Inequalities in women's health insurance coverage before and after the implementation of universal health insurance in Indonesia

Indonesia implemented a National Social Security System (Jaminan Kesehatan Nasional, JKN) in 2014. To examine the changes in the magnitude of socioeconomic inequity in women's health insurance coverage among those of reproductive age, we conducted a repeated cross-sectional study design using data from the Indonesia Demographic and Health Surveys conducted in 2012 and 2017, before and after the implementation of JKN. Results showed that while the JKN program helped to increase health insurance coverage among Indonesian women of childbearing age, low education level and household wealth status were associated with an increase in inequalities in health insurance coverage. The findings highlight the need to sustain coverage for citizens and to extend the JKN program to informal workers to reduce health coverage disparities. Further research is required to explore the mechanisms responsible for health coverage inequality based on socioeconomic indicators.

Mental Health and Aggression in Indonesian Women

Aggression is a global problem and complex social behavior. In Indonesia, some common manifestations of aggression are sexual harassment, domestic violence, and the stigmatization of other people. However, unlike men, aggression in women is still rarely studied, whereas facts find that many conditions can make women more vulnerable. There are various aspects related to biological, psychological, social, and cultural issues that can potentially provoke female aggression. Furthermore, mental health and aggression are often viewed as an automatic association and are inseparable in society, reinforcing the stigma against people with mental problems, particularly women, who tend to suffer more stigma of mental health issues than men. However, there has not yet been a study explicitly related to this relationship in the general population of women. The current study aims to examine the overall relationship between mental health and aggression in the extensive general population of Indonesian women with various mental conditions ranging from a normal mental state to severe mental health problems. This was a cross-sectional study conducted using uncontrolled quota sampling via distributing online self-report questionnaires, the modified Indonesian version instruments of the Brief Symptoms Rating Scale-5, and the Buss Aggression Scale with high internal consistency. This study among 203 women aged 19-67 in Indonesia, a multicultural nation and the fourth densest country in the world, proposes that mental health can be a predictor of aggressive behavior, with the influence of mental health on the aggression of women being 21.6% only. The finding indicates that mental health issues are not a macro contributing factor to women's aggressiveness in society and may help reduce stigma against women with mental health problems.

Determinants of early breast cancer presentation: a qualitative exploration among female survivors in Indonesia

OBJECTIVE

Early presentation with breast cancer symptoms is crucial to the effectiveness of treatment and the affected women's long-term survival. However, in Indonesia, 60-70% of breast cancer patients first present themselves to the hospital in an advanced stage. Knowledge about the determinants of breast cancer early presentation could inform efforts to promote healthcare seeking at earlier symptomatic stages. In the current study, we explored the psychosocial determinants of early presentation among female breast cancer survivors.

METHODS

Face-to-face semi-structured interviews were conducted with 23 female breast cancer survivors in Surabaya, Indonesia (mean age = 49.8 years). Directed content analysis approach was used to analyse the data.

RESULTS

Half of the respondents underwent breast cancer screening prior to onset of symptoms. Nine determinants of breast cancer early presentation were reflected in the women's responses: (lack of) knowledge, perceived behavioural control, previous health related experiences and risk perceptions, attitudes and beliefs, norms, competing priorities, financial issues, instrumental factors, and health provider factors.

CONCLUSION

Health promotion efforts should focus on both internal and external psychosocial determinants related to the breast cancer early presentation, and on involving women's social environment as target for education. Additionally, providing accessible and affordable healthcare is important for early presentation.

Breast cancer stigma among Indonesian women: a case study of breast cancer patients

BACKGROUND

The stigma experienced by cancer patients stems from the association of cancer with death, as cancer is the most feared disease worldwide, especially among cancer patients and their families. The stigma regarding breast cancer screening behaviour has not been critically evaluated and is poorly understood; therefore, we aimed to analyse the stigmatization of breast cancer patients in Indonesia to reduce the morbidity and mortality of breast cancer.

METHODS

A qualitative study using a focus group discussion (FGD) and in-depth interviews with thematic analysis was conducted.

RESULTS

One informant experienced breast pain and kept the referral letter, in which the medical doctor advised medical treatment, to herself for 3 months due to her embarrassment. A traditional healing practice known as 'kerokan', which involves scraping of the skin, and consumption of a traditional drink were used by most informants to decrease their breast pain. Finally, most informants were diagnosed with an advanced stage of cancer when they returned to the health care facility. In addition, financial difficulties were noted as barriers to breast cancer screening in Indonesia.

CONCLUSIONS

Feelings of fear and shame when diagnosed with breast cancer were reported by the informants in this study. Alternative treatment known as 'kerokan' was the first treatment sought for breast cancer symptoms due to financial difficulties among breast cancer patients. Informants were diagnosed with an advanced stage of cancer after they returned to the health care facility. A better understanding of early breast cancer symptoms could motivate women to seek out breast cancer treatment.

Dietary and Plasma Carboxymethyl Lysine and Tumor Necrosis Factor-α as Mediators of Body Mass Index and Waist Circumference among Women in Indonesia

Dietary and plasma carboxymethyl lysine (dCML, pCML) and plasma tumor necrosis factor-α (pTNF-α) may be associated with obesity in affluent society. However, evidence in women from low-middle income countries with predominantly traditional diets is lacking. We investigated the mediator effects of dCML, pCML and pTNF-α on body mass index (BMI) and waist circumference (WC) among Indonesian women. A cross-sectional study was conducted among 235 non-diabetic, non-anemic and non-smoking women aged 19–50 years from selected mountainous and coastal areas of West Sumatra and West Java. Dietary CML, pCML, pTNF-α were obtained from 2 × 24-h recalls, ultra-performance liquid chromatography-tandem mass spectrometry and enzyme-linked immunosorbent assay, respectively. Between-group differences were analyzed by the Chi-square or Mann-Whitney test and mediator effects by Structural Equation Modeling. The medians and interquartile-ranges of dCML, pCML and pTNF-α were 2.2 (1.7–3.0) mg/day, 22.2 (17.2–28.2) ng/mL and 0.68 (0.52–1.00) IU/mL, respectively, and significantly higher in the WC ≥ 80 cm than in the WC < 80 cm group, but not in BMI ≥ 25 kg/m² compared to BMI < 25 kg/m² group. Plasma CML and pTNF-α were positively and directly related to WC (β = 0.21 [95% CI: 0.09, 0.33] and β = 0.23 [95% CI: 0.11, 0.35], respectively). Dietary CML that correlated with dry-heat processing and cereals as the highest contributions was positively related to WC (β = 0.33 [95% CI: 0.12, 0.83]). Ethnicity, level of education, intake of fat, and intake of energy contributed to dCML, pCML and pTNF-α, and subsequently affected WC, while only ethnicity contributed to BMI through dCML, pCML and pTNF-α (β = 0.07 [95% CI: 0.01, 0.14]). A positive direct effect of dCML on pCML and of pCML and pTNF-α on WC was seen among Indonesian women. Dietary CML seems to have several paths that indirectly influence the increases in WC if compared to BMI. Thus, intake of CML-rich foods should be reduced, or the foods consumed in moderate amounts to avoid the risk of central obesity in this population.

Determinants of breast self-examination practice among women in Surabaya, Indonesia: an application of the health belief model

Background

Breast cancer has become one of the most common causes of mortality among Indonesian women. Many women in Indonesia present with late-stage breast cancer, negatively affecting prognosis and treatment outcomes. Better prognosis of breast cancer will be achieved if it is diagnosed in an earlier stage, thus efforts to detect breast cancer earlier are important. Breast Self-Examination (BSE) is considered as an important first step to encourage women to actively be responsible for their own health, especially for women in low-and middle-income countries with limited resources and access to other forms of preventive healthcare (e.g., screening programs). The present study aimed to predict BSE practice among women in Surabaya, Indonesia using the Health Belief Model (HBM).

Methods

This investigation was a cross-sectional survey which was distributed among 1967 women aged 20–60 years. The Indonesian version of Champion’s Health Belief Model Scale (I-CHBMS) was used to explain self-reported BSE practice. Logistic regression analysis was used to examine the association of HBM variables with BSE practice.

Results

44.4% of the respondents indicated they had performed BSE. Further, the results indicated that the HBM variables were significantly associated with BSE practice. Specifically, higher perceived benefits and self-efficacy, lower perceived barriers and less cues to action were unique correlates of BSE practice. The result also showed that perceived severity and susceptibility were not associated with BSE practice.

Conclusion

This study indicated that several HBM constructs significantly associated with BSE practice among Indonesian women, suggesting that BSE health education programs should emphasize the perceived benefits of BSE, focus on increasing women’s self-efficacy to address and overcome perceived barriers in performing BSE, and help them in identifying personally relevant cues to action.

Awareness Level about Breast Cancer Risk Factors, Barriers, Attitude and Breast Cancer Screening among Indonesian Women

Background: Globally, breast cancer is the second most common cancer in women and is a leading cause of mortality in Indonesia. Raising awareness of breast cancer is particularly important to help at risk women seek medical treatment for this disease. This study aimed to comprehensively investigate the Indonesian women’s level of knowledge about breast cancer risk factors, barriers, attitude and breast cancer screening. Methods: This population-based cross-sectional study administered the breast cancer awareness Indonesian scale (BCAS-I) to 856 Indonesian women. Samples were selected in rural and urban combinations from three provinces by stratified random sampling. The ordinal logistic model was used to investigate the clustering effect of the participant’s characteristics in this study. Results: Of the women, 62% lived in rural areas and 38% lived in urban areas. Living in an urban area was significantly associated with a lower knowledge of the risk factors. However, living in an urban area was significantly associated with better attitudes and healthier behaviours related to breast cancer awareness. Women with higher education levels had 70% worse attitudes toward breast cancer awareness. Women living South of Sumatera, women living in Yogyakarta, and unmarried women were 5.03, 3.84, and 1.56 times as likely to have higher perceived barriers, respectively. Conclusion: Urban women had a poorer level of knowledge of breast cancer risk factors compared to women living in more rural areas. The result of this study may reflect inadequate breast cancer awareness campaigns or a lack of breast cancer awareness campaigns. These findings suggest that additional education programs aiming to increase awareness and educate the public are needed.

Validation of an Indonesian Version of the Breast Cancer Awareness Scale (BCAS-I)

Background: Raising breast cancer awareness is a key strategy to reduce associated mortality. While a paucity of adequately validated instruments for breast cancer awareness is applicable across cultures, even outside the health care setting such instruments have been developed. Objective: This study investigated the validity and psychometric properties of a breast cancer awareness scale in Indonesia (BCAS-I). Methods: This cross-sectional study was carried out among Indonesian women conveniently selected within three provinces (Yogyakarta, South of Sumatera and East Nusa Tenggara) located in rural-urban areas using stratified random sampling. First, we translated all questionnaires from English to the local language and then back-translated. The third step was to perform psychometric testing of the adapted instrument by establishing internal consistency (Cronbach’s alpha score 0.79) and construct validity by confirmatory factor analysis (CFA). Results: In the 856 participants who responded (responded rate = 98.28%), the age ranged from 18 to 80 years old (mean = 30, SD = 11). The BCAS-I was shown to have good internal consistency, and CFA demonstrated the model fit data adequately (χ2 = 922.267, df = 515, p <0.001, comparative fit index = 0.965, Tucker-Lewis Index = 0.96, goodness-of-fit index = 0.97, adjusted goodness-of-fit index = 0.97, root-mean-square error of approximation = 0.03 95% confidence interval: 0.027, 0.034). The final version of BCAS-I consists of 33 items across 5 domains that cover most key aspects of breast cancer awareness for this population. Conclusion: The BCAS-I demonstrated good psychometric properties and was found to be valid to provide a measurement of breast cancer awareness in Asian women in general and Indonesian women in particular.