turned
off and the runners are told to stop at their respective
places
d. What is measured is how many meters can be
taken while running for 12 minutes. If it stops it is
considered a failure
e. Record of results
  The distance taken during a 12-minute run is
recorded in meters, as a result of the test takers.
236  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

Ways To Calculate Cooper's VO2max test Result And Discussion

(Distance (Meter) - 504,9) This study was conducted from October 2018 to
Vo2max (ml/kg/mnt) =
44,73 January 2019. Selection of respondents by age category
and sex at SMPN 3 Sungguminasa Gowa Regency by
Ways To Calculate Cooper’s VO2max test ages 13 to 14 years old. In this study involved 59 male
sex students. Characteristics of research subjects include
Results obtained from the above calculations. After
age, weight, and height.
that, classify according to the fitness category table
based on the Cooper test.

Table1.General characteristics of research subjects

No. Variable Means± SD Min- max P

1 Age 13,02 + 0,13 13 - 14 0,000

2 Weight 37,07 + 8,073 25 - 64

3 Height 144,51 + 6,654 129 - 159

Source: Primary Data, 2018

Table 1 above present information on average age of sample 13,02 years old with a range of 13 to 14 years old,
average weight of 37,07 kg with a range of a minimum weight of 25 kg and a maximum weight of 64 kg, the average
height of 144,51 cm with the range of 129 - 159 cm.

Table 2.Characteristics of the subject gene variation

Cardiovascular Endurance VO2max (ml/kg/min) P* P**

Gene Variation
Before After Change
Mean±SD Mean±SD Mean±SD

II 27,6±4,5 32,5±3,8 4,9±0,7 0,000 0,000

Non II 29,2±4,9 31,8±4,8 2,6±0,1 0,000

Total 28,5±4,8 32,1±4,4 3,6±1,8 0,000

Table 2 provides information on the gene variations angiotensin-converting enzyme found among the sample
population. There are two variations group of the ACE gene in which samples with a variation within the variations
in Non II genotype have a greater number than II genotype from 59 samples in this study.

Table 3. Cooper Test Results before the fartlek training program

NO. Gene Variation n %

1 II 25 42,4

2 Non II 34 57,6

Total 59 100
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  237
*Paired T test **Independent T test

Based on Table 3 above it can be seen that the effect of fartlek training for 3 months showed an increase in
cardiovascular endurance (VO2max) significantly p < 0.001 by (4.9 ± 0.7) ml / kg / min, from (27.6 ± 4.5 ) ml /
kg / min to (32.5 ± 3.8) ml / kg / min in the genotype II group. Whereas the Non II genotype showed a significant
increase in VO2max p <0.001 by (2.6 ± 0.1) ml / kg / min, from (29.2 ± 4.9) ml / kg / min to (31.8 ± 4.8) ml / kg /
min. Furthermore, the fitness test category can be seen in table 4.

Table 4. Fitness Test Category (VO2max) for Men (value in ml/kg/min)

2. Lower aver- . Above aver-

Age 1. Bad 3. Average 5.excellent 6. Superior
age age

13-19 < 35.0 35.0 - 39.9 40.5 - 45.1 45.2 - 50.9 51.0 - 55.9 > 55.9

20-29 < 33.0 33.0 - 39.0 39.9 - 43.3 43.9 - 48.7 49.3 - 52.5 > 52.6

30-39 < 31.5 31.5 - 38.4 38.5 - 41.8 42.4 - 47.4 48.0 - 51.4 > 51.6

The increase in VO2max due to the effect of fartlek training for 3 months on subjects in the II genotype and Non
II genotype groups showed an increase in cardiovascular endurance (VO2max) significantly p <0.001, however the
increase did not change the category of fitness level which was still in the “Bad” category, if adjusted to the table
above categories.

Statistical test results obtained significance value of 0.000 (P <0.005), so it was concluded that there was a
difference in Test cooper on the first measurement with the second measurement score.

To see a comparison of the increase in cardiovascular endurance (VO2max) in both groups of II genotypes
and Non II genotypes ACE genes after taking 3 months of fartlek training can be seen in Figure 1.

Figure 1. comparison of increase in cardiovascular endurance (VO2max)

238  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Conclusion
In this study, the distribution of 59 participants
who were students aged 13 to 14 years at SMP N 3
Sungguminasa, Gowa Regency obtained II genotype
57.6% and Non II genotype 42.6%.
Based on the results of the variation of the
angiotensin converting enzyme gene that was interacted
with changes in cardiovascular endurance showed male
subjects aged 13-14 years who took fartlek training for
3 months with the ACE gene, that group II genotypes
had a greater increase than the Non II genotype group
either through approach to distance when running for
12 minutes or the ability of VO2max. However, the
increase in cardiovascular endurance of subjects in both
genotypes II and Non II subjects did not change in the
fitness category.
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance: From the University
Hasanuddin committee.
REFERENCES
1. Ma F, et. al. The Association of Sport Performance
with ACE and ACTN3 Genetic Polymorphisms: A
Systematic Review and Meta-Analysis. 2013
2. Holdys J, et. Al. ACE I/D Gene Polymorphism in
Athletes of Various Sports Disciplines. Human
movement vol. 2011; 12 (3), 223– 231.
3. De Souza JC, et. al. Association of cardiovascular
response to an acute resistance training session with
the ACE gene polymorphism in sedentary women:
a randomized trial. BMC Cardiovascular Disorders
2013, 13:3.
4. Fernanda M and Slocombe R. The Use of
Angiotensin-I Converting Enzyme I/D Genetic
Polymorphism as a Biomarker of Athletic
Performance in Humans. Biosensors 2012, 2, 396-
404.
5. Arimbi et.al. Role of Genetic Polymorphisms
of Angiotensin - Converting Enzyme Insertion
Resistance to the Performance of Badminton Youth
Athlete. Journal of Applied Environmental and
Biological Sciences. J. Appl. Environ. Biol. Sci.,
2015.; 5(8)134-138,
6. Rankinen T, et. al,. Genetics and Blood Pressure
Response to Exercise, and Its Interactions With
Adiposity. 2002
7. Goessler KF, et.al., ACE polymorphisms and
the acute response of blood pressure to a walk in
medicated hypertensive patients. Journal of the
Renin-Angiotensin-Aldosterone System 2015, Vol.
16(4) 720 – 729.
8. Myerson S, et al. Human angiotensin I-converting
enzyme gene and endurance performance. the
American Physiological Society. 2017.
9. Aziza, L. Hipertensi: the silent killer. Jakarta: Ikatan
Dokter Indonesia. 2007.
10. Goncalves R et al.. Genetic polymorphisms
determining of the physical performance in elite
athletes. Rev Bras Med Esporte 2007; Vol. 13, No 3.
Comparison of Intraoperative Bleeding and Postoperative Pain
of Tonsillectomy Using Method of Radiofrequency
Dissection and Excision Dissection

Amsyar Akil1, Eka Savitri1, Heike Wilda Lokey1

1
Department of Ear, Nose, throat, head-neck surgery, Faculty of Medicine, Hasanuddin University, Makassar

Abstract
Background: The operation of tonsillectomy in addition to the technique of simple tonsillectomy can also
be done by the technique of bipolar radiofrequency that in research in 2007 in German universities found
postoperative pain and Intraoperative bleeding is significantly lower with the use of bipolar radiofrequency
compared with simple tonsillectomy. To date, there has been no research on the comparison of radiofrequency
techniques and excision dissection in Indonesia, especially in Makassar.

Purpose: Find the best tonsillectomy technique based on the volume of bleeding and postoperative pain.

Research materials and Methods: This research is done by the cross sectional of fourteen patients. The
tonsillectomy procedure done by using radiofrequency dissection of 6 patients and with excision dissection
of 8 patients, then measured the number of intraoperative bleeding and postoperative pain.

Results: This study showed that there was a decrease in the volume of intraoperative bleeding and a lighter
pain in radiofrequency dissection compared to the excision dissection that was evaluated during the 6-hour
post-operative. The 24-hour postoperative evaluation does not exhibit significant pain differences in both
dissection techniques.

Conclusion: The use of radiofrequency techniques in tonsillectomy procedure is better than the excision
dissection technique because it can reduce the volume of intraoperative bleeding as well as the lighter
postoperative pain complained .

Keywords: chronic tonsillitis, radiofrequency, excision dissection

Introduction in 2006, more than 530,000 operating procedures

Tonsilectomy is the most commonly performed
procedure in the history of surgery and one of the oldest
procedures that is still done since 1000 BAD and the
frequency decreases drastically since the emergence of
antibiotics. In 1985 in the United States, the incidence
of tonsilectomy was 350,000 to 400,000 per year and
Corresponding author:
Wilda Heike Lokey,
Department of Ears, Nose, Throat, Head – Neck
Surgery, Faculty of Medicine at Hasanuddin
University, Makassar, 90245 Indonesia.
Email: heikelokey86@gmail.com
of tonsilectomy in children were carried out. In the
last decade, the tonsilectomy is not only performed
for recurrent tonsillitis, but also for a wider range of
conditions including dietary difficulties, weight gain
failure, overbite, tounge thrust, halitosis, snoring,
and also Speech disorder. The American Academy of
Otolaryngology-Head and Neck Surgery has issued
an official recommendation which is an agreement of
experts on the indication of the action of Tonsilectomy.
1, 2, 3
Tonsilectomy can cause pain, bleeding and edema
in the injured part, sore throat, difficulty swallowing,
eating and drinking disorders, nausea and vomiting until
it falls on a state of dehydration. It can decrease patient
240  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
satisfaction against the operation of Tonsilectomy. calculation of blood density overall is 0, 94x10-9 in ml
The results of previous retrospective studies received and added to the volume of blood in the suction tube that
a secondary incidence of post-tonsillectomy reaching has been reduced by another fluid used to rinse.
10.1%, this is largely due to the release of mediators
Measurement of postoperative pain
during pain that resulting an increased treatment
duration. 4 Pain is calculated by using a visual analog scale
(VAS) with the results obtained are the value of VAS
The use of radiofrequency is widely applied
more than 0 mm and less than 10 mm expressed no
in the medical world. Previously researched use of
pain, mild pain is the value according to the VAS more
radiofrequency in fat-attachment surgery on the palate,5
than equal to 10 mm to 30 mm, moderate pain is values
on thoracic surgery and joint operations,6 and also used
according to VAS 31 mm to 70 mm. Severe pain is the
for chemotherapy,7 some researchers also connect the
value according to VAS 71 mm to 90 mm, very severe
use of radiofrequency in surgery Adenootonsillectomy in
pain is the value according to the VAS 91 mm to 100
patients with cochlear implant implants with results of no
mm. This pain measurement is measured during 6 hours
influence that worsens due to the use of radiofrequency.8
post-operative and 24-hour post-operative.
The study of Pfaar et al for treatment using bipolar
radiofrequency compared with simple tonsilectomy was
Results
conducted at German University in 2007 with results on Sample characteristics
radiofrequency groups, found that Postoperative pain,
difficulty swallowing and speaking, and intra-operative The gender of the sample is more male sex patients
blood loss is significantly lower, and the operating who are 8 people (57.14%) The most sample age is the
duration is significantly shorter (all p< 0.05).9 age of < 20 years, which is 6 people (42.86%), for the
category of tonsils size 6 people (42.86%) has a tonsils
Materials and Method size of T2-T2 and 8 persons (57.14%) has a T3-T3
tonsils size.
Patient Group Criteria
Table 1. Frequency Distribution
The study consisted of 14 patients suffering from
chronic tonsillitis undergoing tonsilectomy and divided
Sampel Characteristics N %
into two groups. The first group, 6 patients of chronic
tonsillitis, used a radiofrequency dissection and a second Gender
group of 8 patients with chronic tonsillitis, using excision Male 8 57,14
dissection technique. Patients conducted anamnesis, Female 6 42,86
physical examination, as well as fill in the approval
Age
of the operation procedure and conducted laboratory
examination and thorax x-ray for the preparation of <20 year 6 42,86

surgery. The postoperative patiens was given the same 20-35 year 5 35,72
analgesic paracetamol that is adjusted for the patient’s >35 year 3 21,42
weight. Patients with persistent adenoid hypertrophy,
Tonsil size
lower respiratory tract infection, tonsil tumor, anatomical
disorder of the head and neck area, suffering from T1-T1 0 0
systemic or metabolic diseases such as diabetes mellitus, T2-T2 6 42,86
hypertension, stroke, pulmonary tuberculosis, and blood T3-T3 8 57,14
disorders patients, are included in the exclusion criteria.
Comparison of the volume intraoperative bleeding
Intra-operative bleeding measurement
between an excision dissection and radiofrequency
The bleeding measured in this study is an intra- surgery
operative bleeding measured based on the volume of the
The mean value of the volume of bleeding in the
gauze weight mixed with blood reduced by the initial
excision dissection of the surgery is 75.625 ml with a
kassa weight of 0.4 grams, then calculated based on the
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  241
standard deviation of 49.3672, while the average volume surgery is 4.17 with a standard deviation of 1.94. Based
of bleeding in radiofrequency surgery is 7.612 with a on the statistical T-Test showed that there was no
standard deviation of 4.4058. According to statistical significant comparison of pain between the patients with
T-test shows that there is a comparison of the volume excision dissection and radiofrequency in the value of
of significant bleeding between the patient’s excision Ρvalue = 0.484 (ρ = < 0.05).
dissection and radiofrequency with a value of 𝜌 value =
Table 4. A comparison of 24-hour postoperative
0.000 (ρ = < 0.05) (table 2).
pain
Table 2. Volume of intraoperative bleeding
Deviation
Group Mean P-Value
Standard
Deviation
Group Mean P-Value
Standard Excision dissection 3,38 1,18
0,484
Excision Radiofrequency 4,17 1,94
75,625 ml 49,3672
dissection
0,000
Decreased postoperative pain of tonsilectomy using
7,612 ml 4,4058
Radiofrequency radiofrequency and excision dissection.

In table 5 shows a comparative reduction in

Comparison of Pain 6 hours post-operative
postoperative pain between excision dissection and
tonsillectomy patients surgical dissection of excision
radiofrequency dissection, the average pain decrease in
and radiofrequency.
excision dissection is 2.75 with a standard deviation of
Table 3 shows a comparison of 6-hour postoperative 1.03, while the average pain reduction in the dissection
pain between excision dissection and radiofrequency, radiofrequency is 1.33 with a standard deviation of
the average pain in excision dissection is 6.13 with 2.06. Based on statistical T-test shows that there is
a standard deviation of 0.64, while the average pain a comparison of significant pain reduction between
in radiofrequency dissection is 5.50 with standard the patients of excision dissection and dissection of
Deviation 2.07. Based on the statistical T-Test showed radiofrequency with a value of Ρvalue = 0.010 (ρ = <
that there was a significant pain ratio between excision 0.05).
dissection and radiofrequency dissection with a value of
Table 5. Comparison of postoperative pain
Ρvalue = 0.000 (ρ = < 0.05).
reduction
Table 3. 6-hour post-operative pain ratio
Deviation
Group Mean P-Value
Standard
Deviation
Group Mean P-Value
Standard Excision
2,75 1,03
dissection
0,010
Excision dissection 6,13 0,64
Radiofrequency 1,33 2,06
0,000
Radiofrequency 5,50 2,07
Discussion

Comparison of 24-hour postoperative pain on
tonsillectomy patients performed by excision dissection
and radiofrequency.
In table 4 shows a comparative pain of the 24-hour
postoperative tonsillectomy using excision dissection
and dissection of radiofrequency, the average pain in
an excision dissection is 3.38 with a standard deviation
of 1.18, while the average pain in the Radiofrequency
In this study, it can be seen that most male gender
samples were 8 people (57.14%), evidenced by the study
results on the profile of tonsillitis patients in Sangla
hospital, men are more often exposed to tonsillitis
because men have lower immune system than women,
where women Has an estrogen hormone that has
functions as a reinforcement of humoral and cellular
antibodies.10
242  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
The most sample age is < 20 years, which is 6 people
(42.86%), describing that children and adolescents have
low body resistance so it is easy to get infected.1 Described
also in some children followed by the enlargement of
the adenoid gland . So that there can be an obstruction
in respiratory system at bedtime is referred to as OSAS
(Obstructive Sleep Apnea Syndrome).10 Obstruction of
upper respiratory system that occurs at bedtime can cause
hypoxia (lack of oxygen), this condition can decrease
Immunological resistance that can lead to infection and
frequency of pain can interfere with children’s growth
and development, especially in childhood growth, so that
the tonsilectomy needs to be done. 1 ,10 Carneiro study
in Brazil also reported improvement in quality of life in
children who have had tonsillectomy. This occurs due
to reduced sleep disorders caused by tonsil hypertrophy.
The tonsilectomy also reduces the incidence of upper
respiratory tract infections and reduce antibiotic use. 10,15
In this study there were 6 people with a tonsils size
of T2-T2 (42.86%) and 8 people have a tonsils size of
T3-T3 (57.14%), which means the largest tonsils size
is found to be the size of T3 – T3. This result was in
accordance with the cross sectional study in 812 patients
who had tonsilectomy, there were 341 (42%) with a
tonsils size of T3, as much as 308 (38%) T4 size, as much
as 130 (16%) T2 size and as much as 33 (4%) ukuranT
1.10 Until now there is no data that can explain about
the differences between some of these studies. One of
the tonsils enlargement factors is the infection in tonsils.
The size of the tonsils is enlarged due to a parenchyma
hyperplasia or fibrinoid degeneration with a crypts
tonsils obstruction.13 Recurrent infections and blockages
of the tonsils resulting in increased stasis of debris or
antigen in the crypts, also occurring reduced integrity
of the crypts epithelium so as to facilitate bacteria into
tonsil parenchyma. 17
This study showed a comparison of the bleeding
volume between excision dissection and radiofrequency
surgery. The average volume of bleeding in an excision
dissection is 75.625 ml with a standard deviation of
49.3672, while the average volume of bleeding in
radiofrequency surgery is 7.612 with a standard deviation
of 4.4058. Based on statistical T-test shows that there is a
significant comparison of the bleeding volume between
the patient’s excision dissection and radiofrequency with
a value of Ρvalue = 0.000 (ρ = < 0.05). The Volume of
bleeding during surgery depends on the condition of the
patient and its own operatoric factor. Bleeding may be
more when there is excessive scarring or acute infections
such as acute tonsillitis or peritoncil abscesses. Bleeding
that occurs due to capillary or small veins, ripped
veins generally stop spontaneously or with tampons. If
it still fails, the external carotid artery ligation can be
performed. From reports of various libraries, the surgical
techniques known as “hot” techniques (Electrokauter,
radiofrequency, Koblasi, etc.) can reduce morbidity and
risk of postoperative bleeding. 11,12
Comparing the 6-hour postoperative pain between
excision dissection and radiofrequency, the average pain
in excision dissection is 6.13 with a standard deviation
of 0.64, while the average pain in radiofrequency
dissection is 5.50 with a standard deviation of 2.07.
According to statistical T-test shows that there is a
significant ratio of pain between the patient’s excision
dissection and radiofrequency with a value of Ρvalue =
0.000 (ρ = < 0.05) Whereas at 24 hours post operation,
comparison of pain between dissection radiofrequency
and excision dissection obtained the average pain in
excision dissection is 3.38 with a standard deviation
of 1.18, while the average pain in the dissection of
radiofrequency is 4.17 with a standard deviation of
1.94. Based on statistical test T-test shows that there is
no significant comparison of pain between the patient
excision and dissection of radiofrequency with a value of
Ρvalue = 0.484 (ρ = < 0.05). Of these two different pain
statements can be seen that each person’s pain threshold
differs. For severe post-operative pain tonsilectomy
depends on several factors, such as: patient’s health
condition, operator skills, tonsilectomy technique,
surgical complications and pain management. 14,15
Comparative postoperative pain reduction between
excision dissection and radiofrequency dissection
obtained an average decrease in pain in excision
dissection is 2.75 with a standard deviation of 1.03,
while the average reduction of pain in radiofrequency
dissection is 1.33 with standard deviation 2.06. Based on
T-test statistics, there is a significant comparison of the
pain reduction between the patient’s excision dissection
and the dissection of radiofrequency with a value of
Ρvalue = 0.010 (ρ = < 0.05). This suggests that in the
excision dissection there is a noticeable change of pain
reduction from the 6-hour post-operative to the 24-hour
postoperative. The possibility of the use of the dissection
dissection of many tissue damage occurs compared to
the use of radiofrequency. This is in accordance with the
literature says that pain caused by tissue damage as well
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  243
as increased release of the mediator that can generate
pain impulses subsequent pain and finally causing
muscle spasm (16,20)
The frequent postoperative pain of tonsilectomy is
difficult to prevent since the oropharyngeal region and
fossa of the peri-tonsiller are pain-sensitive areas. Both
are innervate by the trigeminal nerve (n. III) branches
and the glossofaringeus nerve (n. IX) which is highly
sensitive to pain stimulation and connected to the
somatic cortex in the cerebral. (18,19)
Post-operative pain management of tonsilectomy is a
special concern for both ENT-HN surgeon and anesthetic
doctors. High incidence of pain or postoperative anxiety
after tonsilectomy increase the risk of secondary
bleeding of postoperative tonsilectomy. 21
To prevent these postoperative pain, it is necessary
to know the mechanism for postoperative pain, the
negative impact of pain, the effort to reduce postoperative
pain and to choose rational analgetic to overcome the
postoperative pain of tonsilectomy. 4 12
In research from Victor et al. 2018 the use of
radiofrequency can reduce postoperative pain in
comparison with other methods of operation. 12
Conclusion
The use of radiofrequency techniques in tonsilectomy
is better than the excision dissection technique because it
can reduce the volume of bleeding occurring as well as
the pain complained more lighter.
Patients undergoing tonsilectomy using
radiofrequency should be considered for analgesic use
while those undergoing excision dissection should use
analgesic for postoperative pain treatment.
Conflicts of Interest: The authors have no conflicts
of interest to declare.
Acknowledgment: The authors very gratefully
thanks to all patients who were willing to be a respondent
in this study.
Ethical Clearance: Taken from Biomedical
Research Ethics Committee on Human Faculty of
Medicine Hasanuddin University of Makassar, Indonesia
(Register number :52 / UN4.6.4.5.31 / PP36/ 2019).
Source of Funding: All costs in this study are
funding by the searcher and do not get any sponsors.
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 Video Effect for the Prevention of Knowledge Increasing
Stunting in State High School 1 Children in Topoyo
Central Mamuju

Ismail Kamba1, Amran Razak2, Sirajuddin Saefuddin3, Sukri Palutturi4

1
Department of Community Nutrition Mulawarman University, 2Department of Health Policy Administration
Hasanuddin University, 3Department of Community Nutrition, University of Hasanuddin,
4
Administration Department of Health Policy, University of Hasanuddin

Abstract
The purpose of this study was to find the influence of video compared to videos plus and increase knowledge
for the prevention of stunting in the State high school students in Topoyo Central Mamuju. The research
was conducted on February 1, 2018 until February 1, 2019. The research in State High School Topoyo
Central Mamuju regency of West Sulawesi province. The population of this study were all male and female
students at State High School Topoyo totaling 710 people. While the control sample by using a ratio of 1
: 1 the number of control samples as much as 171 respondents. So the total sample of 171 + 171 = 342
respondents. Knowledge changes from pre-test to post test after intervention by watching videos and video
learning material plus 1000 HPK and prevention of stunting among children under five had an influence (the
measurement result p = 0.000); then tested in the control group did nothing to influence the control group
(p = 0.713 measurement results); and the use of video plus in learning there is no difference between the
video and the video plus (the measurement result p = 0.640). It is recommended that pWhat Knowledge
society about the golden period of life known as the first 1,000 days of life needs to be established early to
the students so that Central Mamuju Regency Health Office, needs to create a joint program with the school
so that the students’ understanding as the nation becomes more qualified generation.

Keywords: Knowledge, Stunting, HPK. Pregnant woman

Introduction One third of children stunted in the world is India, and

Based on data from the Global Nutrition Report,
Indonesia is onranking top 15 from behind1-3. So that
Indonesia is considered as the 15th worst in the world
after Madagascar stunting2-4. Sequence worst stunting
in the world the following are: Timor Leste amounted
to 57.7 percent, Madagascar amounted to 49.2 percent,
Guatemala amounted to 48.0 percent, Pakistan amounted
to 45.0 percent, Lao People’s Democratic amounted
to 43.8 percent, Republic Mozammbique amounted to
43.1 percent, Nigeria amounted to 43.0 percent, Malawi
amounting 42.4 percent, the Central African Republic
by 40.7 percent, amounting to 40.4 percent of Ethiopia,
Chad amounted to 38.7 percent, India by 38.7 percent,
amounting to 38.5 percent of Mali and Indonesia is rated
fifteen world with stands at 36.4 percent5.
children in rural areas worst affected6-8. The determinants
of stunting among children in rural indigenous and
odisha jharkhand, India, requires intervention and
treatment9,10. The World Health Organization (WHO)
reported that a total of 49.2% of children were
chronically malnourished in Madagascar11, Placing the
country suffered the highest prevalence of stunting in the
world. Short children as a result of chronic malnutrition,
causing adverse consequences of short-term and long-
term if not addressed at an early age6, Short-term risks
are susceptible to various infectious diseases such as
diarrhea and pneumonia due to a weakened immune
system12. Toddlers with nothing short category stood at
52.0 percent. This means that there are approximately
48.0 percent of children under five in West Sulawesi
who suffered stunting. It shows much higher than the
national average there is difference in numbers about
246  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

10.2 percent compared to 37.2 pesen national stunting13. Computer Managed Instruction (CMI). This research
“The Effects of Increasing Knowledge Against the video
Learning media is the messenger technology that
for the prevention of stunting among children under five
can be used for learning purposes. So learning media
in State High School Topoyo in Central Mamuju.” This
is a tool that can be used for learning.The types of
study used a quasi-experimental or quasi-experimental.
instructional media according to taxonomy Leshin,
et al (in Arsyad, 2002: 79-101) are as follows: (a) Materials and Method
human-based media is the medium used to transmit
The research design uses “Quasy-Experiment”,
and communicate the role or information; (B) print-
namely pre-test and post-test with control group design.
based media is most commonly known are textbooks,
The research was conducted at the date of February 1,
handbooks, workbooks or exercises, journals, magazines
2018 until the date of April 1, 2019. The research in State
and loose sheets; (D) visual-based media (image) in this
High School Topoyo Central Mamuju regency of West
case plays a very important in the learning process in
Sulawesi province. The population of this study were all
schools; (D) based audiovisual media combines the
male and female students at State High School Topoyo
use of sound require additional work to produce it; (E)
Central Mamuju Regency, which amounted to 710
a computer-based media choose different functions in
people. By using proportional random sampling. Total
the field of education and training, the computer acts
sample of 171 respondents totaled treatment and control
as a manager in the learning process, known as the
sample as many as 171 respondents.

Results and Discussion

Table 1. characteristics of Respondents

characteristics Intervention group Control group

n
% n %
Man 53 31.0 121 70.8

Gender woman 118 69.0 50 29.2

total 171 100 171 100

16 years 12 7.0 20 11.7

17 years 113 66.1 91 53.2

Age (Years)
18 years 46 26.9 60 35.1

total 171 100 171 100

Elementary School 89 52.0 101 59.1

Junior High School 36 21.1 19 11.1

Education Parents
Senior High School 34 19.9 50 29.2

PT 12 7.0 1 0.6

total 171 100 171 100

farmer 125 73.1 150 87.7

Government Employes 9 5.3 11 6.4

Parents’ job
entrepreneur 37 21.6 10 5.9

total 100 100 171 100

 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  247
The table above shows that respondents aged 17
years more than other respondents as many as 113
respondents (66.1%). More female respondents than
male respondents as many as 118 respondents (69.0%).
Parental education more respondents completed primary
school (primary school) other than as many as 89
respondents (52.0%). Respondents’ parents work more
farmers than other jobs as many as 125 respondents
(73.1%).
To determine the student’s absorption associated
with this video presentation, first pre-test on two groups.
The first group is called the group of cases and the second
group is called a control group. The case group targeting
State High School 1 Topoyo. The number of students as
many as 710 people. By using the formula Slovin obtained
a sample of 171 people. In applying these samples using
the technique of proportional sampling conducted in
18 classes. Each member of a representative sample
in each class taken at random, but still consider the
representation of the sexes. At the time of randomization
to enroll students who are elected to the sample in each
Research Result
Table 2. Student Knowledge Level Before and After Intervention In Central Mamuju Regency, West
Sulawesi, 2018
Measurement results
Group Knowledge Pre Test
n %
Well 131
intervention Video
Less 40
Total 171
Well 128
Control Less 43
Total 171
Table 2. showed that the intervention group Pre
Test measurement results with both categories of
131 (76.6%) and the category is less by 40 (23.4%);
while the measurement results of Post Test with both
categories of 149 (87.1%) and the category is less
by 22 (12.9%); while the value of p = 0.000, which
means that there is the effect of the intervention to the
class. Members of the sample is what will be the target
of experimentation as follows: (a) first, follow the pre-
test by answering a questionnaire distributed to each
class in accordance with a list of predetermined sample;
(B) second, watch video learning material 1000 HPK
on the first day and watch the instructional video with
1000 HPK material accompanied by explanations of
the teacher / instructor (in this experiment researchers
who act as teachers / instructors) on the second day.
Intervention / treatment on the first day done in four
classes with each set schedule so as not to interfere with
the learning process. Intervening on the second day was
also performed on four classes to organize their own
schedule; (C) third, following the post-test twice. Post
the first test done after the intervention / treatment on the
first day (watch the video) and the first post-test is also
done post-intervention / treatment on the second day
(watch video plus explanations of teachers / instructors).
Post second test carried out on the fifth day post-
intervention / treatment performed on each class based
on the target that the research samples.
Test Post p
n %
87.1
76.6 19
12.9
23.4 22 0,000
171
100 171
74.9 37 21.6
25.1 134 78.4 0.672
100 171 100
respondent in improving knowledge in the prevention of
stunting in State High School 1 Topoyo Central Mamuju
regency of West Sulawesi province. The control group
Pre Test measurement results with both categories of
128 (74.9%) and the category is less by 43 (25.1%);
while the measurement results of Post Test with both
categories by 37 (21.6%) and less category amounted
248  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
to 134 (78.4%); while the value of p = 0.672, which
means that in the control group there was an increase
of knowledge because no intervention on the students
of Vocational High School 1 Topoyo Central Mamuju
regency of West Sulawesi province.
Table 3. Knowledge Level Differences With Use of
Video and Video Plus in State High School 1 Topoyo
Central Mamuju Regency, West Sulawesi, 2018
Measurement
results
Group Knowledge p
n %
Well 84 49.1
Video
Less 87 50.9
Total 171 100.0
0.640
Well 128 74.9
Video Plus Less 43 25.1
Total 171 100.0
Table 3. shows that knowledge of respondents
viewing through video with good category were 84
respondents (49.1%) and less category total of 87
(50.9%); knowledge of respondents viewing through
video plus good category as many as 128 respondents
(74.9%) and less category as many as 43 respondents
(25.1%); whereas the results of the analysis of
differences in the level of knowledge after watching the
video and video plus is p = 0.640, which means there is
no difference in the level of knowledge after watching
the video and video plus or in other words.
Discussion
The first results, namely that there is a significant
effect of pre-test to post-test in the treatment group.
It is clear that knowledge is formed when there is the
stimulus provided by the sources of knowledge. Stimulus
will respond strongly in case of the sensory impression.
Received knowledge will be stored in memory until
the specified time will be released back into the raw
knowledge to someone. The stronger the person’s
knowledge of something, it is determined that a deep
impression received by the human brain. Impression is
also influenced by the experience of a person against
such knowledge. So that a person’s level of knowledge
to be better if it has a better experience on such
knowledge. The experience in question is never gain the
same knowledge repeatedly. For example, the provision
of material on nutrition only incidentally do it, it will
be different results if done systematically. In addition
to the influence of the frequency of administration of
knowledge, it is also influenced by the intensity or the
power of knowledge. For example, knowledge of which
is given sporadically, would be different if knowledge
is only given spontaneously. By him, knowledge is
not only determined at the time of its formation, but
how to maintain the required knowledge, including
elevation. also influenced by the intensity or the power
of knowledge. For example, knowledge of which is
given sporadically, would be different if knowledge
is only given spontaneously. By him, knowledge is
not only determined at the time of its formation, but
how to maintain the required knowledge, including
elevation. also influenced by the intensity or the power
of knowledge. For example, knowledge of which is
given sporadically, would be different if knowledge is
only given spontaneously. By him, knowledge is not
only determined at the time of its formation, but how
to maintain the required knowledge, including elevation.
The second result, that there was no significant
effect of pre-test to post test in the control group, it
is clear that knowledge of a person does not have
restrictions on the sources from which it came. When
the students of Vocational High School 1 Topoyo, not
given the intervention or treatment that does not mean
knowledge of the 1000 HPK is not owned, because the
sources of knowledge can come from anywhere. Sources
of knowledge at this time are manifold, ranging from the
conventional sources of knowledge such as interpersonal
communication, also with the involvement of the simplest
medium to modern. Ranging from personal media to
social media, such as media phones, mobile messaging
to facebook, whatsapp (wa), and others. It’s just that
being able to explore knowledge specifically requires a
focus on specific learning. In addition, Vocational High
School students do not really discuss matters relating to
certain subjects (such as biology and the like).
The third result, it is known that there is no difference
between the two methods use video and video plus, it is
explained that the video plus does not mean there has
a better ability for a process of confirmation given by
the teacher or instructor. Only the confirmation process
does not occur because students are more passive after
watching the video. Supposedly after watching a process
of confirmation or interactive porses. This confirmation
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  249
process in accordance with the theory of communication
that requires a transformation in communication
feedback or feedback so that doubts on the received
knowledge, could confirmed back to the communicator
or on a media source. In the communication process
tersebesar doubt an obstacle to acceptance or adoption
of a message in the form of knowledge.
The significant difference in the forms of such
treatment. New knowledge is essentially formed from the
existing knowledge is then used in a particular context.
The process of formation of knowledge through shared
experiences while interacting directly. For example one
can know the knowledge about child care because he had
been taking care of children. Formation of knowledge by
transforming knowledge into explicit form. For example,
concepts, drawings and written documents. An effective
way to externalization is through dialogue. Formation
of knowledge to manage existing knowledge from both
inside and outside in the form of more complex and
systematic.
Conclusions
Knowledge changes from pre-test to post test after
intervention by watching videos and video learning
material plus 1000 HPK and prevention of stunting
among children under five had an influence (the
measurement result p = 0.000);
Then tested in the control group did nothing to
influence the control group (p = 0.713 measurement
results);
Plus the use of video in learning there is no difference
between the video and the video plus (the measurement
result p = 0.640).
Ethical Clearance- Taken from Faculty of Public
Health committee
Source of Funding- Self
Conflict of Interest – Nil
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 Religius Character in Improving Primary Health Services
Quality in South Sulawesi

Muhammad Tahir1, Ridwan Amiruddin2, Sukri Palutturi3, Fridawaty Rivai4, Lalu Muhammad Saleh5.
1) Doctoral Students of Public Health at Hasanuddin University and Stikes Muhammadiyah Sidrap, 2)
Department of Epidemiology Faculty of Public Health Hasanuddin University, 3) Department of Health Policy
and Administrative Faculty of Public Health Hasanuddin University 4) Department of Hospital Management and
Administration Faculty of Public Health Hasanuddin University 5) Department of Occupational Health and Safety.

Abstract
Measurement of service quality with accreditation method is one of the tools to ensure the quality of service
for community health centre, but from several models of quality improvement it is considered to have
weaknesses because no one pays attention to religion, so that the model is not properly used in Indonesia.
The aims of this study was to analyze the effect of religious character on the continuous improvement of
the quality of primary health services in South Sulawesi. This research is a qualitative study with a case
study approach. The data collection technique was carried out by Focus Group Discussion (FGD). The
informants in this study were 10 people consisting of surveyors, religious leaders, community health centre
heads, non-governmental organizations, lecturer and academics. Data analysis was done by content analysis
method. The results of the study state that there were 10 religious characters that should be owned by health
center officers, namely discipline, fair, honest, clean, trustworthy, good at communicating, patient, friendly,
committed and wise. It is recommended to community health centre officers to apply this religious character
so that service quality can be improved and sustainable.

Keywords: service quality, religious character, community health centre officers.

Introduction The Model for Understanding Success in Quality

The World Health Organization1 expects all people
in the world to get quality health services. For this
reason, Indonesia has made efforts to provide quality and
affordable health services. One of the quality recognition
is the result of accreditation. Accreditation is a form of
evaluation of the quality and feasibility of an institution
carried out by an organization or accreditation body.
Improving service quality as a concept according to
Baldrige has dimensions, including: leadership, strategic
planning, focus on patients served, measurement,
analysis and knowledge of management, focus on
human resources, management programs, and results
obtained.2,3
(MUSIQ) which was developed to improve the quality
of health services has also yet conducted a study of
consumer focus, implementation focus, access, patient
safety, religious character, and innovation. Though this
aspect is also very important influence on improving
service quality.
Even though building religious character on each
employee will certainly have a positive impact on the
ability to act in providing services to patients. This
has been proven through research that the quality of
Islamic services has a positive and significant impact on
customer satisfaction. In line with the CARTER Theory
which was suggested by Othman and Owen (2001) that
there is a strong relationship between compliance with
Islamic law and consumer satisfaction. 4-6

Research conducted at 25 German hospitals to

assess the relationship between accreditation status and
patient satisfaction involving 3,000 patients using the
252  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Picker questionnaire to assess the seven dimensions of
patient satisfaction, found that there was no significant
relationship between patient satisfaction and hospital
accreditation status. 7 The
Number of community health centre in Indonesia is
9,913 and there are 7,508 accredited community health
centre. Based on data from 13 provinces in Indonesia
for 3 years (2016-2018) that 45 community health
centers had been evaluated for 3 days per health center
using accreditation instruments that had been prepared
and determined by the Indonesian Ministry of Health
consisting of 9 chapters, 42 standards, 168 criteria
and 776 rating elements. The results showed that there
were 2.2% not accredited and 97.8% accredited. Basic
accreditation status was 45.5%, middle accreditation
status was 40.9%, primary accreditation status was
13.6% and there was no community health centre with
plenary accreditation. This showed that the quality of
health services in health centers is still very low8.
Unsustainable quality improvement will have an
impact on low patient satisfaction, lack of trust in health
services, increased morbidity and mortality, increased
maternal mortality, infant mortality, under-five mortality,
decreased life expectancy, and low degree of public
health. From these various problems, it is expected that
there will be a concept for developing a model for the
continuous improvement of primary health services that
can be applied in health centers.
Materials and Method
This research is a qualitative study with a case study
approach. The data collection technique carried out was
by Focus Group Discussion (FGD). This research was
conducted at the Grand Puri Perintis Hotel on April 9,
2019. Informants in this study were 10 people consisting
of surveyors, religious leaders, community health
centre heads, non-governmental organizations (NGOs),
lecturer and academics. Data analysis was done by
content analysis method.
Results
Informants involved in this study were ten
informants consisting of two surveyors, 1 religious
leader, 1 accreditation assistant, 1 head of community
health centre, 2 people from NGOs, 1 lecturer and 2
academics. Specifically, characters based on religious
values ​​refer to the basic values ​​contained in religion
(Islam). From the results of the Focus Group Discussion
(FGD), all informants agreed that religious character is
important to be applied in the community health centre.
The informant’s answer about the religious character that
must be possessed by a community health centre officer
has revealed several characters. The informant who
stated that discipline was one of the religious characters
that must be attached to the officers of the center, the
quotations from the FGD were as follows:
“......... Well, I think between religious characters
and disciplines characters is very similar, so how to
develop a firm discipline based on the basics of religion
so it will grows the sense of awareness... “
(Surveyor, 63 years)
“Well alluding to religious character, if we were in
Makassar the religious character was actually what you
mentioned, almost the same meaning as the disciplinary
character that was said earlier …………… .. ”
(Accreditation companion, 42 years)
In addition, some informants stated that taking fair
action during the service process is also a reflection of
religious character, as the following quote:
“ …… ... So on, then each officer must provide safe
services and also do not discriminate ethnic groups,
religions, so health services are universal, so they
cannot discriminate. Therefore an officer must be fair,
regardless of the patient’s background “
(NGO, 40 years old)
“ so on the fifth, everything is for the patient, so
whatever happens to the patient, moreover service
must provide justice, all layers of society come to the
community health centre ”
(Surveyor, 63 years old)
There are also informants who specifically argue
that religious character refers to the basic values​​
contained in the Islamic religion, namely the value that
comes from the example of the Prophet in behaving
daily, namely shiddiq (honest), amanah (trusted), tabligh
(communicative) and fathanah (intelligent/wise), and all
behavior always remembers Allah SWT. The following
is the quote for the interview:
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  253
“... a quality is influenced by the leader, well, this
leader, as mentioned by Mr. Adam, that the character
is attached to the actor, but to the leader and besides
the actor in its attached to the structure, this must be
based on the prophetic character, the trust, siddiq and
tabliq this, this is what should be a legalization when
someone wants to be a leader, for this researcher I will
give advice when the leader wants to be appointed as
decision maker he should have this trait “
(Surveyor, 41 years)
“ ... Well this maybe, my advice also might be that
religious characters could be brought to the nature of
the prophet, trusteeship, siddiq and so forth “
(Lecturer, 52 years)
“ ... So that with his ears he heard there was Allah,
with his eyes there there was Allah, with his hands Allah”
(Religious figure, 55 years)
Results of the FGD with several informants, there
are those who say that maintaining cleanliness is also a
religius because cleanliness is a part of faith, moreover
hygiene has also been regulated in the accreditation of
community health centre. The following are the results
of the FGD with the informant:
“So hand washing is part of what is called, well-
dressed, and it is regulated in the accreditation of the
community health center that binding in a commitment,
there is a culture of shame, also a part of faith, it is
associated with religious it is already approached “
(surveyor, 41 years)
Patience in working especially in service is also
included as one of the religious characters that should be
owned by the officer. As quoted by the following FGD
interview:
“after I thought about it, it seems like mmm…
community health centre had two key words, namely
patience and trust”
(Surveyor, 63 years old)
“This religious character is also inseparable from
patience, this must be translated as patience, can the
workload be handled by complaining, meaning not
complaining, not giving up, high fighting spirit, now it
must be measurable “
(Academician, 52 years old)
Other religious characters that should be owned by
service officers in the community health centre discussed
in the FGD are commitment and friendly attitude.
“The religious character of the officer must have a
high commitment, there is a strong sense of empathy, that
is the religious character that if there are sick people to
be well served, this religious character must also be an
example”
(Academician, 47 years old)
“... then the behavior approach, that is what we
might know at this community health centre smile,
greetings and regards”
(Lecturer, 52 years)
Discussion
Understanding character according to Maxwell is
how far better than just words. According to Shihab,
character is a set of experiences about education and
history which then encourage abilities that exist within
a person to be able to be a measuring tool or a human
side to make it happen. The character of a person can
be concluded that something found in individuals who
personalities that are different from others in the form of
attitudes, thoughts, and actions.
The results of the discussion of informants
about religious characters agreed upon the indicators
consisting of discipline, presenting God in his activities,
fairness, patience, friendliness, commitment, tabligh
(transparent/ communicative), fathanah (intelligent),
amanah, and shiddiq (honest).
Discipline is the operative function of human
resource management that is very important, because
the better the level of discipline of the community health
centre officers, the higher the work performance that
can be achieved. Without good discipline it is difficult
for the head of the community health centre to realize
quality and optimal work results. The issue of work
discipline continues to be sought for its upgrading and
improvement. This is based on the assumption that with
a high culture of discipline, it will improve the quality of
work. Disruption of service to patients or the community
will be a complaint so that people are not satisfied with
254  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

the services they receive, the dissatisfaction of patients
or the community means the inability of community
health centers to improve their quality continuously.
Presenting God in its activities means that every
action of a health worker in providing health services to
the community believes that God is witnessed everything
done so that it can give service sincerely, work on the
basis of worship, without any pressure / force in giving
tasks. With the principle of presenting God in their
activities, health workers at the health center will be able
to provide health services as much as possible so that
they can improve the quality of ongoing services.
According to informants, fair is a part of religious
character, being fair in providing health services is an
act that does not discriminate patients/society, does not
discriminate men and women, does not discriminate
services based on religion, ethnicity, race, and socio-
economic status. Health services in the community health
center do not apply to the queue system but apply to a
triage system (prioritizing patients who are more serious
and emergency) and priority patient systems (disability
patients, the elderly, pregnant women and infants). The
principle of fairness in providing health services will
certainly be able to provide continuous upgrading and
quality improvement.
Informants agreed that patience and friendliness is
a must for health workers in providing health services
to the community, although taking care patients/
communities who are emotionally unstable and do not
understand service procedures need extra patient in
dealing with it. Facing these conditions, health workers
should not be carried away with emotion on the behavior
of patients / communities, instead they must remain calm
and friendly to give explanation to patients / society.
Commitment to improve the quality of community
health centre is an important factor in the delivery of
services. Commitments in improving the quality of
health services for community health centre must start
from the head of the community health centre to all
staff, because the commitment is actually an agreement
to improve the quality of services to the community.
Weak commitment in service will have an impact on
not providing maximum service to the community. Not
optimal community health centre services will be a
public complaint.
Rasulullah’s exemplary values ​​according to the
informant must become the attitude and behavior of
the community health centre staff, such as shiddiq
(honest), trust (trustworthy), tabligh (communicative /
transparent), fathanah (intelligent) must be the value of
health services, community health centre officers must be
honest in providing health services, being able to convey
the health condition of the community properly, there
are no corruption, collusion and nepotism officers in
providing services, being honest with fellow community
health centre officers, including not using community
health centre facilities for personal gain.
Community health center officers must be
trustworthy to do the work according to their main
tasks, authority and responsibilities, carry out activities
in accordance with the schedule, targets and places that
have been determined, be responsible for all actions /
services provided to the community, and if there is
an error, dare to bear the risks. The nature of tabligh
(transparent/ communicative) is very important for a
community health centre officer to provide services
because they must be able to convey information
accurately and clearly to the community and be able to
motivate the community in achieving performance.
The nature of Fathanah (smart) is one of the
characteristics that can be applied by community health
centre officers in providing services such as being
able to understand the needs and expectations of the
community towards community health centre services,
acting very carefully and in accordance with policies,
guidelines / guidelines, terms of reference for activities
and procedures, and being able to carry out analysis on
the issue of continuous quality improvement8-10.
Conclusions and Recommendations
Based on the results of the FGD conducted with
ten informants, all informants agreed that important
religious character was applied in the community health
centre. The religious characters that should be owned
by officers in the community health centre according
to the informants are quite varied. The informant
stated that religious character cannot be separated
from the character of discipline, being honest is one
of the religious characters that should be possessed by
community health centre officers.
Patience in carrying out the workload according
to the informant is very important to be included as
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  255
a religious character. Apart from being patient, high
commitment, clean and friendly nature also become
a character that can not be separated from religion.
According to the informant, being friendly in services at
the community health centre is considered an important
point in efforts to improve the quality of the community
health centre.
Informants agreed that religious characters cannot
be separated from values ​​derived from the example of
the Prophet in behaving in daily life, namely shiddiq
(honest), trust (trustworthy), tabligh (communicative)
and fathanah (intelligent / wise).
It is recommended that each officer in the community
health centre be able to apply religious character in
providing services, so that the quality of service can be
sustainable in accordance with what is expected, not
limited to just accreditation assessment. In addition, the
results of this study suggest that these characters are
not only shown when in a service building, but can be
applied in daily life including outside service time.
Ethical Clearance- Taken from Faculty of Public
Health committee
Source of Funding- Self
Conflict of Interest – Nil
References
1. WHO. Quality of care: a process for making
strategic choices in health systems. Geneva: World
Health Organization, 2006
2. McLaughlin, C., Johnson, J., & Sollecito, W..
Implementing continuous quality improvement in
health care. Sudbury: Jones & Bartlett publishers.
2011.
3. Brown, MG. Winning Quality Baldrige Award: How
to Interpret the Baldrige cariteria form performance
excellence. New York: CRC press. 2013
4. Geertz, C. The Interpretation of cultures (Vol. 5019).
New York: Basic books. 1973.
5. Putra, RP, & Herianingrum, S.. Effect of Islamic
Service Quality on Bank BRI Syariah Surabaya
Customer Satisfaction and Loyalty. Theory and
applied sharia economic journal, 2015; 1 (9).
6. Othman, A., Owen, L.. Adopting and measuring
customer service quality (SQ) in Islamic banks: a
case study in Kuwait finance house. International
Journal of Islamic Financial Services. 2011; 3 (1),
1-26.
7. Sack, C., Latkes, P., Ganther, W., Erbel, R., Juckel,
K.-H., & Holtmann, GJ. Challenging the Holy Grail
of Hospital Accreditation; a cross sectional study of
patient satisfaction in the field of cardiology. Journal
of BMC Health Service Research, 2010; 10 (1), 120.
8. Heuer, AJ. Hospital accreditation and patient
satisfaction: testing the relations. J Health Qual,
2004; 26 (1), 46-51.
9. Posmaningsih, D.A., Aryasih, G.A.M., Hadi, M.C.,
Marwati, N.M., Mallongi, A. The influence of media
booklet in behavior change of waste management
in elementary school students, South Denpasar,
Bali. Indian Journal of Public Health Research &
Development. 2018
10. Hadi, M.C., Marwati, N.M., Aryasih, I.G.A.M.,
Sujaya, I.N., Mallongi, A . The use of owner house
ID card to increase effectiveness of monitoring larva
visit by jumantik. Indian Journal of Public Health
Research and Development. 2018.  
Hygiene and Sanitation Management of Drinking Water Refill
Depots for Feasibility Consumption in Kendari City, Indonesia

Ratna Umi Nurlila1, Jumarddin La Fua2, Yuli Munandar K1, Muh. Sainal A1,
Laode Sahlan1, Anwar Mallongi3
1
Senior Lecturer of STIKES Mandala Waluya Kendari, 2 Senior Lecturer Institute of Agama Islam Negeri
Kendari, 3Assoc Prof. Department of Environmental Health, Faculty of Public Health,
Hasanuddin University, Makassar

Abstract
Aim: Safe and healthy drinking water is drinking water by which has well controlled and maintained hygiene
sanitary. This study aims at investigating the sanitation and hygiene of drinking water found in several refill
drinking water depots in Kendari City, Southeast Sulawesi Province, Indonesia.

Method: Selecting the sample was done randomly with a total 32 samples of drinking water refill depots
scattered in Kendari City. Data collection uses questionnaires as stated in the Regulation in the Republic of
Indonesia’s Minister of Health Regulation No. 492 / Menkes / Per / IV / 2010 concerning on drinking water
quality requirements which includes aspects of premises, equipment and handlers.

Results: The results of the research is hygiene and sanitation conditions in 32 refill drinking water depots
scattered in Kendari City showed 66.33% met the eligibility requirements and 33.26 were not feasible.
For the parameters of the equipment used in the refill drinking water depots, it is as much as 92.75%
roomates meet the eligibility requirements and 5.40% are not feasible, while for the hygiene and sanitatation
conditions of the handlers, as much as 52.68% are eligible and 47.37 % are not feasible.

Conclusion: Hygiene and sanitation requirements in the management of drinking water are very important
to prevent the incidence of spreading diseases caused by water and sanitation. Hygiene and sanitation
of drinking water refill depots will be able to control infectious diseases and can provide protection to
consumers so as to ensure human safety and health.

Keywords: Hygiene, Sanitation, Management of Drinking Water, and Refill Depots

Introduction contaminated, it would be the media spread of infectious

Safe drinking water is a very basic need for human
life.1,2Accessibility and availability of safe drinking
water plays an important role in economic development
and human health.3 Drinking water contamination is
a serious threat that will cause problems for human
life.4 Pollution of drinking water is mainly caused by
microoganism, organic matter and disinfectants that
affect the quality of drinking water and cause disruption
to human health.5 Therefore, the availability of safe and
health drinking water is a challenge faced by the world
today.
Refill drinking water quality continues to be
a concern as it relates to public health and when it is
diseases that can cause death.6 Sanitary and hygienic
drinking water is one of the prerequisites for improving
the quality of drinking water produced and can provide
health security and safety to consume.1 However, the
hygiene and sanitation of drinking water is still a problem
that is overlooked. This condition contributes to the high
diarrheal diseases listed in Kendari.The survey results
in one of the health centers in Kendari city in 2013 that
there were 2.915 cases of diarrhea and in 2015, it is
recorded 529 cases of the diarrhea disease.7 Therefore,
it is required periodic monitoring and improvement of
drinking water quality management in order to improve
public health. In Kendari city, drinking water distributed
by several companies of refill drinking water depot and
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  257
most of them apply hygiene and standard sanitation of
drinking water for water safety before distributing to
consumers.
Several previous studies have shown that the
hygiene and sanitation of drinking water refill depot
that is not managed properly can become a medium for
spreading and infectious diseases, as reported in Afrika8,
Mali9, Bangladesh10, and some European countries
11
. If the hygiene and sanitation of drinking water
refill depot knowable, then counseling about drinking
water sanitation and hygiene management can be
approved to maintain the quality of safe drinking water
produced.1Although several studies on hygiene and
sanitation have been conducted in various countries, such
as USA12, UEA1, Bangladesh12, India13, Malaysia14, and
some areas in Indonesia15, hygiene sanitary evaluation
of drinking water in Kendari, Indonesia still has not
been widely publicized. The purpose of this study was
to investigate hygiene and sanitation of drinking water
refill depot in producing potable drinking water.
Table 1. Hygiene sanitation of refill drinking water place in Kendari
Materials and Method
This study is a descriptive study conducted to provide
an overview of sanitary and hygienic refill drinking
water depot with parameters of premises, equipment,
and healthy life of refill drinking water depot handler.
This research was conducted at several places in Kendari
from March to August 2018. Year Determination of the
number of samples is done randomly by the number
of 32 samples of drinking water refill depots scattered
in Kendari. The data collection used questionnaire as
contained in the Minister of Health 492 / Menkes / Per
/ IV / 2010 concerning on the quality requirements of
drinking water in Indonesia.
Results
1. Place Water Sanitation Hygiene Refill
Most of refill drinking water depot in Kendari,
owned by an individual business with the service’s reach
limited to the area around the place of business. Results
observation sanitary hygienic refill drinking water are
presented in the following table.

Qualify Not eligible

No Variables
F % F %
1 Location is free from pollution and disease transmission 30 93,75 2 6,25

2 The building is strong, safe, easy to clean and easy to maintain 31 96,88 1 3,13

The floor is water resistant, the surface is flat, smooth, not slippery,
3 does not crack, does not absorb dust, and is easy to clean, and has a 30 93,75 2 6,25
gentle slope
The walls are waterproof, the surface is flat, smooth, not slippery, does
4 not crack, does not absorb dust, and is easy to clean, and has bright 29 90,63 3 9,38
colors
Roofs and ceilings must be strong, rat repellent, easy to clean, do not
5 30 93,75 2 6,25
absorb dust, flat surfaces, and light colors, and have enough height

Spatial planning consists of processing, storage, distribution /

6 24 75,00 8 25,00
provision space, and visitor / consumer waiting rooms

7 Lighting is bright enough to work, not dazzling and evenly distributed 31 96,88 1 3,13

8 Ventilation guarantees good air circulation 28 87,50 4 12,50

9 Air humidity can provide comfort in doing work / activity 28 87,50 4 12,50
10 It has an access to the bathroom and toilet 7 21,88 25 78,13
11 There is a sewerage sewer that has smooth and closed flow 14 43,75 18 56,25
12 There is a closed trash bin 4 12,50 28 87,50
13 There is a hand washing area with running water and soap 4 12,50 28 87,50
14 Free from rats, flies and cockroaches 9 28,13 23 71,88
  Average 66,74 33,26
258  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
It is found that 2 depots of refill drinking waters’ Nevertheless, only some refill drinking water depots
roofs and ceilings are inadequate since the constructions meet the requirements, for instance, building sanitation
are not strong, do not closed perfectly, the surfaces are and hygiene conditions include access to bathrooms and
uneven, dark in color, difficult to clean and allow rat to latrines, sewerage drains, closed trash cans, hand washing
enter the processing room. However, all refill drinking places equipped with running water, and buildings that
water depots in Kendari already have several air vents. are free of rats, flies and cockroa ches (Table 1).

2. Drinking Water Sanitation Hygiene Tool Refill

Tabel 2. Hygiene and sanitation of refill drinking water in Kendari city

Qualify Not Eligible

No Variable
F % F %

1 The equipment used is made from foodstuffs 31 96,88 1 3,13

2 Microfilter and disinfection equipment are still in their use / not expired 32 100,00 0,00

3 Standard water reservoirs must be covered and protected 32 100,00 0,00

4 Gallon container before cleaning is done 31 96,88 1 3,13

Cleansing Containers / gallons that have been filled with drinking water
5 must be given directly to consumers and should not be stored in DAM 26 81,25 6 18,75
for more than 1x24 hours

Performing a reverse washing system (back washing) periodically

6 32 100,00 0,00
replaces the macro filter tube.

7 There are more than one micro filter (µ) with tiered size 32 100,00 0,00

There is sterilization equipment, in the form of ultra violet and or

8 ozonation and or other disinfection equipment that functions and is 32 100,00 0,00
used correctly

9 There is a bottle washing and flushing facility (gallon) 29 90,63 3 9,38

10 There is a bottle filling facility (gallon) in a closed room 26 81,25 6 18,75

11 New clean bottle caps are available 30 93,75 2 6,25

  Average   94,60   5,40

3. Hygiene Officer Water Refill hygienic cleanliness handlers include uniforms, using
of headgear, the use of aprons, and the use of muzzles
Results of this study found that the involvement
to clean nails. It is also seen handlers behaviors such
of workers who assist the refill drinking water depot
as hand washing, spitting, talking, eating and drinking,
on average employ at least 2-3 people with an area
smoking, and scratching during work. The hygiene and
of ​​buildings used as places of business ranging from
sanitation observation result in table 3.
5 m2 to 70 m2. Obsevervation conducted on sanitary
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  259

Table 3. The handler/ operator condition of refill drinking water depot in Kendari

Qualify Not Eligible

No Variable
F % F %

1 Healthy and free from infectious diseases 32 100,00 0,00

2 Not being a carrier of germs 32 100,00 0,00

Hygiene and sanitation behavior every time serving

3 28 87,50 4 12,50
consumers

Always wash hands with soap and water flowing every time
4 24 75,00 8 25,00
in serving consumers

5 Using clean and neat work clothes 2 6,25 30 93,75

6 Conduct regular health checks at least 1 (one) time a year 0,00 32 100,00

The operator / person in charge / owner has a certificate

7 for taking hygiene sanitation courses at the drinking water 0,00 32 100,00
depot

  Average   52,68   47,32

Health checks are necessary to prevent contamination
of the drinking water produced when employees have a
disease that can be transmitted through the air. Therefore,
it needs necessary guidance through relevant agencies
to increase awareness and knowledge officer of depot
refill drinking water to improve the safety of drinking
water produced, because even though the condition of
sanitary hygienic premises and equipment are eligible
not necessarily produce drinking water that is safe to eat
if the hygiene and sanitation handlers / operator do not
meet the standards of drinking water management17. This
is because the handlers / operators are in direct contact
with drinking water produced and could potentially be a
source of contaminants.
Discussion
Assessment of the quality of drinking water is
a great way to ensure the risk of spreading disease
through air.18 This research conducted in Kendari city
which aims to measure hygiene sanitation of drinking
water produced with a focus on the observation of
sanitary premises, equipment and operators. This study
is an exploratory study that contributes to a portrait of
hygiene and sanitation program undertaken management
of refill drinking water depot in ensuring the quality of
drinking water production. This is due to the spread
of diseases, pathogens and other infectious diseases is
largely determined by improving hygiene in sanitation
and hygiene measures undertaken by the management of
refill drinking water depot.19
The findings of this study indicate that the sanitation
hygiene of 32 refill drinking water depots in Kendari
seems not ideal. This is because only around 66.33%
meets the eligibility requirements, while 33.26% has not
fulfilled the eligibility requirements. Management of a
good place will reduce the risk of transmission of the
disease, letting the place that is not hygienic will be a
medium for disease spreading so that the water produced
becomes unsafe for consumption and increases the risk
of infection that can cause death. For hygiene sanitation
of the place, the following components contribute to
sanitation hygiene which are not massive, such as: (1)
unavailability of bathroom and latrine access (2) no
closed trash can, (3) no hand washing area equipped
with water flow and soap, and (4) not free from rats,
cockroaches and flies.
The safety of drinking water equipment is
very important in supporting human health, since if the
equipment used does not meet water health standards so
260  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
that it can reduce health benefits for those who consume
it.20 Based on the data described above, it appears
that supervision of drinking water sanitation hygiene
towards refill drinking water depots must be carried
out continuously and scheduled in order to reduce the
amount of pollutants and can provide health benefits for
the drinking water production by carrying out continuous
and scheduled monitoring of refill drinking water depots
which include places, tools and handlers / operators. It
will reduce the rate of pathogen / pollutant release into
drinking water, as well as minimize the spread of disease
among consumers and improve the quality of drinking
water so it is safe for consumption.21-24
Ethical Clearance- Taken from institution of
Mandala Waluya Ethical committee
Source of Funding- Self
Conflict of Interest – None
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Hussain, A.. Microbiological quality of drinking
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2. Baquero, F., Martínez, J. L., & Cantón, R..
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Jensen, P. K. M. Drinking cholera: salinity levels
and palatability of drinking water in coastal B
angladesh. Tropical Medicine & International
Health, 2015; 20(4), 455-461.
5. Liguori, G., Cavallotti, I., Arnese, A., Amiranda,
C., Anastasi, D., & Angelillo, I. F.. Microbiological
quality of drinking water from dispensers in Italy.
BMC microbiology, 2010; 10(1), 19.
6. Marshall, J. K., Thabane, M., Garg, A. X., Clark, W.
F., Salvadori, M., Collins, S. M., & Walkerton Health
Study Investigators. Incidence and epidemiology of
irritable bowel syndrome after a large waterborne
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2006; 131(2), 445-450.
7. Askrening, A., & Yunus, R.. Analisis Bakteri
Coliform Pada Air Minum Isi Ulang Di Wilayah
Poasia Kota Kendari. Jurnal Teknologi Kesehatan
(Journal of Health Technology), 2017; 13(2), 71-76.
8. Wolf, J., Hunter, P. R., Freeman, M. C., Cumming, O.,
Clasen, T., Bartram, J., ... & Prüss‐Ustün, A.. Impact
of drinking water, sanitation and handwashing with
soap on childhood diarrhoeal disease: updated meta‐
analysis and meta‐regression. Tropical medicine &
international health, 2018; 23(5), 508-525.
9. Harris, M., Alzua, M. L., Osbert, N., & Pickering, A.
Community-level sanitation coverage more strongly
associated with child growth and household drinking
water quality than access to a private toilet in rural
Mali. Environmental science & technology, 2017;
51(12), 7219-7227.
10. Ercumen, A., Pickering, A., Kwong, LH, Mertens,
A., Arnold, BF, Benjamin-Chung, J., & Khalil,
MMR. Do sanitation improvements reduce fecal
contamination of water, hands, food, soil and flies?
Evidence from a cluster-randomized controlled trial
in rural Bangladesh. Environmental science and
technology. 2018.
11. Stavenhagen, M., Buurman, J., & Tortajada, C.
Saving water in Cities: Assessing policies for
residential water demand management in four Cities
in Europe. Cities, 2018; 79, 187-195.
12. Cohen, A., & Colford, JJM. Effects of boiling
drinking water on pathogen-specific diarrhea and
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 Analysis of the Expression Toll-Like Receptor 4 (TLR4)
in Chronic Suppurative Otitis Media with and without
Cholesteatoma

Riskiana Djamin1, Restu Isnayah Handayani1, Abdul Kadir1, Muhammad Fadjar Perkasa1
1
Department of Otolaryngology Head and Neck Surgery, Medical Faculty, Hasanuddin University,
Makassar, Indonesia

Abstract
In recent years, the increasing incidence of chronic suppurative otitis media (CSOM) diseases worldwide
is often associated with the role of TLR4 as a component of innate immunity. This study aimed to analyze
the TLR4 levels in patients with chronic suppurative otitis media with and without cholesteatoma. This
study was conducted using the cross-sectional technique on 30 patients divided into two groups. The first
group is CSOM with cholesteatoma that consisted of 10 patients and the second group is CSOM without
cholesteatoma that consisted of 20 patients. Each sample was examined for TLR4 levels and bacterial
identification cultures in secretions and several samples were also examined for TLR4 levels in the middle
ear mucosa. TLR4 levels were examined by the ELISA method.

The results showed that TLR4 levels in middle ear secretions and mucosa of CSOM patients with
cholesteatoma were higher than chronic suppurative otitis media without cholesteatoma but there were no
significant differences. TLR4 levels in mucosal samples are higher than secret samples but there are no
significant differences. There were no significant differences in TLR4 levels in both secret and mucosal
samples between groups of CSOM with cholesteatoma and CSOM without cholesteatoma. There were no
significant differences in TLR4 levels between the secret and mucosal sample in both CSOM with and
without cholesteatoma.

Key Words: Chronic Suppurative Otitis Media, Cholesteatoma, TLR4, Innate Immunity

Introduction media is the most common disease in children in the

Otitis media (OM) is a middle ear infection
associated with inflammation. This disease frequently
afflicts humans and is the major cause of hearing loss
worldwide. Substantial morbidity associated with OM is
further exacerbated by the high frequency of recurrent
infections leading to chronic suppurative otitis media
(CSOM).1 Chronic suppurative otitis media (CSOM)
is a serious health care concern worldwide due to its
substantial financial and non-financial burden.2 Otitis
Corresponding author:
Restu Isnayah Handayani,
Department of Ear, Nose, Throat, Head-Neck Surgery,
Medical Faculty, Hasanuddin University, Makassar
(90245) Indonesia.
Email : restuisnayah_md @ yahoo.co.id
United States, with about 5 billion spent each year in
direct and indirect costs.3 The World Health Organization
(WHO) estimates that about 65-330 million people suffer
from CSOM and that as many as 50% of these have
some form of significant associated hearing loss and this
disease results in reduced quality of life for patients.1,4
Chronic suppurative otitis media is divided into
chronic suppurative otitis media without cholesteatoma
and with cholesteatoma. Both are distinguished by
looking at the inflammatory process, the presence or
absence of cholesteatoma and the location of the tympanic
membrane perforation, and different management.5 The
pathogenesis of otitis media is considered multifactorial,
however, a bacterial infection is a major cause of acute
and chronic otitis media.6,7 In a study conducted by
Pancawati in 2016 in Makassar, it was found that the
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  263
overall pattern of the pathogen that caused CSOM was
gram-negative aerobic bacteria.8 The body’s immune
response to microorganisms, including bacteria, consists
of innate immunity and adaptive immunity. The innate
immunity response acts as a non-specific first-line
barrier to defense.4,9
Toll-like receptor (TLR) is a homologous protein
in the cell membrane Antigen Presenting Cell (APC)
that functions as a functional receptor that activates
leukocytes to trigger innate immune responses or
inflammatory responses to fight pathogens.10 TLR is an
important mediator and the best innate immune receptor
of the innate immune response.6,11,12 There are 11 types
of TLRs have been identified from mammals and each
response to a different class of pathogenic infections and
is named TLR1-11.10 TLR4 mainly recognizes a large
number of pathogens associated with PAMP that are
specific to LPS (lipopolysaccharide) in gram-negative
bacteria.13,14
Studies in humans have been carried out regarding
the role of TLR in CSOM.15,16,17,18,19 Studies in animals
have added in vivo evidence regarding the importance
of TLR as innate immunity in OM resistance.16,18 The
involvement of the innate immune system and TLRs
in OM, as well on their relevance for new vaccination
strategies and immunotherapies.20
Materials And Method
Patient selection
The research subjects were selected from two
patient groups of CSOM : Group I consist of 10 patients
CSOM with cholesteatoma and Group II consist of 20
patients CSOM without cholesteatoma. Each sample was
examined for TLR4 levels and bacterial identification
cultures in secretions. 5 of 10 patients from Group
I and 10 of 20 patients from Group II was examined
for TLR4 levels in middle ear mucosa. All patients
are diagnosed based on history, physical examination
and CT-Scan of temporal bone examination. Patients
with acute suppurative otitis media, inactive chronic
suppurative otitis media, congenital and primary
acquired cholesteatoma, and patients with a history of
other acute and chronic infectious diseases were not
included as subjects in this study.
Middle ear secretion swab culture
Middle-ear swab culture was performed for both
sample groups. The external auditory canal was cleaned,
and the middle ear discharge was collected using sterile
cotton swabs than placed in a sterile tube and subjected
to bacteriological examination.
Middle ear secretion collection
The external auditory canal was cleaned, and the
middle ear discharge was collected using sterile cotton
swabs than placed in an Eppendorf tube contains 1 ml
phosphate buffer saline (PBS). The samples were stored
in a freezer with a temperature of -20oC for further use
in ELISA.
Middle ear mucosa collection
During each operation, the middle ear mucosa
was exposed via tympanostomy anterior or posterior.
The mucosae were collected using a microcurette and
forceps than placed in an Eppendorf tube contains 1 ml
phosphate buffer saline (PBS) than stored in a freezer
with a temperature of -20oC for further use in ELISA.
ELISA
TLR4 protein levels were selectively tested by
ELISA kits. The standard curve range of the ELISA kit
is 0,05 ng/ml – 15 ng/ml and sensitivity are 0,027 ng/ml.
Middle ear secretion and mucosae from the two groups
were recollected. Middle ear secretion and mucosae
homogenized in 0.5 ml of PBS. All samples were
centrifuged for 5min at 13,000 g and the supernatant
was tested in duplicate for TLR4 according to the
manufacturer’s instruction.
Statistical Analysis
Data were analyzed using SPSS (Statistical Package
for Social Sciences) version 24.0 for Windows. Samples
were analyzed using independent T-test.
Results
Types and proportions of cultured pathogens
All of the samples were positive for bacteria.
The most pathogen in CSOM without cholesteatoma
are gram-negative bacteria, species Pseudomonas
aeruginosa with 8 samples (40%), followed by gram-
positive species Staphylococcus haemolyticus with 3
264  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

samples (15%). The most pathogen in CSOM with cholesteatoma are gram-negative bacteria, species Pseudomonas
aeruginosa (Table 1).

Table 1. Organisms are cultured from middle ear swabs.

Cholesteatoma
Gram Cholesteatoma(-)
No Bacteria (+)
(+) / (-)
n % n %

1 Pseudomonas aeruginosa Gram (-) 8 40 2 20

2 Acinetobacter baumanii Gram (-) 1 5 1 10

3 Serratia marcescens Gram (-) 1 5 0 0.0

4 Serratia rubidaea Gram (-) 1 5 0 0.0

5 Enterobacter cloacae Gram (-) 0 0.0 1 10

6 Providentia stuartii Gram (-) 1 5 0 0.0

7 Proteus mirabilis Gram (-) 1 5 1 10

8 Pantoea spp Gram (-) 1 5 0 0.0

9 Achromobacter xylosoxidans Gram (-) 1 5 0 0.0

10 Acinetobacter iwolfii Gram (-) 0 0.0 1 10

11 Staphylococcus haemolyticus Gram (+) 3 15 1 10

12 Staphylococcus aureus Gram (+) 0 0.0 1 10

13 Staphylocoocus warneri Gram (+) 1 5 0 0.0

14 Kocuria kritsinae Gram (+) 1 5 1 10

15 Kocuria varians Gram (+) 0 0.0 1 10

  Total   20 100.0 10 100.0

TLR4 levels

In the secret samples with the independent T-test obtained p-value 0.460 (p > 0.05) that showed no significant
difference. In the mucosal samples with the independent T-test obtained p value 0.114 (p > 0.05) that showed no
significant difference (Table 2).

Table 2. TLR4 levels between groups of CSOM with cholesteatoma and CSOM without cholesteatoma
based on secretions and mucosal samples.

CSOM N Mean Std. Deviation p-Value

With Cholesteatoma 10 3.7244 0.583

Secret 0.460
Without Cholesteatoma 20 3.4615 1.024
With Cholesteatoma 5 4.1660 0.610
Mucosa 0.114
Without Cholesteatoma 10 3.7595 0.332
* Independent T-Test
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  265
TLR4 levels were also examined to compare TLR4
levels in secretions with TLR4 levels in the mucosa in each
study group. In the group of CSOM with cholesteatoma
with the independent T-test obtained p-value 0.196 (p >
Table 3. TLR4 levels between secret samples with mucosal samples in CSOM with cholesteatoma and
CSOM without cholesteatoma
Sample n Mean
Secret 10 3.7244
With
Cholesteatoma
Mucosa 5 4.1666
Secret 20 3.4615
Without Cholesteatoma
Mucosa 10 3.7595
* Independent T-Test
Discussion
In this study, the most pathogen in CSOM with
and without cholesteatoma are gram-negative bacteria,
species Pseudomonas aeruginosa. Pancawati8 in
Makassar also received the most pathogen in CSOM
without cholesteatoma are gram-negative bacteria but
species Proteus mirabilis in CSOM with cholesteatoma.
Harshika21 in India also obtained the dominant
microbiological pathogen in CSOM is Pseudomonas
aeruginosa.
P. aeruginosa is the main cause of CSOM disease
in the tropics.22 Pseudomonas is more able to survive
than other pathogens because it only requires minimal
food and produces pyocyanin and bacteriocin which
is its ability to carry out local infections in the form of
necrotic activity by extracellular enzymes, which have
characteristics such as epithelium damage, circulatory
breakdown, and loss of tissue protection devitalizing
organisms from normal defense mechanisms.23
Toll-like Receptors (TLR) 1-10 plays a very crucial
role in inducing and activating the natural immune
system during an infection. Recent data have shown an
important role for TLR in the inflammatory response to
bacteria in the ear, and these receptors are particularly
important during recovery from otitis media in mice.24,25
Si (2014) on examining TLR4 levels using Real-
Time - PCR and Western blot found low TLR4 mRNA
0.05) that showed no significant difference. In the group
of CSOM without cholesteatoma with the independent
T-test obtained p-value 0.381 (p > 0.05) that showed no
significant difference (Table 3).
Std. Deviation p-Value
.58336
0.196
.60976
1.02485
0.381
.33240
levels and TLR4 protein levels in the middle ear mucosa
of CSOM compared to normal middle ear mucosa.
This is one proof of the involvement of TLR4 in the
pathogenesis and recovery of CSOM.25
Usually, TLR is expressed in immune cells,
epithelial cells, and endothelium. The ligand is called
Pathogen Associated Molecular Patterns (PAMP). The
TLR bond and its ligand will cause signal transduction
to release proinflammatory cytokines such as IL-1
and TNF-α. The most important histopathological
features of cholesteatoma are the cholesteatoma matrix,
immune cells, and stroma (stroma). The pathogenesis of
cholesteatoma is still controversial. Excessive production
of several cytokines such as IL-1α and IL-1ß is found
in the cholesteatoma epithelium and stroma. IL-6 is
found in the stroma and intestines of cholesteatoma.
These cytokines affect epithelial proliferation and bone
resorption that occur in cholesteatoma. The discovery
of these inflammatory mediators and the intercellular
connecting molecule explain the immunologic aspects
of the growth of cholesteatoma.24
The results of this study generally obtained levels
of TLR4 secret samples and mucosal samples in the
CSOM group with cholesteatoma higher than TLR4
levels in CSOM without cholesteatoma but did not
show a significant difference. Jesic et al.17 also found
no significant difference in TLR4 expression between
the granulation tissue of CSOM with cholesteatoma
and CSOM patients without cholesteatoma on
266  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
TLR4 examination with histopathological and
immunohistochemical examination techniques.
Whereas Hirai et al.26 found higher TLR4 expression
in middle ear mucosa CSOM with cholesteatoma than
middle ear mucosa CSOM without cholesteatoma by
immunohistochemical examination.
Higher TLR4 levels in CSOM with cholesteatoma
caused by an infection process that occurs in CSOM with
cholesteatoma is more severe than in CSOM without
cholesteatoma. Cholesteatoma is a good medium for
bacterial growth so that infection occurs. Infection
can trigger a local immune response which results in
the production of various inflammatory mediators and
various cytokines. Inflammatory mediators and cytokines
can stimulate keratinocytes of the cholesteatoma matrix
to be hyperproliferative, destructive.27 In this study,
TLR4 levels did not show a significant difference
probably due to the lack of samples in this study.
The results of this study generally obtained levels
of TLR4 in mucosal samples higher than TLR4 levels in
meddling ear secret samples both on group CSOM with
cholesteatoma and CSOM without cholesteatoma but
did not show a significant difference. TLR4 levels in the
secretions and mucosa which are almost the same and
statistically do not show a significant difference in each
sample group show that TLR4 levels can be measured
using secret samples and mucosal samples.
Bacterial infections are the dominant factor in most
cases of otitis media. The natural immune system of
the mucosa (epithelial cells and other mucous cells)
functions as a barrier and anti-infection. The natural
immune system of the mucosa plays an anti-infectious
role by recognizing Pathogen Associated Molecular
Patterns (PAMP) through Pattern Recognition
Receptors (PRR), such as Toll-like receptors (TLR).
TLR activation mobilizes the innate immune response,
including infiltration of inflammatory cells, production
of inflammatory cytokines, and defense against bacterial
infections.25
Conclusion
TLR4 levels in secret and mucosal samples are higher
in CSOM with cholesteatoma than in CSOM without
cholesteatoma but there were no significant differences.
TLR4 levels in mucosal samples are higher than secret
samples but there ware no significant differences in both
group CSOM with and without cholesteatoma.
Conflicts of Interest: The authors have no conflicts
of interest to declare.
Acknowledgments: The authors very gratefully
thank all chronic suppurative otitis media patients who
were willing to be a respondent in this study.
Ethical Clearance: Taken from Biomedical
Research Ethics Committee on Human Faculty of
Medicine Hasanuddin University Makassar Indonesia
(Register number : 1122 / H4.8.4.5.31 / PP36-KOMETIK
/ 2018).
Source of Funding: All costs in this study are
borne by the researcher and do not get sponsors from
anywhere.
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 Intranatal Care Documentation Information System
Integrated With Web-Based Goverment Employed Midwife
Permormance Index (Seindah Paniai)

1
Novita D.Ch.Kana, 2Ansar Suyuti, 3Mardiana Ahmad, 4Syafruddin Syarif, 5Samrichard, 6Azniah Syam,
Midwifery Study Program, Post-Graduate School, Hasanuddin University, 2Faculty of Electrical Engineering,
1

University of Hasanuddin Makassar, 3 Midwifery Study Program, Post-Graduate School, Hasanuddin University,
Makassar, 4 Faculty of Electrical Engineering, University of Hasanuddin Makassar, 5Pelamonia Hospital
Makassar, 6Nani Hasanuddin Makassar School of Health

Abstract
Introduction. Midwifery care documentation which is written in the forms of Subjective, Objective,
Analysis, and Management development (SOAP) is not committed maximally which is caused by the double
responsibility, unavailable format, tiredness, limited time, and repeatedly written data in the registering
conventional book and it complicates the collecting of midwife’s credit numbers to increase their functional
level.

This study aims to design an integrated information system of childbirth care documentation for the credit
numbers of civil servant midwives (Seindah Paniai).

Method. The design of Seindah Paniai uses the System Development Life Cycle (SDLC) method. The
Prototype of Seindah Paniai system is designed by using MySQL database and Apache web server.

Results. The design of Seindah Paniai system includes: login use, midwife care assignments, patient data,
delivery (subjective data, objective data, case analysis, management of I-IV first-time delivery care, informed
consent, latent phase observation sheets, partographs, internal reference forms), performance midwife and
recapitulation of delivery data in one month. The constructive validity or the content of information system
involves experts and intrinsic validity is done with black box testing, all test items are accepted. Reliability
of information system uses a questionnaire (Likert) with retesting test and Alpha Chornbach methods (p =
0.832> 0.05).

Conclusion. Seindah Paniai system documented Kala I-IV’s delivery care. Seindah Paniai displays the value
of the midwife’s credit number according to the functional level. Seindah Paniai is valid and reliable to use.

Seindah Paniai system needs to be completed with the interesting wall displays and the trials of service
system to see the accepting.

Keywords: Information system, Delivery documentation, Midwife permormance index.

Corresponding author:
Novita D.Ch. Kana
Prodi Ilmu Kebidanan, Sekolah Pascasarjana,
Universitas Hasanuddin Makassar, Hp 08114908791
Email: novita.kana1975@gmail.com
Introduction
Midwifery documentation is the legal proof of
recording and reporting the frame of thought which is
used in the process of taking decision in accordance
with their competence (1)
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  269
Midwifery documentation as a reflection of care
models illustrates the problem solving methods
which is carried out at each stage of midwifery care
in systematic, precise, clear, accurate, concise, and clear
manner (2). Documentation is carried out immediately
and write it in the note forms on the progress of SOAP
(Subjective, Objective, Analysis, Management) that can
be a legal evidence for implementation of midwifery
care (3).        manually calculate the credit score acquisition one by
Dike’s 2015 study on childbirth documentation
obtained results: 80 (87%) respondents knew about
documentation; 92 (100%) for continuity of care;
89.1% for law; 87% for quality care. But 71 (77.2%)
respondents did not do documentation (4).
The role of technology in documenting midwifery in
the form of recording and reporting to the Information
system has been widely developed, such as SIK 5NG
(5),
Development of Information Systems for Maternal
and Infant Health Services (6), PrasavGraf Android (7), e-
Partograf (8) and PartoPen (9)       
Information systems with digital partographs have
been used as a means of detecting and clinical decision
making in childbirth (10,11). But in its implementation,
even though midwives have good knowledge about
partographs, its use is still lack(12,13)
This case is caused by the lack of midwife
motivation, physical and emotional fatigue. Therefore,
the support and appreciation from supervisor are needed
so that, the care can be well documented (14–16)
One of the appreciation terms for work performances
and midwife services is promoting them for being Civil
Servants (17). There has been the determination for the
number of credit assignments for functional health
officials,(18) but the application of maternity care with
SOAP documentation that refers to normal delivery care
does not yet exist.
Preliminary studies about hospitalization in five
Public Health Centers in Makassar City and two others
in North Luwu Regency found that, the data of delivery
was recorded in more than one register manually. The
data and recording reports were stored in the form of
‘paper base’ which make it difficult for searching when
the data is needed. On the other hand, it also requires
much time for finding it which is caused by the buildup
of data files. And when the recording data is incomplete,
the data or archives cannot be shown. Documentation
of giving birth in several places is only a delivery
report without any care of providing documents. The
unavailable of care documenting format is the reason of
the incomplete data to the daily activities of the midwife.
When completing the list of proposed credit numbers for
an increase in the functional level, the midwife must
reopen the stack of delivery care documenting files and
one.
MATERIALS AND METHODS
Materials and Methods
The design of Seindah Paniai uses the System
Development Life Cycle (SDLC) method, which
includes problem identification, need analysis, system
design, implementation, and evaluation(19,20). The
Prototype of Seindah Paniai system is designed by using
MySQL database and Apache web server. The prototype
simulation test was carried out for 1 month.
Data analysis
Information systems are validated constructively
(involving experts), intrinsic with (black box testing)
(21,22)
and reliability with the retesting test by using Alpha
Cronbach. And the process of collecting data use the
SPSS version 24.
Results
Designing Information system
Software for building systems includes: MySQL
with programming languages: html, java script, php, css
for display; graphic User Interface / GUI for MySQL:
phpMyadmin; application for text editor: Sublime
Text Editor; File Treanser Protocol (FTP) application:
FileZilla.
The results of Seindah Paniai Information designing
system
a. Login and start page
Seindah Paniai system can be accessed by logging
in the user name using the midwife employee’s number
and personal password for each user.
270  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

Figure 1. Start Page Design (Seindah Paniai’s Home)

The initial page with the slogan «Save and Health”. Before conducting documentation input, the midwife must
input a guard assignment that is tailored to her condition, whether the duty is to keep the shift in place, on call, or to
work in the affected area.

The data on registered patients is the biodata of spouse using the citizenship registered number and the patient›s
medical record number as the identity key.

b. Delivery

Figure 2. Delivery Design

Seindah Paniai system provides subjective data,
objective data, analysis and management from the period
of giving birth I-IV. The options are checked according
to the patient’s condition. Subjective data includes
patient complaints, menstrual history, the history of
past and postpartum pregnancy, current pregnancy
history, family disease, and psychosocial conditions.
Objective data includes the whole body such obstetric
examinations, internal examinations and investigations.
Case analysis consists of physiological cases without
problems, physiological problems, pathology, pathology
with co-morbidities, and emergencies. Management is
adjusted to analyze cases chosen by midwives.
Before the management is done, informed consent
is inputted first. In the first stage of childbirth, there is a
latent and partograph phase observation sheet to assess
the progress of giving birth. In every delivering babies,
the care is given by chosing and giving a check mark.
If not available in the choice, the midwife can input
the care in the column provided. The midwife cared
for her according to authority, so that the output of the
internal referral form was provided. At the step of IV,
midwives completed their documentation in partograph
and supervision two hours postpartum. Seindah Paniai
system keeps all childbirth documentation in the patient’s
medical record file. If data is needed, the medical record
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  271
file can be viewed again.

c. Performance (performance index of civil servants midwives)

Figure 3. The designing recapitulation of midwives performance

Goverment employed midwife permormance index The testing of constructive validities and content.
are obtained in accordance with midwives’ functional
The Items and content which are validated
levels and analysis of cases handled, referring to
constructively is the format data assessment of
Minister of Health Regulation number 551/2009 (17)
subjective, objective, analysis, management (SOAP),
and PerMenPAN 001/2008 (23). Seindah Paniai system
and the integrated item with SOAP performance index.
displays the credit score obtained from each patient at
each period of birth and the outgoing credit score in one The testing of intrinsic.
month. Recapitulation of delivery service coverage data
in one month is displayed at the end of the system. The intrinsic validities of Seindah Paniai system
use the black box testing. Black box testing examine the
The system of validities and reliabilities. special function from application and the test of input
and output is for the function without concerning to the
The Validities of Seindah Paniai system involves
process. There are some errors that can be identified such
the experts (Doctor Specialists Obtetri Ginecology, team
as: the lost and error function, the error between face,
members of midwife’s documenting evaluators, the
the error of data structure (database access) the error of
specialists of technology information and the counting
initialization and performance in the end of program(24).
of midwife performance index of South Sulawesi
province).

No Testing Class Testing Items Conclusion

1 Login Use Check registered user Accepted
2 Guard duty Date and duty guard Accepted
3 Patient Data New Data Accepted
Subjective data
Objective data
Delivery Analysis Accepted Accepted Accepted
4
Period Management Accepted Accepted Accepted
Latent Phase observation sheet
Front sheet partograph
272  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

Subjective data
Objective data Accepted Accepted Accepted
5 Period II
Analysis Accepted
Management

Subjective data
Objective data Accepted Accepted Accepted
6 Period III
Analysis Accepted
Management

Subjective data
Objective data
Accepted Accepted Accepted
7 Period IV Analysis
Accepted Accepted
Management
Back sheet partograph

8 Informed Consent Sheet Accepted

9 Internal Reference Sheet Accepted

Performance Integration of SOAP and midwife Credit Numbers

10 Accepted
from each patient.

Recapitulation of the acquisition of midwife's Credit

11 Accepted
Score in one month

12 Data Recap Data Recap Accepted

Table 1 shows that the output Seindah Paniai is in
accordance with what is expected or received and it can
fulfill the needs of user which is free from errors.
c. Reliability Test
The reliability testing of Seindah Paniai system
uses a Likert questionnaire with 13 items of questions
which include information system logins, guard duty,
patient data, SOAP I-IV delivery, performance (SOAP
integration and credit score acquisition according to
midwife’s functional level) and data recapitulation.
Questionnaires with 4 items of answers were tested by
retesting test by using Cronbach Alpha (p = 0.832 >
0.05).
Conclusions and Recommendations
Information systems document the period I-IV
delivery care. The information system displays the
midwife credit score according to the functional level.
Valid and reliable information system to be used.
Seindah Paniai system needs to be completed with
the interesting wall displays and the trials of service
system to see the accepting.
Etical Clereance Number: 1066 / H4.8.4.5.31 /
PP36-KOMETIK / 2018 issued by the Health Research
Commitee Hasanuddin Makassar University.
Source of Funding: Self
Conflict of Interest: None
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 Analysis of Cotinine Levels in Urine as a Risk Factor of Otitis
Media With Effusion in Children

Eka Savitri1, Sutji Pratiwi Rahardjo2, Haerul Saleh3

Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, 2Department of
1

Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, 3Department of Otorhinolaryngology-Head

and Neck Surgery, Medical Faculty, Hasanuddin University, Indonesia

Abstract
Otitis media effusion (OME) is presence of fluids in the middle ear without any sign and acute inflammation
symptoms with complete of tympanicy membrane. This study aimed to analyse the cotinine level in urine
as a risk factor of otitis media efusion in children.

This study is using the analyse observasional with case control design. Involving 52 childrens devided into
2 groups. First group consists of 22 patients with otitis media efusion. Second group consists of 30 childrens
as controls. The diagnosis of otitis media efusion are determined by tympanometry examination and we
found B type for the result. All subjects was checked the cotinine level in urine.

The result of this study show that mostly the cotinine levels in Otitis Media efusion (2.55) a little lower than
controls (2.63), but the statistic not significant. This shows there’s not significant relation between cotinine
level and otitis media efusion.

Keywords : otitis media effusion, cotinine level in urine, tympanometry.

Introduction The etiology and pathogenesis of OME are

Otitis media effusion (OME) is presence of fluids in
the middle ear without any sign and acute inflammation
symptoms with complete of tympanic membrane. The
presence of fluids in the middle ear can cause decrease
function of tympanic membrane that make hearing
loss1,2.
OME generally occurs as a short term disorder
accompanying with respiratory infection in children, or
as a chronic process. About 80% of children can have
one episode of OME before 10 years old with mostly
case occurring the range of 6 months until 4 years old
and about 50% children sustain bilateral OME 1,3.
In 2007, WHO reported all prevalence 3,8% of non
suppurative chronic of otitis media4. A cross sectional
study in Saudi Arabia showed data on prevalence of
OME in 1488 children 6-12 years old) are 7,5% (5). Chen
and friends in Taiwan reported the frequency of OME in
3013 children (3-6 years old) are 5,24 % 6. Rizaldi in his
study reported the prevalence of OME in the children
0-14 years old in East Jakarta are 1,3% 7.
multifactorial. The Expose of cigarette’s smoke is one of
the environment factors that cause OME that can cause
irritation (toxic trauma) which is can damage the cilia,
hyperplasia in the goblet cell, and hypersecretion in the
mucus, and impaired function of mucociliary transport
in Eustachian tube and middle ear8,9.
The American Academy of Otolryngology Head
and Neck Surgey (AAO-HNS) officially said that the
exposure of cigarette’s smoke can increase the risk of
otitis media in children. According to Talaat et al, the
effect of harm cigarrete’s smoke not only for the active
smoker but also risks to peoples around them, especially
infants and children10.
Materials and Method
Study design
This study is using the analyses observational with
case control design.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  275
Place and Time The test results are significant if the value is p <0.05

This study take place in ORL-HNS clinic at Wahidin Results

Sudirohusodo Hospital and Hasanuddin University
(Unhas) Hospital, research laboratory Hasanuddin Case control study have been conducted in children
Univercity Hospital. Study started from November 2018 between 0-18 years old. Total sample 52 children, 22
until March 2019. with OME (Case group), and 30 children without OME
(control group).
Population and Sample
Table 1. Descriptive statistic Ages and Cotinin levelTable 1. Descriptive statistic Ages and Cotinin
Statistic
The population
(n=52) target are children between 0-18 level Statistic (n=52)
years old who got the ORL-NHS treatment in Wahidin
Std.
Sudirohusodo hospital and Unhas
Variabel Minhospital.
MaxThe selection
Mean Deviation
Variabel Min Max Mean
Std.
population using children between 0-18 years old Deviation

because WHO Ages 2 until 1816years old9,19

announce children have 2,10
Ages 2 16 9,19 2,10
a big risk to Cotinin
get OME and
level highest
1,38 prevalence
4,69 of passive
2,60 0,75
smoker in Indonesia (1).
Cotinin level 1,38 4,69 2,60 0,75
Data Process
Table 1, 52 subjects, include 22 OME (42,3%) and 30 subject control (57,7%). The Ages
of subjects
Analyze databetween
using 2-16
SPSSyears
2.2oldversion.
with mean 9,2 years old. Table
Statistic While cotinine level rangeinclude
1, 52 subjects, between22 OME (42,3%)
analyze1,38-4,69
with descriptive
with mean 2,60 statistic calculation and and 30 subject control (57,7%). The Ages of subjects
distribution of frequency and also Independent t-test between 2-16 years old with mean 9,2 years old. While
statistical test, if the test result show significant statically. cotinine level range between 1,38-4,69 with mean 2,60

Table 2. Study variable category (n=52)

N % OR
Variable
OME Control OME Control 95% CI

Male 13 17 59 56,7
Gender 2,762
Female 9 13 41 33,3

Sleep Disorder (adenoids Yes 5 7 22,7 23,3

3,826
hypertrophy) No 17 23 77,3 76,7

Yes 8 6 36,4 20
Snoring (enlarge adenoids) 1,522
No 14 24 63,6 80

Common Cold (upper Yes 14 13 63,6 43,3

1,352
respiratory tract infection) No 8 17 36,4 56,7

Yes 0 0 0 0
Active Smoker
No 22 30 100 100

Yes 20 13 91 43,3
Member Of Family Smoking
No 2 17 9 56,7
276  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

1 person 19 13 86,4 43,3

Number of Family Smoking >1 1 0 4,5 0
None 2 17 9,1 56,7

Father 19 13 86,4 43,3

Who’s Smoke Others 1 0 4,5 0
None 2 17 9,1 56,7

Yes 20 5 90,9 16,7

Smoking near child No 0 8 0 26,7
None 2 17 9,1 56,6

>20 sticks 14 2 63,5 6,7

11-20 sticks 3 8 13,6 26,7
Amount of cigarette stick
1-10 sticks 3 3 13,6 10
None 2 17 9,1 56,6

Inside the house 20 6 90,9 20,1

Place of Smoking Outside house 0 7 0 23,3
None 2 17 9,1 56,6

Table 2, show mostly subjects are male with OME, (6,&%), and smoking place in the house are 20 (90,9%)
13 (59%) Table 2, show
nor the controlmostly subjects
17 (56,7%), areratio
odds male(OR)with OME, 13 (59%)
and 6 (20,1%) nor the
in group control 17 (56,7%), odds
control.
2,762. Based on the
ratio (OR) resultsBased
2,762. from on
thethe
interviews usingthe interviews using questioners, 5 with sleep disorder
results from
Table 3. Mean cotinine level in Group
questioners, 5 with sleep disorder in OME group
in OME group (22,7%), and group control in 7 (23,3%), OR 3,82, 8 subjects snoring (36,4%) who
(22,7%), and group control in 7 (23,3%), OR 3,82,
suffered OME and 6who(20%) in group control, Cotinin
8 subjects snoring (36,4%) suffered OME and OR 1,52. Common
Group N cold 14%(63,6)Mean
in OME
SD and P13
Level
6 (20%)(43,3)
in group control, OR
in control, OR 1,352.
1,52. Common cold were
All subjects 14 passive smokers (100%) both those who suffered
(63,6) in OME and 13 (43,3) in control, OR 1,352. OME 22 Positive - -
OMEwere
All subjects and passive
controls, families
smokers smokeboth
(100%) in 20 (91%) in OME patients and 13 (43,3%) in controls, the
those -
who suffered
numberOME and controls,
of families families 19
who smoked smoke in 20more than 1 person as many as 1 (4,9%) and the group
(86,4%) Negative 100 2,55 0,77
(91%) in OME patients and 13 (43,3%) in controls, the
control, most of whom were 13 (43,3%) smoker were Control19 fathers ( 86,4%) in
30 Positive - OME - and 13 (43,3%)
number of families who smoked 19 (86,4%) more than
-
1 personinascontrols,
many asSmoking
1 (4,9%)nearand childrens
the groupincontrol,
20 (90,9%) in OME and 5 (16,7%) in controls, the number
Negative 100 2,63 0,75
most of whom were 13 (43,3%) smoker were 19 fathers
( 86,4%) in OME and 13 (43,3%) in controls, Smoking
P can not count because all subjects not cross
near childrens in 20 (90,9%) in OME and 5 (16,7%) in
the cut off level (>100ng/ml).
controls, the number of dominant cigarettes smoked >20
sticks in OME group are 14 (63,5%) and 2 in controls
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  277
Tabel 4. Mean Cotinine Level from Tympanometry
Group N Mean
OME (type B) 22
Control (type A) 30
The mean results of tybe B tympanometry found
(2,55) slightly lower than in type A (2,63), but not
statistically significant with a value of p> 0.05. This
shows that there is no significant relation between
cotinine levels and tympanometry results.
Discussion
The characteristics according gender in OME sample
were obtained with ratio 59%:41% (table 2). Xenelis et
al, 3:1. Rizaldi found that comparison between male and
female in children range ages 0-14 years old is 1,5: 17,11.
As Restuty said correlating this study with the volume
of mastoid cells in female tend to have a greater volume
of mastoid cells than male, so OME is less common in
women12.
In this study children with OME were highest ages
range of 2 to 16 years old with mean of 9.2 years old (table
1). This is not related with some literature as Casselbrant
and Mandel (2014) stating that the prevalence of OME
is highest at the age of 6 months to 4 years old and this
number will decline at the age of 6 . This cause by the
anatomy of Eustachian tube in infants and children
under 7 years old is shorter and more horizontal and also
the unperfect of immune system causes a higher risk of
OME in children.12
From samples in table 2, it can be concluded
that all samples were passive smoker and there’s no
positive of cotinine level were found. This happens
because subjective judgments do not always get reliable
information, so that’s why the level of exposure can
be influenced by the type of cigarrete, the distance to
the source of cigarrete smoke, the length of exposure
and the condition of ventilation at that time. Its useful
for epidemiological study and intervention to control
subsequent of exposure to cigarette smoke.13
We found the result of the OR in sleep disorder and
snoring that cause the adenoid hypertrofi is 3,8 times
and 1,5 times increase the risk of OME. Whereas for
common cold that cause by ISPA, increase the risk of
OME 1,3 times. In children, OME is generally arises
SD P
2,55 0,77 0,688*
2,63 0,75
as a short term disorder, with accompanying an upper
respiratory tract infection. Several studies have been
proven it, Zhang et all in their study, collecting 4 studies
of URTI, obtained results that URTI means increasing
the risk of Otitis Media. (OR,6,59;95% CL,3,13-13,89;P
<0.00001), Children who have a history of URTI in
the last 1 month, have chances 7 times to suffer OME,
compared to children who do not have a history of
URTI.1,23
This is supported by the literature which is said that
URTI can cause inflammation and impair the fuction
of eustachian tube, so that, it decreases the pressure
in the middle ear, followed by the entry of bacteria
and viruses into the ear, through the eustachian tube
causes inflammation and effusion in the middle ear.
In addition, the eustachian tube in children has not yet
growing like an adult size, the eustachian tube in child
is shorter and located more flat or horizontal, so that
the secretions of nasopharynx can enter the middle ear
easily. The imperfect of immune system of children
causes children to be susceptible to get infection, such
as upper respiratory tract infection, thereby facilitating
the occurence of Otitis Media.8
From table 4, the mean results of type B
tympanometry were obtained (2,55) slightly lower than
in type A (2,630.,but not statically significant with a
value p >0.05. This shows there’s no realtion between
cotini level and tympanometry results. In table 3 the
mean cotinine level in OME (2,55) was slightly lower
than controls (2,63), but not statistically significant. This
shows that there is no relation between the cotinine level
and OME.
Examination of cotinine level in urine, this study was
carried out by the Enzym-linked immunosorbent Assay
(ELISA) method, using a cut-off 100ng/ml referring to
the Yeh et al study that was available in Indonesia. The
result of this study, we found that there is no positive
cotinine level or exceeded the cut off limit in case group
or group controls. The result of this study not correlated
with the theory which state that exposure to cigarette
278  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
smoke acts as a risk factor of OME which is believed to
occur through the mechanism of irritation in Eustachian
tube and middle ear that cause hyperplatia of goblet cell
and damage the cilia can cause disappearance fuction of
mucociliary transport.15.
Some study have different in setting the cut off rate
of cotinine level in urine to assess a person’s smoking
status between not being exposed to cigarette smoke
(non smoker and being exposed (active/passive smoker).
Moyer et al. conclude that the cut off 20 ng/ml for the
boundary between non smoker and mild passive smoker
used the HPLC tandem mass spectrometry method. Yeh
and friends set a cut of 100 ng/ml to limit non smoking
status and smokers (passive and active) using the lateral
flow chromatographic immunoassay method.14,17,18.
According to Danch, to get an estimate of cut off
the cotinine level in urine, its necessary to have a
statistical distribution of cotinine level in urine for the
local population so that’s persons smoking status can be
distinguished. Cut-off number can be different among
population in various regions of the world because of
many influencing factor. Kwon et al. stated that cotinine
metabolism from nicotine is associated with genetic
polymorphism of cytochrome P450 (CYP) 2A618-21
There have been no studies in Indonesia determined
the cut-off of a person’s smoking status, so the authors
refer to the study of Yeh et al, who used a cut-off 100ng/
ml using the lateral flow chromatographic Immnoassay
method that available in Indonesia. The cut-off number
has a sensitivity of 92% and specificity of 91 %14. But
according to Jung and Danch’s opinion, that the cut-off
number will different between population in various
regions, of course the cut off selection in this study that
refers to the study of Yeh et all has limitations because
held in another populations. So that method of analysis
and determination of the cut-off in this study needs to be
adjusted to the characteristic of the Indonesian peoples.
Conclusion
That can not be proven significantly, the cotinine
levels in urine as a risk factor of OME. Upper respiratory
tract infection and adenoid hypertrophy increase the risk
factor of OME. OME is more common in male than
female. Need a further study with an objective method
of analysis the cotinine levels in urine using other
techniques and large of samples size to obtain more
accurate data. We need to set the cut-off number of value
as a reference for cotinine levels in urine.
Conflict of Interest: Authors declare that there is
no conflict of interest within this publication.
Ethical Clearance: Ethical clearance was made by
Medical Faculty, Hasanuddin University, Makassar.
Source Funding: Source funding came from
authors their selves.
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 Analysis of Plasma F2-Isoprostane Level After Administration
of Vitamin C in Patients with Chronic Tonsillitis

 Sutji Pratiwi Rahardjo1, Abdul Qadar Punagi1, Magdalena Octavia Sidabutar1, Muh. Fadjar Perkasa1
1
Department of Ear, Nose, Throat, Head-Neck Surgery, Medical Faculty, Hasanuddin University,
Makassar, Indonesia

Abstract
Background: Chronic tonsillitis can cause oxidative stress in the body.

Objective: The study aims to analyse plasma F2-Isoprostane level in chronic tonsillitis patients with and
without risk of Obstructive Sleep Apnea Syndrome (OSAS).

Materials and Method: The design of this study is a clinical trial with pre and posttest control group.
Sampling was done in Wahidin Sudirohusodo Hospital and Kassi-kassi Health Center, Makassar. In this
study, the sample size of each group was 20 samples, consisting of chronic tonsillitis patients with OSAS
risk in the first group and chronic tonsillitis patients without the risk of OSAS in second group. Both groups
were given 1x1000 mg tablet of vitamin C for 14 days.

Results: The results of this study showed that there was no significant decrease in plasma F2-Isoprostane
level in patient with chronic tonsillitis with and without risk of OSAS after administration of vitamin C.
There was no significant difference in decreased of plasma F2-Isoprostane level in patients with chronic
tonsillitis at risk of OSAS after the administration of vitamin C especially in chronic tonsillitis patients
without OSAS risk.

Conclusions: There was no significant decrease in plasma F2-Isoprostane level in patient with chronic
tonsillitis with and without risk of OSAS after administration of vitamin C. There was no significant
difference in decreased of plasma F2-Isoprostane level in patients with chronic tonsillitis at risk of OSAS
after administration of vitamin C especially in chronic tonsillitis patients without OSAS risk.

Key Words: Chronic Tonsillitis, OSAS, F2-Isoprostane, Vitamin C

Introduction at the sub-laryngeal polyclinic and 163 cases underwent

Chronic tonsillitis is the most common disease of
recurrent inflammation of the throat. Based on medical
records of Laryngology and Pharyngology of ENT Head
and Neck Department in 2010 at RSUP dr. M. Djamil
Padang stated that there were 465 patients diagnosed
with chronic tonsillitis from a total of 1110 patients visit
Corresponding author:
Magdalena Octavia Sidabutar,
Department of Ear, Nose, Throat, Head-Neck Surgery,
Medical Faculty, Hasanuddin University, Makassar
(90245) Indonesia. Email : lena.sidabutar@gmail.com
tonsillectomy1,2, meanwhile the number of the new
patients diagnosed with chronic tonsillitis at Wahidin
Sudirohusodo Hospital Makassar from January 2013
until July 2018 were 320 patients.3
A study conducted by Khan et al4 at Khyber Hospital,
Pakistan in 2011-2012 regarding the distribution of ENT
disease and found 8980 people suffering from chronic
tonsillitis as much as 27.37%. In this study chronic
tonsillitis was at the top of the incidence of other ENT
diseases.4,5 Another study conducted by Alfrida (2009)6
in Makassar found that chronic tonsillitis was also found
in school age of 5-15 years (61.4%).
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  281
Chronic tonsillitis with or without adenoid
hypertrophy is very common in childhood. Recurrent
inflammation can cause sore throat, fever, dysphagia and
malaise. Chronic tonsillitis is one of the most common
causes of Obstructive Sleep Apnea Syndrome (OSAS)
in children and lead to negative impact on sleep quality.7
OSAS is the forced cessation of breathing during
sleep for at least 10 seconds, with a decrease of oxygen in
the blood due to blockage of the upper respiratory tract.
This is characterized by the occurrence of hypopnea,
where respiration decreases by more than 50% at least 5
times per hour. This metabolic change triggers oxidative
stress and systemic inflammation which then causes the
release of reactive oxygen species, antioxidant enzymes
and inflammatory indicators.8
The definitive diagnosis of OSAS is by
polysomnography. In some countries, if polysomnography
is not available, other parameters can be used such as
Berlin questionnaire, Epworth Sleepiness Scale (ESS) as
a parameter for OSA diagnosis.9
In India a study was conducted to test the validity
of Berlin questionnaire to identify patients at risk of
developing OSA, this questionnaire was considered
easier to use and more accurate. With this questionnaire
people could be differ from high risk and low risk of
OSA, and the internal reliability is acceptable because
the answers of each questionnaire are assessed per
category.10
OSAS is characterized by the present of period
of recurrent upper airway collapse which results
in a hypoxic or reoxygenation cycle and causes an
increase in oxygen species formation by oxidative
stress. The oxygen free radicals formed will catalyze
lipid peroxidation which will produce isoprostane.
Carpagnano et al (2002)11 reported that isoprostane in
peripheral blood and exhalation of condensate in OSAS
patients has increased.
Free radicals are involved in various pathological
conditions including chronic tonsillitis. Lipid
peroxidation is the main indicator of free radicals
related to the severity of cell membranes.12 Free radicals
including Reactive Oxygen Species (ROS) and lipid
peroxidation formed in chronic tonsillitis can increase,
lead to cell damage and tissue injury. Plus, the free
radicals can damage the leukocyte lipid membranes,
hence permeability increases and reduces the function
of leukocyte immunity. It can also damage DNA, thus
reducing the synthesis and reproducibility of leukocytes.
Human body will form antioxidants to prevent further
cell damage. Low levels of antioxidants can cause
frequent tonsillar infections.13
The formation of free radicals will not cause damage
or interfere the physiological processes of the body if the
enzymatic protection system (the free radical scavenger)
and non-enzymatic protection systems (antioxidants)
are sufficient to inhibit the reaction of the free radical
and can detoxify the formed free radicals. One of the
non-enzymatic protection systems for free radicals is
vitamin C. Vitamin C acts as an antioxidant by donating
the hydrogen atoms to free radicals. A study conducted
by Block et al. (2008)14 that dose of vitamin C was given
1000 mg per day for two months can reduce plasma
F2-Isoprostane level in overweight smokers, passively
exposed nonsmokers and healthy nonsmokers.15 Another
study conducted by Moreno et al (2004)16, by giving the
orange juice rich in vitamin C can reduce plasma F2-
isoprostane level in healthy people on day 14th.
 Materials and Method
Patient selection
The research subjects were selected from two groups
of chronic tonsillitis: Group I consist of 20 patients
chronic tonsillitis with OSAS risk and group II consist
of 20 patients chronic tonsillitis without OSAS risk and
both groups were given 1x1000mg of vitamin C for 14
days.
 Sampling procedures
History taking and examination (otoscopy, anterior
and posterior rhinoscopy, pharyngoscopy, indirect
laryngoscopy) were conducted on the patients with the
inclusion criteria as samples. The subject or patient’s
family signed the informed consent form. The subjects
filled out the Berlin questionnaire which evaluated
the symptoms of OSA. Examination of plasma F2-
Isoprostane level with the working principle:
Taking Blood Samples
Performed in the cubital median vein. Draw 3 cc of
blood using a needle into a tube that already contains
EDTA. Plasma separation and storage is carried out
in the Molecular Biology Laboratory of Hasanuddin
University Hospital Makassar.
282  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Measurement of plasma F2-Isoprostane level
> 35 years old 8 20
was measured in the Molecular Biology laboratory
of Hasanuddin University Hospital Makassar. Tonsill size    
Measurements were made according to the Enzyme- T1-T1 0  
Linked Immunosorbent Assay (ELISA) method.
T2-T2 25 62.5
 ELISA T3-T3 15 37.5

F2-Isoprostane measurement were carried out Table 1 shows that most samples in this study were
according to the ELISA method. female which is 24 patients (60%). The most common
age was <20 years which is 15 patients (37.5%). As for
 Statistical analysis
tonsil size category, 25 patients (62.5%) with T2-T2 and
All data is processed using SPSS version 22, then 15 patients (37.5%) with tonsil size T3-T3.
tested using the T-Test.
  Table 2. Decreased F2-Isoprostane in chronic
Results tonsillitis patients with OSAS risk

From January 2nd 2019 to April 4th 2019, a study was

Std.
conducted to analyze the plasma F2-Isoprostane level in Group Mean P-Value
Deviation
patients with chronic tonsillitis after giving 1x1000 mg
of vitamin C for 14 days. Chronic tonsillitis patients with F2-Isoprostan before
inclusion criteria were given the Berlin questionnaire administration of 106.92 40.21
Vit. C
to assess the risks of OSAS, then their plasma F2-
Isoprostan level were examined. 0.064
F2-Isoprostan after
In this study there were 40 samples of chronic administration of 85.38 48.05
tonsillitis patients, 20 samples were chronic tonsillitis Vit. C

patients with risk of OSAS and 20 samples of patients T-test

with chronic tonsillitis without risk of OSAS and both
groups were given 1x1000 mg vitamin C for 14 days. Table 2 shows a decrease in F2-Isoprotane level in
patients with chronic tonsillitis at risk of OSAS after
Based on general and clinical characteristics in this administration of vitamin C. The average level of F2-
study, the variables studied in the group of patients with Isoprostane before administration of vitamin C was
chronic tonsillitis with and without OSAS risk who were 106.92 with a standard deviation of 40.21, while the
given vitamin C therapy including gender, age, and average F2-Isoprostane level after administration of
tonsil size. vitamin C was 85.38 with a standard deviation of 48.05.
Based on the T-test statistical test showed that there was
Table 1. Characteristics of samples based on
no significant decrease in F2-Isoprostane level after the
gender, age, and tonsil size
administration of vitamin C in patients with chronic
tonsillitis with OSAS risk with a value of 𝜌 value =
Sample Characteristics N %
0.064 (𝜌 = <0.05).
Gender    
  Table 3. Decreased F2-Isoprostane in patients
Man 16 40
with chronic tonsillitis without OSAS risk
Woman 24 60

Age     Std.
Group Mean P-Value
Deviation
<20 years old 15 37.5
F2-Isoprostan before
80,19 39.97
20-25 years 12 30 administration of Vit. C
0.383
26-30 years 2 5 F2-Isoprostan after
71,37 34.22
administration of Vit. C
31-35 years old 3 7.5 T-test
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  283
Table 3 shows a decrease in F2-Isoprotane level in
patients with chronic tonsillitis without OSAS risk after
administration of vitamin C. The average level of F2-
Isoprostane before administration of vitamin C was 80.19
with a standard deviation of 39.97, while the average F2-
Isoprostane level after administration of vitamin C was
71.37 with a standard deviation of 34.22. Based on the
T-test statistical test showed that there was no significant
decrease in F2-Isoprostane level after administration
of vitamin C in patients with chronic tonsillitis without
OSAS risk with a value of 𝜌 value = 0.383 (𝜌 = <0.05).
  Table 4. Comparison of decreases in F2-
Isoprostane levels between chronic tonsillitis patients
with and without OSAS risk.
Decrease in F2-
Mean Std. Deviation P-Value
Isoprostan
With OSAS 21,54 48.92
0.751
Without OSAS 8.81 44,19
T-test
Table 4 shows a comparison of the decrease
in F2-Isoprostane level between chronic tonsillitis
patients with OSAS risk and without OSAS risk. The
average decrease of F2-Isoprostane level in patients
with chronic tonsillitis with OSAS risk is 21.54 with a
standard deviation of 48.92, while the mean average of
F2-Isoprostane decrease level in patients with chronic
tonsillitis without OSAS risk was 8.81 with a standard
deviation of 44.19. Based on the independent T-test
statistical tests showed that there was no significant in
comparison of the decrease in F2-Isoprostane levels
between chronic tonsillitis patients with OSAS risk and
without OSAS risk with a value of 𝜌 value = 0.751 (𝜌
<0.05).
 Discussion
This study were conducted on 40 chronic tonsillitis
patients who came to the ENT Head and Neck polyclinic
of Dr. Wahidin Sudirohusodo Hospital and Kassi-Kassi
Health Center from January 2nd to April 4th 2019. To assess
the prevalence of Obstructive Sleep Apnea Syndrome
(OSAS), patients and their families were given Berlin
questionnaires that has been translated into Indonesian.
This questionnaire consists of three parts. The first part
is about do they snore, how hard and how often they
snore and if it disturbs others. The second part is about
do they experience fatigue after sleep, how often they
feel tired and have they fall asleep while driving. The
third part includes the history of high blood pressure.
Someone is assumed at risk of OSAS if they have at least
two of the above criteria.
From 40 samples, venous blood sampling was
carried out in 20 chronic tonsillitis patients with OSAS
risk and 20 chronic tonsillitis patients without OSAS
risk. Then the blood samples were sent to the laboratory
of University Hasanuddin Hospital Makassar to examine
plasma F2-Isoprostane level.
The results of this study found that the proportion
of women (60%) is higher than men (40%) whom were
diagnosed with chronic tonsillitis. This is corresponded
with the study reported by Shalihat, et al. (2015)17
as chronic tonsillitis were most commonly affects
female which is 84 people (56.4%). Teenagers are
more concerned with their body shape and appearance
so many of them will delay their eating schedule and
reduce the portion of food they consume as for a perfect
body posture. But this behavior will lead to malnutrition
and weaken the body immunity which then vulnerable to
infections and other health problems.
Out of the total number of 40 patients, maximum
number of patients belonged to the age group of less than
20 years (37.5%). This is corresponded with the study
conducted by Alfrida in Makassar (2009)6 at which the
percentage of chronic tonsillitis patients at school age of
5-15 years were 61.4%. These children often consume
unhealthy foods which contain a lot of preservatives,
sweeteners and also cold drinks. These foods and drinks
can cause irritation to the throat, which can lead to
infection of the throat or tonsil. Besides, children who
often suffer from upper respiratory tract infection or
acute tonsillitis usually are not adequately treated.
The most tonsil size found was T2-T2 in 25 samples
(62.5%). This is different from the study reported by
Shalihat, et al. (2015)17, as mostly tonsillar size in patients
with chronic tonsillitis is T3-T3. In chronic tonsillitis
there is a persistent or recurrent infection occur, causing
the tonsils to work harder to fight germs so that the tonsil
become enlarged. Consequently, hyperplasia and fibrosis
formation from the parenchymal connective tissue and
lymphoid tissue results in tonsillar hypertrophy.
In this study, there was a decrease in plasma F2-
Isoprostane level in patients with chronic tonsillitis
284  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
with OSAS risk after the administration of vitamin C
for 14 days, which is from 106.92 to 85.38, but this is
not statistically significant (𝜌 value = 0.064). While in
patients with chronic tonsillitis without OSAS risk there
was also a decrease in plasma F2-Isoprostane levels after
administration of vitamin C for 14 days, which is from
80.19 to 71.37, but not statistically significant (𝜌 value
= 0.383). Previous study by Alain (2011)18 has shown
that isoprostane level was significantly higher in OSAS
patients compared to healthy patients. Some mechanisms
are responsible for increasing ROS and RNS production
in OSAS, including recurrent hypoxia and reoxygenation
cycle, increased of inflammatory response, sympathetic
activity and ROS production.18 Recurrent hypoxia
occurs in patients with OSAS. Hypoxia will decrease
the oxygen supply to tissues and cells, thus disrupt the
electron transport to the cell membrane. These result in
electron leakage and lead to oxygen radicals formation
that will trigger the occurrence of superoxide radicals
(O2-). Superoxide radicals can damage cells and tissues.
Sleep apnea syndrome has been recognized as
a very common public health problem (3-6% in adult
population) with an increase of cardiovascular morbidity
and mortality. The studies recognize the most common
form in syndrome (80%), obstructive sleep apnea
syndrome (OSAS), as 60-70% of patients are obese, about
68% is hypertensive patients, 63% of dyslipidemia, and
16% are diagnosed with type 2 diabetes or prediabetes.19
OSAS consists of recurrent apnea episodes or
hypopnea during sleep resulting in hypoxemia. The
cycle change in arterial oxygen saturation can increase
ROS production and disturb the balance between
prooxidants and antioxidants. The recurrence episodes
of apnea or hypopnea and the decreased of oxygen
saturation in the blood can alter cell metabolism, such
as ischemia or reperfusion. Thus, result in loss of cell
compartment integrity. At this state, the iron released
from lysosomes can cause or increase the production of
free radicals. These abnormalities in cell then followed
by mitochondrial damage, associated with a direct
relationship of free radicals to the respiratory chain.
Both of these situations result in the accumulation of
ROS, namely superoxide radicals (O2-).
From this study there were differences in the
decrease of F2-Isoprostane level between chronic
tonsillitis patients with OSAS risk and without OSAS
risk, but it is not statistically significant (𝜌 value=0.751).
The average decrease in F2-Isoprostane level in patients
with chronic tonsillitis with OSAS risk is 21.54, whereas
chronic tonsillitis patients without OSAS are 8.81. Based
on the study reported by Soetjipto (2007)20, airway
obstruction can cause OSAS, from 79 samples of adults
there were 64.56% with multi-location obstruction.
The location that caused obstruction in most adults was
nasal turbinate (76.4%), followed by oropharynx due
to enlargement of tonsils (65.91%) and velopharynx
caused by palatal abnormalities (64.81%). Besides that,
obstructive hypoventilation is caused by the partial
obstruction of the air flow which causes hypoventilation
and hypoxia.21
Oxidative stress has been involved in various
diseases including cancer, cardiovascular disease,
ischemia or reperfusion, aging, and chronic tonsillitis.
Reactive oxygen species (ROS) including hydroxyl
radicals, superoxide radicals, and hydrogen peroxide,
which are produced by activated granulocytes, play an
important role in many biochemical processes such as
intracellular messages in cell differentiation, apoptosis,
immunity, and defense against microorganisms. In
contrast, the overproduction of these ROS, which occurs
in inflammation process, produces oxidative stress. The
main target of ROS is polyunsaturated fatty acids in cell
membranes that cause lipid peroxidation and isoprostane
formation, which can cause damage to cell structure and
function.
There are many evidences show that ROS during
chronic inflammatory process mediates the regulation of
tonsillar pathophysiological functions. The inflammatory
response is the first protective barrier against upper
respiratory tract infections. Several recent studies have
shown that inflammatory reactions are often closely
related to the generation of free radicals. It has been
shown that oxidative metabolism of peripheral blood
granulocytes is altered in 30% of patients with tonsillar
hypertrophy and in 75-90% of patients with recurrent
tonsillitis.22
OSAS is characterized by a recurring period of
upper airway collapse and a hypoxic or reoxygenation
cycle that causes an increase in oxygen species
formation by oxidative stress. Oxygen free radicals
formed will catalyze lipid peroxidation which will
produce isoprostan. Research conducted by Carpagnano,
et al (2002)11 showed that isoprostane in the peripheral
blood and condensate breaths from patients with OSAS
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  285
were increased. Hypoxia is a condition of low oxygen
11
concentration in cells or tissues that can threaten the life
of cell, and it can result in cell injury which will cause an
increase in ROS by mitochondria. Cells have a defense
against attack from ROS, in the form of antioxidant
enzymes, they act as inhibitors that can inhibit oxidation
by reacting with reactive free radicals that will form
non-reactive free radicals. In the body, free radicals
cause lipid peroxidation processes which can produce
isoprostane compounds.
Isoprostane is a prostaglandin-like compound formed
in vivo through lipid peroxidation through unsaturated
fatty acids. Isoprostane has several advantages over
other oxidative stress biomarkers. One of the advantages
of isoprostane is that chemically stable. Isoprostane has a
different ring structure and has strong biological activity.
Vitamin C is one of the antioxidants that dissolves
in water, has an effect as free radical scavenging and
inhibiting the process lipid peroxidation.23 The study
conducted by Block et al. (2008)14 that dose of vitamin
C was given 1000 mg per day for two months can
reduce plasma F2-Isoprostane level in overweight
smokers, passively exposed nonsmokers and healthy
nonsmokers.15 This difference in results may be due
to a short duration of intervention, a lack of patient
compliance with vitamin C, patients exposed to cigarette
smoke even though as a secondhand smoke and other
extrinsic factors which can increase levels of free
radicals.
Vitamin C is an effective antioxidant and is called
the first defense system. When ascorbate runs out, F2-
Isoprostane will form in plasma which is exposed to
aqueous peroxyl radicals, so that vitamin C can be used
as an antioxidant against lipid peroxidation.24
 Conclusion
There was an insignificant decrease in plasma F2-
isoprostane level in patients with chronic tonsillitis
with and without risk of OSAS after administration of
vitamin C and there was no significant difference in
decreased of plasma F2-isoprostane level in patients with
chronic tonsillitis at risk for OSAS after administration
of vitamin C especially in chronic tonsillitis patients
without OSAS risk.
  Conflict of Interest: The author does not have a
conflict of interest to express.
  Acknowledgments: The author is very grateful to
all patients who were willing to participate in this study.
  Ethical Clearance: Biomedical Research on
Human Ethics Committee, Faculty of Medicine,
Hasanuddin University, Makassar, Indonesia (Register
number: 72 / UN4.6.4.5.31 / PP36 / 2019).
Source of Funding: All costs in this study are
borne by the researcher and do not get sponsors from
anywhere.
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Comparison of Intraoperative Bleeding and Postoperative Pain
of Tonsillectomy Using Method of Radiofrequency Dissection
and Excision Dissection

Amsyar Akil1, Eka Savitri1, Heike Wilda Lokey1

1
Department of Ear, Nose, throat, head-neck surgery, Faculty of Medicine, Hasanuddin University, Makassar

Abstract
Background: The operation of tonsillectomy in addition to the technique of simple tonsillectomy can also
be done by the technique of bipolar radiofrequency that in research in 2007 in German universities found
postoperative pain and Intraoperative bleeding is significantly lower with the use of bipolar radiofrequency
compared with simple tonsillectomy. To date, there has been no research on the comparison of radiofrequency
techniques and excision dissection in Indonesia, especially in Makassar.

Purpose: Find the best tonsillectomy technique based on the volume of bleeding and postoperative pain.

Research materials and methods: This research is done by the cross sectional of fourteen patients. The
tonsillectomy procedure done by using radiofrequency dissection of 6 patients and with excision dissection
of 8 patients, then measured the number of intraoperative bleeding and postoperative pain.

Results: This study showed that there was a decrease in the volume of intraoperative bleeding and a lighter
pain in radiofrequency dissection compared to the excision dissection that was evaluated during the 6-hour
post-operative. The 24-hour postoperative evaluation does not exhibit significant pain differences in both
dissection techniques.

Conclusion: The use of radiofrequency techniques in tonsillectomy procedure is better than the excision
dissection technique because it can reduce the volume of intraoperative bleeding as well as the lighter
postoperative pain complained .

Keywords: chronic tonsillitis, radiofrequency, excision dissection

Introduction in 2006, more than 530,000 operating procedures

of tonsilectomy in children were carried out. In the
Tonsilectomy is the most commonly performed
last decade, the tonsilectomy is not only performed
procedure in the history of surgery and one of the oldest
for recurrent tonsillitis, but also for a wider range of
procedures that is still done since 1000 BAD and the
conditions including dietary difficulties, weight gain
frequency decreases drastically since the emergence of
failure, overbite, tounge thrust, halitosis, snoring,
antibiotics. In 1985 in the United States, the incidence
and also Speech disorder. The American Academy of
of tonsilectomy was 350,000 to 400,000 per year and
Otolaryngology-Head and Neck Surgery has issued
an official recommendation which is an agreement of
Corresponding author: experts on the indication of the action of Tonsilectomy.
1, 2, 3
Wilda Heike Lokey,
Department of Ears, Nose, Throat, Head – Neck
Tonsilectomy can cause pain, bleeding and edema
Surgery, Faculty of Medicine at Hasanuddin University,
in the injured part, sore throat, difficulty swallowing,
Makassar, 90245 Indonesia.
eating and drinking disorders, nausea and vomiting until
Email: heikelokey86@gmail.com
it falls on a state of dehydration. It can decrease patient
288  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

satisfaction against the operation of Tonsilectomy. kassa weight of 0.4 grams, then calculated based on the
The results of previous retrospective studies received calculation of blood density overall is 0, 94x10-9 in ml
a secondary incidence of post-tonsillectomy reaching and added to the volume of blood in the suction tube that
10.1%, this is largely due to the release of mediators has been reduced by another fluid used to rinse.
during pain that resulting an increased treatment
Measurement of postoperative pain
duration. 4
Pain is calculated by using a visual analog scale
The use of radiofrequency is widely applied
(VAS) with the results obtained are the value of VAS
in the medical world. Previously researched use of
more than 0 mm and less than 10 mm expressed no
radiofrequency in fat-attachment surgery on the palate,5
pain, mild pain is the value according to the VAS more
on thoracic surgery and joint operations,6 and also used
than equal to 10 mm to 30 mm, moderate pain is values
for chemotherapy,7 some researchers also connect the
according to VAS 31 mm to 70 mm. Severe pain is the
use of radiofrequency in surgery Adenootonsillectomy in
value according to VAS 71 mm to 90 mm, very severe
patients with cochlear implant implants with results of no
pain is the value according to the VAS 91 mm to 100
influence that worsens due to the use of radiofrequency.8
mm. This pain measurement is measured during 6 hours
The study of Pfaar et al for treatment using bipolar post-operative and 24-hour post-operative.
radiofrequency compared with simple tonsilectomy was
conducted at German University in 2007 with results on
Results
radiofrequency groups, found that Postoperative pain, Sample characteristics
difficulty swallowing and speaking, and intra-operative
blood loss is significantly lower, and the operating The gender of the sample is more male sex patients
duration is significantly shorter (all p< 0.05).9 who are 8 people (57.14%) The most sample age is the
age of < 20 years, which is 6 people (42.86%), for the
Materials and Method category of tonsils size 6 people (42.86%) has a tonsils
size of T2-T2 and 8 persons (57.14%) has a T3-T3
Patient Group Criteria
tonsils size.
The study consisted of 14 patients suffering from
Table 1. Frequency Distribution
chronic tonsillitis undergoing tonsilectomy and divided
into two groups. The first group, 6 patients of chronic
Sampel Characteristics N %
tonsillitis, used a radiofrequency dissection and a second
group of 8 patients with chronic tonsillitis, using excision Gender

dissection technique. Patients conducted anamnesis, Male 8 57,14

physical examination, as well as fill in the approval Female 6 42,86
of the operation procedure and conducted laboratory
Age
examination and thorax x-ray for the preparation of
surgery. The postoperative patiens was given the same <20 year 6 42,86
analgesic paracetamol that is adjusted for the patient’s 20-35 year 5 35,72
weight. Patients with persistent adenoid hypertrophy,
>35 year 3 21,42
lower respiratory tract infection, tonsil tumor, anatomical
Tonsil size
disorder of the head and neck area, suffering from
systemic or metabolic diseases such as diabetes mellitus, T1-T1 0 0
hypertension, stroke, pulmonary tuberculosis, and blood T2-T2 6 42,86
disorders patients, are included in the exclusion criteria.
T3-T3 8 57,14
Intra-operative bleeding measurement

The bleeding measured in this study is an intra- Comparison of the volume intraoperative bleeding
operative bleeding measured based on the volume of the between an excision dissection and radiofrequency
gauze weight mixed with blood reduced by the initial surgery
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  289

The mean value of the volume of bleeding in the surgery is 4.17 with a standard deviation of 1.94. Based
excision dissection of the surgery is 75.625 ml with a on the statistical T-Test showed that there was no
standard deviation of 49.3672, while the average volume significant comparison of pain between the patients with
of bleeding in radiofrequency surgery is 7.612 with a excision dissection and radiofrequency in the value of
standard deviation of 4.4058. According to statistical Ρvalue = 0.484 (ρ = < 0.05).
T-test shows that there is a comparison of the volume
Table 4. A comparison of 24-hour postoperative
of significant bleeding between the patient’s excision
pain
dissection and radiofrequency with a value of 𝜌value =
0.000 (ρ = < 0.05) (table 2).
Deviation
Group Mean P-Value
Table 2. Volume of intraoperative bleeding Standard

Excision
Deviation 3,38 1,18
Group Mean P-Value dissection
Standard 0,484
Excision Radiofrequency 4,17 1,94
75,625 ml 49,3672
dissection
0,000
7,612 ml 4,4058 Decreased postoperative pain of tonsilectomy using
Radiofrequency
radiofrequency and excision dissection.

Comparison of Pain 6 hours post-operative In table 5 shows a comparative reduction in

tonsillectomy patients surgical dissection of excision
and radiofrequency.
Table 3 shows a comparison of 6-hour postoperative
pain between excision dissection and radiofrequency,
the average pain in excision dissection is 6.13 with
a standard deviation of 0.64, while the average pain
in radiofrequency dissection is 5.50 with standard
Deviation 2.07. Based on the statistical T-Test showed
that there was a significant pain ratio between excision
dissection and radiofrequency dissection with a value of
Ρvalue = 0.000 (ρ = < 0.05).
Table 3. 6-hour post-operative pain ratio
Deviation
Group Mean P-Value
Standard
postoperative pain between excision dissection and
radiofrequency dissection, the average pain decrease in
excision dissection is 2.75 with a standard deviation of
1.03, while the average pain reduction in the dissection
radiofrequency is 1.33 with a standard deviation of
2.06. Based on statistical T-test shows that there is
a comparison of significant pain reduction between
the patients of excision dissection and dissection of
radiofrequency with a value of Ρvalue = 0.010 (ρ = <
0.05).
Table 5. Comparison of postoperative pain
reduction
Deviation
Group Mean P-Value
Standard

Excision Excision
6,13 0,64 2,75 1,03
dissection dissection
0,000 0,010
Radiofrequency 5,50 2,07 Radiofrequency 1,33 2,06

Comparison of 24-hour postoperative pain on Discussion

tonsillectomy patients performed by excision dissection
and radiofrequency.
In table 4 shows a comparative pain of the 24-hour
postoperative tonsillectomy using excision dissection
and dissection of radiofrequency, the average pain in
an excision dissection is 3.38 with a standard deviation
of 1.18, while the average pain in the Radiofrequency
In this study, it can be seen that most male gender
samples were 8 people (57.14%) ,evidenced by the study
results on the profile of tonsillitis patients in Sangla
hospital, men are more often exposed to tonsillitis
because men have lower immune system than women,
where women Has an estrogen hormone that has
functions as a reinforcement of humoral and cellular
290  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

antibodies.10 bleeding during surgery depends on the condition of the

patient and its own operatoric factor. Bleeding may be
The most sample age is < 20 years, which is 6 people
more when there is excessive scarring or acute infections
(42.86%), describing that children and adolescents have
such as acute tonsillitis or peritoncil abscesses. Bleeding
low body resistance so it is easy to get infected.1 Described
that occurs due to capillary or small veins, ripped
also in some children followed by the enlargement of
veins generally stop spontaneously or with tampons. If
the adenoid gland . So that there can be an obstruction
it still fails, the external carotid artery ligation can be
in respiratory system at bedtime is referred to as OSAS
performed. From reports of various libraries, the surgical
(Obstructive Sleep Apnea Syndrome).10 Obstruction of
techniques known as “hot” techniques (Electrokauter,
upper respiratory system that occurs at bedtime can cause
radiofrequency, Koblasi, etc.) can reduce morbidity and
hypoxia (lack of oxygen), this condition can decrease
risk of postoperative bleeding. 11,12
Immunological resistance that can lead to infection and
frequency of pain can interfere with children’s growth Comparing the 6-hour postoperative pain between
and development, especially in childhood growth, so that excision dissection and radiofrequency, the average pain
the tonsilectomy needs to be done. 1 ,10 Carneiro study in excision dissection is 6.13 with a standard deviation
in Brazil also reported improvement in quality of life in of 0.64, while the average pain in radiofrequency
children who have had tonsillectomy. This occurs due dissection is 5.50 with a standard deviation of 2.07.
to reduced sleep disorders caused by tonsil hypertrophy. According to statistical T-test shows that there is a
The tonsilectomy also reduces the incidence of upper significant ratio of pain between the patient’s excision
respiratory tract infections and reduce antibiotic use. 10,15 dissection and radiofrequency with a value of Ρvalue =
0.000 (ρ = < 0.05) Whereas at 24 hours post operation,
In this study there were 6 people with a tonsils size
comparison of pain between dissection radiofrequency
of T2-T2 (42.86%) and 8 people have a tonsils size of
and excision dissection obtained the average pain in
T3-T3 (57.14%), which means the largest tonsils size
excision dissection is 3.38 with a standard deviation
is found to be the size of T3 – T3. This result was in
of 1.18, while the average pain in the dissection of
accordance with the cross sectional study in 812 patients
radiofrequency is 4.17 with a standard deviation of
who had tonsilectomy, there were 341 (42%) with a
1.94. Based on statistical test T-test shows that there is
tonsils size of T3, as much as 308 (38%) T4 size, as much
no significant comparison of pain between the patient
as 130 (16%) T2 size and as much as 33 (4%) ukuranT
excision and dissection of radiofrequency with a value of
1.10 Until now there is no data that can explain about
Ρvalue = 0.484 (ρ = < 0.05). Of these two different pain
the differences between some of these studies. One of
statements can be seen that each person’s pain threshold
the tonsils enlargement factors is the infection in tonsils.
differs. For severe post-operative pain tonsilectomy
The size of the tonsils is enlarged due to a parenchyma
depends on several factors, such as: patient’s health
hyperplasia or fibrinoid degeneration with a crypts
condition, operator skills, tonsilectomy technique,
tonsils obstruction.13 Recurrent infections and blockages
surgical complications and pain management. 14,15
of the tonsils resulting in increased stasis of debris or
antigen in the crypts, also occurring reduced integrity Comparative postoperative pain reduction between
of the crypts epithelium so as to facilitate bacteria into excision dissection and radiofrequency dissection
tonsil parenchyma. 17 obtained an average decrease in pain in excision
dissection is 2.75 with a standard deviation of 1.03,
This study showed a comparison of the bleeding
while the average reduction of pain in radiofrequency
volume between excision dissection and radiofrequency
dissection is 1.33 with standard deviation 2.06. Based on
surgery. The average volume of bleeding in an excision
T-test statistics, there is a significant comparison of the
dissection is 75.625 ml with a standard deviation of
pain reduction between the patient’s excision dissection
49.3672, while the average volume of bleeding in
and the dissection of radiofrequency with a value of
radiofrequency surgery is 7.612 with a standard deviation
Ρvalue = 0.010 (ρ = < 0.05). This suggests that in the
of 4.4058. Based on statistical T-test shows that there is a
excision dissection there is a noticeable change of pain
significant comparison of the bleeding volume between
reduction from the 6-hour post-operative to the 24-hour
the patient’s excision dissection and radiofrequency with
postoperative. The possibility of the use of the dissection
a value of Ρvalue = 0.000 (ρ = < 0.05). The Volume of
dissection of many tissue damage occurs compared to
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  291
the use of radiofrequency. This is in accordance with the
literature says that pain caused by tissue damage as well
as increased release of the mediator that can generate
pain impulses subsequent pain and finally causing
muscle spasm (16,20)
The frequent postoperative pain of tonsilectomy is
difficult to prevent since the oropharyngeal region and
fossa of the peri-tonsiller are pain-sensitive areas. Both
are innervate by the trigeminal nerve (n. III) branches
and the glossofaringeus nerve (n. IX) which is highly
sensitive to pain stimulation and connected to the
somatic cortex in the cerebral. (18,19)
Post-operative pain management of tonsilectomy is a
special concern for both ENT-HN surgeon and anesthetic
doctors. High incidence of pain or postoperative anxiety
after tonsilectomy increase the risk of secondary
bleeding of postoperative tonsilectomy. 21
To prevent these postoperative pain, it is necessary
to know the mechanism for postoperative pain, the
negative impact of pain, the effort to reduce postoperative
pain and to choose rational analgetic to overcome the
postoperative pain of tonsilectomy. 4 12
In research from Victor et al. 2018 the use of
radiofrequency can reduce postoperative pain in
comparison with other methods of operation. 12
Conclusion
The use of radiofrequency techniques in tonsilectomy
is better than the excision dissection technique because it
can reduce the volume of bleeding occurring as well as
the pain complained more lighter.
Patients undergoing tonsilectomy using
radiofrequency should be considered for analgesic use
while those undergoing excision dissection should use
analgesic for postoperative pain treatment.
Conflicts of Interest: The authors have no conflicts
of interest to declare.
Acknowledgments: The authors very gratefully
thanks to all patients who were willing to be a respondent
in this study.
Ethical Clearance: Taken from Biomedical
Research Ethics Committee on Human Faculty of
Medicine Hasanuddin University of Makassar, Indonesia
(Register number :52 / UN4.6.4.5.31 / PP36/ 2019).
Source of Funding: All costs in this study are
funding by the searcher and do not get any sponsors.
References
[1] Benjamin J. Rubinstein, C. S. 2017.
Rethinking surgical technique and priorities for
pediatric tonsillectomy. American Journal of
Otolaryngology- Head and Neck Medicine and
Surgery vol. 38 , 233-236.
[2] Leif Back, M. P. Traditional Tonsillectomy
Compared With Bipolar Radiofrequency
Thermal Ablation Tonsillectomy in Adults. Arch
Otolaryngology Head Neck Surgery 2001.vol.
2016. 127 , 1106
[3] Metin Yilmaz, M. D. Thermal welding versus
cold knife tonsillectomy : A prospective
randomized study. Kaohsiung Journal of Medical
Sciences. 2012. vol. 28 , 270-272.
[4] Dedi K. Penggunaan Blok Peritonsiler untuk
mengurangi Nyeri pasca operasi Tonsilektomi.
Jurnal FK.UNAND. 2018. 291-296.
[5] Woodson tucker.b, tadokoro s.kent. mackay G.
stuart. Radiofrequency ablation of the lateral
palatal space for snorry. World journal of
Otorhinolaryngology-Head and Neck Surgery.
2017. 3, 106e10.
[6] Mendis victor, mottaleb ramy, fung ming.
Radiofrequency techniques in pain management.
Anaesthesia and intensive care medicine.
Elsevier.2016
[7] Mackeyev Yuri, mark Colette, kumar Natasha,
serda. E. Rita. The influence of cell and
nanoparticle properties on heating and cell death
in a radiofrequency field. Acta Biomaterialia 53.
2017. 619–630
[8] Gropler c. matthew. Et. Al. Safety of
radiofrequency ablation for adenotonsillectomy
after cochlear implantation. International Journal
of Pediatric Otorhinolaryngology 114. 2018. 67–
70
[9] Pfaar O, et al. Treatment of hypertrophic
palatine tonsils usin bipolar radiofrequency-
induced thermotherapy (RFITT). NCBI Journal.
Ruprecht-Karls Univercity Heildelberg,
Mannheim, Germany. 2009. 127(11), 1176-81.
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[10] Ni Made Putri Rahayu Srikandi, Sari Wulan Dwi
Sutanegara, I Wayan Sucipta. Profil pembesaran
tonsil pada pasien tonsilitis kronis yang menjalani
tonsilektomi di rsup sanglah. Department of Ear,
Nose and Throat, Medical School, Udayana
University/Sanglah Hospital, Denpasar. 2013.
[11] Told, T. N. Tonsillectomy and Adenoidectomy.
In Eyes, Ears, Nose and Throat (pp. 519-528).
Elsevier. 2018.
[12] Victor, M, Ramy M, Ming F, 2016.Radiofrequency
techniques in pain management.Anaesthesia and
intensive care medicine (17.11).Elsevier.
[13] Designer A. Elise. Et.al. Preoperative opioid
use and postoperative pain associated with
surgical readmissions . The American journal of
surgery.2019
[14] Hunter A. selena,martin Rachel,weat berall
mark,gallet Duncan. Anasthetists and surgeon
predict postoperative pain. American society of
perianesthesia nurses.2016
[15] Aubrun Frederic et.al. Revision of Expert
Panel’s Guidelines on Postoperative Pain
Management. Anaesthesia Critical Care and Pain
Medicine.2018.
[16] Evans w.s, mc. Cahon.A.R. Management of
postoperative pain in maxillofacial surgery.
british journal of oral and maxillofacial surgery
57. 2018. 4-11
[17] Battal Tahsin Somuk, E. S. 2016. Evaluation
of iron and zinc levels in recurrent tonsilitis
and tonsilar hypertrophy. American Journal of
Otolaryngology - Head and Neck Medicine and
Surgery , 116-119..
[18] Phillip Huyett, J. E. Tonsillectomy. In Pediatrics-
Airway. Elsevier.2018. (pp. 1347-1358)
[19] Irenland c.katharine, lalkhen G abdul.
Postoperative analgesia. Elsevier. 2019. 20:2.
[20] Kurnia, D. Penggunaan Blok Peritonsil untuk
Mengurangi Nyeri Pasca Operasi Tonsilektomi.
Junral Kesehatan Andalas.2018.vol.7
[21] Bacb mette anne, forman axel,lene seiback.
Postoperative pain management: a bedside
perspective. The American society for pain
management nursing. 2018.
 Relationship between Inflammatory Response on Chronic
Rhinosinusitis with Polyps and without Polyps Review for Il-8,
Eosinophyl and Neutrophyl

Abdul Qadar Punagi1, Sofiatun Nurhuda Putri1, Husni Cangara2, Sutji Pratiwi1
1
Department of Otorhinolaryngology, Head-Neck Surgery, 2Department of Pathology Anatomy,
Faculty of Medicine, Hasanuddin University, Makassar, Indonesia

Abstract
Background: This study aimed to ascertain the association between inflammatory response in chronic
rhinosinusitis with polyp and without polyp based on IL-8, eosinophil, and neutrophil observation.

Method: the study was conducted on 20 chronic rhinosinusitis patients with polyp and 20 chronic
rhinosinusitis patients without polyp. Examination of IL-8 level was done by using ELISA method, while
eosinophil and neutrophil cell examination was done by using nasal cytology.

Results: Of the 20 patients with chronic rhinosinusitis with polyps and 20 patients without polyps, IL-8 levels
were significantly increased in patients with chronic rhinosinusitis without polyps. Meanwhile, in nasal
cytology examination, eosinophil cells increased dominantly in chronic rhinosinusitis patients with polyps,
while neutrophil cells increased dominantly in chronic rhinosinusitis patients without polyp (p<0.05).

Conclusion: There were difference of IL-8 level and eosinophil, neutrophil cells between chronic
rhinosinusitis with polyp and without polyp.

Keywords: IL-8, eosinophil, neutrophil

Introduction secretions from mediated meatus and edema in the

According to the 2012 European Position Paper
on Rhinosinusitis and Nasal Polyps (EPOS), chronic
rhinosinusitis (RSK) is an inflammation of the nasal
mucosa and paranasal sinus which symptoms’ last for
than 12 weeks, characterized by two or more symptoms,
such as nasal congestion, obstruction, congestion or
nasal discharge. This condition can be accompanied by
facial pain spontaneously or appear when suppressed,
and reduced ability to smell. Meanwhile, in endoscopic
examination could find polyps or mucopurulent
meatus. Besides, Computed Tomography (CT) scan
results are obtained mucosal changes in the ostiomeatal
complex or paranasal sinuses.1
Rhinosinusitis is an inflammatory disease of the nasal
mucosa and paranasal sinuses. According to consensus
of 2004, rhinosinusitis is classified chronologically into
several categories; acute (up to 4 weeks), sub-acute (4 to
12 weeks), and chronic (more than 12 weeks). When it
occurs on several sinuses, it is called multisinusitis and
called pansinusitis if it occurs on all sinuses.2

The prevalence of chronic rhinosinusitis has also

Corresponding author:
Sofiatun Nurhuda Putri
Department of Otorhinolaryngology, Head-Neck
Surgery Faculty of Medicine, Hasanuddin University
Perintis Kemerdekaan Km.11, Tamalanrea
Makassar (90245) Indonesia.
Email : sofiatun.nurhuda @ gmail .co .id
been reported in several areas in Indonesia. A study in
Cipto Mangunkusumo Hospital’s Department of ENT’s
Rinology Division found 69% of 435 patients had
rhinosinusitis, while a study in Makassar which taken
from three hospitals had prevalence 41.5% of all cases
treated in rhinology sub-division.3,4
294  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Chronic rhinosinusitis can be classified into two
subtypes namely chronic rhinosinusitis without polyps
and rhinosinusitis with polyps. The two groups are
different in inflammatory profile and remodeling
process. Those differences can affect prognosis, asthma
comorbidity, appropriate surgical procedures, relapse
rates, and pharmacological management.
The main cause of chronic rhinosinusitis is
obstruction of sinus ostium. Various factors, either local
or systemic can cause inflammation or conditions that
lead to obstruction of the sinus ostium, such as recurrent
upper respiratory tract infections, allergies, irritant
material exposure, anatomic disorders, and immune
deficiency. Although some studies mentioned the role of
eosinophils in the pathogenesis of chronic rhinosinusitis,
especially in patients with a history of allergies,
other studies also mentioned the effect of neutrophil
recruitment into mucosal surfaces, especially in patients
without a history of allergies.
Materials and Method
This study was conducted in otorhinolaryngology
division of Hasanuddin University Hospital and Wahidin
Sudirohusodo hospital during December 2018-March
2019. This study aimed to identify the difference of
inflammatory responses (IL-8 levels, eosinophils,
neutrophils) in patients with chronic rhinosinusitis
with polyps and without polyps, and also observed the
pathomechanism of the occurrence of polyps in chronic
rhinosinusitis.
The sample is affordable population who met the
study criteria. Samples were taken by using consecutive
sampling method, which is all patients with chronic
rhinosinusitis with polyps and without polyps who met
the inclusion and exclusion criteria based on the order
of the patients’ register. Inclusion criteria, based on
European Position Paper criteria on Rhinosinusitis and
Nasal Polyps (EPOS) 2012, were ages 18-70 years old,
consent to take part in the research study and sign the
Informed Consent, while the exclusion criteria including;
have a history of severe systemic disease (kidney disease,
liver disease, malignancy, autoimmune disease, heart
disease). Nasal / paranasal sinus tumor, Has a history
of previous sinus / nose surgery (Functional Endoscopic
Sinus Surgery), Anatomic variations such as severe
septal deviation, septal perforation, and synechiae,
Atrophic Rhinitis Patients.
Samples were taken from the right and left
inferior nasal concha surfaces of patients diagnosed
with chronic rhinosinusitis with polyps or without
polyps, and examined for IL-8 levels by using ELISA
method. Meanwhile, Eosinophil and neutrophil cells
were analyzed by using nasal cytology method under
a microscope with a 100x objective and examined
throughout the field of view were grouped into 6 grades:
1. Grade 0, inflammatory cells <10 per field of view
2. Grade 1, inflammatory cells 10-49 per field of
view
3. Grade 2, inflammatory cells 50-149 per field of
view
4. Grade 3, inflammatory cells 150-299 per field of
view
5. Grade 4, inflammatory cells> 300 per field of
view
Results
Table 1 shows that eosinophils cells in the polyp
group mostly categoriezed 1 and 2 (80% and 10%)
compared to category 0 (10%), while in the group
without polyps, there are more categories 0 and 1 (80%
and 20%), while category 2 does not exist at all, the
results of chi square statistical test show a significant
difference with p = 0.000 (p <0.05).
The mean of eosinophils counts per10 field of view
in chronic rhinosinusitis with polyps was 297.95, while
without polyps was 236.25. There were significant
differences between the two groups with p = 0.000 (p
<0.05). (table 2)
Table 3 shows category 0 and 1 of neutrophils in
the polyp group is the same (50% and 50%), while in
the group without polyps, neutrophils category 1 (75%)
is more than category 0 and 2 (15% and 10%). The
results of statistical tests showed a significant difference
between the two groups with p = 0.046 (p <0.05).
Mean of neutrophil level in polyp was 168.35
and without polyp were 245.45. there were significant
differences between the groups with p = 0.041 (p <0.05).
(table 4)
Based on the table 5, there are significant differences
between IL-8 levels in chronic rhinosinusitis with polyps
and without polyps with p = 0.004 (P <0.005)
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  295
Table 1. Distribution of eosinophil cells category in chronic rhinosinusitiswith polyp and without polyp

Rhinosinusitis Eosinophil Total P

0 1 2

Polyp 2 (10%) 16 (80%) 2 (10%) 20 (100%) 0.000

Without polyp 16 (80%) 4 (20,0%) 0 (0%) 20 (100%)

X 2 (chi square ) test

Table 2. The difference of eosinophil cells between chronic rhinosinusitis with polyp and without polyp.

Eosinophil Polyp Without Polyp P

Mean 297.9500 236.2500

Median 320.00 215.00
Standard deviation 152.35 121.62
0.000
Minimum 86.00 78.00

Maximum 640.00 520.00

Mann whitney U test

Table 3. Distribution of neutrophil cells category in chronic rhinosinusitis with polyp and without polyp

Rhinosinusitis Neutrophil Total P

0 1 2

Polyp 10 (50%) 10 (50%) 0 (0%) 20(100 %) 0.046

Without Polyp 3 (15%) 15 (75%) 2 (10%) 20(100%)

X2 (Chi-square) Test

Table 4. The difference of neutrophil cells between chronic rhinosinusitis with polyp and without polyp

Neutrophil Polyp Without Polyp P

Mean 168.3500 245.4500

Median 141.500 215.00
Standard Deviation 102.34 111.41

0.041
Minimum 56.00 120.00

Maximum 365.00 520.00

Uji Mann-whitney U
296  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
Table 5. IL-8 level of chronic rhinosinusitis with polyp and without polyp
Rhinosinusitis
IL8 Polyp
Mean 201.3391
Median 189.85
Std. Deviasi 1310.80
Minimum 154.53
Maksimum 272.45
*T test
Discussion
The result of this study showed a significant
difference between eosinophil counts in chronic
rhinosinusitis with polyps and without polyp. It means
that the role of eosinophils is very dominant in chronic
rhinosinusitis with polyps. This is similar with previous
studies.7 EPOS 2012 showed that chronic rhinosinusitis
with polyps is an inflammation triggered by Th2 which
caused infiltration of eosinophils in the blood to nasal
mucosal tissue.8 High eosinophil levels in chronic
rhinosinusitis with polyps lead to more severe disease
associated with olfactory nerve dysfunction, more nasal
obstruction and nasal secretions. Inflammation due to
Th2 and eosinophils affects polyp formation through
stromal tissue and pseudocystic edema, and also increase
fibrin production due to activation of factor XIII-A which
causes the process of remodeling nasal mucous tissue.9
This study found a significant difference between
neutrophil counts in chronic rhinosinusitis with polyps
and without polyp. It means that the role of neutrophil is
very dominant in chronic rhinosinusitis without polyps.
This result is similar with a study conducted in Korea
which stated that chronic rhinosinusitis without polyps is
dominated by inflammation due to neutrophyl-associated
mediators and chemokines such as CXCL-2 and IL-8,
which are associated with the severity of the disease.
The Korean study also proves that the pathogenesis of
chronic rhinosinusitis without polyps have two forms of
inflammation regulated by Th1 and Th2, although the
role of neutrophils remains dominant and is associated
with disease progression.10 chronic rhinosinusitis
without polyps is dominated by neutrophils because the
inflammatory type is a combination of Th1 and Th17. A
Without Polyp P
279.1389
282.00
38.68
0.004*
218.15
351.29
previous study was also stated that the Asian race had
the characteristics of chronic rhinosinusitis with polyps
dominated by neutrophils, while Caucasian (European)
race dominated by eosinophils.7
IL-8 expression in the sinus mucosa increases in
chronic rhinosinusitis especially without polyps because
it is associated with its main activity in neutrophils and
through stimulation by Th1. The results ofInterleukin 8
(IL-8) are a chemokine produced in large quantities by
epithelial cells in response to various stimulus including
proinflammatory cytokines, bacteria, fungi, and viruses,
and tend to be a kind of protein that activate neutrophils
with two invitro effects, chemotaxis and the release
of enzyme granules. In allergic diseases, IL-8 is also
chemoattractant in eosinophils, so it can be increased in
rhinosinusitis with polyps du to Th2 effect that stimulates
eosinophils.11 Normal values ​​of IL-8 in adults based on a
cohort study in Europe are 0.56 - 3.80 (18 - 39 years) and
0.56 - 7.52 (40 - 65 years), so in general, mean of IL-8
levels in the patients of this study was quite high from its
normal range, which shows that IL-8 activity in chronic
inflammatory processes such as CRS is very high.12
Conclusion
This study concludes that eosinophil cells were
higher in rhinosinusitis with polyps, while neutrophil
cells were higher in rhinosinusitis without polyps. IL-8
level was significantly higher in rhinosinusitis without
polyps.
References
1. Fokkens W, Lund V, Mullol J, Bachret C, Baroody
F, Chen N, et al. European Position Paper On
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  297
Rhinosinusitis And Nasal Polip. Rhinology Journal
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 The Women’s Pregnancy Intention in Makassar City,
Indonesia

Apik Indarty Moedjiono¹, Arifin Seweng1, Indra Fajarwati Ibnu1, Anwar Mallongi1
Faculty of Public Hdealth, Hasanuddin Universitas Hasanuddin, Makassar Indonesia
1

Abstract
Contraceptive use is one of the main ones, which suggests that serious efforts are needed to increase
contraceptive use. Understanding comprehensively the issue of the intention of conceiving by referring
to ecological theory, this study provides benefits in preventing unwanted pregnancies. This study aims to
analyze determinant factors of pregnancy intention with a cross sectional study design. Subjects were 100
fertile women selected randomly in working area of Patingalloang and Panambungan Community Health
Center, Makassar City in 2018. Determination of study sample was based on results of the screening for
pregnancy intention in last pregnancy, women who take part in screening are divided into intended and
uninteded pregnancies. Data obtained through interviews using a structured questionnaire and analysis by
logistic regression. Results showed that side effects, availability of methods and number of living children
were found to be significantly associated with the pregnancy intention.

Keywords: pregnancy intention, theory of ecology, maternal health

Introduction or at any time in future. Mistimed pregnancies occur if a

The increase in uninteded pregnancies is marked by
high case of unmet need for contraceptive. An estimated
225 million women in developing countries have unmet
needs for modern contraception, of this number, 71%
million do not use any method and rest use traditional
methods1. Unmet need for contraceptive in Indonesia
in 2017 which is 10.5%, this percentage has decreased
slightly compared to 2012 which was 11.4%, and around
29% of contraceptive users stopped their methods in first
12 months of use2,3.
Unmet needs for contraceptive are defined as
married women of reproductive age who do not use any
contraceptive method but want to delay or limit the next
pregnancy4. In ideal situations, all women who want to
delay or limit their pregnancy will use contraception. But
some women do not use contraception and are at risk of
having unintended pregnancy. An unintended pregnancy
occurs if a woman does not intend to get pregnant later
Coresponding Author:
Apik Indarty Moedjiono
Email: indarty.95@gmail.com
woman does not intend to get pregnant when pregnancy
occurs, but intends to get pregnant at some time in the
future. Subsequent division, uninteded pregnancies
include unwanted and mistimed. Intended pregnancy is
a pregnancy that is desired when it occurs or faster 5,6.
Based on the results of the PMA survey in Makassar,
2015, unmet need (25.4%) higher than the national level
(14.4%)7. Based on the 2016 report, Patingalloang and
Panambungan Community Health Center are two health
centers with work areas serving coastal communities with
a high birth rate8, thus the study of pregnant intentions
is feasible for studied at women who use that facilities
at the working area. This research then uses Ecological
Theory to analyze determinant factors of the intention
of pregnant women. Choice of ecological theory in
determining determinant factors is very important to
look at these factors holistically9, so that the study of
specific pregnancy intentions in coastal communities
will provide comprehensive information, that there are
certain systems that shape women’s life experiences in
form of their intention to conceive.
Materials and Method
This study uses a quantitative method with a cross
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  299
sectional study design. This study looked at effects of Determination of study sample based on results of
side effects, susceptibility to pregnancy, role of the screening the last pregnancy intention, women who were
husband, value of the child, mechanism of promises, netted in the screening were divided into intended and
waiting times, availability of methods, provision of unintended pregnancies. Samples will be selected from
information, age of mother and number of children each group of pregnant intentions, with proportions
alive. This research was conducted in working area of​​ equal to simple random sampling. Data will be obtained
Patingalloang and Panambungan Community Health through interviews using a structured questionnaire.
Center. Study population was 100 fertile women. Data analysis will be carried out by logistic regression.

Results
Table 1. Characteristics of women dan husband in Makassar City, Indonesia

Variables n %

Age (Year) Wife

17-25 31 31
26-35 54 54
36-45 15 15

Level of education (Wife)

None
1 1
Elementary
25 25
Junior
24 24
High school
44 44
Higher education
1 1

Level of education (Husband)

None 0 0
Elementary 16 16
Junior 18 18
High school 55 55
Higher education 11 11

Condition of woman
Pregnant 55 55
Not pregnant 45 45

Currently using contraceptive

No 73 73
Yes 27 27
The last type of contraception used
Female sterilization
1
1
2
Male sterilization 2
1
IUD 1
74
Injection 74
16
Implant 16
6
Pill 6
300  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10

Place to get contraceptive methods

Goverment hospital 8 8
Community Health Center (Puskesmas) 71 71
Auxiliary puskesmas 1 1
Field officer of family planning (PLKB) 1 1
Health cadre 1 1
Private hospital 2 2
Private clinic 1 1
Private practice midwife 11 11
Pharmacies / drug stores 4 4
The duration of stopping contraception (years)
<1 25 25
1-5 45 45
6-10 2 2
≥10 1 1

Reasons for stopping contraception

Want to have children 46 46
Side effects 20 20
Distance 1 1
Husband is rarely at home 1 1
Husband’s desire 1 1
Contraceptive failure 4 4

Pregnancy intention
50
Intended 50
9
Mistimed 9
41
Unintended 41

Table 1 shows that wife’s age category is the most
aged 26-35 years (54%). The highest husband age is
in the age group 26-35 years (61%). The highest wife
education is at the level of high school graduation /
equivalent (44%). Husband’s education is highest at
senior high school level / equivalent (55%). Women
who have used and are not currently using contraception
(73%). The most widely used type of contraception is
injection (74%). Place to get the most contraception is
at the puskesmas (71%). The length of termination of
contraception is 1-5 years (45%). Reason for the women
to stop using the highest contraception was because they
wanted to have children (46%). Respondents who want
pregnancy (50%).

Table 2. Factors associated with pregnancy intention among women in Makassar City, Indonesia

CI Lower CI Upper
Standard Error p value Odds Ratio
Limit Limit
Individual Factor
Side effects 0,081 0,069 1,159 0,989 1,358

Susceptibility to pregnancy 0,197 0,262 1,248 0,848 1,837

Interpersonal factors
Role of the husband 0,119 0,777 0,967 0,766 1,221
Cultural Factors
Value of the child 0,162 0,177 1,244 0,906 1,709
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  301
Service Access Factor
Mechanism of promises 0,201
Waiting times 0203
Service quality factor
Availability of methods 0,474
Provision of information 0,135
Age of the mother 0,064
Number of children 0,333
Constants 2,013
Table 2 shows the multi-variable factors associated
with pregnancy intention among women in Makassar
City, Indonesia.
Susceptibility to pregnancy, role of the husband,
value of the child, mechanism of promises, waiting
times, provision of information, age of the mother are
found as a factor that are not significantly related to
pregnancy intention, while side effects, availability of
methods was found to be a significantly related factor
with alpha 10% toward the pregnancy intention, and
number of children living with alpha 5%.
Discussion
Injectable contraception and pills are contraceptives
most often stopped because of side effects at 12
months of use in developing countries10, the same
thing was found in this study that 74% of women used
injection contraception followed by other hormonal
contraceptives namely implants and pills, reasons
for stopping contraception 20% due to side effects
(Table 1). Statistical tests showed that side effects
had a significant effect on pregnancy intention at 10%
significance (Table 2). Termination of contraception for
reasons of side effects without being followed by use
of contraception immediately which causes women to
experience an unintended pregnancy is very important
to anticipate, including in women who perceive side
effects11, information about contraception including
about side effects obtained from fellow women not
through health workers so that errors at occur in given
and receipt of information 12. Misinformation can lead
to non-compliance. Including the contraceptive use
0,483 0,868 0,585 1,288
0,344 1,212 0,814 1,802
0,075 0,430 0,170 1,089
0,341 0,879 0,675 1,146
0,810 0,985 0,868 1,117
0,032 2,041 1,062 3,921
0,418 0,196
in a typical way and increase cases of contraceptive
failure ultimately increasing the incidence of unwanted
pregnancies13.
The results of this study found that although the
level of significance of method was alpha 10%, this
variable needs to be an important concern (Table
2). The favorite method among women is the short-
acting hormonal method but the continuity of the use
of the method is hampered because it often runs out of
stock14. One indicator of service quality and can prevent
termination of contraception is to provide various
types of contraception15, even preparing 1 additional
method can anticipate discontinuation of contraception
because the method preferred by women is not available
16,17
. Improving the recording and reporting system
that is integrated with various other health institutions
by adopting a technology system will provide quick
information about contraceptive supplies. This will also
support institutions in their efforts to map and analyze
institutions to increase the availability of contraception.
In addition to addressing the depleted stock
instead of letting women go home from service
without contraceptive protection or making referrals
to other facilities, because women cannot go directly
to the referral service, this is related to opportunities
or personal constraints for women to access services.
Efforts to provide comprehensive counseling on the
types of contraception will be able to help women use
contraception that has never been used or tried, because
women choose contraception not because they have been
used before but it can also be because only that method
302  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
is women known. Counseling is an important component
of service quality 15 counseling can also be a solution in
preventing cessation of contraception because of an error
in perceiving contraception, therefore it can be said that
termination of contraception is not caused by a woman’s
fault but can occur because the information delivery
system is not optimal, whether the service provider
has given women’s rights to obtain contraceptive
information. The thing that needs to be understood and
anticipated is the possibility of counseling efforts that
are not functioning properly, because the performance
of officers in providing counseling is very dependent on
the training and skills they have, so this can limit the
methods they can offer18. In addition, if the institution
is only based on waiting time as an indicator of quality
service, certainly giving counseling is considered
contrary to efforts to reduce patient waiting time19
including to set the mechanism for the next visit, can be
anticipated with several solutions namely to encourage
more women to come outside of rush hour, add staff and
consultation rooms, to ask for the opinions of women
the most preferred service hours20. Set the provider break
time in turn, preparing social media-based consulting
services.
The results of this study indicate that vulnerability
does not have a significant relationship toward the
pregnancy intention. Similar research results have
been reported21 that vulnerability does not motivate
women to use contraception, even though women
perceive themselves to be fertile but women report
having sex without contraception. One strategic effort in
encouraging contraceptive use is through the involvement
of husbands in maternal health services22. Indicator of
the role of the husband in improving maternal health
there are various kinds23, 24 husbands who are involved
in the planning phase, discussing and reminding
mothers to use contraception can prevent mothers from
experiencing unwanted pregnancies through the use of
contraception 22. The results of this study indicate that
the role of the husband does not significantly influence
at pregnancy intention. In addition, even though the
husband’s education was quite good, 55% said that he
had graduated from high school but this was not enough
to encourage the husband’s role. Researchers previously
reported that the role of husbands is constrained by
factors of cultural and traditional beliefs. Maternal
health services are considered the domain of women,
only women can be involved in maternal services so that
this is the reason husbands do not have a maximum role
in maternal health 24.
These results indicate that value of child is not
significant, but number of children born alive is
significant (alpha 5%) toward pregnancy intention
(Table 2). This shows that for some women control of
fertility is needed after the target number of children
has been reached. This shows that there are rational
considerations for the number of children based on
financial burdens and occasion to care for children. The
consideration of the ideal number of children is also the
result of social construction embedded in the traditional
cultures and beliefs of some countries 25. The magnitude
of the influence of norms of society can influence
decisions about the number of ideal children ultimately
affecting the decision to use contraception. The results
of this study imply that contraceptive services need to
target women whose are have the number of children
and a certain reproductive age. Synergizing with various
parties because changes in attitude require a local culture
approach and culture-based approach.
Conclusion
There is a need to reduce the desire to increase the
number of children by synergizing various parties. The
ideal number of children is formed because of cultural
structure of society, and dealing with it requires collective
change in social norms and attitudes of the community.
In addition, the importance of increasing women’s
awareness and understanding in interpreting side effects
and increasing staff capacity to motivate women to use
contraception. Addressing the issue of availability of
contraception requires a variety of policies and systems
that are strong in providing services so as to prevent
depleted stocks.
Conflict of Interest: None
Source of Funding: Hasanuddin University
Ethical Clearance: Obtained from faculty
committee and respondents agreement
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 Analysis of VDR Gene Expression and its Relationship with
Bacterial Load in Typhoid Fever Patients

Suradi Efendi1,2, Budu3, Mochammad Hatta4, Rosd iana Natsir 5, Nour Sriyanah6,
Maryunis7, Ressy Dwiyanti4
Nursing Study Program, Sekolah Tinggi Ilmu Kesehatan Makassar, Indonesia, 2Doctoral Students, Post
1

Graduate School, Universitas Hasanuddin Makassar, Indonesia, 3Ophthalmology Department, Faculty of

Medicine, Universitas Hasanuddin Makassar, Indonesia, 4Molecular Biology and Immunology Department,
Faculty of Medicine, Universitas Hasanuddin Makassar, 5Biochemistry Department, Faculty of Medicine,
Universitas Hasanuddin Makassar, Indonesia, 6Nursing Study Program, Sekolah Tinggi Ilmu Kesehatan Makassar,
Indonesia, 7Public Hospital of Dr. Wahidin Sudirohusodo Makassar, Indonesia

Abstract
In Indonesia, Typhoid must be taken seriously from various parties, because this disease is endemic
and threatening public health. The vitamin D receptor gene (VDR) has been involved in modulation of
susceptibility on inflammatory conditions including typhoid fever.

This study aimed at investigating VDR genes expression and its relationship with bacterial load in typhoid
fever patients

This study used analytical survey design with cross-sectional approach, which focuses on Vitamin D
Receptor (VDR) genes expression and its relationship with bacterial load in typhoid fever patients. The total
sample was 55 sufferers. The statistical test used was Mann U Whitney with the confidence degree of 95%
and value of α <0.05. All data were analyzed using the SPSS Version 21.0 program.

The results showed the weak VDR gene expression (47.3%) and the strong one (52.75%), bacterial load was
in the average at 43,583,636.36 ± 75,649,400.29, and there was relationship between VDR gene expression
with bacterial load (p <0.001), which is the bacterial load tendency is higher in patients with weak VDR
gene expression than the strong one.

Strong VDR gene expression decreases bacterial load in cases of typhoid fever.

Keywords: VDR, bacterial load, typhoid fever

Introduction other febrile illnesses. However, clinical severity varies

Typhoid fever is a systemic infection caused by
Salmonella typhi, usually through consumption of
contaminated food or water. Acute illness is characterized
by prolonged fever, headaches, nausea, loss of appetite,
and constipation or sometimes diarrhea. Symptoms are
often non-specific and clinically indistinguishable from
Corresponding author:
Suradi Efendi1
E-mail: atolnurse@gmail.com
08114111075
and severe cases can cause serious complications or even
death. The poor sanitation and lack of sterile drinking
water make it worst1,2,3.
Typhoid fever is a concerning public health
problem in the world, especially in poor populations
from developing countries. Globally, this disease is
estimated lead to 220,000 deaths and 22 million cases
per year, especially in school-age children or younger.
Typhoid fever is one of the most common sources of
bacteriological etiology in many developing countries.
In these countries, the burden of disease is often
306  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
distributed heterogeneously in the worst hygiene and
sanitation area4.
In Indonesia, typhoid must be taken seriously from
various parties, because this disease is endemic and
threatening public health. The problem is increasingly
complex with increasing carrier cases or relapse and
resistance to the drugs used, obstructing treatment
and prevention efforts. In 2008, typhoid morbidity in
Indonesia was reported at 81.7 per 100,000 population,
with distribution by age group 0.0 / 100,000 population
(0–1 years), 148.7 / 100,000 population (2–4 years-old),
180,3 / 100,000 (5-15 years-old), and 51.2 / 100,000
(≥16 years-old). This figure shows that the highest
number of carriers is 2-15 years-old group. The study
of cases in major hospitals in Indonesia, indicate a trend
increase in typhoid cases year by year with an average
pain 500 / 100,000 population and deaths estimated at
around 0.6–5%5.
Typhoid is caused by the bacterium Salmonella.
Salmonella infection in humans can be categorized
into two types, caused by the low virulence serotype
of Salmonella enterica which causes food poisoning,
and caused by high virulence serotype of Salmonella
enterica typhi (S. typhi), which lead to typhoid, and a
group of serovars, known as S Paratyphi A, B and C,
which causes Paratyphoid6.
Blood cultures are generally used in laboratory
diagnoses, but little information about the number of
bacteria circulating in the blood or the distribution
between plasma and phagocytic cells. Previous
research found that in the bone marrow of 78 patients
had an average of 4 times more bacteria. There was a
significant negative correlation (p <0.05) between the
number of bacteria and the age and length of fever
before hospitalization. There was a significant positive
correlation (p = 0.05) between bacterial count and
temperature, period of decline fever after treatment,
and multiple resistance from each bacterial isolate, even
though there was a similar previous treatment history7,8.
The vitamin D receptor gene (VDR) has been
involved in modulation of susceptibility to inflammatory
and autoimmune conditions9. Vitamin D directly
modulates T cell receptors (TCR)11. The action of
vitamin D 1,25-dihydroxyvitamin D3 (1,25 (OH)2D3)
hormone is mediated by the vitamin D receptor (VDR),
the ligand activated transcription factor which control
the gene expression. After activation of the ligand,
VDR binds directly to the specific sequence located
near the promoter and recruits a variety of coregulation
complexes that perform the additional functions required
to modify transcription output12.
Previous research on 426 mild typhoid fever patients
and 35 severe typhoid fever patients where all patients
lived in geographically isolated villages in South
Sulawesi, Central Sulawesi, Southeast Sulawesi, East
Kalimantan and Papua islands which are endemic areas
in Indonesia. It was found that there was no evidence
for gene association of VDR polymorphisms with the
severity of typhoid fever2.
In this study, researchers will examine the gene
expression of the Vitamin D Receptor (VDR) and its
relationship with bacterial load in patients with typhoid
fever.
Material and Method
Design
This study is an analytical survey study with a cross
sectional study to look at the expression of the Vitamin D
receptor gene (VDR) and its relationship with bacterial
load in patients with typhoid fever.
Sampling
The population in this study was the blood of patients
with typhoid fever who were admitted to hospitals in
Makassar (Wahidin Sudirohusodo Hospital, Pelamonia
Hospital, Bhayangkara Hospital), Salewangang
Hospital, Maros Regency, and Pangkep Regional
Hospital in South Sulawesi. This study used purposive
sampling technique with total sample as many as 55.
Inclusion criteria: patients with typhoid fever with
the length of fever > 3 days above 37.5ºC consecutively,
dirty tongue and positive (+) widal and willing to take
part in the study and sign the informed consent.
Exclusion criteria: patients with fever caused
by other types of bacteria and have already received
antibiotic treatment.
Examination of VDR and Bacteria load
Tools
The tools used in this study were: micro pipette P2 (2-
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  307
20 µl), micro pipette P100 (100-1000 µl), micro pipette Table 1: Examination results of VDR gene
P20 ( 20-200 µl), incubator, oven, autoclave, pipette, expression and Bacterial Load
tube, incubator, vortex shaker, waterbath, Eppendorf
tube (1.5 ml and 0.3 ml), eppendorf tube rack, stopwatch, Amount
10 cc spoit, micropipette + tip filters, saucers, freezers, Variable
n (55) %
stirring rods, gloves, vacutainer without anticoagulants
(10 ml), vacutainer needle holder, needle vacutainer
(G.21), alcohol swab and Ice box.
VDR Gene
Materials Expression ;

Weak
Blood samples infected with S. typhi, label paper, 26 47.3
BD Bactec, Real Time Reagent PCR mRNA Gene VDR, Strong 29 52.7
L6, L2 Buffer, Ethanol 70%, Aceton and Tris EDTA.

Examination of VDR gene expression

Mean SD
Peripheral venous blood specimens from the study Bacterial Load
43,583,636.36 75,649,400.29
subjects were taken as much as 10 ml, inserted in the
blood tube containing EDTA, and then DNA extraction
Bacterial load of respondents whose VDR gene
and purification were carried out. The measurement of
expression was weak in average (41.94) and VDR
VDR gene mRNA expression was measured using real-
gene expression was strong in average (15.50) where
time reverse transcriptase polymerase chain reaction
statistically there was a relationship between VDR
(RT-PCR) (Agergaard, et al., 2015). Strong: if the VDR
gene expression and bacterial load (p <0.001) with a
value is ≥ the average value (10,24); Weak: if the VDR
tendency for bacterial load to be higher in patients whose
value <average value (10,24)
expression of VDR gene is weak compared to patients
Bacterial load examination whose VDR gene expression is strong. (Table 2).

Laboratory tests in the form of bacteria load by Table 2: Relationship of VDR gene expression
taking blood samples from veins aseptically and then with Bacterial Load
performed blood sampling used Hemocytometry tool to
determine the number of bacterial load to be reported Bacterial Load
VDR gene
per / mm³, then bacterial load is measured using colony expression
n p*
count. Mean

Data Analysis
Weak 26 41.94
The statistical test used was Mann U Whitney with <0.001
a confidence degree of 95% and a value of α <0.05. All Strong 29 15.50
data were analyzed using the SPSS Version 21.0 program * Mann U Whitney Test.
(SPSS, Inc. Chicago, IL).
Discussion
Result and Discussion
VDR gene expression
The average age of the respondents was 31.93 ±
10.075 years, more than half are male (50.9%), living The results of this study found the weak VDR gene
in Pangkep (50.9%), high school / College (67.3%), and expression (47.27%) and the strong one (52.73%).
work as professionals (41.8%)
Vitamin D receptor (VDR) is the ligand activated
The expression of VDR gene was strong (52.73%) transcription factor found almost in all cells and
and the weak one (47.27%). The bacterial load was in tissues in human body. The gene encoding the VDR is
average at 43,583,636.36 ± 75,649,400.29 (Table 1). located on chromosome 12q13 (Figure 5), consisting of
308  Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10
11 axons, and more than 100 kilo base (kb) stretched
genomic DNA13.
Bacterial Load
The results of this study showed bacterial load
average of 43,583,636.36 ± 75,649,400.29. Bacterial load
is the number of bacteria measured in the compartments
of objects and organisms. The bacterial amount of a
material can be determined in various ways, depending
on the material and type of microbes specified.
Germs can also replicate in macrophages. After the
replication period, the bacteria are spread back into the
circulatory system and cause secondary bacteremia while
marking the end of the incubation period. Secondary
bacteremia causes clinical symptoms such as fever,
headache, and abdominal pain14.
Relationship between VDR gene expression and
bacterial load.
The statistical test results found that there was a
relationship between VDR gene expression and bacterial
load (p <0.001) with a higher bacterial load tendency in
patients with weak VDR gene expression than the strong
one.
VDR is very important in regulating intestinal
homeostasis by preventing invasion of pathogenic
bacteria, inhibiting inflammation, and maintaining cell
integrity10. Vitamin D directly modulates T cell receptors
(TCR)11. The action of vitamin D 1,25-dihydroxyvitamin
D3 (1,25 (OH)2D3) hormone is mediated by the vitamin
D receptor (VDR), the ligand activated transcription
factor which control gene expression. After ligand is
activated, VDR binds directly to the specific sequence
located near the promoter and recruits a variety of
co-regulation complexes that perform the additional
functions needed to modify transcription output12.
Vitamin D shown to reduce the expression of pro-
inflammatory cytokines and have a regulating effect on
autophagy and various immune cells including T cells, B
cells, macrophages, dendritics cell, and epithelial cells15.
It has been reported that 1,25 (OH)2D3 suppresses the
development of inflammatory bowel disease (IBD) in
animal models16. 1,25 (OH)2D3 deficiency has been
reported in patients with IBD17. Given the diverse
immune function of vitamin D, the degree of deficiency
may have important implications for the development
and maintenance of intestinal homeostasis. Possible
roles of vitamin D status and VDR signals in modulating
the effects of intestinal microflora in other conditions
such as asthma and obesity have been suggested10.
Previous research showed that VDR - / - of the
mice had increased bacterial clotting in the intestine18.
The microarray data found that VDR signals respond
to Salmonella pathogens in intestinal colitis in vivo19.
Bacterial stimulation, both commensal and pathogenic,
regulates VDR expression and location and negatively
regulates bacterial-induced intestinal NF-κB activation.
In general, probiotic-induced nuclear receptor signals
are not well marked. The proliferation of VSL3 # is
associated with nuclear receptor signals in the IL10 -
/ - colitis model. Nuclear receptors have been shown
to negatively regulate NF-κB activity stimulated
by bacteria in the intestinal epithelium. Probiotic
treatments can increase VDR expression and activity
of the host. Increased expression of VDR and increased
mRNA cathelicidin in intestinal epithelial cell cultures
when treated with Lactobacillus plantarum were seen.
Monoassociated probiotic pig models for assessing
probiotic effects on VDR expression in vivo and finding
intestinal VDR increased significantly after probiotic
colonization compared to germ-free pigs10.
Conclusion
The strong VDR gene expression decreases bacterial
load in cases of typhoid fever.
Ethical Clearance: Research permit is obtained
from Ethics Commission FK UH Makassar (No. 609
/ H4.8.4.5.31 / PP36-KOMETIK / 2018). After that,
the researcher explained to the respondents about the
objectives, benefits of the research, and procedures for
collecting data. Researchers asked respondents to sign
an informed consent as a form of consent to become
respondents.
Source of Funds: Domestic Postgraduate Education
Scholarship (BPPDN) and author’s personal funds,
which are managed by the author.
Conflict of Interest: None.
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