Geographic and socioeconomic disparity in cardiovascular risk factors in Indonesia: analysis of the Basic Health Research 2018

Does a sprawling neighborhood affect obesity? Evidence from Indonesia

While the causes of obesity have been widely discussed from various perspectives, studies that examine how the physical form of a neighborhood could causally affect obesity remain limited. This study combined individual-level longitudinal data from the Indonesian Family Life Survey and subdistrict-level land cover data to investigate whether a neighborhood's physical form affects individuals' obesity status. We controlled for individual and location fixed-effect to account for individuals' sorting preferences and unobserved heterogeneity at the subdistrict level. Our results suggest that a sprawling neighborhood corresponds to a lower body mass index, particularly among males. We also show that consumption behavior can explain this mechanism.

Impact of SGLT-2 inhibitors on modifiable cardiovascular risk factors in Romanian patients with type 2 diabetes mellitus

BACKGROUND

Modifiable cardiovascular risk factors are high blood pressure, smoking, diabetes, sedentary lifestyle, obesity, and hypercholesterolemia.

AIM

To investigate the impact of sodium-glucose 2 co-transporter inhibitors (SGLT-2i) on modifiable cardiovascular risk factors in Romanian patients diagnosed with type 2 diabetes mellitus (T2DM).

METHOD

A retrospective study was conducted on 200 Romanian patients with T2DM who were being treated with SGLT-2i, either Dapagliflozin or Empagliflozin. Collected data included demographic characteristics, such as weight, body mass index (BMI), fasting blood glucose (FBG), creatinine, glycated hemoglobin (HbA1c), abdominal circumference (AC), urine albumin-to-creatinine ratio (UACR), systolic blood pressure (SBP), diastolic blood pressure (DBP), C-reactive protein (CRP) and N-terminal pro b-type natriuretic peptide (NT-proBNP). The patients were observed for one year after being treated with SGLT-2i.

RESULTS

The mean value of FBG decreased from 180.00 mg% (IQR: 154.50-207.00) to 130.00 mg% (IQR: 117.50-150.00) (p < 0.001), and the mean of HbA1c values decreased from 8.40% (IQR: 7.98-9.15%) to 7.30% (IQR: 6.90-7.95%) (p < 0.001). We also obtained significant positive effects on body weight, i.e., the weight decreased from 90.50 kg (82.00-106.50) to 89.00 kg (77.50-100.00) (p = 0.018), BMI from 32.87 kg/m2 (29.24-36.45) to 31.00 kg/m2 (27.74-34.71) (p < 0.001) and AC from 107.05 (± 16.39) to 102.50 (± 15.11) (p = 0.042). The UACR decreased from 23.98 mg/g (19.76-36.85) to 19.39 mg/g (1.30-24.29) (p < 0.001). Initially, the median value for SBP was 140.00mmgHg (130.00-160.00), and for DBP was 80.00 mmgHg (72.00-90.00), and one year after treatment, the medium value was 120.00 mmgHg (115.50-130.00) for SBP (p < 0.001), and 72.00 mmgHg (70.00-78.00) for DBP (p < 0.001) The mean CRP values decreased from 68.00 mg/dL (56.25-80.25) to 34.00 mg/dL (28.12-40.12) (p < 0.001), and the mean NT-proBNP decreased from 146.00pg/mL (122.50-170.50) to 136.00 pg/mL (112.50-160.50) (p = 0.005).

CONCLUSION

Treatment with SGLT-2i in Romanian patients with T2DM has beneficial effects on modifiable cardiovascular risk factors.

Implementation of mobile-health technology is associated with five-year survival among individuals in rural areas of Indonesia

There is an urgent need to focus on implementing cost-effective health interventions and policies to reduce the burden of cardiovascular disease in Indonesia. This study aims to evaluate whether a mobile technology-supported primary health care intervention, compared with usual care, would reduce the risk of all-cause mortality among people in rural Indonesia. Data were collected from 11,098 participants in four intervention villages and 10,981 participants in four control villages in Malang district, Indonesia. The baseline data were collected in 2016. All the participants were followed for five years, and the mortality data were recorded. Cox proportional hazard model was used to examine the association between the intervention and the risk of all-cause mortality, adjusted for the covariates, including age, gender, educational attainment, employment and marital status, obesity and the presence of diabetes mellitus. During the five-year follow-up, 275 participants died in intervention villages, compared with 362 in control villages. Participants residing in intervention villages were at 18% (95%CI = 4 to 30) lower risk of all-cause mortality. Higher education attainment and being married are associated with lower risks of all-cause mortality among respondents who lived in the control villages, but not among those living in the intervention villages. A mobile technology-supported primary health care intervention had the potential to improve the five-year survival among people living in villages in an upper-middle income country.

In-hospital mortality of patients with acute coronary syndrome (ACS) after implementation of national health insurance (NHI) in Indonesia

BACKGROUND

The National Health Insurance (NHI) was implemented in Indonesia in 2014, and cardiovascular diseases are one of the diseases that have overburdened the healthcare system. However, data concerning the relationship between NHI and cardiovascular healthcare in Indonesia are scarce. We aimed to describe changes in cardiovascular healthcare after the implementation of the NHI while determining whether the implementation of the NHI is related to the in-hospital mortality of patients with acute coronary syndrome (ACS).

METHODS

This is a retrospective comparative study of two cohorts in which we compared the data of 364 patients with ACS from 2013 to 2014 (Cohort 1), before and early after NHI implementation, with those of 1142 patients with ACS from 2018 to 2020 (Cohort 2), four years after NHI initiation, at a tertiary cardiac center in Makassar, Indonesia. We analyzed the differences between both cohorts using chi-square test and Mann-Whitney U test. To determine the association between NHI and in-hospital mortality, we conducted multivariable logistic regression analysis.

RESULTS

We observed an increase in NHI users (20.1% to 95.6%, p < 0.001) accompanied by a more than threefold increase in patients with ACS admitted to the hospital in Cohort 2 (from 364 to 1142, p < 0.001). More patients with ACS received invasive treatment in Cohort 2, with both thrombolysis and percutaneous coronary intervention (PCI) rates increasing more than twofold (9.2% to 19.2%; p < 0.001). There was a 50.8% decrease in overall in-hospital mortality between Cohort 1 and Cohort 2 (p < 0.001).

CONCLUSIONS

This study indicated the potential beneficial effect of universal health coverage (UHC) in improving cardiovascular healthcare by providing more accessible treatment. It can provide evidence to urge the Indonesian government and other low- and middle-income nations dealing with cardiovascular health challenges to adopt and prioritize UHC.

Hypertension care cascades and reducing inequities in cardiovascular disease in low- and middle-income countries

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

Beyond the Plate: Uncovering Inequalities in Fruit and Vegetable Intake across Indonesian Districts

BACKGROUND

Non-communicable diseases (NCDs) are responsible for the deaths of 41 million individuals every year, with 77% of them occurring in low- and middle-income countries. Among the main NCD risk factors, inadequate intake of fruits and vegetables (FV) was one of the leading causes of death in 2019. Our study aims to identify disparities in inadequate FV intake among adults in 514 districts. We utilized the latest Indonesian Basic Health Survey 2018 to conduct geospatial and quantitative analyses. We used the World Health Organization's definition of inadequate FV intake, which refers to consuming less than five servings of fruit and vegetables daily. We analyzed inadequate FV intake among adults over the age of 18 years, as well as by gender and age group (including young adults 18-24 years, adults 25-59 years, and older adults 60+ years). Our study showed an alarmingly high prevalence of inadequate FV intake among adults, with 96.3% in 2018. The prevalence of inadequate FV intake drastically varied across 514 districts, ranging from 70.1% to 100%. Notable geographic and socioeconomic disparities were observed across the districts studied. Rural districts exhibited a higher prevalence of inadequate FV intake, translating to poorer diets, particularly among females and older adults, when compared to their urban counterparts. Interestingly, districts within more developed regions had poorer FV diets than those in less developed regions. Although districts with lower incomes generally had poorer FV diets, the association was not significant in multivariate analysis. However, districts with lower levels of education demonstrated poorer FV diets, especially among females, adults, and older adults. Despite its limitations, our study provides crucial insights for health policies in Indonesia and other LMICs.

Does the Disparity Patterning Differ between Diagnosed and Undiagnosed Hypertension among Adults? Evidence from Indonesia

Background: Healthcare systems in many low- and middle-income countries (LMICs) are not yet designed to tackle the high and increasing burden of non-communicable diseases (NCDs), including hypertension. As a result, a large proportion of people with disease or risk factors are undiagnosed. Policymakers need to understand the disparity better to act. However, previous analyses on the disparity in undiagnosed hypertension, especially from LMICs, are lacking. Our study assessed the geographic and socioeconomic disparity in undiagnosed hypertension and compared it with diagnosed hypertension. Methods: We used the Basic Health Survey (Riskesdas) 2018 and performed geospatial and quantitative analyses across 514 districts in Indonesia. Dependent variables included diagnosed and undiagnosed hypertension among adults (18+ years) and by gender. Results: A high prevalence of undiagnosed hypertension at 76.3% was found, with different patterns of disparity observed between diagnosed and undiagnosed hypertension. Diagnosed hypertension was 1.87 times higher in females compared with males, while undiagnosed hypertension rates were similar between genders. Urban areas had up to 22.6% higher rates of diagnosed hypertension, while undiagnosed hypertension was 11.4% more prevalent among females in rural areas. Districts with higher education rates had up to 25% higher diagnosed hypertension rates, while districts with lower education rates had 6% higher rates of undiagnosed hypertension among females. The most developed regions had up to 76% and 40% higher prevalence of both diagnosed and undiagnosed hypertension compared with the least developed regions. Conclusion: The disparity patterning differs between diagnosed and undiagnosed hypertension among adults in Indonesia. This highlights the need for effective measures, including healthcare system reforms to tackle NCDs in LMICs.

Low physical activity is associated with adverse health outcome and higher costs in Indonesia: A national panel study

Aims

To assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia.

Methods

In this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40-80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables.

Results

The prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51-2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07-1.96) and inpatient care (AOR 1.45, 95% CI: 1.07-1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21-2.28), and have lower labor participation (AOR: 0.24, 95% 0.20-0.28).

Conclusions

Low physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits.

Disparities in Obesity Rates among Adults: Analysis of 514 Districts in Indonesia

BACKGROUND

Globally, it was estimated that over 650 million adults 18 years old and older were obese in 2016. It is an increasing global health challenge with a significant health and economic impact. Thus, understanding geographic and socioeconomic disparities in obesity among adults is crucial.

METHODS

We combined geospatial and quantitative analyses to assess the disparity in obesity across 514 districts in Indonesia. We used the Basic Health Survey (Riskesdas) 2018 for obesity data and the World Bank database for socioeconomic data. Dependent variables included obesity prevalence among all adults (18+ years), males, females, young adults (18-24 years), adults (25-59 years), and older adults (60+ years).

RESULTS

We found significant geographic and socioeconomic disparities in adult obesity in Indonesia. In terms of region, districts in Java and Bali had a significantly higher prevalence of obesity than those in Papua, Maluku, and Nusa Tenggara. Districts in Java had 29%, 32%, 60%, and 28% higher prevalence of obesity among all adults, female adults, young adults, and adults. By income, compared to the poorest ones, most affluent districts had a significantly higher prevalence of obesity; they had a 36%, 39%, 34%, 42%, 33%, and 73% higher prevalence of obesity among all adults, males, females, young adults, adults, and older adults. Similarly, by education, compared to the least educated ones, the most educated districts had a significantly higher prevalence of obesity; they had a 34%, 42%, 29%, 36%, and 80% higher prevalence of obesity among all adults, males, females, adults, and older adults.

CONCLUSIONS

There are significant disparities in adult obesity among 514 districts in Indonesia. Efforts by policymakers and stakeholders are needed to reduce obesity among adults, especially within districts with high prevalence.

Patient Education Strategies among Patients with Acute Myocardial Infarction: A Systematic Review

  BACKGROUND: There is a need to summarize the effect of existing research-based education strategy on patients’ physical condition, health behaviour change, as well as psychosocial well-being in patients with acute myocardial infarction. AIM: to review and synthesis relevant studies on patient educational strategy and its effect on patients’ physical condition, health behaviour change, as well as psychosocial well-being in patients with acute myocardial infarction. METHODS: A literature search was conducted on MEDLINE, Academic Search Ultimate, CINAHL-EBSCO, and PubMed. Articles were selected by predefined inclusion and exclusion criteria. Assessment of methodological quality of each study was executed using The Downs and Black scale. RESULTS: Nineteen studies (3588 patients with myocardial infarction) were included. Educational intervention methods ranged from face-to-face method only, face-to-face method in combination with telephone call(s), the combination of both face-to-face method and telephone call(s) with one other method. Outcome measured on each study varied and the effectiveness of the intervention in at least one of their outcome measures demonstrated in 17 studies. CONCLUSIONS: Findings support the pivotal role of patient education on the management of myocardial infarction patient.   Key-words: coronary heart disease, education, educational strategy, learning needs, systematic review

Geographic and Socioeconomic Disparity in Child Undernutrition across 514 Districts in Indonesia

BACKGROUND

Globally, in 2020, 45 million children were estimated to be wasted, and 149 million children under five years of age were estimated to be stunted. Undernutrition makes children in particular much more vulnerable to disease and death. Our study aims to examine geographic and socioeconomic disparities in child undernutrition across 514 districts in Indonesia.

METHODS

Employing both geospatial and quantitative analyses (descriptive statistics and Ordinary Least Squares regressions), we analyzed the disparities in the prevalence of underweight, severe underweight, wasting, severe wasting, stunting, and severe stunting among districts. Child undernutrition data were from Indonesia Basic Health Survey (Riskesdas) 2018, which included a sample of 93,620 children under five years. Socioeconomic data were from the World Bank.

RESULTS

We found a relatively large geographic and socioeconomic disparity in child undernutrition in Indonesia. By region, districts in the Papua region (including Maluku and Nusa Tenggara) had a significantly higher prevalence of underweight and wasting than those in the Java region (including Bali). Districts in Papua had 44%, 121%, 38%, and 57% higher prevalence of underweight, severe underweight, wasting, and severe wasting, respectively. Similarly, the poorest districts had a significantly higher prevalence of underweight, wasting, and stunting than the wealthiest districts. The poorest districts had 30%, 83%, 16%, 21%, and 74% higher prevalence of underweight, severe underweight, wasting, stunting, and severe stunting, respectively. These results were similar among rural districts.

CONCLUSION

There is a significant disparity in child undernutrition across districts in Indonesia. The government needs to prioritize the reduction of child undernutrition, especially in rural areas, districts outside of Java and Bali, and the poorest and least educated areas.

Indonesian registry on atrial fibrillation (OneAF)

BACKGROUND

Data on the optimal therapeutic international normalized ratio (INR) for non-valvular and valvular atrial fibrillation (AF) in Indonesia is currently unavailable. Therefore, we designed the Indonesian Registry on Atrial Fibrillation (OneAF) registry in order to seek a safe and beneficial range of INR in Indonesian patients with non-valvular and valvular AF.

METHODS/DESIGN

The OneAF registry is a nationwide collaboration of the Indonesian Heart Rhythm Society (InaHRS) enrolling all hospitals with cardiac electrophysiologists in Indonesia. It is a prospective, multicentre, nationwide, observational study aiming to recruit non-valvular and valvular AF patients in Indonesia. The registry was started in January 2020 with a planned 2 years of recruitment. There are 2 respondents for this registry: non-cohort and cohort respondents. Non-cohort registry respondents are AF patients at hospitals who fulfill inclusion and exclusion criteria but did not consent for a 24 month follow up. Whereas patients who consented for a 24 month follow up were included as cohort registry respondents. Key data collected includes basic sociodemographic information, symptoms and signs, medical history, results of physical examination and laboratory test, details of diagnostics and treatment measures and events.

RESULTS

Currently, a total of 1568 respondents have been enrolled in the non-cohort registry, including 1065 respondents with non-valvular AF (67.8%) and 503 respondents with valvular AF (32.2%). We believe that the OneAF registry will provide insight into the regional variability of anticoagulant treatment for AF, the implementation of rhythm/rate control approaches, and the clinical outcomes concerning cardiocerebrovascular events.

TRIAL REGISTRATION

Registered at clinicaltrials.gov (NCT04222868).

High visibility of outdoor tobacco advertisements around health facilities in East Java, Indonesia: a geospatial analysis

BACKGROUND Indonesian tobacco control initiatives are minimal despite having the second-highest adult male smoking prevalence in the world, with less than 10% of districts/cities banning outdoor tobacco advertisements. This research aimed to provide evidence on the presence of outdoor tobacco advertisements near health facilities in Surabaya where there is no outdoor advertising ban. METHODS Data collection was carried out in Surabaya from October to November 2018. Data of government (public) and private health facilities were obtained from the city health office. Two spatial data analyses were carried out: a buffer analysis near the healthcare facilities and an advertisement hotspot analysis using ArcMap 10.6. RESULTS From 308 tobacco advertisements that were identified, there were billboards (63%), banners (31%), and videoboards (7%). Of 142 public and 1,242 private health facilities in Surabaya, 26% and 31% had advertisements within 300 m and 63% and 70% were within advertisement hotspots, respectively. Furthermore, 5% of advertisements were within 300 m from public health facilities and 21% of them were within 300 m from private health facilities. CONCLUSIONS Outdoor tobacco advertisements were widespread throughout the city, prominently around public and private health facilities.