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

Background

Cardiovascular diseases (CVDs) accounted for over 17 million deaths and 353 million disability-adjusted life years lost in 2016. The risk factors are also high and increasing with high blood pressure, smoking, and high body mass index contributed to up to 212 million disability-adjusted life years in 2016. To help reduce the burden, it is crucial to understand the geographic and socioeconomic disparities in CVD risk factors.

Methods

Employing both geospatial and quantitative analyses, we analyzed the disparities in the prevalence of smoking, physical inactivity, obesity, hypertension, and diabetes in Indonesia. CVD data was from Riskesdas 2018, and socioeconomic data was from the World Bank.

Results

Our findings show a very high prevalence of CVD risk factors with the prevalence of smoking, physical activity, obesity, hypertension ranged from 28 to 33%. Results also show the geographic disparity in CVD risk factors in all five Indonesian regions. Moreover, results show socioeconomic disparity with the prevalence of obesity, hypertension, and diabetes are higher among urban and the richest and most educated districts while that physical inactivity and smoking is higher among rural and the least educated districts.

Conclusion

The CVD burden is high and increasing in particularly among urban areas and districts with higher income and education levels. While the government needs to continue tackling the persistent burden from maternal mortality and infectious diseases, they need to put more effort into the prevention and control of CVDs and their risk factors.

On the verge of a chronic disease epidemic: comprehensive policies and actions are needed in Indonesia

In the midst of tackling the persistent burden of maternal mortality and infectious diseases, Indonesia is facing an increasing burden of non-communicable diseases (NCDs). Although there are increasing national efforts in NCD prevention and control, the worsening trend of NCD risk factors and morbidity is alarming. We provided assessment and discussion on the policies and actions needed in the country including comprehensive efforts to reduce tobacco use and unhealthy diet, the need to reorient the health systems for better NCD prevention and control, and the promotion of NCD-related research that are still lacking.

Geographic distribution, socio-economic disparity and policy determinants of smoke-free policy adoption in Indonesia

BACKGROUND: Indonesia has the second highest smoking prevalence among adult males in the world, and smoking prevalence is increasing among youths.OBJECTIVE: To evaluate the smoke-free policy (SFP), a flagship national tobacco control programme, by providing evidence on geographic distribution, socio-economic disparities and policy determinants of SFP adoption by district in Indonesia.METHODS: We employed spatial and quantitative methods to obtain data respectively on geographic distribution of SFP adoption, and on disparities and associations between national and provincial SFP regulations and SFP adoption by the districts.RESULTS: Twenty-one of 34 provinces, and 345 of 514 districts adopted SFP. We found significant geographic disparities: all districts outside of Papua were up to 6.3 times more likely to adopt the policy and to implement it for a period of up to 3 years longer in duration. We also found significant socio-economic disparities: urban districts, those that were wealthiest and those most educated were respectively 3.9, 9.1 and 2.8 times more likely to adopt the policy. Moreover, districts in provinces that had SFP regulation were 3.2 times more likely to adopt. Finally, the adoption rate in the period after the 2012 national regulation was up to 7.8 times higher than that before.CONCLUSION: In addition to geographic and socio-economic disparities, national and provincial regulations and policies were determinants of SFP adoption.

Density of cigarette retailers around educational facilities in Indonesia

BACKGROUND: With 61.4 million smokers in 2018, Indonesia makes a significant contribution to the global number of smokers. The latest data show that smoking is increasingly common in youth.OBJECTIVE: To examine the density of cigarette retailers around formal and informal educational facilities in Indonesia.METHODS: We employed geospatial and quantitative analyses using data on cigarette retailers (from surveys during July-August 2019) and educational facilities in Depok City. Data analyses, in ArcMap 10.6 and Stata v15, compared the density within 100 m and 100-200 m from the facility.RESULTS: We found a 40% higher density of cigarette retailers in areas close to educational facilities. This high density is similar between formal (i.e., primary, junior high, and senior high schools) and informal educational facilities (i.e., early years education centers and mosques). Moreover, compared to the average, the density is higher near primary schools and senior high schools.CONCLUSION: There is a higher density of cigarette retailers around formal and informal educational facilities in Indonesia. This evidence confirms there is a need to regulate cigarette retailers near educational facilities, to enforce the ban on sale to minors and to ban product displays at retailers.

Visibility and hotspots of outdoor tobacco advertisement around educational facilities without an advertising ban: Geospatial analysis in Surabaya City, Indonesia

INTRODUCTION

Despite having over 60 million smokers in 2018, Indonesia still lacks tobacco control measures, including an outdoor tobacco advertising ban. This study aimed to provide evidence on the visibility and hotspots of advertisements around educational facilities in a city without a ban.

METHODS

We collected data on the locations of outdoor tobacco advertisements and schools and universities in Surabaya city. We conducted buffer and hotspots analyses using ArcMap. Using Getis-Ord Gi* statistics, hotspot analysis identifies significant clusters with a high number of advertisements.

RESULTS

We found 307 large and medium-sized outdoor tobacco advertisements and 1287 educational facilities (1199 schools, 88 universities). Almost 80% of those advertisements (237 units) were just 300 m away (10-minute walk) from primary schools and high schools in the city. More than half of all schools (652) and two-thirds of all universities (59) were inside hotspots where there were statistically significant clusters with a high number of advertisements. These hotspots were more densely populated and more-deprived areas.

CONCLUSIONS

There was high visibility of large and medium-sized outdoor tobacco advertisements around educational facilities in the city without the ban.

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.

Secondary amenorrhea: two kinds of psychogenic disorder--a case report

A brief review of the limited sources in the literature on secondary amenorrhea indicates that this symptom may, in many cases, be psychogenic in origin. The disorder in such instances is often short term, spontaneously reversible, and occurs as a reaction to stress or a traumatic event. Most of these women are basically healthy, psychologically speaking. In some cases, however, this menstrual disturbance may continue for months or longer. In such instances, one may expect to find a neurotic conflict related to feminine identity as the cause. The therapeutic approach in these two alternative forms of secondary psychogenic amenorrhea (SPA) will differ; hence, it is essential that the gynecologist and psychiatrist distinguish between them. A case illustration is presented, describing in detail the treatment of a women with longstanding SPA which resolved with dynamically-oriented psychotherapy.

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.

District-Level Inequalities in Hypertension among Adults in Indonesia: A Cross-Sectional Analysis by Sex and Age Group

BACKGROUND

An estimated 1.28 billion adults 30-79 years old had hypertension globally in 2021, of which two-thirds lived in low- and middle-income countries (LMICs). Previous studies on geographic and socioeconomic inequalities in hypertension among adults have limitations: (a) most studies used individual-level data, while evidence from locality-level data is also crucial for policymaking; (b) studies from LMICs are limited. Thus, our study examines geographic and socioeconomic inequalities in hypertension among adults across districts in Indonesia.

METHODS

We combined geospatial and quantitative analyses to assess the inequalities in hypertension across 514 districts in Indonesia. Hypertension data were obtained from the Indonesian Basic Health Survey (Riskesdas) 2018. Socioeconomic data were obtained from the World Bank. Six dependent variables included hypertension prevalence among all adults (18+ years), male adults, female adults, young adults (18-24 years), adults (25-59 years), and older adults (60+ years).

RESULTS

We also found significant geographic and socioeconomic inequalities in hypertension among adults across 514 districts. All hypertension indicators were higher in the most developed region than in the least developed region. Districts in the Java region had up to 50% higher prevalence of hypertension among all adults, males, females, young adults, adults, and older adults. Notably, districts in the Kalimantan region had the highest prevalence of hypertension, even compared to those in Java. Moreover, income level was positively associated with hypertension; the wealthiest districts had higher hypertension than the poorest districts by up to 30%, but only among males and older adults were statistically significant.

CONCLUSIONS

There were significant inequalities in hypertension among adults across 514 districts in the country. Policies to reduce such inequalities may need to prioritize more affluent urban areas and rural areas with a higher burden.

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.

Growing Up Unequal: Disparities of Childhood Overweight and Obesity in Indonesia's 514 Districts

BACKGROUND

Childhood obesity is a major public health concern as it increases the risk of premature death and adult disability. Globally, the latest estimates showed that more than 340 million children and adolescents between the ages of 5 and 19 were overweight or obese in 2016. This study aimed to investigate the disparities in childhood overweight and obesity across 514 districts in Indonesia, based on geographic and socioeconomic factors.

METHODS

Geospatial and quantitative analyses were performed using the latest Indonesian Basic Health Survey data from 2018. Dependent variables were rates of overweight and obesity among children aged 5-17 years including by gender.

RESULTS

This study found that the rates of overweight were 17.2%, 17.6%, and 16.8% among all children, boys, and girls, while the rates of obesity were 7.0%, 7.9%, and 6.1%, respectively. Boys were 1.30 times more likely to be obese than girls, while overweight was similar between both sexes. Urban cities had significantly higher prevalence of childhood overweight and obesity compared with rural districts by up to 1.26 and 1.32 times, respectively. In addition, the most developed region had significantly higher prevalence of childhood overweight and obesity than the least developed region by up to 1.37 and 1.38 times, respectively. With regard to socioeconomic factors, our analysis demonstrated a notable disparity in the prevalence of childhood overweight and obesity across income quintiles. Specifically, the wealthiest districts exhibited a 1.18 times higher prevalence of overweight and obesity among all children compared with the poorest districts. This association was particularly pronounced among boys; in the richest quintile, the prevalence of overweight and obesity was 1.24 and 1.26 times higher, respectively, in comparison to the poorest income quintile. In contrast, district-level education appears to exhibit an inverse relationship with the prevalence of childhood overweight and obesity, although the findings were not statistically significant.

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.