Setyawan, 2017

Kesmas
National Public Health Journal
Volume 11, Issue 3, February 2017 p-ISSN 1907-7505

e-ISSN 2460-0601
TABLE OF CONTENT
Impact of National Health Insurance Policy towards the Implementation of Health Promotion
Program at Public Health Centers in Indonesia................................................................................ 103-110
Mochamad Iqbal Nurmansyah, Bulent Kilic
Effect of School Community Empowerment Model towards Handwashing Implementation

among Elementary School Students in Dayeuhkolot Subdistrict.......................................................111-116
Tetti Solehati, Cecep Eli Kosasih, Sri Susilawati, Mamat Lukman, Sayu Putu Yuni Paryati
Acceptance of Medical Resume Completion at Dr. Radjiman Wediodiningrat Lawang Psychiatric

Hospital............................................................................................................................................. 117-122
Silvia Shinta Devi, Aryo Dewanto, Lukman Hakim
Risk Factors of Carpal Tunnel Syndrome among Food-Packing Workers in Karanganyar................ 123-126
Haris Setyawan
Psychosocial Determinants of Risky Sexual Behavior among Senior High School Students
in Merauke District............................................................................................................................127-132
Fenny Etrawati, Evi Martha, Rita Damayanti
Risk Factors of Premature Rupture of Membrane............................................................................. 133-137

Maryuni, Dede Kurniasih
Nurses’ Intention and Behavior in Reporting Adverse Event: Application of Theory of Planned
Behavior.............................................................................................................................................138-144
Ni Putu Ekayani, Viera Wardhani, Asih Tri Rachmi
Evaluation of Momentum Male Sterilization Service Effectiveness as an Attempt to Reach

Museum Rekor Indonesia............................................................................................................... 145-152
Endah Winarni, Muhammad Dawam
Nationally Accredited by Director General of Higher Education Ministry of Education and

Culture Republic of Indonesia No.56/DIKTI/Kep/2012 dated on July 24, 2012
Kesmas
National Public Health Journal
Volume 11, Issue 3, February 2017 p-ISSN 1907-7505

e-ISSN 2460-0601
Kesmas: National Public Health Journal is a journal that contains both research articles and invited review
articles in the field of public health and published quarterly
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Dumilah Ayuningtyas (Faculty of Public Health Universitas Indonesia)
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Zarfiel Tafal (Faculty of Public Health Universitas Indonesia)
Doni Hikmat Ramdhan (Faculty of Public Health Universitas Indonesia)
Ahmad Sulaeman (Faculty of Human Ecology Bogor Agricultural University)
Upik Kusumawati Hadi (Faculty of Veterinary Medicine Bogor Agricultural University)
Yodi Mahendradhata (Faculty of Medicine Universitas Gadjah Mada)
Honorary Editors
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Peter D Sly (Faculty of Medicine and Biomedical Science, University of Queensland, Australia)
Budi Haryanto (Faculty of Public Health, Universitas Indonesia, Indonesia)
Prathurng Hongsranagon (University of Chulalongkorn, Thailand)
Hidayatulfathi Othman (Faculty of Health Sciences, National University of Malaysia, Malaysia)
Don Eliseo Lucero-Prisno III (Xi’an Jiatong-Liverpool University, China)
Orawan Kaewboonchoo (Mahidol University, Thailand)
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On the issue of Volume 11 Issue 2 November 2016, I am interested in the article entitled “Lack
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important for child development. In this study, working mother are two times more likely to not pro-
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them flexibility of break schedules, so they can express breast milk with comfortable condition.
(Shellina, Sukabumi)
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Nurmansyah et al. Kesmas: National Public Health Journal. 2017; 11 (3): 103-110 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.1262
Impact of National Health Insurance Policy towards the

Implementation of Health Promotion Program at Public
Health Centers in Indonesia
Dampak Kebijakan Jaminan Kesehatan Nasional terhadap Implementasi

Program Promosi Kesehatan pada Pusat Kesehatan Masyarakat di Indonesia
Mochamad Iqbal Nurmansyah, Bulent Kilic
Department of Public Health, Institute of Health Sciences, Dokuz Eylul University, Izmir, Turkey
Abstract
The National Health Insurance (NHI) Program was implemented in Indonesia on January 1st 2014. This program definitely brings some changes into mana-
gerial aspect in public health center (PHC). This study aimed to determine an impact of NHI policy in the implementation of health promotion programs at PHC
in South Tangerang City, Indonesia. This study was conducted using qualitative method during February and March 2016. The impact of NHI is seen on pol-
icy, budget, equipment, human resource and implementation of health promotion program. With purposive sampling method, six policy makers, eight service
providers and eight service users were selected for in-depth interview. 17 documents were analyzed. Observation was conducted at four selected PHC’s.
Data analysis used thematic content analysis. There was no difference of PHC’s functions before and after NHI period. Budget expended for health promo-
tion programs increased after NHI was implemented which could represent an opportunity for PHC to innovate, procure materials and implement better health
promotion programs. Capitation budget which could be used for executing health promotion program and some recently implemented health promotion pro-
grams in the NHI era evidences that NHI policy has a positive impact on the implementation of health promotion programs at PHC.
Keywords: Health promotion program, national health insurance, public health center
Abstrak
Jaminan Kesehatan Nasional (JKN) telah diimplementasikan di Indonesia pada 1 Januari 2014. Hal tersebut membawa beberapa perubahan pada aspek
manajerial pada pusat kesehatan masyarakat (puskesmas). Penelitian ini bertujuan untuk mengidentifikasi dampak dari kebijakan JKN terhadap implemen-
tasi program promosi kesehatan di puskesmas di Kota Tangerang Selatan, Indonesia. Penelitian menggunakan metode kualitatif. Data dikumpulkan pada
Februari – Maret 2016. Dampak program dilihat dalam hal kebijakan, pendanaan, fasilitas, sumber daya manusia dan pelaksanaan program promosi kese-
hatan. Dengan menggunakan metode purposive sampling, enam pengambil kebijakan, delapan pemberi layanan dan delapan penerima layanan diambil se-
bagai informan dalam penelitian ini. Pada analisis dokumen, 17 dokumen telah dianalisis. Observasi dilakukan dengan melihat kegiatan yang dilakukan di
empat puskesmas. Analisis data menggunakan analisis konten tematik. Tidak terdapat perbedaan dari fungsi puskesmas sebelum dan setelah adanya JKN.
Dana yang digunakan untuk kegiatan promosi kesehatan telah mengalami peningkatan setelah implementasi kebijakan JKN dimana dana tersebut dapat di-
gunakan untuk berinovasi, memberi peralatan dan melakukan promosi kesehatan dengan lebih baik. Dana kapitasi yang dapat digunakan untuk melaksanakan
program promosi kesehatan dan beberapa kegiatan promosi kesehatan yang baru dilaksanakan pada saat era JKN menjadi bukti bahwa kebijakan JKN memi-
liki dampak positif terhadap pelaksanaan program promosi kesehatan di puskesmas.
Kata kunci: Program promosi kesehatan, jaminan kesehatan nasional, pusat kesehatan masyarakat
How to Cite: Nurmansyah MI, Kilic B. Impact of national health insurance Correspondence: Mochamad Iqbal Nurmansyah, Department of Public Health,
policy towards the implementation of health promotion program at public Institute of Health Sciences, Dokuz Eylul University, Izmir, Turkey 35340, Phone:
health centers in Indonesia. Kesmas: National Public Health Journal. 2017;

+90 4122601, e-mail: [email protected]
11 (3): 103-110. (doi:10.21109/kesmas.v11i3.1262)

Received: November 15th 2016
Revised: January12th 2017
Accepted: January 19th 2017
Copyright @ 2017, Kesmas: National Public Health Journal, p-ISSN: 1907-7505, e-ISSN: 2460-0601, Accreditation Number: 56/DIKTI/Kep/2012, http://journal.fkm.ui.ac.id/kesmas
Kesmas: National Public Health Journal, 2017; 11 (3): 103-110
Introduction tative approach. The study was conducted in South

Indonesia has implemented the National Health Tangerang City which is located in the Southern Jakarta.
Insurance program since January 2014. The National Data were collected within February – March 2016.
Health Insurance program in Indonesia has long been im- The population in this study was workers in the work-
plemented, yet fragmentations still exist as well as mana- ing area of South Tangerang City Health Office consist-
ging institutions and provided services not yet being con- ing of the Health Office staff, 25 Public Health Centers
ducted integratedly.1 Based on the present literature, so- covering the public health center heads, healthcare ser-
cial insurance may improve people’s ability to reach vice providers such as doctors, midwives, nurses and
health services, so it may increase the use, improve the health promotion program officers and service users as
health status, and reduce out-of-pocket health costs.2-5 well as people who participated at the health promotion
After the National Health Insurance program was im- program implementation.
plemented, primary healthcare services including public Selection of informant samples in this study used pur-
health centers had an important role in which public posive sampling method. Samples consisted of three dif-
health center facilities have a gate keeper function. The ferent sources that were six policy makers consisting of
function itself is depicted through the Health Social two persons, namely staff at Health Office that were
Insurance Agency, commonly known as BPJS Kesehatan, Head of Primary Health Care Division and Head of
as the first-contact service, continuous service, compre- Health Promotion Division and four heads of Public
hensive service which includes curative, promotive and Health Centers, eight service providers consisting of
preventive services and also coordination of services.6 three doctors, one dentist and four health promotion pro-
After the implementation, changes also occurred in the gram holders (two midwives and two public health gra-
management of health insurance budgets at public health duates) and eight service users consisting of four patients
centers within the issuance of new regulations related to or their relatives and four community health workers.
implementation of capitation system. The change of bud- Selection of informants was based on the length of work-
geting pattern definitely affects programs conducted by ing time, sex and public health center area (rural/urban).
public health centers. Another impact to primary health- System thinking concept was used as the conceptual
care services resulting from implementation of the National framework in order to generate comprehensive analysis
Health Insurance program is an increase of patient visits. of this study. This study analyzed the impact of National
A study related to the use of capitation budget by pri- Health Insurance in the input component including poli-
mary care in Indonesia mentioned that the percentage of cy and commitment, funding, facility and equipment and
the budget use for promotive and preventive activities human resources which related to implementation of
was only about 2.7%. Meanwhile, among individual health promotion program. Then, in the process compo-
practice doctors, it was found that 5.15% of capitation nent was the implementation of health promotion pro-
budget was used for promotive and preventive activities.7 gram at public health centers.
A study conducted using qualitative methods on the ef- Instrument of study was divided into three parts in-
fect of the National Health Insurance regulation toward cluding document analysis, observation and in-depth in-
the implementation of Population Based Programs at terview. Document analysis was conducted on regula-
Public Health Centers in Sleman, Indonesia also men- tions, annual reports, strategic plans and work plans,
tioned that National Health Insurance regulation result- both issued by the Ministry of Health, South Tangerang
ed in the flexibility of Population Based Programs be- City Health Office or other governmental bodies which
coming limited, so the implementation of those programs related to the aim of the study. In this stage, 17 docu-
was not yet optimized.8 ments were analyzed including 9 legal products, 6 annual
Considering an effect of National Health Insurance reports and 2 strategic documents. Observation was con-
policy to health promotion program and also the circum- ducted on four Public Health Centers (2 rural, 2 urban).
stance whereas public health center in Indonesia still Observation was conducted on health promotion and
faces limited human resources, both from number and health prevention activities process of services, space
quality aspects as well as limited infrastructure used in condition and work environment. The forms of in-depth
implementation of public health center’s programs, this interview were arranged based on a conceptual frame-
study aimed to determine the impact of National Health work developed by the Ministry of Health in its technical
Insurance policies on health promotion programs at pub- guidance related to evaluation of health promotion pro-
lic health centers and to find problems that occurred du- gram implementation at public health centers, with some
ring the implementation. adjustments. Data analysis used content analysis method.
The interview transcript was then read carefully and gi-
Method ven codes. Prior to study, general codes were determined
This study used cross-sectional design through quali including policies and commitment, funding, facilities
104
Nurmansyah et al, Impact of National Health Insurance Policy towards the Implementation of Health Promotion Program
and equipments, human resource and implementation of Center in Rural Area)

health promotion. Based on the interview, public health centers also had
Based on protocol number 2215-GOA with approval to provide more curative services considering that there
dated 2015/30-07 and 2016/06-42 issued by Ethic was a condition which encouraged public health centers
Committee of Faculty of Medicine, Dokuz Eylul to conduct curative and rehabilitative activities. The con-
University, no ethical problems were identified in this dition is the lack of secondary healthcare service facilities
study. in South Tangerang, so it encouraged public health cen-
ters to provide inpatient services. Based on document
Results analysis, 21 of 25 Public Health Centers in South
Policy and Commitment on Health Promotion Program Tangerang provided inpatient services.
In accordance with guidance to National Health According to service providers, functions of public
Insurance implementation, the benefits of National health centers consisted of health promotion and pre-
Health Insurance consist of medical and non-medical as- vention services as well as curative functions. For them,
pects. There were some services that could be used on there was no significant increase of patient visits after
primary healthcare services including health promotion National Health Insurance was implemented. From the
and prevention services, diagnostic, recovery and health perspective of service users, there was no difference in
consulting, non-specific surgery, drug and health device, terms of public health center’s functions before and after
blood transfusion, laboratory service, inpatient service as National Health Insurance was implemented.
well as administration service. Therefore, National “There is no difference (before and after National
Health Insurance contained not only various curative ac- Health Insurance implemented), it concerns on curative
tivities, but also health promotion and prevention pro- [service] by any inpatient facility and promotive preven-
grams. tive [activities]” (Doctor of Public Health Center in
Strategic documents issued by BPJS Kesehatan depict Urban Area).
that public health centers as primary healthcare function
as gate keepers in which one of the functions is to provide Funding for Health Promotion Program
comprehensive services including promotive and preven- Prior to National Health Insurance implementation,
tive services. source of health promotion funding was from Health
Before National Health Insurance was implemented, Operational Fund. Based on guidance for the use of
South Tangerang City Government had implemented so- Health Operational Fund issued by the Ministry of
cial insurance for all citizens in which the citizens of Health, 60% of funds from the Health Operational Fund
South Tangerang City could use public health center’s was used by public health centers to reach Millennium
services for free. Therefore, there was no change of pub- Development Goals (MDGs) and 40% of such fund
lic health center’s functions after National Health could be used for other services and management of pub-
Insurance was implemented in which public health cen- lic health centers.
ter still concerned on promotive, preventive and curative After National Health Insurance was implemented,
services. BPJS Kesehatan made pre-payment to public health cen-
Based on interviews with policy makers, they consi- ter facilities based on capitation for the number of par-
dered that there was no difference found before and af- ticipants registered at the public health center facility.
ter National Health Insurance was implemented. Capitation fund was used for payment of personnel re-
“If looking at the health insurance, [concerns of pri- ward and health service operation. Personnel rewards
mary care] are still on curative [services] because medi- were paid with a minimum of 60% of total capitation re-
cal treatment is written more than the health promotion ceived and was used for medical and non-medical work-
[...]. If we see, there is also counseling service [in ers that provided services at the public health center fa-
National Health Insurance scheme]” (South Tangerang, cility.
Health Office Staff). Distribution of personnel reward was determined by
However, some said that National Health Insurance considering kinds of employment position or education
policies also had focused on promotive and preventive and daily presence. Medical workers got 150 points,
services in which there were several policies related to pharmacist and nursing profession got 100 points, bache-
National Health Insurance requiring public health center lor in health sciences got 60 points, associate degree
to perform health promotion. (Diploma 3) in health or non-health got 40 points, medi-
“Programs are all similar, yet the addition is about cal workers lower than associate degree got 25 points
fund concerns of National Health Insurance available and non-medical workers lower than associate degree got
for counseling and giving health information 15 point. In term of daily presence assessment, workers
[SocialInsurance Program]” (Head of Public Health being present every working day were given a score of 1
105
point per day and minus 1 point if arriving late or going Public health workers also said that the existing fund
home earlier up toseven hours. for health promotion and prevention was considerd ade-
Percentage for health service operation funding was quate and that there was no difference before and after
addressed to fund drug, health equipments and first-used implemention of the National Health Insurance for health
medical materials as well as other operational activities, promotion prevention.
such as individual health attempts including promotive,
preventive, curative and rehabilitative activities, house Facilities and Equipment on Health Promotion Program
visits in order of individual health attempts, operational Policy makers considered that health promotion facili-
for mobile public health center, printed material or office ties, such as projectors, laptops, posters, and banners at
stationery. Therefore, after National Health Insurance public health centers were adequate in terms of quantity
was implemented, there was a change of fund amount re- and quality. Some also mentioned that by existing
ceived by public health center. National Health Insurance funding, health promotion fa-
Policy makers said there was a change of funding cilities increased such as speakers, posters and accom-
source during the National Health Insurance era in which modation provided to patients during health promotion
the fund source before was from Health Operational activities. However, some considered physical infrastruc-
Fund, then now there is a capitation fund, so the budget ture was still inadequate, such as the lack of polyclinic
is larger. They also said that the present fund is adequate rooms and the lower number of chairs in patient waiting
to fund health promotion and prevention activities. room.
“In this era of National Health Insurance, health pro- Service providers said that the present health promo-
motion activities are more optimum and maximum be- tion facilities were already adequate. They mentioned
cause of fund supports. These National Health Insurance that the implementation of the National Health Insurance
policies feel so real [implemented]. We can use the fund program contributed positively to health promotion fa-
for activities in the field, such as outdoor public health cilities because the existing funds could be used to buy
centers’ counseling including dangers of smoking, then posters and other materials needed while performing
people’s mental health. (Head of Public Health Center in health promotion.
Rural Area) “In National Health Insurance, we print leaflets on
“30% of the capitation fund is for public health cen- mother and child health, environmental health about
ters’ operation. From that [fund], we also use [the fund] health promotion, also print banners of promotive, pre-
for promotion, and giving information of National ventive [activities] and backdrop for the events.” (Health
Health Insurance programs”. (Head of Public Health Promotion Program Holder of Public Health Center in
Center in Rural Area) Urban Area)
However, some also said that there was still confusion “I feel it is already adequate as after National Health
on the use of the capitation fund, so heads of Public Insurance is implemented, there are additional funds.
Health Centers had to consult often to the Health Office Counseling also increases. By the fund, we are very as-
within the use. Service providers stated that the fund sisted for speakers and serving snacks.” (Health
used for health promotion and prevention was already Promotion Program Holder of Public Health Center in
adequate and increasing. They also said that the reward Rural Area)
received was fair because it was divided in accordance However, service providers also said that there were
with employment position or education levels. Incentive still less facilities, such as polyclinic room and chairs in
was also considered adequate. waiting rooms. They stated that the funding received
“Calculation of [personnel rewards] on National from the National Health Insurance could not be used to
Health Insurance is quite fair and appropriate with each buy facilities such as chairs in waiting room.
education.” (Health Promotion Program Holder of “Seats in waiting rooms are inadequate because [the
Public Health Center in Urban Area) seats are] still made of wood, so [we have to] wait from
Yet, there was still a complaint regarding the large dif- the Health Office. National Health Insurance does not
ference in capitation fund received by each public health cover furniture purchase because National Health
center in accordance with the number of persons regis- Insurance fund may only be used for health equipment,
tered at the public health center. Therefore, public health drugs, BMHP and promotive and preventive operational
centers which had a larger number of patients had a lar- activities” (Health Promotion Program Holder of public
ger share of the capitation fund than public health cen- health center in Urban Area)
ters which had fewer patients. Service users said that the present health promotion
“[The amount] is less. Service at every public health facilities were already adequate. Some considered them
center is different. It’s better if it can be equalized.” inadequate because there was no place for Integrated
(Doctor in Rural Area) Health Care (Posyandu/the health care organized by
106
community), so people’s houses had to be used for the in- After National Health Insurance applied, some con-
tegrated health care. sidered that there was additional method, such as avail-
ability of specialists or competent speakers in providing
Human Resource on Health Promotion Program and counseling. There were also other programs per-
In accordance with Health Ministry Regulation on im- formed, such as Chronic Disease Management Program
plementation of health promotion, management of health (Prolanis) and health education regarding social insu-
promotion should be performed by coordinators who rance. Based on the Prolanis Implementation guidance
graduated from associate degree (Diploma 3) of health as document issued by BPJS Kesehatan, Prolanis aims to
well as interested and talented in the field of health pro- maintain the health for the National Health Insurance
motion. If none met the requirements, there should be all participants who suffered from chronic diseases to ac-
other medical workers at public health center, such as complish optimum life quality with effective and efficient
doctors, nurses, midwives, sanitarians, etc. costs of health services. Activities and Chronic Disease
Policy makers considered that human resources were Management Program included medical consulting,
already adequate in terms of quantity and quality, yet home visits, reminders, club activities and monitoring of
there were heads of Public Health Centers under rural health status.
criteria area who considered that the existing human re- Informants mentioned problems during the imple-
sources were less in terms of quantity and quality. mentation of promotion and disease prevention, such as
Lack of workers was indicated by the lower number the difficulty to change people’s behavior because of
of doctors. In one public health center in a rural area, some aspects, such as heterogeneous community condi-
there were only three doctors where one doctor worked tion, less awareness and the difficulty to reach male
at morning shift, one doctor worked at afternoon shift groups that worked during afternoons, so health promo-
and one doctor worked outside, therefore the number tion could reach housewives only.
was considered inadequate. It was also mentioned that “As National Health Insurance includes management
nowadays, the Health Office has been trying to meet hu- of chronic diseases and health education, we invite 50
man resources requirements by recruiting non-govern- persons, we use competent speakers from outside. We do
mental workers. counseling on non-communicable diseases, policies in
“I think human resources are still not enough...ideal accordance with the fund we have.” (Head of Public
number for doctor is 6, which is 2 doctors for morning Health Center in Urban Area)
shift, and others can do health program outside public Service providers also said that health promotion and
health center and evening shift.” (Head of Public Health disease prevention were performed outside and inside
Center in Rural Area) buildings. Common activities included distribution of
Service providers at public health centers in rural a- leaflets, installation of posters, and visits to houses,
reas also said that there were still inadequacies in terms schools and work sites. Several informants said that there
of both quantity and quality as shown by professional was a change after National Health Insurance was imple-
services handled by non-professionals, such as midwives mented in which there were additional funds that could
who had to act as a nurse. Service receivers also men- be used for disseminating information regarding social
tioned that inpatient services added to the workload of health insurance and Chronic Disease Management
medical workers. However, most medical workers in Program activities. However, there were also informants
public health centers in urban areas said that the number who said that no change was found before and after
and quality of human resources were already adequate. National Health Insurance implemented. Problems of im-
Service users mentioned that the number and quality plementation of health promotion programs expressed by
of human resources was already adequate. However, service providers were similar to problems mentioned be-
there were community health workers saying that the fore regarding the difficulty of changing people’s beha-
number of public health centers’ human resources was vior. Service providers considered that they already pro-
still inadequate because there were Integrated Health vided adequate health promotion, but the people were
Care which had not been visited by public health centers’ less aware of health as they had healthy lifestyle if they
staff frequently. suffered from diseases.
“After National Health Insurance was implemented,
Implementation of Health Promotion Program we do more regularly direct counseling to neighborhood
Policy makers said that there were some methods groups and hamlets. We also provide counseling on de-
used in health promotion, such as providing leaflets, generative diseases. Now the target is larger.” (Health
posters and health promotion inside and outside build- Promotion Program Holder of Public Health Center in
ings such as visits to houses, schools, offices and people’s Urban Area)
empowerment both students and communities. Some service receivers knew less about existing health
107
promotion and disease prevention programs, but public receive capitation fund less than it should be. Otherwise,
health workers said that there were several methods of if public health centers exceeded those indicators, who
health promotion including making available posters, would get a reward from BPJS Kesehatan. It is consid-
leaflets and health counseling. Problems mentioned by ered that regulation could be a supporting factor that en-
health promotion program participants were similar and courages public health centers to conduct the Prolanis
included less awareness of health matters and the diffi- program and other health promotion programs.
culty to reach wealthy people living in elite residences. Another factor was the lack of initiative from ma-
They said no change was found before and after National nagers at public health centers to conduct additional
Health Insurance was implemented. health promotion programs. However, staff shortages
Based on observations, there were poster and could also be a reason for public health center being un-
brochures related to health promotion at polyclinics, able to implement additional health promotion programs.
mother and child health rooms, contraception rooms, pa-
tient’s waiting rooms, and drug room. Public health cen- Discussion
ters also performed the Chronic Disease Management There are few studies regarding the impact of the
Program in which the activities included gymnastics, National Health Insurance program on health promotion
medical checkups and drug provision. Several public because the program is still being implemented. This
health centers also used television as a health promotion study used a qualitative approach with three methods of
media in the waiting room. data collection, in order to limit the bias of this study.
It is concluded that some health promotion programs One of the limitations of this study is that it contains
such as providing leaflets, posters, house visits, school only the initial perspectives of service receivers and users
visits, work place visits and people’s empowerment both because the program was implemented recently in early
students and communities have been implemented be- 2014. Therefore, further analysis is needed in the follow-
fore and after National Health Insurance Policy has been ing year. Moreover, it also needs study by different ap-
implemented. However, there are some new health pro- proaches, such as quantitative to compare the efficacy of
motion programs which were implemented recently after health promotion programs before and after implemen-
the National Health Insurance program was implement- tation of the National Health Insurance program.
ed such as Prolanis, promoting National Health Policy on the use of capitation fund at National Health
Insurance, more intense home visits and public counsel- Insurance scheme that could be used for the implemen-
ing. tation of health promotion and additional policies, such
Besides this, informants have said that there was no as Prolanis implementation and health counseling at pub-
change in implemented health promotion before and af- lic health center deemed had positive effects on imple-
ter the National Health Insurance program which may be mentation of health promotion.
due to insufficient regulation. In accordance with basic concepts stated by the
Actually, the guidance for primary health care to im- Indonesian Government regarding the goals of the
plement the Prolanis Program was launched by BPJS National Health Insurance program, comprehensive
Kesehatan. Furthermore, the regulations that encourage services includepromotive, preventive, curative and reha-
primary health care to implement the Prolanis program bilitative services.1 This is similar to the concept of
also were executed through BPJS Kesehatan, Regulation National Health Insurance implemented in Turkey in
Number 2 of 2015. Nevertheless, BPJS Kesehatan which their Health Ministry added health promotion and
Regulation Number 3 of 2015 stated that primary health disease prevention programs for the whole population,
care compulsorily carry out that program on January especially children and women.9
2017. Universal Health Coverage can be well funded when
Precisely that regulation rules out the capitation norm the government performs fact-based health promotion
and commitment based on the capitation system which program and employs health professionals. Effective
aims to enhance efficiency and efficacy of the National health promotion and disease prevention reduces pres-
Health Insurance program through quality control sys- sure on the health system and thus economy and directly
tem and financing system in the primary health care. improves a person’s health as well as lengthening life ex-
Therefore, in order to receive 100% capitation fund, pri- pectancy.10
mary health care should fulfill some indicators such as Considering the basic concept of public health centers
patient contact rate should be more than or equal to 150 as set out in the Health Minister’s Regulation, public
per mile, non spesialistic case referral ratio which should health centers deliver promotive and preventative actions
be under 5% and Prolanis participant attendant should as a primary healthcare facility. Provision of health pro-
be more than or equal to 50% in one month. If public motion service is mandatory for public health centers.
health centers did not meet those indicators, they would At a global level, the first international conference re-
108
lated to primary health care as a device to increase health health centers. A study at a public health center in
status was the Alma-Ata declaration conducted in 1978 Malang City, Indonesia mentioned that public health cen-
in Kazakhstan.11 In the declaration, basic health services ters were not able to provide supporting media, such as
were characterized as including solving health problems video and reading materials for health promotion because
at a community level, and providing promotive, preven- of fund limitations.16
tive, curative and rehabilitative services.12 It was possible for public health centers to use capi-
A lack of number of health workers at public health tation funds to provide supporting facilities in imple-
centers in Indonesia was not only shown in this study. A mentation of health promotion programs, such as trans-
study conducted in Gianyar District also showed that portation for people, competent speakers and meals for
there was a lack of human resources such as physicians attendees. More adequate facilities in health promotion
and nurses at public health centers.13 One of the chal- implementation definitely affected the success of the im-
lenges faced by public health centers in performing health plementation.
promotion, especially public health centers with less hu-
man resources in South Tangerang, was inpatient service Conclusion
burden. The low number of bed at hospitals also oc- Some regulations have been issued regarding National
curred in several cities in Indonesia. Based on the exist- Health Insurance implementation considering the posi-
ing data, public health centers providing inpatient servi- tive impact it could have on the implementation of health
ces were 3,317 and those that did not provide inpatient promotion programs at public health centers. Further-
services were 6,338. Thus, for every three public health more, the existence of additional funding sourced from
centers, 1 public health center provides inpatient servi- the capitation fund in the National Health Insurance era
ces. Ratio of beds at hospitals in Indonesia in 2014 was can be used to procure materials and equipment for exe-
1.12 per 1,000 population. At province level, there were cuting additional health promotion programs. Also health
13 provinces with a ratio less than 1 per 1,000 popula- promotion programs which are newly implemented du-
tion.14 ring the National Health Insurance era such as Prolanis,
The capitation fund portion granted to public health house visits and public counseling evidence the notion
centers, which further was used for health promotion ac- that National Health Insurance policy has a positive im-
tivities became one of the factors that had a positive ef- pact on the implementation of health promotion pro-
fect on the implementation of health promotion activities grams at public health centers.
at public health centers. The percentage of the capitation
fund used for different public health center services va- Acknowledgment
ried from place to place. Our sincere gratitude to Indonesia Endowment Fund
In accordance with the regulation from the Health for Education (Lembaga Pengelola Dana Pendidikan/
Minister of the Republic of Indonesia, the use of capita- LPDP) of Ministry of Finance that provided financial as-
tion funding received by public health center facilities is sistance in conducting this study and South Tangerang
determined by Decision of Regional Head. The regulation City Health Office that granted permits to conduct the
only arranges that personnel rewards are at least 60% of study in its working area.
capitation fund, so it possibly makes regulation in every
region vary. References
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and Insurance of Health Ministry, there were differences jaminan kesehatan nasional. Jakarta: Kementerian Kesehatan Republik
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Kesehatan. 2015; 18 (10): 437-45. pelayanan puskesmas perawatan yang berstatus badan layanan umum
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pelaksanaan fungsi UKM di Puskesmas Ngaglik II Kabupaten Sleman 164-70.
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9. Rifat A, Sabahatin A, Sarbani C, Safir S, Meltem A, Ipek G, et al. tahun 2013. Jakarta: Kementerian Kesehatan Repulik Indonesia. 2014.
Universal health coverage in Turkey: enchancement of equity. Health 15. Pusat Pembiayaan dan Jaminan Kesehatan Kementerian Kesehatan
Policy Journal. 2013; 382: 65-99. Republik Indonesia. Resume laporan daerah dalam penyelenggaraan
10. Gloria C, Joy de B. The imperative for health promotion in universal jaminan kesehatan nasional 2014. Jakarta: Kementerian Kesehatan
health coverage. Global Health: Science and Practice. 2014; 2 (1): 10- Republik Indonesia. 2015.
22. 16. Indah PW, Soesilo Z, Riyanto. Implementasi kebijakan promosi kese-
11. Karl T, Patricia E. An assessment of public health center in the hatan (studi pada pusat kesehatan masyarakat Dinoyo, Kecamatan
Carribean pre and post Alma Ata Declaration and a way forward. Lonokwaru, Kota Malang). Jurnal Administrasi Publik. 2014; 2 (11): 1-
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Solehati et al. Kesmas: National Public Health Journal. 2017; 11 (3): 111-116 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.1171
Effect of School Community Empowerment Model

towards Handwashing Implementation among
Elementary School Students in Dayeuhkolot Subdistrict
Pengaruh Model Pemberdayaan Komunitas Sekolah terhadap Penerapan

Mencuci Tangan di Kalangan Siswa Sekolah Dasar di Kecamatan
Dayeuhkolot
Tetti Solehati*, Cecep Eli Kosasih**, Sri Susilawati***, Mamat Lukman*, Sayu Putu Yuni Paryati****
*Faculty of Nursing, Padjajaran University, Bandung, Indonesia, **Faculty of Nursing, Prince of Songkla
University, Hat Yai, Thailand, ***Faculty of Dentistry, Padjajaran University, Bandung, Indonesia, ****Faculty of
Medicine, Jendral Ahmad Yani University, Cimahi, Indonesia
Abstract
Handwashing behavior in Indonesia remains a problem. The cause is associated with a lack of awareness in handwashing with soap. This study aimed to de-
termine the effect of the school community empowerment model on handwashing implementation among elementary school students in Dayeuhkolot
Subdistrict, Bandung District. This study used quasi experimental design with pre-test and post-test, and descriptive and inferential analyses. Samples con-
sisted of 24 teachers, 377 students at 4th – 6th grade and 24 school-children from the little doctors program. The approach method in this study used inte-
grated school health efforts (combined model of fit for school and selected school health effort) consisting of six stages. Instruments were knowledge ques-
tionnaires, observations and checklist sheets. Handwashing with soap was evaluated for three months. Results found that the score of little doctors in the
good category increased in skill of handwashing with soap from 0% to 100%, the skill among the students who were not little doctors improved in good cate-
gory from 0% to 87.5%. School community empowerment affects handwashing behavior among elementary school students.
Keywords: Elementary school students, empowerment method, handwashing with soap
Abstrak
Perilaku mencuci tangan dengan sabun di Indonesia masih menjadi masalah. Penyebabnya dikaitkan dengan kurangnya kesadaran dalam mencuci tangan
pakai sabun. Penelitian ini bertujuan untuk mengetahui pengaruh pemberdayaan komunitas sekolah terhadap penerapan mencuci tangan di kalangan siswa
sekolah dasar di Kecamatan Dayeuhkolot, Kabupaten Bandung. Penelitian ini menggunakan desain quasi eksperimental dengan pretest dan posttest serta
melakukan analisis deskriptif dan inferensial. Sampel terdiri dari 24 guru, 377 siswa di kelas 4-6, dan 24 dokter kecil. Metode pendekatan dalam penelitian
ini menggunakan usaha kesehatan sekolah terpadu (gabungan model fit for school dan UKS terpilih), yang terdiri dari enam tahap. Instrumen terdiri dari kue-
sioner pengetahuan, lembar observasi, dan lembar checklist. Cuci tangan pakai sabun dievaluasi selama tiga bulan. Hasil menemukan bahwa terdapat pe-
ningkatan skor dalam kategori baik untuk keterampilan cuci tangan pakai sabun dokter kecil dari 0% sampai 100% dan keterampilan mencuci tangan pakai
sabun pada siswa meningkat dalam kategori baik dari 0% menjadi 87,5%. Pemberdayaan komunitas sekolah memengaruhi perilaku mencuci tangan di kalang-
an siswa SD.
Kata kunci: Siswa sekolah dasar, metode pemberdayaan, mencuci tangan pakai sabun
How to Cite: Solehati T, Kosasih CE, Susilawati S, Lukman M, Paryati SPY. Correspondence: Tetti Solehati, Faculty of Nursing, Padjadjaran University, L
Effect of school community empowerment model towards handwashing im- Building Unpad Jatinangor, Indonesia, Phone: +6222 7795596, e-mail: tsh_tet-
plementation among elementary school students. Kesmas: National Public
[email protected]
Health Journal. 2017; 11 (3): 111-116. (doi:10.21109/kesmas.v11i3.1171)

Received: August 30th 2016
Revised: October 17th 2016
Accepted: January 3rd 2017
Introduction promote school health, and also an effective place where

One of the factor contributing to the low achievement students can be taught about the impactsof healthy and
of health indicators is inadequate health promotion and unhealthy behaviors. Targeting school-children is addi-
community development in the field of health. This is tionally advantageous because the children may positive-
evidence by public behaviors do not support healthy hy- ly influence their families.
gienic community, such as handwashing with soap. Basic Dayeuhkolot Subdistrict is one of the areas in
Health Research has shown that the biggest cause of Bandung District which is most often affected by floods.
death of infants and children in Indonesia was diarrheal The interview with the Head of Dayeuhkolot Subdistrict
diseases (9%).1 The incidence of diarrhea in Indonesia determined that Dayeuhkolot area is affected by the
increases every year. In 2005, as many as 5,051 people floods every year causing almost all schools in the area to
suffered from diarrhea, then increased to 10,980 people be flooded. Children often swim in the floodwater. Based
in 2006.2 National prevalence of proper handwashing on interviews with the education officer of Dayeuhkolot,
behavior was 23.2%. Proper handwashing with soap many diseases arose after the flood, such as diarrhea
could reduce the risk of diarrheal diseases by 42% to which became one of the top 10 diseases in the clinic.
47%.3 West Java is one of the provinces with a diarrhea Principals and teachers in charge of the school health ef-
prevalence that is higher than the national prevalence, as fort at some elementary schools in Dayeuhkolot said that
well as a prevalence of handwashing that is lower than many students were absent (20-30%) during the flood
the national prevalence. due to illness (one of the reasons for absenteeism was di-
A risk factor that contributes to handwashing beha- arrhea). Of the 40 children interviewed, 100% of the
vior is poor knowledge and practice. A study found that children did not know about handwashing with soap.
knowledge and practice among elementary school stu- Also observations determined that many children were
dents was poor.4 This study showed that government swimming around schools and homes during the floods.
needed to conduct sustainable promotion of hygienic and A possible method to increase awareness and beha-
healthy behaviors at elementary schools. Health prob- vior of people in handling the impact of floods is to in-
lems among the students can be caused by multifactors volve the school community in the areas of health and ed-
that affect on a health level. ucation. In the field of children’s education, there needs
The health level is not only determined by health ser- to be optimization of knowledge and skills to inculcate
vices, but also by behavioral factors which are the domi- the habits of handwashing with soap at an early age. The
nant factor. Diarrhea is often suffered by those affected health sector needs continuous efforts to educate the
by flood as the efforts in flood prevention are more con- public on the importance of handwashing with soap by
cerned with providing physical building flood control, way of strengthening the understanding of handwashing
but less concerned with health problems that can be with soap at primary school age with comprehensive edu-
caused by flood, such as diarrhea. The environmental cation.
risk for diarrheal disease is compounded by the low Implementation of handwashing with soap at ele-
handwashing rates among children, meaning they are at mentary schools can be done through a school health ef-
a higher risk. fort. School health effort is one way to improve the health
Household behavior is strongly influenced by social of students as early as possible. To improve the behavior
order, such as school order. Handwashing with soap patterns of children in implementing handwashing with
habits need to be formed at schools. Handwashing with soap in their daily life at school, an empowerment pro-
soap at elementary school level is important since the gram is needed, in this case to involve the participation
students are the future generation and the largest age of the little doctors. Several studies showed that peer
group in compulsory education. People at that age are education was effective in improving a person’s behavior.
very adaptable to new healthy living habits, the life ex- A Study on handwashing patterns was conducted among
pectancy is still long, and they are in a period of growth school children in the State Elementary School of
and development. However, this age group is prone to Dayeuhkolot VII and X Dayeuhkolot in 2014, but it did
various diseases, such as diarrhea and worm infection. not involve the participation of little doctors and local au-
The state of health of school children will affect academic thorities.5 The continuity of handwashing behaviors was
achievement. If a child is ill, it will disrupt his or her aca- less than was desired. By involving the little doctors and
demic achievement. Schools are public institutions that support of the local government, it would be expected
are well-organized. Their human resources can affect that the pattern of handwashing with soap in school chil-
positive change to children’s health-related behaviors. dren would decline less over time.
Health education with school children is a very effective A previous study showed that the educational infor-
method to change behavior and lifestyle in general. mation communication model could improve knowledge,
Educational institutions are considered strategic place to attitude and practices.6 However, it needed support from
112
Solehati et al, Effect of School Community Empowerment Model towards Handwashing Implementation
the government and local health agencies through shop was conducted with the policy holders both of the
guidance and supervision.4,6 Therefore, a comprehensive district, village, health agency, education agency, and the
approach involving participation of the school commu- principal. At this stage, socialization with policy maker
nity was needed to improve handwashing behavior officials (Head of Dayeuhkolot Village, Head of
among students. Pasawahan Village, Head of Cangkuang Village, Head of
An Integrated school health effort program was ex- Leuwi Bandung Village, Headmaster of Bojong Asih
pected to reduce the incidence of diarrheal diseases and State Elementary School, Headmaster of Pasawahan
improve the nutritional status of children. An integrated State Elementary School, Headmaster of Cangkuang
school health effort is a model which is a combination of State Elementary School, Headmaster of Leuwi Bandung
the model fit for school with selected school health ef- State Elementary School) was conducted as handwashing
forts which in this case is the handwashing with soap. with soap programs at schools could be a necessity. In
School health efforts fit for school models were tested on stage 2, tools and posters were designed for schools to
elementary school students in the Philippines, showing improve handwashing patterns. Stage 3 was handwash-
that the model was successful in reducing the incidence ing with soap education and demonstration for teachers.
of diseases from intestinal worms, diarrhea and im- At this stage, counseling and demonstration of hand-
provement of the nutritional status of school children.7 washing with soap were performed for all teachers.
Empowerment through little doctors using a model of Delivery was frequently with lectures and many ques-
Integrated school health effort is expected to increase tions were asked. Videos and live demonstrations were
healthy behavior of the school community, which ulti- also used. Stage 4 was election and training of little doc-
mately will reduce the incidence of diarrheal infections. tors using teaching, videos, and live demonstration me-
Thus, this study aims to determine the effect of school thods. At this stage, little doctors taught and trained
community empowerment towards handwashing imple- handwashing with soap. Stage 5 was handwashing with
mentation among elementary school students in soap education and demonstration delivered by little doc-
Dayeuhkolot Subdistrict. tors to all students in the fourth to the sixth grade using
a question and answer session, videos, and live demon-
Method strations and was accompanied by a researcher and
The study design was quasi-experimental with pre- teacher. Stage 6 was evaluation. In this stage, all activi-
test and post-test to examine the effect of methods of ties were evaluated.
empowering little doctor school communities toward Data collection methods included providing all
handwashing with soap implementation among elemen- teachers, students and little doctors with questionnaires
tary school students. The study was conducted at State about their knowledge of handwashing with soap before
Elementary Schools of BojongAsih, Pasawahan, and after the intervention counseling on handwashing
Cangkuang, and Leuwi Bandung in Dayehkolot with soap. To determine handwashing with soap skill, all
Subdistrict, Bandung District. The study was conducted little doctors and students were required to practice the
from April to November 2015. Populations in this study way they performed handwashing and were assessed
were 24 teachers, 24 little doctors, and 377 elementary using an observation sheet. Pattern of handwashing with
school students in the 4th – 6th grade, because they had soap was evaluated using a checklist sheet for three
been given the material about personal hygiene at the months.
fourth grade and higher. The sample was recruited using This study gained permission from Bandung District
a purposive sampling technique that involved all popula- Government, Bandung District Health Office, Bandung
tions of the subject consisting of all students from the District Education Office and four elementary schools.
fourth to the sixth grade. Before the intervention, all sam- Data analysis consisted of descriptive analysis for uni-
ples were informed and agreed to join the study. The in- variate data and inferential analysis for bivariate data. In
strument used in this study consisted of a questionnaire the descriptive analysis of univariate data, frequency and
to measure knowledge of handwashing with soap, obser- percentage were used, while bivariate data was analyzed
vation sheets to measure handwashing with soap skills, using a t-test. This study also conducted multivariate
and checklist sheet to assess patterns of handwashing analysis to investigate the mean difference among the stu-
with soap. dents for three months. However, data in the study did
Methods of empowering the school community were not satisfy the assumption, thus the analysis was changed
all facilitation efforts to improve the knowledge and abili- from RM-ANOVA to Friedman’s test.
ty of the public schools, so that they were able to identi-
fy, plan and perform problem resolutions by utilizing lo- Results
cal potential, including facilities and sources of financing. It was found that there was increased healthy hand-
This method consisted of six stages. In stage 1 a work- washing with soap behaviors after intervention, as com-
113
pared to before intervention, for both little doctors and Discussion

students (Table 1). Based on results, the skill of health cadres increased
Based on Table 1, 24 little doctor respondents after the educational intervention. They said understand-
(100%) had a bad skill of handwashing with soap before ing of handwashing with soap after intervention given, so
intervention. After the intervention, there was an in- that it could perform the skill of handwashing with soap
creasing skill of handwashing with soap in which all 24 properly. Education could increase understanding and
respondents (100%) had a good skill of handwashing skill of handwashing with soap. The intervention in-
with soap. Student responses, showed that, before the increased the skill among little doctors and students.
tervention, all of the students (377 students) had a bad Students poorly in handwashing skill. However, in gen-
skill of handwashing with soap. After intervention, little eral, the skill of little doctors and students had a signifi-
doctors and teachers increased in skill. 330 people cant value before and after intervention. This was in line
(87.5%) respondents had a good knowledge of hand- with a study conducted by Solehati,5 which found that
washing with soap. The table below showed the effect of education raised the skills of elementary school students.
empowering the little doctors regarding handwashing The handwashing with soap skills that they learned could
with soap. then be taught to the students. This would strengthen
Table 2 showed that there were differences in mean the atmosphere and make the learning process more fun.
skill of handwashing with soap before and after the in- In this case knowledge transfer would be aided by the
tervention on the little doctors, also there were diffe- rapport that little doctors would have with the students.
rences in mean skill of handwashing with soap before Teachers and little doctors may create peer pressure that
and after the intervention by teachers and little doctors would make students want to implement handwashing
to students (p value = 0.001). The effect of empowering with soap every day. In addition to peer pressure causing
the little doctors on handwashing with soap pattern after students to be more motivated to implement the hand-
three interventions can be seen in the Table 2.
Table 1. Handwashing with Soap Skill Distribution of Respondents
According to Table 3, all 377 students (100%) did
not perform handwashing with soap at school before the Before Intervention After Intervention
intervention. After the intervention, there was an in- Respondent Category
n % n %
creasing trend of handwashing with soap in month 1, in
which most students, 356 students (94.4%), had a good Little doctor Bad 24 100 0 0
handwashing with soap pattern. All students (100%) Good 0 0 24 100
handwashing with soap pattern was good when evalua- Total 24 100 24 100
ted in months 2 and 3.
Table 4 showed that there was a significant difference Student Bad 377 100 47 12.5
Good 0 0 330 87.5
of handwashing pattern among students between each of
intervention month 0 month 1, month 2 and month 3. Total 377 100 377 100
However, further analysis is required to determine the
difference between groups. Table 2. The Mean Difference of Handwashing with Soap Skill Before and
To determine the difference between two tests, post After Intervention
hoc analysis was conducted as shown in Table 5.
Respondent Category Mean SD p Value
According to Table 5, there was a significant difference
between pretest and posttest month 1, pretest and Little doctor Before intervention 38.75 10.75 0.001
posttest month 2, pretest and posttest month 3, posttest After intervention 96.67 4.81
Student Before intervention 39.28 11.40 0.001
month 1 and posttest month 2, posttest month 1 and After intervention 86.34 6.94
posttestmonth 3, but there was no difference between
posttest month 2 and posttest month 3. Notes: SD = Standard Deviation
Table 3. Frequency Distribution of Handwashing with Soap Patterns of Students
Before Intervention After Intervention
Handwashing with Soap Month 1 Month 2 Month 3

Pattern
Undone Done Undone Done Undone Done Undone Done
f % f % f % f % f % f % f % f %
377 100 0 0 21 5.6 356 94.4 0 0 377 100 0 0 377 100
114
Solehati et al, Effect of School Community Empowerment Model towards Handwashing Implementation
washing with soap, posters on the wall of classes may en- handwashing with soap is very important because factors
courage handwashing also. A study by Amalia suggest- that influence handwashing behavior include support in
ed that images had a key role in the increased retention the form of facility availability, social norms, encourage-
and understanding that can be gained from poster type ment and admonishment, as well as education and infor-
materials.8 Thus handwashing with soap pattern after mation.12 It is expected to establish a cooperation bet-
the intervention showed significantly better results. ween parties, so that illnesses such as infectious diarrhea
The results of this study esults showed that training can be reduced by handwashing with soap which is being
was significantly different between pre-test and post-test used as a health pattern in everyday life.
both for handwashing with soap skill and pattern (p va- Handwashing behavior in the future can decrease the
lue < 0.05). The study determined that training, counse- risk factors of morbidity and mortality among students.
ling or other forms of knowledge renewal are necessary The handwashing with soap pattern in everyday life is im-
for school cadres to maintain their effectiveness in hand- portant because it has been proven to reduce the occur-
washing with soap. Their understanding and skills with rence of diarrhea. The risk of diarrheal diseases could be
handwashing with soap could be implemented into reduced by 42% to 47% with proper handwashing with
everyday life, and it could influence others to implement soap.10 This is in line with a study conducted on children
handwashing with soap. Thus a healthy lifestyle can be in Bangladesh which showed that handwashing can re-
created by handwashing with soap. This is in line with a duce the risk of diarrhea among children.13-15
study conducted in Argentina, which revealed that edu-
cation about handwashing and handwashing policies Conclusion
could significantly improve handwashing.9 Health pro- This study finds that the empowerment of the school
motion carried out by little doctors as part of the school cadre community as health workers (little doctors) can
community could change the pattern of handwashing stu- improve the handwashing behavior of students. Beside
dents because they are directly involved every day and the continuous evaluation of the local health center to
can remind and encourage students to implement hand- make patterns of handwashing with soap at schools.
washing with soap over a long period. Promotional pro-
grams of health could change behavior and could be Recommendation
more effective if performed repeatedly over a longer du- School community empowerment programs are ne-
ration.10 Promotion of handwashing with soap is impor- cessary to improve student handwashing with soap pat-
tant as a study showed that millions of lives could be terns. In addition, specific funds need to be allocated for
saved due to a decreased prevalence of diarrhea.10 the provision of facilities and handwashing with soap ac-
Coordination from various parties, such as health cen- tivities at schools (the needs of agreement between the
ters, education offices, village offices, district govern- policy holders from the Health Agency and Education
ments, health offices, and district heads are indispensa- Agency of Bandung District. There is a need for media
ble. Therefore, any written rules are necessary to be made that encourages handwashing with soap, to be perform-
by the local district head to apply handwashing with soap ing daily. Succesful programs can be used as a powerful
as a program at schools. A study found that promotion- model for other school.
al programs of handwashing with soap reduced students’
absenteeism due to diarrhea.11 Similarly, programs could Acknowledgment
improve the health of children worldwide. We would like to thank the Ministry of Research,
In addition, there should be a directive from the go- Technology and Higher Education of the Republic of
vernment that encourages health cadres at schools to
perform properly and continuously. School cadres as the Table 4. The Mean Difference of Handwashing with Soap Patterns on Students
spearheads of basic services atschools become important
Respondent Category Mean SD p Value
when the implementation of handwashing with soap can
run well. Therefore, it considers the support of know- Student Before intervention 0.00 0.00 0.001
ledge, skills and operations from the clinic as well as sup- After intervention (month 1) 0.94 0.23
After intervention (month2) 1.00 0.00
porting policies and operations of the local government. After intervention (month 3) 1.00 0.00
Support from various parties in the implementation of
Table 5. Post Hoc Analysis of Handwashing Patterns on Students
Variable Pre-Post 1 Pre-Post 2 Pre-Post 3 Post 1 - Post 2 Post 1 - Post 3 Post 2- Post 3
Z -18.868(a) -19.416(a) -19.416(a) -4.583(a) -4.583(a) ,000(a)

P value 0.0001 0.0001 0.0001 0.0001 0.0001 1.000
115
Indonesia and the Director of Research and Community 8. Amalia IS. Evaluasi media poster hipertensi pada pengunjung
Services University of Padjadjaran whom have funded Puskesmas Talaga Kabupaten Majalengka. Kemas: Jurnal Kesehatan
this study through the IPTEK bagi Wilayah scheme, as Masyarakat. 2013; 9 (1): 1-8.
well as to all those who have participated in this study. 9. Rosenthal VD, McCormick, RD, Guzman, S, Villamayor, C & Orellano,
PW. Effect of education and performance feedback on handwashing: the
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1. Badan Penelitian dan Pengembangan Kesehatan Kementerian Journal of Infection Control. 2003; 31(2): 85-92.
Kesehatan Republik Indonesia. Riset kesehatan dasar 2007, laporan na- 10. Curtis V, Cairncross S. Effect of washing hands with soap on diarrhae
sional 2007. Jakarta: Badan Penelitian dan Pengembangan Kesehatan risk in the community: a systematic review. Lancet Infectious Disease.
Kemenkes Republik Indonesia; 2008. 2003; 3(5): 275-81.
2. Departemen Kesehatan Republik Indonesia. Informasi pengendalian 11. Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, et al. Cluster-ran-
penyakit menular dan penyehatan lingkungan. Jakarta: Departemen domized controlled trial evaluating the effect of a handwashing promo-
Kesehatan Republik Indonesia; 2007. tion program in Chinese Primary Schools. American Journal of Tropical
3. United Nations Children’s Fund Indonesia. Ringkasan kajian: air bersih, Medicine and Hygiene. 2007; 76(6): 1166–73.
sanitasi, dan kebersihan. Jakarta: United Nations Children’s Fund 12. Chittleborough CR, Nicholson AL, Basker E, Bell S, Campbell R.
Indonesia; 2012. Factors influencing hand washing behaviour in primary schools: process
4. Krianto T. Perilaku hidup bersih sehat dengan pendekatan partisipatif. evaluation within a randomized controlled trial. Health Education
Kesmas: Jurnal Kesehatan Masyarakat Nasional. 2009; 3 (6): 254-8. Research. 2012; 27(6): 1055-68.
5. Solehati T, Susilawati S, Lukman M, Kosasih EK. Pengaruh edukasi ter- 13. Allison EA, Coulborn RM, Perez VMS, Larson EL. Effect of hand hy-
hadap pengetahuan dan skill guru serta personal hygiene siswa SD. giene on infectious disease risk in the community setting: a meta-analy-
Kemas: Jurnal Kesehatan Masyarakat. 2015; 11(1): 135-43 sis. American Journal of Public Health. 2008; 98(8): 1372-81.
6. Said RM,Thaha MR, Syafar M. KIE untuk peningkatan pengetahuan, 14. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, et
sikap, dan praktik pencegahan dan penanggulangan penyakit flu bu- al. Effect of handwashing on child health: a randomised controlled tri-
rung di Kabupaten Gowa, Sulawesi Selatan. Kesmas: Jurnal Kesehatan al. Lancet. 2005; 366(9481): 225-33.
Masyarakat Nasional. 2010; 5(1): 23-8. 15. Luby SP, Halder AK, Huda T, Unicom BL, Johnston RB. The effect of
7. MonseB, Benzian H, Naliponguit E, Belizario, V, SchratzA, Helderman handwashing at recommended times with water alone and with soap on
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116
Devi et al. Kesmas: National Public Health Journal. 2017; 11 (3): 117-122 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.1147
Acceptance of Medical Resume Completion at

Dr. Radjiman Wediodiningrat Lawang Psychiatric
Hospital
Penerimaan Pengisian Resume Medis di Rumah Sakit Jiwa Dr. Radjiman

Wediodiningrat Lawang
Silvia Shinta Devi, Aryo Dewanto, Lukman Hakim
Postgraduate Program in Hospital Management, Faculty of Medicine, Brawijaya University, Malang, Indonesia
Abstract
The health system in Indonesia has undergone major changes with the enactment of National Health Insurance program. Medical resume have an important
role in health insurance claims, so delayed and incomplete medical resume completion will disrupt the process of insurance claims. This study aimed to de-
termine effects of perceived ease of use, perceived usefulness, and attitude on doctor’s acceptance in completing medical resume at Dr. Radjiman
Wediodiningrat Lawang Psychiatric Hospital based on Technology Acceptance Model (TAM). TAM was used as a model in this study because medical re-
sume is one form of information technologies that is still manual. Data collection for this study was conducted in March 2016 by using questionnaires given
to 32 doctors at Dr. Radjiman Wediodiningrat Lawang Psychiatric Hospital. The five-level Likert scale was used to measure each of the variables. The data
were analyzed using Partial Least Square. The result showed that in general, physician acceptance at Dr. Radjiman Wediodiningrat Lawang Psychiatric
Hospital againts medical resume charging is in the high category and has perceived usefulness and attitude in both categories, while perceived ease of use
is in the medium category.
Keywords: Acceptance, health insurance, medical resume
Abstrak
Sistem kesehatan di Indonesia mengalami perubahan besar dengan diberlakukannya program Asuransi Kesehatan Nasional. Resume medis memiliki peran
penting dalam klaim asuransi kesehatan, sehingga resume medis yang terlambat dan tidak lengkap akan mengganggu proses klaim asuransi. Penelitian ini
bertujuan untuk mengetahui pengaruh persepsi kemudahan penggunaan, persepsi manfaat, dan sikap pada penerimaan dokter dalam menyelesaikan re-
sume medis di Dr Radjiman Wedyodiningrat Psychiatric Hospital Lawang berdasarkan Technology Acceptance Model (TAM). TAM digunakan sebagai model
dalam penelitian ini karena resume medis merupakan salah satu bentuk teknologi informasi yang masih dilakukan secara manual. Pengumpulan data untuk
penelitian ini dilakukan pada bulan Maret 2016 dengan menggunakan kuesioner yang diberikan kepada 32 dokter di Rumah Sakit Jiwa Dr Radjiman
Wediodiningrat Lawang. Skala Likert lima tingkat digunakan untuk mengukur setiap item variabel. Data dianalisis dengan menggunakan Partial Least Square.
Hasil penelitian menunjukan bahwa secara umum, acceptance dokter di RSJ Dr. Radjiman Wediodiningrat Lawang terhadap pengisian resume medis ma-
suk dalam kategori ringgi dan memiliki perceived usefulness and attitude yang dalam kategori baik, sedangkan perceived ease of use dalam kategori sedang.
Kata kunci: Penerimaan, asuransi kesehatan, resume medis
How to Cite: Devi SS, Dewanto A, Hakim L. Acceptance of medical record Correspondence: Silvia Shinta Devi, Postgraduate Program in Hospital
completion at Dr. Radjiman Wediodiningrat Lawang Psychiatric Hospital. Management Faculty of Medicine Brawijaya University Malang, Veteran Street
Kesmas: National Public Health Journal. 2017; 11 (3): 117-122.
65145, Phone: +62341 568989, e-mail: [email protected]
(doi:10.21109/kesmas.v11i3.1147)
Revised: November 7th 2016
Accepted: December 29th 2016
Introduction information forms. The behavior of doctors in charge of

The health system in Indonesia has undergone major medical resumes will be examined on two aspects of the
changes since the introduction of a health insurance sys- TAM, the benefits (perceived usefulness) and services
tem called National Health Insurance program. This pro- (perceived ease of use) to resume charging medical doc-
gram is a national program issued by the government on tor. This model has been used previously by researchers
January 1st, 2014. According to Health Minister Decree who have applied and tested it both within company and
No. 28 Year 2014, Social Security Agency (Badan health environments.8 This study aimed to determine ef-
Penyelenggara Jaminan Sosial/BPJS) is the organizing fects of perceived ease of use, perceived usefulness, and
body of health insurance program as established by Act doctor’s willingness to comple medical resumes at Dr.
No. 24 Year 2011. This health insurance is now compul- Radjiman Wediodiningrat Lawang Psychiatric Hospital.
sory for all Indonesian citizens and foreigners who work
at least six months in Indonesia. Method
National Health Insurance payment claims will be This study was quantitative and the study type was ex-
paid directly by the government. For hospital inpatient planatory with cross-sectional design. Data collection
claims there are administrative requirements including a used a survey method which provided a direct question-
hospitalization permit, participant eligibility letter, medi- naire with a list of statements to all the medical doctors
cal resume and additional supporting evidences. If a who filled resumes. Quantitative study was a process of
medical record document is incomplete, then the claim finding knowledge which used data in the form of num-
will be lower.1,2 Currently, BPJS fund claims are submit- bers.9 This study was an explanatory survey study that
ted to BPJS and will first be verified by BPJS verifier. If was based on relationship influence, or presence of causal
approved by the verifier, the fund claims will be delivered relationship. Indicator variables included perceived ease
to the hospitals.3 of use (PEU) which described whether or not the medical
The medical resume plays an important role in the resume was easy to learn and use.10 Another indicators
current BPJS era as a required document for a claim.4 used was the perceived usefulness (PU) which detailed
BPJS claims require well-timed and complete medical re- whether medical resume charging aids communication,
sume documents as a part of hospital medical records. In aids the process of making an insurance claim, protect
practice, however, medical record documents may not case law, improve the quality of hospital services, and im-
have been completed well. proves health statistic Attitude indicator (At) that is ac-
Doctors have an important role in completing medical ceptance, interest behavior. Indicators Acceptance (Ac)
record documents, including medical resume, which are is a real use, frequency of use, user satisfaction.11 The
detailed in Health Minister Decree No. 269 Year 2008 study population included specialist and general practice
Article 6. This regulation explains that doctors, dentists, doctors (32 doctors) who worked at Dr. Radjiman
and/or certain additional health personnel are responsi- Wediodiningrat Lawang Psychiatric Hospital and who
ble for records and/or documents created as a medical filled medical resumes.
record.2 In reality, there are many doctors who fill out the The data source used in this study was the primary da-
medical resume incompletely. A previous study explained ta collected through questionnaires given to the respon-
that medical record incompleteness was due to physician dents. The scale of measurement on the instrument used
behavior.5-7 a Five-level Likert scale where a score of 5 signaled
One of the barriers perceived by the hospital is in- strongly agree (SA), 4 for agree (A), 3 for neutral (N), 2
complete medical resumes filled out by doctors. Doctors for do not agree (D), and 1 for strongly disagree (SD).
have an important role in completing medical resumes The study instrument used in this study had previous-
since they can only be filled by a doctor. Doctor’s incom- ly been tested for validity and reliability. Analysis of the
pleteness in writing diagnoses included in the medical re- data in this study used Partial Least Square (PLS) with
sume is also problematic for the hospital when making PLS SMART program. PLS was used because it could
insurance claims.4 work efficiently with a smaller sample size compared to
BPJS fund claims of Dr. Radjiman Wediodiningrat Structural Equation Modeling (SEM) for a more com-
Lawang Psychiatric Hospital’s inpatients unit are delayed plex model. PLS also could analyze the measurement of
each month due to medical resume files being incom- reflective, formative and latent variables with one indica-
pletely filled by doctors. Additionally, most patients at the tor without causing problems of identification.
Dr. Radjiman Wediodiningrat Lawang Psychiatric
Hospital (71% in the first half 2015) used BPJS facilities, Results
so the hospital will suffer deprivation if BPJS fund claims The study results conducted on the doctors who filled
are always later than the specified time. out the medical resume at Dr. Radjiman Wediodiningrat
Medical resumes are considered as one of the written Lawang Psychiatric Hospital showed an overview of age,
118
Devi et al, Acceptance of Medical Resume Completion
sex, education level, and tenure at Dr. Radjiman loading value (0.901). This indicated that the actual us-
Wediodiningrat Lawang Psychiatric Hospital. age was the most dominant indicator in measuring ac-
Respondent characteristics in this study indicated that all ceptance. Figure 1 showed the line diagram model of this
doctors were older than 31 years old and the majority study.
(53%) were aged 31-40 years and females (78%). Most The contribution of perceived ease of use on per-
respondents attained bachelor degree (47%), and had up ceived usefulness was 8.8%, while the remaining 91.2%
to 10 years of work experience. The characteristic fea- was contributed by other variables that were not ad-
tures of the respondents were presented in Table 1. dressed in this study. This might indicate that attitude di-
The perceived ease of use variable measurement mo- versity was able to be explained by perceived ease of use
del determined that easy to learn indicator had the high- and perceived usefulness, perhaps 40.1%, or in other
est loading value (0.729). This showed that easy to learn words, the contribution of perceived ease of use and per-
indicator (X1.1) was the most dominant indicator vari- ceived usefulness on the attitude was 40.1%, while the
able in measuring perceived ease of use. Perceived use- remaining 59.9% was contributed by other variables that
fulness measurement model showed that the insurance were not covered in this study. R-square acceptance vari-
claim indicator (Y1.2) had the highest loading value able was worth 0.372 or 37.2%. It was clear that the di-
(0.890). This showed that insurance claim indicators versity of acceptance was able to be explained by the per-
were the most dominant indicator in measuring perceived ease of use, perceived usefulness, and the attitude
ceived usefulness variable. Attitude variable measure- as high as 37.2%, or in other words, the contribution of
ment model showed that acceptance indicator (Y2.1) had ease of use, perceived usefulness and attitude on accept-
the highest loading value (0.867). This indicated that ac- ance was 37.2%, while the remaining 62.8% was con-
ceptance was the most dominant indicator in measuring tributed by other variables that were not addressed in
attitude variable. Acceptance variable measurement this study.
model showed that actual usage indicator has the highest Table 2 showed that exogenous variables had a domi-
nant influences on endogenous variables that could be
Table 1. Respondent Characteristics recognized through the highest effect of grand total. The
analysis showed that the variable that had the greatest ef-
Respondent Characteristic Total Percentage (%)
fect of the grand total on attitude was perceived useful-
Age 31-40 17 53.1 ness with a total effect of 0.472. The variable that had the
41-50 11 34.4
greatest effect of grand total on acceptance was perceived
51-60 4 12.5
Sex Male 7 21.9 usefulness with a total effect of 0.438. Thus, perceived
Female 25 78.1 usefulness had the most dominant influence on doctors’
Level of education Doctor of Medicine (MD) 15 46.8
acceptance.
Master 1 3.1
Specialist 14 43.7 The results showed that charging resumes doctor in
Master & Specialist 2 6.4 protecting doctors in legal cases, but not so with the
Tenure 0-10 23 72.0
smooth running of medical services. Hospital mana-
11-20 6 18.7
21-30 1 3.1 gement should ensure that doctors are aware that service
31-40 1 3.1 fluency, both for amount and timing of services, will be
>40 1 3.1
enhanced if medical resumes are fully completed in a
Figure 1. Partial Least Square Line Diagram
119
Table 2. Conversion Line Diagram
Exogenous Med1 Med2 Endogenous Direct Indirect Total Grand Total
PEU PU 0.297* - 0.297 0.297

PEU PU AT 0.305* 0.140* 0.445 0.445
PU AT 0.472* - 0.472 0.472
PEU PU AC 0.212* 0.099* 0.310 0.409
PEU AT AC 0.068 0.279
PEU PU AT AC 0.031 0.243
PU AT AC 0.333* 0.105* 0.438 0.438
AT AC 0.222* - 0.222 0.222
Note: PEU= Perceived Ease of Use, PU= Perceived Usefulness, AT= Attitude, AC= Acceptance.
timely manner. form of medical resumes made the doctors complete

The results showed that although most physicians ac- medical resumes easily. If the hospital could help doctors
cepted the need and are motivated to fill out medical re- to facilitate medical resume completion, then the benefits
sumes, the process was still considered a burden. The of completing medical resumes would be felt by the doc-
hospital management party should convince doctors that tors.
correct medical resume filling would provide benefits. Perceived ease of use impacts positively and signifi-
cantly on doctor’s attitude. It was clear that the higher the
Discussion perceived ease of use, the more positive the attitude of
The doctors who responded to the survey at Dr. doctors. Doctors at Dr. Radjiman Wediodiningrat
Radjiman Wediodiningrat Lawang Psychiatric Hospital Lawang Psychiatric Hospital considered that completing
were still relatively young and inexperienced and had medical resume was not easy, but doctors accepted the
worked less than 10 years, and mostly attained a doctor need and were interested in filling out the medical re-
of medicine (MD). Most respondents were female doc- sume. Doctors at Dr. Radjiman Wediodiningrat Lawang
tors, which in line with a study conducted by Allen which Psychiatric Hospital assumed that completing medical re-
showed that there are more female doctors today.12 sume was not easy, and there were still some who thought
Doctors who were still at their productive age and had at- that it interfered with their work, so hopefully, improving
tained a high level of education were advantageous for the perceived ease of use would improve the attitude in
Dr. Radjiman Wediodiningrat Lawang Psychiatric completing medical resume. Better performance results
Hospital in completing medical resumes because em- would be obtained if communication technology among
ployees at productive age had a greater potential in uti- doctors was easy to use.17,18
lizing information systems. In addition, tenure will im- Perceived usefulness affected positively and signifi-
prove the perception of benefits a person receives.13 cantly on doctor’s attitude. This explained the observa-
Commitment of doctor to maintain complete medical tion that the higher the perceived usefulness, the more
records is absolutely necessary.14 The longer the working positive the doctors’ attitude. Most doctors said that ge-
period is, the higher the expectation on doctors to inter- nerally, completing resumes is a useful means of commu-
nalize the benefit of filling out medical records well.15 nication, helps the insurance claim, protects against legal
Perceived usefulness had the most dominant influ- cases, sees the quality of hospital services, and helps to
ence on doctors’ attitude. This was in line with a previ- calculate the health statistics, but doctors also stated that
ous study which suggested that the perceived usefulness completing medical resumes did not smoothen any ser-
was the most significant factor influencing physicians in vice offered to them. Medical resumes as one of the BPJS
using information technology.16 A person’s belief that do- claim requirements does not stand alone but as part of
ing work which provided benefits for themselves will give the medical record that can assist doctors in legal cases.
a positive feeling in doing so.17 This is in line with a previous study which suggested that
Perceived ease of use had positive and significant ef- the completeness of medical records can protect patients,
fect on perceived usefulness. It was clear that the higher doctors, and hospitals.19 Doctors claimed that complet-
the perceived ease of use, the higher the doctors’ per- ing medical resume disturbed their work, and there were
ceived usefulness. According to the doctors, completing some doctors who hesitated to remind their colleagues to
medical resumes was easy to learn, did not take long fill the medical resume. Positive feeling would be ob-
time, did not require concentration, but also that it was tained if someone had felt the benefits for himself.17
not easy. Doctors also considered that completing medi- Perceived usefulness affected positively and signifi-
cal resume had not been easy, but was helpful. Simple cantly on doctors’ acceptance. The higher the perceived
120
Devi et al, Acceptance of Medical Resume Completion
usefulness was, the higher the doctor’s acceptance would ance at Dr. Radjiman Wediodiningrat Lawang Psychiatric
be. Several previous studies also suggested that perceived Hospital of medical resume charging is in the high cate-
usefulness would have a significant influence on doctors’ gory and has perceived usefulness and attitude in both
acceptance.10,20 Doctors’ perception was that complet- categories, while perceived ease of use is in the medium
ing medical resume did not aid in smooth delivery of the category. Although acceptance, perceived usefulness and
services, but that completing medical resumes was very attitude scored in the category of high and good, the real
beneficial in terms of legal protection. Doctors were will- value of all three is still close to the area being (except
ing and accepting the implementation of medical resume perceived usefulness that gets most response both), so
completion, but did not do it happily. Doctors possibly there is still a need for further improvement.
felt that they did not have any barriers in granting the
services, or otherwise granting the services remained not References
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Setyawan. Kesmas: National Public Health Journal. 2017; 11 (3): 123-126 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.1185
Risk Factors of Carpal Tunnel Syndrome among Food-

Packing Workers in Karanganyar
Faktor Risiko Carpal Tunnel Syndrome pada Pekerja Pengepakan Makanan

di Karanganyar
Haris Setyawan
Occupational Safety and Health Department, Faculty of Medicine, Universitas Sebelas Maret, Surakarta,
Indonesia
C
Y
Abstract
Carpal Tunnel Syndrome occurs when the median nerve, which runs from the forearm into the hand, suffers pressure or is squeezed in the wrist. The results
may be pain, weakness, or numbness in the hand and wrist, radiating up to the arm. This study aimed to examine the risk factors i.e age, sex, work period
CM
MY
and repetitive movements toward Carpal Tunnel Syndrome complaints among food-packing workers in Karanganyar. The study was conducted in October to
CY December 2014 that used analytic observational design with cross sectional study. Samples were 50 of 67 food-packing workers in Jaten Karanganyar in-
CMY
dustrial area as taken by using simple random sampling technique. Data were analyzed using chi square and multivariate logistic regression. Results showed
that age and sex had significant relation with Carpal Tunnel Syndrome and age was the most influential factor 24 times to increased risk of Carpal Tunnel
Syndrome (p value = 0.057, Exp. β = 24.965).
K
Keywords: Age, carpal tunnel syndrome, food-packing workers, repetitive movement, sex
Abstrak
Carpal Tunnel Syndrome terjadi ketika saraf median, yang membentang dari lengan bawah ke tangan, mengalami tekanan atau terpuntir di pergelangan
tangan. Hasilnya mungkin sakit, kelemahan atau mati rasa di tangan dan pergelangan tangan, yang memancar ke lengan tangan. Penelitian ini bertujuan un-
tuk mengkaji faktor risiko usia, jenis kelamin, masa kerja dan gerakan repetitif terhadap keluhan Carpal Tunnel Syndrome pada pekerja pengepakan makanan
di Karanganyar. Penelitian ini dilaksanakan pada bulan Oktober – Desember 2014 menggunakan desain observasional analitik dengan penelitian potong lin-
tang. Sampel terdiri dari 50 orang dari total 67 pekerja pengepak makanan di kawasan industri Jaten Karanganyar yang diambil dengan menggunakan teknik
simple random sampling. Data penelitian diolah menggunakan uji kai kuadrat dan regresi logistik multivariat. Hasil penelitian menunjukkan bahwa usia dan
jenis kelamin signifikan berhubungan dengan keluhan Carpal Tunnel Syndrome, dan usia merupakan faktor yang paling berpengaruh 24 kali lipat untuk
meningkatkan risiko terjadinya Carpal Tunnel Syndrome (nilai p = 0.057, Exp. β = 24.965).
Kata kunci: Usia, carpal tunnel syndrome, pekerja pengepakan makanan, gerakan repetitif, jenis kelamin
How to Cite: Setyawan H. Risk factors of carpal tunnel syndrome among Correspondence: Haris Setyawan, Occupational Safety and Health Dept. Faculty
food-packing workers in Karanganyar. Kesmas: National Public Health of medicine Universitas Sebelas Maret,Ir. Sutami Street No. 36A Kentingan Jebres
Surakarta, Phone: +62271 664178, e-mail: [email protected]
Journal. 2017; 11 (3): 123-126. (doi:10.21109/kesmas.v11i3.1185) Received: September 23th 2016
Introduction cross sectional study. Samples were 50 of 67 food-pack-

Carpal tunnel syndrome occurs when the median ing workers in Jaten Karanganyar industrial area as taken
nerve, which runs from the forearm into the hand, suffers by using simple random sampling technique. This study
pressure or is squeezed in the wrist. The results may be aimed to determine the most influential factors in the in-
pain, weakness, or numbness in the hand and wrist, ra- cidence of carpal tunnel syndrome among food-packing
diating up to the arm.1 Carpal tunnel syndrome is the workers in Jaten Karanganyar industrial area. The inde-
most common hand problem, affecting as much as 5% of pendent variables in this study were age, sex, work peri-
the adult population; yet in most of cases, the condition od and repetitive movement, while the dependent vari-
is idiopathic. While surgical treatment often results in able was carpal tunnel syndrome Symptoms collected
improvement, residual loss of function and some persis- with A Self Administrative questionnaire for the
tence of symptoms are common.2 Carpal tunnel syn- Assessment of Severity of Symptoms and Functional
drome is due to extended periods of repetitive forceful Status in carpal tunnel syndrome by DW Levine.8 In
work, work involving vibration, extreme postures of the carpal tunnel syndrome symptom questionnaire, Levine
wrist, or a combination of the three.3 Carpal tunnel syn- et al.,8 identified six critical domains for the evaluation of
drome is also caused by factors outside of work, such as carpal tunnel syndrome that were pain, test-retest relia-
sex, age, heredity, hormonal, weight, diabetes mellitus bility of paraesthesia, numbness, weakness, nocturnal
and pregnancy. Musculoskeletal disorders, including symptoms and overall functional status. Each question
carpal tunnel syndrome, represented 59% of all recog- had five ordinal severity scale ranging from 0 (none or
nized diseases recorded by the European Occupational never) to 4 (very severe).
Diseases Statistics in 2005.4 Data collected from the Levine questionnaire were
In Jakarta, Indonesia a study in the garment industry then processed for further analysis with SPSS 17
found that workers had high prevalence of carpal tunnel Program. Univariate analysis provided the distribution of
syndrome at 20.3%.5 In the informal sector in Central frequency, while bivariate analysis applied chi square test
Java, especially sauces and soy sauce industries in using α = 0.05 and then multivariate analysis used bino-
Karanganyar, there are many complaints from the work- mial logistic regression. Binomial logistic regression was
ers about pain, weakness, or numbness in their arms the approach to analyze one or more independent vari-
while installing bottle of soy sauce and sauces using a ables that had more than two dichotomized values.
press machine. Risk factors for carpal tunnel syndrome Variables with a p value less than 0.025 were included in
are found in activities that require repetitive hand move- this model.
ments, vibration and forceful gripping which may be
present when using a press machine and packing bottle Results
of soy sauce and sauces into boxes. More prolonged and This study was conducted in Karanganyar, Indonesia.
repetitious flexion or extension of the wrist materially, The respondents in this study were persons working for
can increase the risk of carpal tunnel syndrome, espe- a food factory and running a pressing machine to close
cially when allied with a forceful grip. The study found the bottle of soy sauce and sauce. Table 1 showed the
reasonable evidence that regular and prolonged use of characteristics and risk factors of carpal tunnel syndrome
handheld vibratory tools was associated with a more than and most variables had high risk to exposure of carpal
double risk of carpal tunnel syndrome.6 It is the most tunnel syndrome symptom such as age, work period and
common form of nerve entrapment syndrome. It can be repetitive movement. Table 2 showed that age and sex
a debilitating condition with significant socioeconomic had significant relation with carpal tunnel syndrome
costs in the form of reduced productivity, wage reim- symptom, and the most dominant factor of carpal tunnel
bursement and compensation claims.7 This study aimed
to determine the most influential factors in the incidence Table 1. Distribution of Respondents Risk Factors of Carpal Tunnel Syndrome
of carpal tunnel syndrome among the food-packing work- Variable Category Frequency Percentage
ers at Jaten Karanganyar industrial area including sex,
age, work period, and repetitive movement. This study Sex Male 23 46 %
Female 27 54 %
did not include the other factors of carpal tunnel syn- Age > 40 years 19 38 %
drome because most respondents had no records of con- ≤ 40 years 31 62 %
genital diseases of carpal tunnel syndrome, had normal Work period ≤ 1 year 15 30 %
> 1 year 35 70 %
weights, and none had diabetes mellitus or were preg- Repetitive movement > 10 movements/minute 14 28 %
nant. ≤ 10 movements/minute 36 72 %
CTS symptom None 9 18 %
Mild 27 54 %
Method Moderate 14 28 %
The study used the analytic observational design with
124
Setyawan, Risk Factors of Carpal Tunnel Syndrome among Food-Packing Worker
Table 2. Bivariate Analysis of Carpal Tunnel Syndrome Using Chi Square Statistical Test
CTS Severity Category (N/%)

Risk Factors of CTS
Category Moderate Mild None Total p Value
Age Old > 40 years 11 (57.9%) 7 (38.8%) 1 (5.3%) 19 (100%) 0.001

Young ≤ 40 years 3 (9.7%) 20 (64.5%) 8 (25.8%) 31 (100%)
Sex Male 2 (8.7%) 14 (60.9%) 7 (30.4%) 23 (100%) 0.008
Female 12 (44.4%) 13 (48.1%) 2 (7.44%) 27 (100%)
Work period Old > 1 year 12 (34.2%) 17 (48.7%) 6 (17.1%) 35 (100%) 0.312
New ≤ 1 year 2 (13.3%) 10 (66.7%) 3 (20%) 15 (100%)
Repetitive movement >10 Movements/minute 5 (35.7%) 8 (57.1%) 1 (7.1%) 14 (100%) 0.423
≤10 Movements/minute 9 (25%) 19 (52.8%) 8 (22.2%) 36 (100%)
Table 3. Multivariate Analysis Using Multinomial Regression Statistical Test variate analysis. This result might be because the sample
Variable b
β p Value b
Exp.β 95% CI
contained a similar number of male (54%) and female
(46%) and they were all given the same target in the
Age 3.217 0.057 24.965 0.908 - 686.393 packing of soy sauce and sauces. These results were not
Sex -1.806 0.202 0.164 0.010 - 2.625
in line with meta analyses showing that sex was the most
important predisposing factor related to carpal tunnel
syndrome symptom was age with significance value of syndrome.13
0.025 with exp B 5.014 (Table 3). Several studies suggested that exposure to low load
repetitive tasks could increase the risk factor for carpal
Discussion tunnel syndrome development, especially with prolonged
Age of the workers can effect with musculoskeletal activity.14,15 The pressure inside the carpal tunnel in-
disorders symptoms. Muscle strength decrease with age creases during wrist extension and flexion. Repetitive ex-
leading to an increased risk of musculoskeletal disor- tension and flexion movements of the wrist, along with
ders.9 Carpal tunnel syndrome has a high prevalence in flexion of the fingers and supination of the forearm, have
patients aged between 40 – 50 years. The syndrome de- been implicated in this increase risk.16 The result of bi-
velops more easily when there is an increase in the sheath variate analysis showed no significant relation between
(edema) thickness or in occasions where there is a re- repetitive movement and carpal tunnel syndrome (p va-
duction in the carpal canal’s dimensions.2 The result of lue = 0.423). These results were inversely with the data
bivariate analysis showed significant relation between of repetitive movement, that mostly food-packing work-
age and carpal tunnel syndrome (p value = 0.001), and ers performed repetitive movement more than 10 times in
multivariate analysis showed that age was the most do- one minute (72%). It could be because the food-packing
minant factor of carpal tunnel syndrome (significance workers had a chance to take a rest when they were tired
value = 0.025, Exp. B = 5.014) which means that age ac- or fatigued. These results were not in line with a review
counted for a five fold change in carpal tunnel syndrome by Palmer,17 which examined several cross-sectional
prevalence. This could be because the food-packing studies and six case-control studies on occupational as-
workers in Karanganyar were mostly older than 40 years sociations with carpal tunnel syndrome. Most investiga-
(62%) so were in the age category which was to carpal tions analyzed risks by job title and found high preva-
tunnel syndrome. This is in line with a study by Toosi lence rates and relative risks in several jobs believed to in-
KK,10 which found a positive correlation between age volve repetitive and forceful gripping.
and carpal tunnel syndrome risk for those in computing The risk factors associated with carpal tunnel syn-
jobs. drome were present in jobs that involved repeated forced
Female had a higher risk of carpal tunnel syndrome.11 movements of flexion extension of the wrist and fingers
It might be that the wrist bones are naturally smaller in with incongruent posture and use of vibrating instru-
most women, creating a tighter space through which the ments.18 The result of bivariate analysis showed no sig-
nerves and tendons must pass. Women also deal with nificant relation between work period and carpal tunnel
strong hormonal changes during pregnancy and syndrome (p value = 0.312). This result was in line with
menopause that make them more likely to suffer from a study by Tana,5 that work period did not show a signi-
carpal tunnel syndrome.12 The result of bivariate analy- ficant relation with carpal tunnel syndrome. In the mi-
sis showed significant relation between sex and carpal ning industry, a study showed that 15% of the reported
tunnel syndrome (p value = 0.008), but did not show the carpal tunnel syndrome prevalence could be accounted
dominant factor in carpal tunnel syndrome with multi- for by vibration.19
125
Work period is one of many factors that may increase 9. Ulfah N, Harwanti S, Nurcahyo PJ. Sikap kerja dan risiko muscu-
the risk of musculoskeletal disorders beside repetitive loskeletal disorders pada pekerja laundry. Kesmas: Jurnal Kesehatan
and flexion. In the long term it may cause damage to the Masyarakat Nasional. 2014; 8(7): 313–8.
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a long period of time can also cause musculoskeletal dis- boarding biomechanics and acute changes in median nerve indicative of
order.21 These studies were different with presence of carpal tunnel syndrome. Clinical Biomechanics [Internet]. 2014; 30(6):
carpal tunnel syndrome in repetitive and flexion jobs 546–50. A vailable from: http://dx.doi.org/10.1016/j.clinbio-
with mouse computer. There was a significant relation mech.2015.04.008
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drome. Repetitive manual tasks increase mechanical tors for carpal tunnel syndrome related to the work organization: a
stress on the median nerve and result in elevated carpal prospective surveillance study in a large working population. Applied
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Recommendation tunnel pressure in patients with carpal tunnel syndrome. Applied
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Etrawati et al. Kesmas: National Public Health Journal. 2017; 11 (3): 127-132 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.1163
Psychosocial Determinants of Risky Sexual Behavior

among Senior High School Students in Merauke District
Determinan Psikososial Perilaku Seksual Berisiko pada Siswa Sekolah

Menengah Atas di Kabupaten Merauke
Fenny Etrawati*, Evi Martha**, Rita Damayanti***
*Health Promotion Department, Public Health Faculty, Sriwijaya University, Palembang, Indonesia, **Health
Education and Behavior Science Department, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia,
***Center for Health Research Universitas Indonesia, Depok, Indonesia
Abstract
Adolescents aged 10-24 years old are susceptible group to premarital sex, drugs abuse, and HIV/AIDS infection. Papua is the largest contributor to AIDS/HIV
number in Indonesia. To overcome such problem, Rutgers WPF formed Dunia Remajaku Seru! (DAKU!), an intervention program aimed towards adolescent
reproductive health at senior high school level. This study aimed to determine psychosocial determinants of risky sexual behavior among senior high school
students in Merauke District through cross-sectional approach. The sample included 1,364 second grade students that took the DAKU! program and pairing
was conducted with students from schools that did not take the DAKU! program. Data analyses included univariate analysis, bivariate (chi square test) and
multivariate (logistic regression test). Results showed that variables significantly related to adolescent risky sexual behavior were peer group with negative
behavior, self-efficacy, parental control, exposure to DAKU! program and sex. Meanwhile, based on multivariate analysis, peer group with negative behavior
(RP = 4.7 CI = 2.8 - 7.7) was the most dominant factor influencing risky sexual behavior.
Keywords : Adolescent, peer group, psychosocial determinant, risky sexual behavior
Abstrak
Remaja usia 10-24 tahun merupakan kelompok yang rentan terhadap perilaku seksual pranikah, penyalahgunaan narkoba dan infeksi HIV/AIDS. Papua meru-
pakan penyumbang angka HIV/AIDS terbesar di Indonesia. Untuk menanggulangi permasalahan tersebut Rutgers WPF membentuk suatu program intervensi
kesehatan reproduksi remaja di tingkat sekolah menengah atas (SMA) yakni program Dunia Remajaku Seru! (DAKU!). Penelitian ini bertujuan untuk menge-
tahui determinan psikososial perilaku seksual berisiko pada siswa SMA di Kabupaten Merauke dengan menggunakan pendekatan potong lintang. Sampel
berjumlah 1.364 siswa SMA kelas dua yang mendapatkan program DAKU! dan dilakukan proses pencocokan pada sekolah yang tidak mendapat program
DAKU!. Analisis data meliputi analisis univariat, bivariat (uji kai kuadrat) dan multivariat (uji regresi logistik). Hasil analisis menunjukkan bahwa variabel yang
signifikan berhubungan dengan perilaku seksual berisiko remaja adalah kelompok teman sebaya dengan perilaku negatif, efikasi diri, kontrol orangtua, keter-
paparan dengan program DAKU! dan jenis kelamin. Sedangkan berdasarkan hasil analisis multivariat, kelompok teman sebaya dengan perilaku negatif (RP
= 4.7 CI = 2.8 - 7.7) merupakan faktor yang paling dominan memengaruhi perilaku seksual berisiko.
Kata kunci : Remaja, kelompok teman sebaya, determinan psikososial, perilaku seksual berisiko
How to Cite: Etrawati F, Martha E, Damayanti R. Psychosocial determi- Correspondence: Fenny Etrawati, Jl. Raya Palembang Prabumulih Gedung
nants of risky sexual behaviors among senior high school students in Dekanat Lantai 3 Fakultas Kesehatan Masyarakat Universitas Sriwijaya, Ogan
Merauke District. Kesmas: National Public Health Journal. 2017; 11 (3):
Ilir-Indralaya, 30662, Phone: +62711 580089, e-mail: [email protected]
127-132. (doi:10.21109/kesmas.v11i3.1163)
Revised: Descember 2nd 2016
Introduction Method
The important target elements in achieving the vision The study design used cross sectional approach that
of reproductive health enhancement is adolescent. Based was part of final evaluation towards adolescent repro-
on census in 2010, Indonesia had a population of 63 mil- ductive health program (DAKU! Papua) in Merauke.
lion adolescents aged 10 – 24 years old. This age group This study involved 1,364 students as respondents from
deserves focus because of the reproductive health risks 17 senior high schools, including public and private
which they face, such as premarital sexual behavior, schools in Merauke District in 2013. All students in the
drugs abuse and HIV/AIDS infection. These problems sample were in second grade of senior high school.
occur in the adolescent transition phase between child- Students that had been taught in the DAKU! program
hood and adulthood.1,3 were paired with those who had not. Data were collect-
Limited access to information about reproductive ed by self-assessment tools using the DAKU! Papua ques-
health contributes to the problems of reproductive tionnaire. The questionnaire was tested to 30 Yayasan
health. Basic Health Research in 2010 showed that mere- Pendidikan Kristen High School students in Merauke
ly 25.1% of adolescent aged 10-24 years old in Indonesia with the result that Crombach’s alpha value was more
were taught about reproductive health. Limited access to than 0.616 indicating that it was reliable. The main de-
reproductive health information effects the likelihood of pendent variable in this study was risky sexual behavior,
risky sexual behavior by adolescents. In the period of while independent variables were self-efficacy, peer
2005-2008, sexual intercourse among adolescents in- group’s negative bahavior and parents’ control.
creased. Male almost doubled from 7.6% in 2005 to Confounding variables included school types, sex, expo-
14.6% in 2008, meanwhile female did not increase sig- sure to DAKU! program, residence, and place of living.
nificantly (1%).4 This matter is pertinent as the World Data analysis included univariate analysis, bivariate
Health Organization (WHO) stated that half of HIV in- analysis (chi square) and multivariate (risk factor logistic
fection cases occurred among those aged 15-25 years old. regression models).
The Asian Development Bank (ADB) recorded Indonesia
as one of six countries in Asia with the highest HIV ca- Results
ses per 1,000 population and determined that 3.3% of Results of study on 1,364 students in Merauke
HIV infection occurred in adolescents.4,5 District showed distributions in which numbers of male
Merauke District is part of Papua Province and be- and female respondents were almost equal; about 80%
came one of HIV prevalence rate contributors in Papua adolescents in total were public school students, 51.6%
that reaches 2.4%. Result of the Integrated Bio- were not fully exposed to DAKU! program, almost 80%
Behavioral Survey in 2007 indicated that 8% of prosti- students lived in the city, and 64.2% of respondents were
tutes in Merauke District were students.6,7 Based on living with their parents. About half of students had low
Problem Behavior Theory, formation of risky behavior self-efficacy and parents’ control and most of them had
was influenced by psychosocial factors consisting of in- friends with negative behaviors. Table 1 showed respon-
dividual systems, environment systems and behavior sys- dent distributions based on demography and psy-
tems. Psychosocial factors that influence behavior are chososial factors.
self-efficacy, peer’s negative behavior and parents’ con- 48.2% of students participated in a risky sexual be-
trol.8-11 Table 1. Respondent Distributions Based on Demography and Psychososial
Through the adolescent reproductive health edu-
cation program, known as Dunia Remajaku Seru! Variable Category N %
(DAKU!), Papua is expected to be able to control psy- Sex Male 654 47.9
chosocial risk factors and reduce risky sexual behavior of Female 710 52.1
adolescents. This program used photo and video media School type Private 234 17.2
Public 1130 82.8
to describe elements of adolescent reproductive health. Exposure to health program (DAKU!) Full DAKU! 357 26.2
Rutgers WPF Indonesia and Yayasan Pelita Ilmu (YPI) Non-full DAKU! 248 18.2
created and implemented this program in several loca- Non-DAKU! 759 55.6
Place of living Urban 1080 79.2
tions in Indonesia including Jakarta, Lampung, Jambi and Rural 284 20.8
Bali since 2005. Meanwhile, in Papua, the program was Residentiary With parents 876 64.2
launched in 2009 at six senior high schools. The inter- Without parents 488 35.8
Self-efficacy Low 634 46.5
vention was conducted over a year and was divided into High 730 53.3
two semesters in the school’s curriculum. This study Peer group negative behavior None 120 8.8
aimed to identify psychosocial determinants influencing Exist 1244 91.2
Parents’ control Low 692 50.7
on risky sexual behavior among senior high school stu- High 672 49.3
dents in Merauke District.
128
Etrawati et al, Psychosocial Determinants of Risky Sexual Behavior among Senior High School Students
havior at least once. Common non-risky sexual behaviors efficacy (RP = 2.6), parents’ control (RP = 1.7), exposure
included holding hands followed by hugging and caress- to DAKU! program (RP = 1.5) and sex (RP = 1.6) (Table
ing, cheek kissing, groping and self masturbation. 4). The most dominant factors affecting on risky sexual
Meanwhile, risky sexual behavior that were most com- behaviors was peer group with negative behavior in
monly done by students were frenchkissing followed by which the risk of respondents who had friends with nega-
vaginal sex intercourse, petting, oral sex, mutual-mas- tive behaviors were 4.7 times higher than those who did
turbations and anal sex. The overview of students’ dating Table 2. Sexual Behavior Distributions Based on Dating Activities among
activities in Merauke District was shown in Table 2. Senior High School Students
Bivariate analysis results with chi-square method
Sexual Behavior Variable Category N %
showed that the students with low self-efficacy were
nearly three times more likely to engage in risky sexual Holding hands 1237 90.7
behavior, having a peer group with negative behavior Hugging and caress 923 67.7
Cheek kissing 877 64.3
were at nearly five times higher risk, and those with low Frenchkissing 618 45.3
parents’ control were at two times higher risk. Besides, Groping 504 37.0
exposure to DAKU! program and sex also showed sig- Self masturbation 175 12.8
Mutual masturbation 72 5.3
nificant relations with risky sexual behavior and the risk Genital kissing 78 5.7
was less than two times. Otherwise, variables such as Petting 122 8.9
school types, place of living, and residence did not sig- Oral sex 113 8,3
Vaginal sex 199 14.6
nificantly relate to risky sexual behavior (Table 3). Anal sex 67 4.9
Multivariate test with logistic regression showed fac- Sexual behavior Risky 657 48.2
tors affecting on risky sexual behavior among students Unrisky 707 51.8
were peer group with negative behavior (RP = 4.7), self-
Table 3. Respondent Distributions Based on Independent Variables and Risky Sexual Behavior among Senior High School Students
Sexual Behavior
Variables Category Risky Unrisky Total p Value RP

(n=1313) (CI 95%)
n % N % n %
Sex Male 355 54.3 299 45.7 654 100 0.000 (1.3-2.0)
Female 302 42.5 408 57.5 710 100 1.6
School type Private 115 49.1 119 50.9 234 100 0.797 (0.8-1.4)
Public 542 48.0 588 52.0 1130 100 1,0
Exposure to health Non-full DAKU! 507 50.3 500 49.7 1107 100 0.008 (1.1-1.8)
program (DAKU!) Full DAKU! 150 42.0 207 58.0 357 100 1,4
Place of living Urban 523 48.4 557 51.6 1080 100 0.759 (0.8-1.4)
Rural 134 47.2 150 52.8 284 100 1.1
Residentiary Without parents 242 49.6 246 50.4 488 100 0.466 (0.9-1.4)
With parents 415 47.4 461 52.6 876 100 1.1
Self-efficacy Low 395 62.3 239 37.7 634 100 0.000 (2.4-3.7)
High 262 35.9 468 64.1 730 100 2,9
Peer group negative None 636 51.1 608 48.9 1244 100 0.000 (3.0-8.0)
behavior Exist 21 17.5 99 82.5 120 100 4,9
Parents’ control Low 398 57.5 294 42.5 692 100 0.000 (1.7-2.7)
High 259 38.5 413 61.5 672 100 2,2
Table 4. Multivariable Modeling Stage
Full
Variable p Value Model Model I Model II Model III Model IV Model V
RP RP ∆ RP RP ∆RP RP ∆RP RP ∆RP RP ∆RP
Peer group negative behavior 0.000 4.704 4.707 0% 4.715 0.23% 4.704 0% 4.665 0.83% 4.555 3.17%
Self-efficacy 0.000 2.615 2.614 0.04% 2.611 0.15% 2.615 0% 2.584 1.19% 2.576 1.49%
Parents’ control 0.000 1.712 1.712 0% 1.710 0.12% 1.710 0.12% 1.697 0.88% 1.696 0.93%
Exposure to health 0.006 1.469 1.472 0.20% 1.468 0.07% 1.460 0.61% 1.464 0.34% - -
program (DAKU!)
Sex 0.733 0.958 0.958 0% 0.958 0% 0.960 0.21% - - - -
School type 0.866 1.028 1.029 0.1% 1.024 0.33% - - - - - -
Residentiary 0.873 0.981 0.981 0% - - - - - - - -
Place of living 0.952 1.009 - - - - - - - - - -
129
not have. health.16,17 Communication between parents and chil-

dren related sexuality in adolescent is one of parents’ con-
Discussion trols in order to prevent risky sexual behavior in adoles-
Dating activities among adolescents ranged from no cents.11 Thus, there is a need to strengthen the family
risk to high risk. In many studies, holding hands was a unit to aid in improving adolescent behavior.
sexual activity nearly always done by adolescents. In a Another study showed that there was no significant
more risky stage, adolescents engaged in mutual-mastur- difference in sexual behavior pattern between public and
bation, petting and sexual activities where vaginal sex private schools. This might be caused by information
was the most common, as compared to oral and anal about reproductive health that were less well implement-
sex.12 The high number of risky sexual behaviors among ed in schools. Controversy about formal reproductive
adolescents was also shown by Youth Risk Behavior health education in schools is an obstacle for adolescents
Survey in 2011 in Oklahoma.13 Of the senior high school in getting high quality information about sexuality.18
student respondents, 50% had engaged in sexual activi- Instead, adolescents tend to use internet resources in
ties. Additionally, 5% of them said that it happened be- which case the quality cannot be guaranteed. Schools are
fore the age of 13 years. The higher the percentage of expected to take a lead role in providing reproductive
adolescents sexually active, the higher the risks they health education for adolescents, and potentially in pro-
faced, including from sexual transmitted disease and viding skills and positive values that may prevent risky
pregnancy. Therefore, there was a need for protective ac- sexual behaviors.
tions to prevent adolescents from the effects of risky se- Beside those three main variables, another factor that
xual behaviors. influenced risky sexual behavior was sex. Similar to an-
Risky sexual behavior could be prevented by strength- other study, this study found that adolescents in Merauke
ening the psychosocial circumstances of the adolescent, showed significant correlation in bivariate statistical test,
such as self-efficacy to abstain from sexual intercourse. although influence of sex towards risky sexual behavior
Individuals with low self-efficacy would likely have had was not found in the multivariate test. This might be be-
difficulty in controlling their lifestyles, and they may be cause of other factors that were stronger in influencing
less able to abstain from risky sexual behaviors.9 This is risky sexual behavior after being tested with other inde-
related to a theory developed in 1977 by Jessor that pendent variables.
showed that self-efficacy could be integrated as a risk Males were more likely to engage in risky sexual be-
and protective factor for risky sexual behavior, especial- havior than females. The difference results from biologi-
ly for adolescents.8 Adolescent is a subject that needs to cal and social factors. Biologically, males tend to be sti-
change, until there will be no pressure from outside.14 mulated more easily than females. Socially, men are more
Component in social enviroment that takes a role in aggressive and free than women. Men’s dating styles tend
forming individual’s behavior is peer group. Peer group is to be more aggressive than women’s, from groping, pet-
the closest group for an individual and has the potential ting to sexual intercourse.18 Furthermore, men need to
to influence the individual towards risky behaviors. talk about sexuality problems with women that could
Adolescents with peer groups that tend towards negative boost their sensitivity to their partners, so it could de-
behaviors are more likely to engage in for risky sexual be- crease the pressure of women to do sexual intercourse.
haviors. Peer group environment affected adolescent’s Meanwhile, women are more comfortable with open dis-
behavior. Moreover, the perception of peer groups may cussions about sexual experiences and their feelings
be that sexually active individuals are cool and popular.10 about societal pressures.19
The existence of friends who are sexually active may in- Since most adolescents are still in school, health pro-
crease the chance of others engaging in sexual activities, grams delivered in schools may be an effective strategy.20
so individuals may find both encouragement and first- Access to adolescent reproductive health information in
time sexual partners within their peer group.15 Without Indonesia could be through the DAKU! program, which
high self-efficacy, individuals tend to be influenced by is adapted from World Start With Me Program which
peer group’s behavior. So, it is critical to optimize inter- was first developed in Uganda, which effectively in-
ventions towards adolescent reproductive health through creased adolescent’s knowledge and attitude towards se-
peer education. xual behavior. This program is integrated with local
Parents’ control is an important factor in controlling school subject at senior high schools of five pilot
adolescents’ risky behavior. Adolescent sexual behavior provinces that are Special Capital Region of Jakarta, Bali,
in Merauke showed the loss of parents’ control. A con- Lampung, Jambi and Papua.21
tributing factor to this increase in risky sexual behaviors According to this study in Papua, researchers con-
was the infrequent and low quality communication bet- cluded that low adolescent exposure to reproductive
ween parents and children regarding reproductive health information could increase risky sexual behavior.
130
Etrawati et al, Psychosocial Determinants of Risky Sexual Behavior among Senior High School Students
If there was a lack of formal education, adolescents may on reproductive health and low level of parents-child
have accessed information through the internet, in which communication make adolescents more likely to discuss
case the quality cannot be guaranteed. Because of this, sexuality with their peer groups. Moreover, those who
implementation of reproductive health programs at have the low self-efficacy may copy their friends’ beha-
schools needs to be continously increased. Moreover, viors. These factors contribute to the issue of risky sexu-
programs may be more successful when starting from an al behaviors in adolescents in Indonesia.
early age. In Tanzania, a program began with the highest
three grades at elementary school through the MEMA Recommendation
kwa Vijana program. This program improved the knowl- Reproductive health education for high school stu-
edge and perception of adolescents regarding the effects dents is necessary. Such programs can increase students’
of premarital sex, decreased the number of couples and knowledge of reproductive health and life skills (ability to
increased the use of condoms.22 communicate, negotiate, and act assertivity) to decrease
This study found that most students (79.2%) lived in the effects of risky sexual behavior among adolescents.
urban areas, while 20.8% lived in rural areas. This phe- Furthermore, such programs should involve peer groups
nomenon indicated the high rate of citizens from rural to and parents as educators in order to increase adolescents’
urban areas, including adolescent. The aim of rural-urban self-efficacy and thus their ability to abstain from pre-
migration may be to continue education or get a better marital sex.
job. This matter did not influence the differences of sig-
nificant sexual behavior among demographic areas. Acknowledgment
Burkina Faso,23 found that there was no difference in Data of this study are collected through endline sur-
sexual behavior based on indicator of pairs between men vey of School Reproductive Health Program (DAKU!
and women in urban, rural, and border areas. Rural and Papua) in Merauke District year 2013. Researchers
urban areas had the same influence on adolescent sexual would like to thank Center for Health Research
behavior. Adolescents in rural areas were prone to engage Universitas Indonesia and Rutgers WPF of Indonesia that
in risky sexual behavior as they wanted to be considered enabled and facilitated the researchers to conduct the
as modern adolescents, while adolescents in urban areas survey.
had more access to sexual information so they were also
motivated to engage in risky sexual behaviors. A lack of References
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Maryuni et al. Kesmas: National Public Health Journal. 2017; 11 (3): 133-137 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.1153
Risk Factors of Premature Rupture of Membrane
Faktor Risiko Ketuban Pecah Dini
Maryuni, Dedeh Kurniasih
Midwifery Studies Institute of Health Science Binawan, Jakarta, Indonesia
Abstract
Maternal mortality rate in Indonesia based on 2012 Indonesia Demographic and Health Survey is 359 per 100,000 live births. Causes of the maternal mor-
tality are still dominated by bleeding, pre-eclampsia/eclampsia and infections. One of causes of infections is premature rupture of membrane. Premature rup-
ture of membrane may increase morbidity and mortality among mothers and children. Incidence of premature rupture of membrane amount to 10% of all child-
births. This study aimed to analyze risk factors of premature rupture of membrane incidence at Mother and Child Hospital of ANNISA Citeureup, Bogor District
in 2014. This study was analytical and used a case control design. The samples consisted of 114 mothers who suffered from premature rupture of membrane
and control, 228 mothers who did not suffer from premature rupture of membrane. Results of this study showed that risk factors of premature rupture of mem-
brane were age, parity and education. Based on multivariate analysis, education was the most dominant risk factor for premature rupture of membrane inci-
dence.
Keywords: Education, pregnancy, premature rupture of membrane
Abstrak
Angka kematian ibu di Indonesia berdasarkan Survei Demografi dan Kesehatan Indonesia tahun 2012 sebanyak 359 per 100.000 kelahiran hidup. Penyebab
kematian ibu tersebut masih didominasi oleh pendarahan, pre-eklampsia/eklampsia, dan infeksi. Salah satu penyebab infeksi adalah ketuban pecah dini.
Ketuban pecah dini dapat meningkatkan morbiditas dan mortalitas pada ibu dan anak. Insiden kejadian ketuban pecah dini sekitar 10% dari seluruh persali-
nan. Penelitian ini bertujuan untuk mengetahui faktor risiko kejadian ketuban pecah dini di Rumah Sakit Ibu dan Anak (RSIA) ANNISA Citeureup, Kabupaten
Bogor tahun 2014. Penelitian ini merupakan penelitian analitik dengan rancangan penelitian kasus kontrol. Sampel terdiri dari 114 orang kasus ibu yang men-
galami ketuban pecah dini dan kontrol sebanyak 228 ibu bersalin yang tidak mengalami ketuban pecah dini. Hasil penelitian menunjukkan faktor risiko ter-
hadap kejadian ketuban pecah dini yaitu usia, paritas dan pendidikan. Berdasarkan analisis multivariat, didapatkan faktor yang paling dominan berisiko ter-
hadap kejadian ketuban pecah dini yaitu pendidikan.
Kata kunci: Pendidikan, kehamilan, ketuban pecah dini
How to Cite: Maryuni, Kurniasih D. Risk factors of premature rupture of Correspondence: Maryuni, Midwifery Studies Binawan Institute of Health
membrane. Kesmas: National Public Health Journal. 2017; 11 (3): 133-137. Science, Kalibata Raya street No 25-30, Jakarta, Phone: +6221 8011777, e-mail:
(doi:10.21109/kesmas. v11i3.1153)
[email protected]
Introduction fetal malposition, younger than 20 years and older than

Every year, around the world, there are approximate- 35 years age of women, blood type factor, multi-gravidi-
ly 358,000 maternal deaths of which about 99% oc- ty/parity factor, smoking, socio-economic condition, an-
curred in poor countries and about 67% in developing tepartum bleeding, abortus records and prior preterm
countries including Indonesia.1 Maternal mortality rate partus, previous premature rupture of membrane
(MMR) and infant mortality rate (IMR) are highest in de- records, nutrition deficiency including bronze or ascorbic
veloping countries. Mortality and morbidity among preg- acid, excessive tension of uterus, narrow hips, mother’s
nant and birth-giving women are thus significant issues in fatigue at work, and trauma suffered such as sexual in-
developing countries. The MMR in Indonesia based on tercourse, internal check up and amniocentesis.9
2012 Indonesia Demography and Health Survey (IDHS) Several risk factors of premature rupture of membrane
data, was 359 per 100,000 live births, and IMR was 32 incidence include intrauterine infection at early pregnan-
per 1,000 live births.2 cy, the low social status of pregnant women, lack of treat-
Ministry of Health stated that West Java is one of nine ment during pregnancy, the low nutritional status during
provinces that contributes 70% of the Indonesian mater- pregnancy, sexual transmitted infections, bleeding per
nal mortality. West Java Province has the highest mater- vaginam, smoking during pregnancy and heavy weight of
nal mortality rate at 321 per 100,000 live births and it de- fetus.4 Premature rupture of membrane incidence at
creases to 123.29 per 100,000 live births in 2009. About Mother and Child Hospital of ANNISA Citeureup, Bogor
809 mothers are died because of bleeding, pre-eclamp- District in 2012 was 232 cases, 305 cases in 2013 as in-
sia/eclampsia and infections. One of infection causes is creased by 30% and 424 cases in 2014 as increased by
premature rupture of membrane.3 38%. This study aimed to analyze risk factors of prema-
Premature rupture of membrane is defined as the leak ture rupture of membrane incidence at Mother and Child
of amniotic membrane before childbirth and less than 37 Hospital of ANNISA Citeureup, Bogor District in 2014.
weeks gestation. Premature rupture of membrane inci-
dence is about 3 – 10% of childbirth. Premature rupture Method
of membrane incidence is almost 10% of all childbirths, This study was analytical study using case control de-
11% occurred in America and more in developing coun- sign. Population of study consisted of case population
tries. Premature rupture of membrane is the factor caus- (birth-giving mothers suffering from premature rupture
ing premature birth, also the high rate of perinatal pain of membrane) and control population (birth-giving moth-
and death. Moreover, 40% – 75% of deaths on neonatal ers who did not suffer from premature rupture of mem-
occurred because of premature rupture of membrane.4 In brane) at Mother and Child Hospital of ANNISA
China, premature rupture of membrane incidence with Citeureup, Bogor District in a year from January to
the age of pregnancy less than 37 weeks is 2.7% of 3% December 2014. This study aimed to analyze risk factors
all cases of childbirth with premature rupture of mem- of premature rupture of membrane incidence at Mother
brane.5 Premature rupture of membrane is wifery case and Child Hospital of ANNISA Citeureup, Bogor District
that often occurs related to complications, both among in 2014. Samples consisted of case as many as 114 moth-
mothers and fetus, even though pathogenesis of prema- ers who suffered from premature rupture of membrane
ture rupture of membrane itself is not yet known.6 and control as many as 228 mothers who did not suffer.
The quite high perinatal mortality is caused by deaths Variables of this study consisted of independent vari-
due to preterm partus, and the increasing incidence of in- ables, namely age, parity, multiple pregnancy, malposi-
fections because of obstructed labor, prolonged labor and tion and education; and the dependent variable was pre-
artificial labor often found in premature rupture of mem- mature rupture of membrane. Data collection in this
brane case management.7 Women with premature rup- study used medical records of childbirth, and reports of
ture of membrane are 50% more likely to give birth in 24 birth-giving mothers who suffered and did not suffer
to 48 hours, 70% – 90% to give birth in 7 days. from premature rupture of membrane. Instrument used
Premature rupture of membrane relates to the increase of was in the form of checklist. Statistical analysis technique
perinatal mortality and neonatal pain rate. Complications used bivariate and multivariate. The p value of less than
on perinatal include breathing disorder syndrome, infec- 0.05 was taken as significant. Inclusion of criteria were
tions, intraventricular bleeding, hypoplasia pulmonary all birth-giving mothers who suffered from premature
and bone disorders as well as umbilical cord prolapse.8 rupture of membrane at gestational age 37 weeks to 42
Cause of premature rupture of membrane is not yet weeks and recorded on medical record. Exclusion crite-
known certainly, however, the possible predisposing fac- ria were birth-giving mothers who suffered from prema-
tor is infection that occurs directly in amniotic membrane ture rupture of membrane at gestational age less than 28
or asenderen from vagina or cervix. Moreover, abnormal weeks or more than 42 weeks and not recorded on me-
physiology of amniotic membrane, incompetent cervix, dical records.
134
Maryuni et al, Risk Factors of Premature Rupture of Membrane
Table 1. Bivariate and Multivariate Results
Case Control
Variable Category p Value OR (95% CI)
n % n %
Age Risky 71 62.3 87 38.2 0.000 2.676 (1.683 – 4.254)

Not risky 43 37.7 141 61.8
Parity Second child or more 58 50.8 78 34.2 0.003 1.992 (1.260-3.149)
First Child 56 49.2 150 65.8
Multiple disorders Yes 9 7.8 0 0.0 0.000 2.000 (2.707 – 3.715)
No 105 92.2 228 100
Malposition Yes 13 11.4 0 0.0% 0.000 2.960 (2.769 – 3.832)
No 101 88.6 228 100
Education Lower than junior high school 65 57.1 61 26.8 0.000 3.632 (2.264 – 5.827)
Junior high school and higher 49 42.9 167 73.2
Table 2. Analysis Results of Logistic Regression Multivariate Model in Every Variable
95% CI
Variable B S.E Sig Exp (B)
Lower Upper
Age .945 .250 .000 2.573 1.577 4.199

Parity .681 .251 .007 1.976 1.208 3.231
Education 1.283 .251 .000 3.606 2.205 5.898
Constant -3.830 .689 .000 .022
Results high level of education.

Study results of influence of age to premature rupture All influential variables were then tested deeper to de-
of membrane incidence could be presented in Table 1. termine influence of or interaction between variables to
Based on Table 1, there was a significant relation be- premature rupture of membrane incidence by using mul-
tween age and premature rupture of membrane incidence tivariate logistic regression test. The test found three sig-
(p value = 0.000) and OR = 2.676 which means that nificant variables, namely age, parity and education.
mothers aged < 20 years and > 35 years were 2.676 times Multivariate analysis of this final model resulted = 0.198,
at risk of suffering from premature rupture of membrane. which means that three independent variables (age, pa-
There was a significant relation between parity and pre- rity and education) simultaneously showed 19.8% and
mature rupture of membrane incidence (p value = 0.003) premature rupture of membrane approximately 80%.
and OR = 1.992 which means that mothers who gave The most dominant variable was education with OR =
birth 2 or > were 1.992 times at risk of suffering from 3.606.
premature rupture of membrane. This study also showed
there was a significant relation between multiple preg- Discussion
nancy and premature rupture of membrane, results of There were more mothers suffering from premature
chi square test showed p = 0.000 < 0.05. Results of rupture of membrane (62.3%) in the group of risky age
analysis showed OR = 2.000 which means that mothers than in the group of not risky age (37.7%). This result of
who got multiple pregnancy were 2.000 times at risk of study is in line with study conducted by Swarini,9 finding
suffering from premature rupture of membrane and there a significant relation between age of mothers and prema-
was a significant relation between malposition p value = ture rupture of membrane incidence.
0.000 (< 0.05) and premature rupture of membrane. Age of mothers < 20 years belongs to the too young
Results also showed OR = 2.960 which means that moth- age with less mature condition of uterus for giving birth,
ers who got pregnant with malposition were 2.960 times so risky of suffering from premature rupture of mem-
at risk of suffering from premature rupture of membrane. brane. Meanwhile, age > 35 years belongs to the too old
Results of bivariate analysis on education level showed p age for giving birth, especially among old mothers and at
value = 0.000 which means that there was a significant high risk of suffering from premature rupture of mem-
relation between maternal education and premature rup- brane.10 Age > 35 years also makes condition and func-
ture of membrane. Analysis also showed OR score = tion of uterus decreasing. One of causes is uterus tissue
3.632 which means that mothers attaining low level of which is no longer fertile, meanwhile uterus wall is the
education were 3.632 times more likely to suffer from place where placenta attached to. This condition raises a
premature rupture of membrane than mothers attaining tendency of placenta previa occurrence or placenta does
135
not attach to the place where it should be. Moreover, tis- incidence, so if there are multigravida mothers in preg-
sue of pelvic cavity and the muscles are weakening as in nancy check, health officers are expected to make plans,
line with the age getting older. This makes the pelvic ca- therefore premature rupture of membrane would not oc-
vity no longer easy to face and solve heavy complications cur or be handled without any complications.14
such as bleeding. In certain condition, its hormonal con- There was a significant relation between multiple
dition is not as optimum as the age before. That is why pregnancy and premature rupture of membrane inci-
the risk of miscarriage, amniotic fluid leak, fetal death dence as considered by p value = 0.000, OR = 2.676, CI
and other complications also increasing. Although the = 1.683 – 4.254, which concluded that mothers with
cause of premature rupture of membrane was not yet multiple pregnancy were 2.676 times more likely to get
known certainly, but the possible predisposing factors premature rupture of membrane incidence than mothers
were women’s age younger than 20 years and older than without multiple pregnancy. Results of this study are in
35 years, previous preterm birth and premature rupture accordance with a theory stating that cause of premature
of membrane records.7 The similar result was also found rupture of membrane could be due to excessive tension of
in study conducted by Purwanti et al.,11 that found rela- uterus, such as multiple pregnancy, hydramnion, fetal
tion between age of mothers and premature rupture of malposition like breech. Then it could be due to infec-
membrane incidence, birth-giving mothers aged > 35 tions that might raise biomechanical process on amniotic
years end to have declining health and uterine condition, membrane, so premature rupture of membrane easy to
also the weak pelvic cavity and its muscles in line with occur.7 Multiple preganancy may raise excessive tension
the age getting older. of uterus and at the end, it may raise contraction. If con-
Different perspective was stated by study of Dars et traction is excessive while labor signs such as cervix
al.,4 which showed that premature rupture of membrane opening is not yet maximum, thus premature rupture of
incidence mostly occurred among patients aged 20 – 30 membrane incidence may arise.15 The similar result of
years, but no significant relation was found between age study was showed by Susilawati that there was relation
and premature rupture of membrane incidence because between number of fetus and premature rupture of mem-
premature rupture of membrane incidence in this study brane incidence, the more number of fetus like in multi-
was influenced more by infection factor, the low socio- ple pregnancy, it would make stomach in tense exces-
economy and quality of antenatal care (ANC). sively, so premature rupture of membrane easy to oc-
Results of statistical test analyzing relation between cur.16
parity and premature rupture of membrane incidence Chi square test on malposition or breech showed a
found p value = 0.003, OR 1.992, CI = 12.260 - 3.149 significant relation between malposition and premature
which means that there was a significant relation be- rupture of membrane incidence with p value = 0.000 (OR
tween parity and premature rupture of membrane inci- = 2.960). Result of this study was in line with theory that
dence. Based on results of multivariate logistic regres- there was relation between malposition and premature
sion, variable parity had significant relation with prema- rupture of membrane incidence. In malposition, the low-
ture rupture of membrane incidence. This is line with est position of fetus does not cover the birth canal, so
theory stating that women who experience pregnancy there is no resistance on amniotic membrane that causes
more than twice need to be more careful of because get- the easy leak of amniotic membrane.13 According to
ting pregnant too often results the weak uterine condition causes of premature rupture of membrane, malpositions
as it is often in tense due to pregnancy.12 namely breech and latitude position are possible because
Multiparity is one of predisposing factors of prema- the lowest position of fetus does not cover the birth canal
ture rupture of membrane incidence because among mul- in maximum, so no resistance is found on amniotic mem-
tiparous women, incompetent cervix is often found, so brane. 11 Based on study conducted by Leihitu and
there is no resistance on amniotic membrane. Parity Ruhyana,17 there was a relation between fetal malposi-
(multi/grande multiparity) is the general cause of pre- tion and premature rupture of membrane incidence.
mature rupture of membrane incidence.13 Parity is one of In education, there was OR = 2.379 which means that
factors causing premature rupture of membrane because mothers with high level of education (> junior high
the increase of parity which enables cervix damage du- school) were 2.379 times more likely to get premature
ring delivery before. The too many number of child is rupture of membrane than mothers with low level of edu-
medical factor that becomes a background of maternal cation (< junior high school) and it was proven by chi
and perinatal mortality. The more number of born child square test analysis that maternal education and prema-
is, it may decrease reproductive health with risks inclu- ture rupture of membrane incidence with p = 0.000
ding abortus, preeclampsia, premature rupture of mem- showed a significant relation between maternal educa-
brane and low birthweight. Multigravida mothers have tion and premature rupture of membrane incidence.
risk of suffering from premature rupture of membrane Based on multivariate logistic regression, there were
136
Maryuni et al, Risk Factors of Premature Rupture of Membrane
three significant variables namely age, parity and educa- 4. Dars S, Malik S, Samreen I, Kazi RA. Maternal morbidity and perinatal
tion. This final of model multivariate analysis resulted = outcome in preterm premature rupture of membranes before 37 weeks
0.198, which means that three independent variables gestation. Pakistan Journal of Medical Sciences. 2014 [cited 2016 April
(age, parity and education) simultaneously showed 11];30(3):626-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/
19.8% and premature rupture of membrane approxi- articles/PMC4048519
mately 80%. The most dominant variable was education 5. Zhou Q, Zhang W, Xu H, Li X. Risk factors for preterm premature rup-
with OR = 3.606. ture of membrane in Chinese women from urban cities. International
Maternal education was one of causes of maternal Journal of Gynekology and Obstetrics. 2015 [cited 2016 March 30].
mortality. High educated women tend to be more aware 2014; 127(3): 254-9. A vailable from: https://www.ncbi.nlm-
of health of themselves and their families as well as aware nih.gov/pubmed/25200254
of nutritional and medical checkup at the time of preg- 6. Hasaneroglu, Bakacak M, Suhhabostanci M, Eminesedaguvendagguven,
nancy. Moreover, the high educated women would be Attar R, Ozgekizilkale, et al. Relationship between premature rupture of
more able to early detect any dangers during pregnancy. membranes and collagen amount in chorioamniotic membranes in term
Another study showed that formal education of pregnancy. Global Journal of Medical Research. 2014 [cited 2016 April
women affected the use of maternal health services. In 25]; 10(2). Available from: https://globaljournals.org/GJMR_
Thailand, maternal education is significantly influential Volume14/4
to the use of health services. Mothers with higher educa- 7. Prawirohardjo S. Ilmu kebidanan. Jakarta: Bina Pustaka. 2010.
tion when suffering from premature rupture of mem- 8. Government of Western Australia Departement of Health.
brane immediately came to the health services because Complications of pregnancy preterm prelabour rupture of membranes
they know it could affect on their health and baby.3 (PPROM). [cited 2016 April 25]. Available from: http://www.kemh.
Level of education relates to knowledge that someone health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/2/b
possesses, the higher education level of someone, the 2.6.1.pdf
higher level of knowledge possessed, so easily health 9. Swarini. Faktor – faktor yang berhubungan dengan kejadian ketuban
workers can tell about the importance of pregnancy pecah dini di RSUD Bayu Asih Kabupaten Purwakarta. [cited 2016
checkup to anticipate high risk and complications during April 11]. Available from: http://onlinelibrary.wile.com
pregnancy.18 10. Nugroho T. Buku ajar obstetri. Yogyakarta: Nuha Medika. 2010.
11. Purwanti E, Afriyani LD, Rosalina. Faktor-faktor yang berhubungan
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age, parity and education, but the most dominant factor http://perpusnwu.web.id/karyailmiah/documents/4239.pdf
to premature rupture of membrane incidence is maternal 12. Kementerian Kesehatan Republik Indonesia. Pedoman seri kesehatan
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Indonesia. 2011.
Recommendation 13. Manuaba IBG. Kapita selekta penatalaksanaan obstetri ginekologi dan
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study recommends pregnant women to increase educa- 14. Morgan G, Carole H. Obstetri dan ginekologi. Jakarta: EGC. 2009.
tion and knowledge to perform early detection of danger 15. Siregar FA. Faktor –faktor yang mempengaruhi terjadinya ketuban pec-
signs and complications during pregnancy, such as early ah dini di rumah sakit umum daerah Padangsidimpuan. [cited 2016
PROM detection. April 17]. A vailable from: http//respirotory.usu.ac.id/han-
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1. Aeni N. Faktor resiko kematian ibu. Kesmas: Jurnal Kesehatan pecah dini (KPD) Di RSUD Cilacap [Skripsi]. Surakarta: Universitas
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137
Ekayani et al. Kesmas: National Public Health Journal. 2017; 11 (3): 138-144 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.1091
Nurses’ Intention and Behavior in Reporting Adverse

Event: Application of Theory of Planned Behavior
Niat dan Perilaku Perawat dalam Melaporkan Kejadian Tidak Diharapkan:

Penerapan Theory of Planned Behavior
Ni Putu Ekayani, Viera Wardhani, Asih Tri Rachmi
Postgraduate Program in Hospital Management, Faculty of Medicine, Brawijaya University, Malang, Indonesia
Abstract
Data show that globally, patient safety incident reporting remains low, as is also the case at Baptis Batu Hospital, East Java. This study aimed to determine
the influence of attitude, subjective norm and perceived behavioral control (PBC) on the intention to report and determine relation between PBC and nurses’
behavior in reporting adverse event. This study used cross sectional approach and was conducted at Baptis Batu Hospital from March 16th to March 31th,
2016. Data were obtained with questionnaires that were distributed to 82 (of 85) nurses working at Baptis Batu Hospital. Data were analyzed using multiple
linear regression and Spearman correlation. The results showed that attitude (B = 0.496; p value = 0.000) and PBC (B = 0.766; p = 0.037) significantly influ-
enced the intention to report adverse events, while subjective norm (B = -0.087; p value = 0.540) did not influence the intention to report adverse events. There
was no relation found between PBC (r = 0.037; p = 0.739) and intention (r = 0.031; p value = 0.783) to behavior of reporting adverse event. These findings
indicated that nurses’ intention in reporting adverse event was influenced by attitude and PBC, but not by subjective norms. In contrast, intention and PBC
did not relate to adverse event reporting behavior.
Keywords: Incidence-reporting behavior, intention, nurses, theory of planned behavior
Abstrak
Data menunjukkan bahwa secara global jumlah pelaporan insiden keselamatan pasien masih rendah, begitu juga di Rumah Sakit Baptis Batu, Jawa Timur.
Penelitian ini bertujuan untuk mengetahui pengaruh antara sikap, norma subjektif, dan perceived behavioral control (PBC) terhadap niat dan untuk menen-
tukan hubungan antara PBC dan niat terhadap perilaku perawat dalam melaporkan kejadian tidak diharapkan (KTD). Penelitian ini menggunakan pendekatan
potong lintang dan dilakukan di Rumah Sakit Baptis Batu pada tanggal 16-31 Maret 2016. Pengambilan data dilakukan dengan menggunakan kuesioner yang
dibagikan kepada 82 (dari 85) perawat yang bekerja di Rumah Sakit Baptis Batu. Data dianalisis menggunakan regresi linier berganda dan korelasi Spearman.
Hasil penelitian menunjukkan bahwa sikap (B = 0.496; nilai p = 0.000) dan PBC (B = 0.766; nilai p = 0.037) secara signifikan memengaruhi niat untuk mela-
porkan KTD, sedangkan norma subjektif (B= -0.087; nilai p = 0.540) tidak berpengaruh terhadap niat melaporkan KTD. Tidak terdapat hubungan antara PBC
(r = 0.037; nilai p = 0.739) dan niat (r = 0.031; nilai p = 0.783) terhadap perilaku melaporkan KTD. Temuan ini menunjukkan bahwa niat perawat dalam mela-
porkan KTD dipengaruhi oleh sikap dan PBC, bukan norma subjektif. Sebaliknya, niat dan PBC tidak berhubungan dengan perilaku melaporkan KTD.
Kata kunci: Perilaku pelaporan insiden, niat, perawat, theory of planned behavior
How to Cite: Ekayani NP, Wardhani V, Rachmi AT. Nurses’ intention and be- Correspondence: Ni Putu Ekayani, Postgraduate Program in Hospital
havior in reporting adverse event: application of theory of behavior. Kesmas: Management Faculty of Medicine Brawijaya University, Veteran Street, Malang
6514, Phone: +62341 569117, e-mail: [email protected]
National Public Health Journal. 2017; 11 (3): 138-144. Received: July 15th 2016
(doi:10.21109/kesmas.v113.1091) Revised: August 24th 2016
Ekayani et al, Nurses’ Intention and Behavior in Reporting Adverse Event
Introduction PSI reporting is a new behavioral form that urges to

Patient safety incident (PSI) reporting in health ser- establish as a part of patient safety culture. One theory
vices is a tool to monitor, prevent and reduce PSI occur- used in assessing a person’s behavior is the theory of
rence. Reportable event range from adverse events, near planned behavior (TPB) developed by Ajzen.6 TPB is
misses, no-harm incident and reportable circumstance.1 relevant to understanding the effect of health personnel
PSI reporting facilitates improvement in practices so that behavior and has been successfully applied to several
incidents are likely to reoccur. The incident report be- health care services.7,8 According to TPB, behavior
comes the basis of evaluation and improvement of the shown by individuals arises because of their intention to
health care system, especially patient safety.2 behave. The emergence of intention to behave is influ-
Huge numbers of PSI in the world and in Indonesia enced by three determinants: attitude towards the beha-
reflect the magnitude of this problem. A study conducted vior; subjective norm; and perceived behavioral control
by World Health Organization (WHO) in 2004 in many (PBC). Numerous studies have applied TPB to the health
developed countries including the United State, the field including Javadi et al.,9 who studied the patient safe-
United Kingdom, Denmark, and Australia found that ad- ty behavior of nurse; Cooke and French,10 who studied
verse events ranging from 3.2 to 16.6%.1 WHO reports the intentions and behavior following the health screen-
on a study involving 11,379 inpatients at 58 hospitals in ing program; Jansma et al.,11 who assessed the intention
Argentina, Colombia, Costa Rica, Mexico and Peru found and behavior of medical residents after patient safety
that PSIs were filled for as many as 10% of patients.3 training.
There is difficulty in gathering accurate PSI data in This study aimed to determine the influence of atti-
Indonesia due to issues with the reporting system, even tude, subjective norm, and PBC on the nurses’ intention
the predicted cases exceed the international cases. The and to determine the relation of PBC and intentions to be-
Hospital Patient Safety Committee (HPSC) published havior on reporting adverse event at Baptis Batu
114 PSI reports in 2009, 103 reports in 2010, and 34 re- Hospital. Nurses play an important role in reporting PSI,
ports in the first quarter of 2011. The PSI report from therefore, their commitment to actively participate in the
January to April 2011 contained adverse event cases PSI reporting system can contribute positively to the safe-
(14.41%) and near miss incident (18.53%) which were ty-based service system.12,13 Results are expectedly used
caused by several situations, such as process or clinical as data to build positive behaviors in PSI reporting sys-
procedures (9.26%), medications (9.26%), and patient tem at Baptis Batu Hospital.
falls (5.15%).4
Low awareness of reporting PSI was also found at Method
Baptis Batu Hospital in Batu, East Java. PSI reports at This study used cross sectional approach. Data were
Baptis Batu Hospital fluctuated over the last three years. collected from 82 of 85 nurses who worked at Baptis
Compared to the predicted PSI data based on admission Batu Hospital. The three nurses not included resulted
rates, there were 179 (64%) in 2013 and as many as 111 from one not being available during the study and two
(29%) in 2015 of incidents that were not reported. Quite providing incomplete responses. A closed ended 5 point
the opposite in 2014, the number exceeding predicted Likert scale questionnaire adapted from Ajzen,6 with a
may due to accreditation assessment. Implementation of total of 32 items of statements, were self-administered to
hospital accreditation motivates management to increase the nurses. The questionnaire had been validated. The da-
PSI reporting, so the PSI report in 2014 increased dra- ta analysis used multiple linear regression to determine
matically. influence of attitude, subjective norm and PBC to the
In health care practice, many barriers to PSI reporting nurses’ intention in reporting adverse event and
remain. One study identified seven causes of low PSI re- Spearman’s correlation for relation between PBC and in-
porting: fear of being blamed, low commitment of the tention toward behavior in reporting incident.
management or related units, the absence of reward on
reporting PSI, low knowledge of circumstances that war- Results
rant PSI reporting, low PSI socialization, no training Table 1 showed the distribution of respondents, and
joined and low socialization from HPSC.5 overview of attitude variable, subjective norm, PBC and
As stated by chairman of HPSC, the factors that in- the intention of adverse event reporting. Attitude variable
hibit PSI reporting in Baptis Batu Hospital were fear of had a high enough mean value (3.85). Outcome evalua-
being blamed, feeling of back-stabbing among friends as tion indicator had higher mean value than behavioral be-
an old culture associated with senior and junior terms lief indicator. The outstanding statements were on that
still attached, concerns about future remuneration and the hospital should significantly dismiss the attitude of
staff, especially inexperienced staff, who fail to identify finding who to blame on every adverse event reporting
near misses. (4.17); the hospital needed to evaluate adverse event re-
139
porting (4.15); and adverse event reporting was needed tention to report adverse event.
in order to learn from the mistakes occured (4.11). Adjusted R square had a value of 0.646 which means
14.6% of respondents stated that they were worried that that the contribution of attitude, subjective norm, and
they would be blamed if reporting an adverse event. PBC on the intention to report adverse event at Baptis
Table 1 showed a subjective norm image consisting of Batu Hospital was 64.6%, while the remaining 35.4%
two indicators, namely normative belief and motivation was contribution from other variables that were not ad-
to comply. The table also showed that the respondents dressed in this study. The dominant variable affecting in-
had quite high mean value of subjective norms (3.54), ei- tention to report adverse event was PBC ( β = 0.552).
ther all or each indicator. These figures indicated a posi-
tive support for adverse event reporting from all referen- Relation between Perceived Behavioral Control and Intention
cing norms i.e. family, friends, managers and manage- on Behavior of Adverse Event Reporting
ment. Although it did not show significant differences, Relation between PBC and intention towards beha-
the highest indicator mean value contained in normative vior was analyzed through Spearman correlation. Result
belief (3.64) with prominent item contained in the state- analysis indicated that there was statistically insignificant
ment “the management (3.84) and the manager (3.83) relation between PBC (r = 0.031; p value = 0.783), and
requires me to report adverse event”. intention (r = 0.037; p value = 0.739) of reporting ad-
Table 1 also showed that the PBC was composed of verse event, furthermore each had a very small correla-
two indicators, namely control belief and perceived po- tion coefficient value.
wer control. The results showed the mean of belief con- Table 1. Distribution of Response and Overview Variable on Attitudes,
trol indicator was in enough category with the lowest Subjective Norms, PBC and Intention to Adverse Event Reporting
mean value in the statement “I get a reward when re-
Mean Mean
porting adverse event” (3.02) and nearly 20% of respon- Variable Indicator Value of Value of
dents disagreed to the statement. In perceived power con- Indicator Variable
trol indicator, a statement regarding the decision to re-
Attitude Behavioral belief 3.71 3.85
port adverse event depended on my control was still low Outcome evaluation 3.99
(3.17). It proved that their control in terms of adverse Subjective norm Normative belief 3.64 3.54
event reporting remained low. Motivation to comply 3.44
Perceived behavioral Control belief 3.55 3.44
Intention variable in Table 1 did not have indicator, control (PBC) Perceived power control 3.33
but only consisted of three statement items with a mean Intention 3.63
of variables 3.63. The highest mean was contained in the
statement “I will always report any PSI that causes injury
Table 2. Distribution of Respondents’ Response and Description about Patient
to the patient” (3.76). Safety Incident
Based on Table 2, 72 of 82 respondents claimed that
they had seen, heard and experienced PSI at the hospital, Have seen, heard, and experienced patient
safety incident at hospital?
which indicated behavior in reporting safety incidents. Kinds of Patient Safety
The highest frequency of respondents’ experience were Incident Yes No
adverse event and no-harm incident which were 87.8%
F % F %
each, although only slight difference occurred between
reportable circumstance and near miss incident (5-9%). Reportable circumstance 67 81.7 15 18.3
Based on the intensity, there was only a small portion of Near miss incident 63 76.8 19 23.2
No harm incident 72 87.8 10 12.2
respondents who always reported any adverse event Adverse event 72 87.8 10 12.2
(11.2%).
Table 3. Analysis on Relation of Attitudes, Subjective Norms and Perceived
Influence of Attitude, Subjective Norm, PBC on Intention of Behavioral Control with Intention of Adverse Event Reporting
Adverse Event Reporting Regression
Result analysis on the influence of attitude, subjective Variable Coefficient Std. Error Beta (β) t Sig.
(B)
norm, and PBC on nurses’ intentions in reporting adverse
event using multiple linear regression could be seen in Attitude 0.496 0.130 0.387 3.800 0.000
Table 3. Subjective norm -0.087 0.140 -0.069 -0.616 0.540
PBC 0.766 0.146 0.552 5.246 0.037
The results showed F count equals to 50.277 with a
probability of 0.000. This means that simultaneously Adjusted R square = 0.646 F count = 50.277
variables attitude, subjective norm, and PBC had a sig- t table = 1.66 F table = 2.73
F significant = 0.000
nificant effect on the intention to report adverse event. α = 0.05
However, partially subjective norm did not affect the in-
140
Discussion ened that cultural factors might affect individuals’ action.

In general, attitudes, subjective norm, PBC and in- If the management and the manager required adverse
tention of adverse event reporting had an average mean event reporting, for example, but when the obeyed fami-
value that indicated a positive evaluation from reporting ly norm said no, then the nurse would not report any ad-
as an effort to improve patient safety. verse event.
Nurses’ Attitude in Adverse Event Reporting Perceived Behavioral Control in Adverse Event Reporting
The results showed that most nurses had a positive at- The results showed that PBC had an average mean
titude towards reporting adverse event. Study conducted value. It was clear that the system offered an ease as well
by Hung also presented a positive attitude on the report- as a desire to report positive adverse event. However,
ing of medication administration error (MAE).14 Several when to report was desired, the control becomes low and
other studies had also suggested that nurses had more tied with the absence of reward and a feeling of guilty.
positive attitudes in terms of reporting PSI. 5,15,16 It From the interview, the chairman of HPSC mentioned
showed that nurses had a positive attitude towards the that Baptis Batu Hospital had implemented a program
problem of patient safety and became more confident to providing rewards to staff who reported PSI as one of
report PSI since nurses were involved more in reporting those was awarding points associated with monthly in-
practices. centive. Therefore, staff motivation to report PSI was ex-
The findings in this study also revealed that although pected to increase. However, if reporting PSI was pur-
it tends to have a positive attitude, still there were res- posefully to get the reward, it could be seen as unethical
pondents who felt blamed if reporting adverse event. This behavior. This is in line with Tucker’s statement in
means blaming culture in reporting adverse event at Cahyono,18 that nurses tend to make adjustments with an
Baptis Batu Hospital remained exist. Blaming culture was insecure and inconvenient environment than having to
one of factors inhibiting PSI reporting. According to the discuss or report any fault that results in injury.
interview, Chairman of HPSC of Baptis Batu Hospital
said that there were factors that inhibited PSI reporting, Intentions in Reporting Adverse Event
one of which was the fear of blame. One of the chal- The results showed that nurses’ intention to report
lenges in the development of patient safety was how to adverse event tend to be high. Most respondents said they
build a patient safety culture without blaming culture. would always report PSI that caused injury to the patient.
The higher the intention was, the higher the behavioral
Nurses’ Subjective Norm in Adverse Event Reporting intention to report adverse event would be. Previous
The results showed that overall the norms of family, studies also mentioned that pharmacists and nurses’ high
co-workers, supervisors, and management had a percep- intention on reporting MAE would improve the behavior
tion that supported adverse event reporting. However, of of reporting MAE. 14,15 Individual understanding on
the four references, the managers and management were something would greatly affect the intention. Intention
considered the sectors that agreed to adverse event re- would greatly affect performance, meaning that if each
porting, then managers was the sector whose opinion was officer intended to report PSI then the performance on
mostly given attention by the respondent. A study by reporting would also be better.13
Hung stated that nurses were willing to report the MAE
due to the strict requirements from the nursing Behavior in Reporting Adverse Event
managers, compared to their own attitudes to report The results showed that most respondents had re-
MAE.14 ported PSI although its intensity varied. The highly con-
There were several factors that influenced a person in veyed PSI types were no-harm incident and adverse
making decision to behave. According to Kotler,17 the event. This is in line with the study stating that PSI re-
factors that influenced the decision were cultural factors ported were those causing injury only.19,20
that included the role of culture, social classes; social fac- Study conducted in Panti Rapih Hospital Yogyakarta
tors that included reference group, family, role and sta- stated that almost 50% of employees did not report ad-
tus; personal factors; and psychological factors. verse event in their work unit and only 6% of employees
The findings that showed differences in the reference reported 21 or more incidents.21 PSI reporting that went
in reporting adverse event at Baptis Batu Hospital ex- into HPSC in one of the hospitals in East Java in 2011-
plained that there were acceptable cultural differences 2013 were 19 reports, 41 reports, and 3 reports respec-
because the embedded culture was not only obtained tively.5 This showed the low PSI reporting that was about
from work, but also from various affecting places, such < 1%, lower than the theoretical predictions by WHO in
as family environment and social groups. However, the 2011 which mentioned that the potential PSI was 10% of
decision was based on individual belief. This strength- admissions.
141
One of factors affecting patient safety, especially in the intention to use clinical guidelines recommendation
PSI reporting, was medical personnel behavior, and it about the use of filter needles. PBC influence lasts until
could be said that PSI reporting depended on how the post intervention and PBC is said to be the determinant
medical officers behaved.9 To achieve a permanent in deciding intention.
change in behavior pattern, it is important to focus not Descriptively, the data showed that resources, such as
only on individual attitudes and intentions, but also forms and reporting route were easily perceived by nur-
stimulates the environment, including hospital culture ses, so nurses’ intentions to report adverse event at hos-
and patient safety policy.16 pital were expected to increase. However, it is contrary to
no-reward concept when reporting adverse event which
Effect of Attitude, Subjective Norm and Perceived Behavioral positively lessen nurses’ intention to report adverse event.
Control on Nurses’ Intention in Reporting Adverse Event Self-control perceived by some nurses was also low. It
The results showed that attitude affected positively could be concluded that although the form and the plot
and significantly on nurses’ intention in reporting adverse were easy but self-control was low and the absence of re-
event. This is in line with previous study conducted by ward, nurses’ intention for reporting adverse event could
Hung on MAE reporting by nurses.14 This finding was al- potentially remain small. Besides, nearly 20% of nurses
so in line with the study that showed a positive relation still felt guilty if reporting adverse event, which could
between attitudes and intentions in reporting medication lead to reduce nurses’ intentions to report.
errors.22,23 This study found no statistical relation between PBC
Almost all nurses at Baptis Batu Hospital expressed a with nurses’ behavior in reporting adverse event. PBC is
positive attitude towards adverse event reporting. It ex- a hallmark of TPB which in this study means the nurses’
plained that reporting adverse event reinforced the ef- perception on the factors that facilitated or complicated
forts to improve patient safety in hospitals. Information reporting adverse event. PBC is contributory in behavior
about patient safety is used by health personnel to form that is not under full control of individual. Based on the
transformation as an effort to reduce recurring mistake, theory, PBC is said to have a direct relation to individual’s
therefore, PSI reporting requires involvement and com- behavior, but this study found no relation between PBC
mitment of the organization and the individual of health and behavior. This situation suggested that there were
care provider.24 Blaming culture among nurses at Baptis other factors that influenced the behavior in reporting
Batu Hospital related to adverse event reporting raised adverse event, such as habit. The habit of reporting de-
the feeling of fear if reporting adverse event. This is in pends on the type of PSI (such as patient falls and
line with the statement that one of the factors inhibiting medication errors were more often reported) and PSI lo-
reporting is afraid of blame.5,25 cation (such as torn skins were more frequently reported
This study identified that there was no statistical ef- in the inpatient unit compared to in the surgery room).13
fect between subjective norm and intention to report ad- This study found no statistical relation between in-
verse event. Mascherek et al,26 stated that the subjective tention and nurses’ behavior in reporting adverse event.
norm did not contribute significantly to the intention of These results are in line with study conducted by Jansma
using surgical checklist. Since WHO issued a surgical et al,16 regarding the effect of patient safety course to in-
checklist in 2009, studies showed that surgical checklist tention and behavior alteration in reporting incident.
had effectively improved patient safety. Surgical checklist Ajzen,6 defined intention as behavior disposition, when
has been considered as the gold standard that does not re- right time and right opportunity exist, it would be exe-
quire approval and consider opinions of others. cuted into action. However, because the accuracy in pre-
On the other hand, Gavaza et al,15 stated that there dicting behavioral intentions varies, some studies found
was a significant relation between subjective norm and that intentions did not always result in expected behavior.
intention. In fact, subjective norm is said to have domi- According to King in Aiken, there were several factors
nant influence. This indicates that the importance of so- that affected the ability of intention in predicting beha-
cial influence as antecedent for intention and behavior of vior, namely whether the intention was specific or not,
reporting adverse drug events (ADEs). Cultural factor the distance and time between intention measurement
explains that a person usually follows the individual ref- and behavior, and the ability to perform what was already
erences that exist around the working area. Then educa- mentioned.28
tion from managers and seniors regarding patient safety
is an important priority that must be fulfilled. Implications and Limitations of Study
The results showed that PBC significantly affected Efforts from Baptis Batu Hospital to improve PSI re-
nurses’ intention to report adverse event. The results are porting, especially adverse event, could be initiated from
in line with study conducted by Cassista et al,27 stating the contributing factors to intentions in reporting adverse
that prior to the intervention, attitudes and PBC affected event as identified in this study. PBC is a factor that has
142
dominant influence on the intention to report adverse on patient safety, particularly PSI reporting, and improve
event. Explanation to the staff is needed that reporting organizational culture in PSI reporting. Further study
PSI will improve the existing system, not to find some- needs to be carried out on other health professionals at
one’s fault. hospitals and in-depth study using qualitative study.
To reinforce positive attitudes, more trainings on pa-
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144
Winarni et al. Kesmas: National Public Health Journal. 2017; 11 (3): 145-152 Kesmas: National Public Health Journal
DOI:10.21109/kesmas.v11i3.800
Evaluation of Momentum Male Sterilization Service

Effectiveness as an Attempt to Reach Museum Rekor
Indonesia
Evaluasi Pelayanan Momentum Keluarga Berencana Sterilisasi Pria dalam

Upaya Mencapai Museum Rekor Indonesia
Endah Winarni*, Muhammad Dawam**
*Research and Development Center for Family Planning and Family Welfare, National Family Planning and
Population Board, Jakarta, Indonesia, **Research and Development Center for Population, National Family
Planning and Population Board, Jakarta, Indonesia
Abstract
Family Planning (FP) program achievement in North Sumatera Province is less encouraging. Total fertility rate in North Sumatera (3.0) is higher than the na-
tional (2.6) and contraceptive prevalence (55.9%) is lower than the national (61.9%). A strategy to increase FP participation called momentum sterilization
service was feared not to meet the standard of medical care because related to Museum Rekor Indonesia (MURI). This evaluation aimed to explain service
quality and satisfaction among male sterilization acceptors. Both qualitative and quantitative evaluation were done cross sectionally against FP officers,
prospectives and acceptors who received medical procedure during momentum service performed in 13 health facilities in Medan City, North Sumatera on
October 23 to 24, 2012. Qualitative data were obtained through in-depth interview with subdistrict and village FP managers. Quantitative data regarding
prospective acceptors and a structured questionnaire to subsample of male sterilization acceptors were collected by the provider at the service location. Results
showed the relatively smooth preparation, mobilization, Information, Education and Communication, male sterilization services and its reporting records. 2001
men were offered services by the sterilization service and 1379 accepted, so the national record was achieved. Almost all respondents were satisfied with the
services provided both by FP and medical officers.
Keywords: Male sterilization, momentum family planning services, museum rekor indonesia
Abstrak
Pencapaian Program KB di Sumatera Utara kurang menggembirakan. Total Fertility Rate Sumatera Utara (3,0) lebih tinggi dibandingkan nasional (2,6); dan
prevalensi kontrasepsi (55,9 %) lebih rendah dibandingkan nasional (61,9%). Sebagai salah satu strategi peningkatan kesertaan KB, pelayanan momentum
sterilisasi pria dikhawatirkan tidak memenuhi standar pelayanan karena dikaitkan dengan rekor Museum Rekor Indonesia (MURI). Evaluasi ini bertujuan un-
tuk menjelaskan kualitas pelaksanaan pelayanan dan kepuasan akseptor sterilisasi pria. Evaluasi bersifat kualitatif dan kuantitatif dilakukan secara potong
lintang terhadap petugas KB, calon akseptor dan akseptor yang mendapat tindakan sterilisasi pada pelayanan momentum di 13 fasilitas kesehatan di Kota
Medan, Sumatera Utara pada 23-24 Oktober 2012. Data kualitatif diperoleh melalui wawancara mendalam terhadap pengelola KB kecamatan dan desa. Data
kuantitatif dikumpulkan provider di tempat pelayanan dengan menggunakan angket mengenai calon akseptor, dan kuesioner berstruktur terhadap sub sam-
pel akseptor sterilisasi pria. Hasil menunjukkan relatif lancar persiapan, penggerakan, KIE, pelayanan sterilisasi pria dan pencatatan pelaporannya.
Pelaksanaan pelayanan sterilisasi pria berhasil melayanai 1379 dari target 2001 target calon akseptor, sehingga mendapatkan rekor MURI. Hampir semua
peserta sterilisasi pria merasa puas terhadap pelayanan dari petugas medis dan petugas KB.
Kata kunci: Pelayanan KB momentum, sterilisasi pria, rekor MURI
How to Cite: Winarni E, Dawam M. Evaluation of momentum male sterili- Correspondence: Endah Winarni, Research and Development Center for Family
zation service effectiveness as an attempt to reach museum rekor Planning and Family Welfare, Permata Street No. 1, Halim Perdana Kusuma,
East Jakarta, Phone: +6221 8008535, e-mail: [email protected]
Indonesia. Kesmas: National Public Health Journal. 2017; 11 (3): 145-152. Received: January 10th 2016
(doi:10.21109/kesmas.v11i3.800) Revised: May 20th 2016
Accepted: July 21th 2016
Introduction 1,379 candidates, of whom 93 underwent sterilization,

The Population and Family Planning program in were included in the survey. Inclusion criteria for res-
Indonesia had not succeeded in decreasing the total fer- pondents were male, married, at least two living children,
tility rate (TFR) from 2.6, for 10 years (IDHS and participated in and/or obtained momentum services
2002/2003-2012). The proportion of family planning on 23 to 24 October 2012. The type of data collected
participation, as the dominant contributor relatively did were both qualitative and quantitative.
not increase substantially in the same period, from 60% The qualitative data were obtained through interviews
(IDHS 2002/2003) to 62% (IDHS 2012). The target to the district and village family planning program mana-
performance indicators for 2010-2014 in the Middle gers. Quantitative data were collected with two instru-
Term National Development Plan were not achieved. ments, both unstructured and structured questionnaires.
They were 2.3 children per woman, 65% family planning The questionnaires were filled out by service provider for
prevalence, and 27.5% use of mix long-term contracep- 1,379 prospective male sterilization participants, and 93
tive method (LTM) as to be achieved by the end of 2014, respondents as subsample of the 1,379 male sterilization
were not reached. North Sumatera Province is one of the acceptors. These respondents were interviewed by the re-
provinces with the low achievement in the Population search team using a structured questionnaire. Variables
and Family Planning Programs. The TFR in North in qualitative data collection regarded male sterilization
Sumatera is still high (3.0 children per-woman), family service process, including planning, target education/mo-
planning use is low (55.9%), and the use of modern fa- bilization, reporting and record keeping. Quanitative
mily planning methods is significantly low (42.8%).3 variables were output variables, included male steriliza-
Male sterilization was the least common method of tion respondent characteristics, Family Planning records,
contraception. The prevalence of male sterilization in service quality and service satisfaction. Qualitative data
North Sumatera, according to various surveys, was be- analysis is written narratively, after data validation using
tween 0.0 to 0.3%, which is similar to the national preva- triangulation of collection techniques against source of
lence of 0.2%.1-3 In recognition of this, momentum ser- data. The quantitative data were presented in frequency
vice activities aim to improve the achievement of LTM. distributions, cross tabulation and multivariately ana-
The people of North Sumatera understand momentum lyzed. This study evaluated the male sterilization mo-
services as an event which supports family planning ser- mentum service in terms of the services output, and the
vices, integrated across relevant institutions or sectors, quality of service; and the male sterilization momentum
and providing a large-scale family planning service in a services in terms of the services output, the quality of
single service movement. Momentum service activities service, and the male sterilization client statisfaction.
are rarely evaluated thoroughly.
This study was conducted to evaluate whether the Results
mass family planning services strategy could achieve the Male sterilization service was implemented in the
expected goals, both in the program and of the recipient stages of planning, mobilization, implementation, re-
sides. The more specific was that the evaluation was ex- porting and record keeping. The planning stage began
pected to explain the implementation process including with the formation of a joint commitment between the
the planning, preparation, socialization, implementation chief representative of North Sumatera Province National
and result of the momentum male sterilization services, Population and Family Planning Board and the Mayor of
in terms of service output, quality of service and client Medan City. Then activities were planned hierarchically
satisfaction. This study was expected to provide input for from the mayor to the neighborhood/environment leader
improvement of the quality of momentum male steriliza- (kepling) level. In order to reach the targeted number of
tion services, for recording and reporting, as well as for male sterilizzation candidate, every kepling was required
services strategy in achieving Museum Rekor Indonesia to prepare one candidate. Because Medan consists of
(MURI) record. 2001 neighborhoods (environment), 2001 candidates for
male sterilization were expected from this city. Male ste-
Method rilization service preparatory activities were monitored
Using ex post facto design, this study collected cross through coordination meetings at the municipal, district
sectionally. This study was located in Medan City, North and village levels.
Sumatera Province, because a large momentum male The acceptor candidate mobilization process was
sterilization service was carried out in this region. The done in several stages. Initially, family planning and
study sites were in 12 family planning clinics in Medan health officers disseminate information in the districts
City during October 2012. The respondents were Family and villages, by inviting speakers such as neighbourhood
Planning district and village managers, and male sterili- head, clinical officers, cadres/pembantu Family Planning
zation acceptors. Six Family Planning managers and village officers and the people. Furthermore, a field
146
Winarni, Evaluation of Momentum Male Sterilization Service Effectiveness as an Attempt to Reach MURI
Family Planning officer assited by Family Planning village gression analysis towards male sterilization participant
officers/cadre identified and collected acceptor candidate who did not meet the inclusion requirements (≤ 2 chil-
data, motivate/perform information, education and com- dren and the youngest child aged < 5 years) as dependent
munication (IEC) and inform prospective male steri- variable. Determinants were identified among the male
lization services acceptors. IEC materials disseminated sterilization participants who did not meet the selection
include male sterilization participant requirements, ef- criteria. The findings would be used as the input to im-
fectiveness, side effects and contra indications, and after- prove the future recruitment of prospective male sterili-
effects. Services were provided to 1379 of 2001 target- zation clients.
ted acceptors. Momentum male sterilization service ac- In Table 2, the dependent variables were male steri-
tivities were conducted in 13 health facilities in Medan lization participants who were unqualified for male steri-
City, simultaneously in two days (October 23-24, 2012). lization compared to those qualified. The independent
Male sterilization experts numbered 28; 8 from North variables were the age of respondent and the wife under
Sumatera, 14 from East Java and 6 from Special Region similar criteria, such as younger versus older age (0 < 35
of Yogyakarta Province. versus 1 ≥ 35 years); low versus high education (0 ≤ JHS
Forms used to record momentum male sterilization versus 1 > JHS); low versus high wife’s education using
services data were similar to what is used in the Family similar criteria namely low vs high education (0 ≤ JHS
Planning Recording Reporting in general. Filling K/I/KB versus 1 > JHS); Family Planning participation variables
(Family Planning Acceptor Card) and K/IV/ KB (Family before changing into male sterilization (1 for Yes and 0
Planning Acceptor Status) were performed by the health for No); and Family Planning counseling variable (1 or
officers. Male sterilization acceptor was recorded as the Yes, 0 or No). (JHS is junior high school or 9 years of
new Family Planning acceptor (PB) in the health facilities education).
where the service obtained, go to the F/II/KB which Variables significantly associated with male steriliza-
record the amount of Family Planning acceptors served. tion participation for those who did not meet the inclu-
Then the participant were recorded as active Family sion criteria were the respondent’s age and the age of the
Planning participant (PA KB) and entered into the form wife. A young aged husband (<35 years) was three times
F/I/Dal (Field Family Planning Participants Control more likely to be a male sterilization participant who did
form) where the acceptor live in. not meet the inclusion criteria as compared to older hus-
bands. A similar pattern occurred in the maternal age
Respondents’ Background variable. Young aged (<35 years), as compared to older
The number of clients who came to the momentum mothers, had a 5 times higher chance that their husbands
male sterilization services was 1379 of 2001 targetted. were sterilization participants who did not meet the in-
The data of 1346 acceptors could be analyzed. Res- clusion requirements. Other variables such as respon-
pondent’s age and age of wife varied. The average of hus- dent’s and wife’s education level, previous Family
band age was 45.24 years, ranged from 23 as the Planning participation, and counseling showed no signifi-
youngest to 81 years as the oldest. Wife’s average age was cant relation to the male sterilization participants who
38.93 years, varied from, aged 19 as the youngest to 62 did not meet the inclusion requirements. Attention and
years as the oldest. Further examination showed that precaution were needed during participant’s recruitment
13% were aged 46 to 50 years and 1,3% were aged >51. towards respondent’s age and wife with younger age (<35
A very young woman (19 years) was also found, despite years), particularly regarding number of children and age
the percentage was low (0.1%). of the youngest child that must fulfill the requirements.
Male sterilization participants’ number of children
varied from one child to six or more children. 3,0% of Records of Contraceptive Use
families had the father undergo sterilization with only Knowing the records of participant or pair’s birth con-
one child. 15.8% of families had two children and 25.6% trol use before participating in male sterilization aimed to
had three children. 14.9% had six children or more. determine whether the participant was new to contra-
To be a male sterilization participant, it is required to ception or changing method. It was found that of all male
have at least two children and the youngest child aged at sterilization participants, 51% were using any contra-
least five years. Table 1 showed that 81.2% of the male ception during the survey, 6% had contraception previ-
sterilization respondents had three or more living chil- ously (before sterilization action), and 43% had never
dren, while 18.8% had 1-2 children. Those who had 1-2 been practicing family planning. Type of method or con-
children (6.3%), had the youngest child aged < 5 years. traceptives used varied. Among those practicing and and
Thus the inclusion requirements that the youngest chil- ever practiced family planning before, 44% used injec-
dren should be at least five years were not met. tion method, 36% took birth control pill, 10% used im-
Table 2 below was resulted from multiple logistic re- plant, 7% traditional contraceptive and 3% Intra Uterine
147
Table 1. Percentage of Respondents by Category of Number of Living Children, Ages of

Youngest Child and Wife
Wife Age Total

Living Children Age of
Youngest Child ≤ 32 Years >32 Years Percents Cases
1-2 children < 5 years 3.7% 2.6% 6.3% 70

≥ 5 years 1.8% 10.8% 12.6% 140
≥ 3 children < 5 years 10.0% 24.0% 34.2% 378
≥ 5 years 1.9% 45.0% 47.0% 518
Total 17.6% 82.4% 100.0% 1,106
(Note: No data of youngest child age in 258 cases)
Table 2. Relation between Respondents and Spouses Characteristics with Participation in Male Sterilization Who
Do Not Meet the Requirements
Variable b
β Standard Error Significancy Odd Ratio
Age of father 1.130 0.363 0.002 3.096

Education of father -0.372 0.345 0.281 0.689
Age of mother 1.775 0.402 0.000 5.903
Education of mother 0.183 0.351 0.602 1.201
Family Planning participation 0.218 0.315 0.488 1.244
Family Planning counselling provision 17.325 8818.218 0.998 33440664.260
Constanta -11.676 4409.109 0.998 0.000
Note :
Dependent Variabel:
1 Male sterilization participant who do not qualify as participant (≤ 2 children and the youngest child aged <5 years)
0 Male sterilization participant who do not qualify as participant
Independent Variabels :
Age of father, mother, 1 young (<35 years) 0 old (≥35 tyears)
Education of father, mothetr 1 low (≤ junior high school) 0 high (> junior high school)
Family Planning partcipation, counselling 1 yes 0 no
Device. From the researcher interview, the type of issue coun-

When calculating the percentage of new Family seled varied (Figure 1). The less common issue were
Planning participants and active participants, the male counseled by respondents was family approval and fail-
sterilization participants coming from 6% of those who ure possibility of male sterilization (1.1% each), fol-
had never been practicing Family Planning; then the per- lowed by requirement, effectiveness, mechanism of ac-
centage of new participants became around 43-49% and tion and side effects of male sterilization (respectively
change method participants became around 51-57%. In 4.3%, 9.7%, 9.7% and 10.8%). While the issue mostly
reality, all result from entirely male sterilization family counseled were male sterilization as a permanent method
planning services were categorized as new participant (66.7%). As much as 63.4% of male sterilization clients
(100 % male sterilization). asked about expecting more children.
Table 3 showed how counselling affected the number
Interpersonal Communication and Counseling of children after which an individual would choose to un-
Data about interpersonal communication and coun- dergo sterilization. Of those who received family plan-
seling (ICC) were based on two sources. Firstly from the ning counseling, those with 3 or more children were sig-
questionnaire of all male sterilization participants that nificantly more likely to accept sterilization. Those who
was filled by officers, and secondly data from researcher received family planning counseling were 2.8 times more
interviews of a subsample of 93 male sterilization partici- likely to plan to participate in male sterilization when
pants. According to the questionnaire, almost all partici- they had three or more children than those who did not.
pants (99.9%) received ICC about male sterilization, Informed consent or client approval is important in a
however the interview determined that only 30.1 % of medical procedure. Almost all male sterilization partici-
the subsample of 93 male sterilization participants re- pants had a signed informed consent form, according to
ceieved ICC. There was a discrepancy between these two data from the questionnaire (99.9%) and from the re-
sources of data. searcher interviews (94.0 %).
148
Almost thirty percent (26.9%) of respondents did not more, 96% of respondents were satisfied with the doc-
make a decision about sterilization or did not know about tor’s services, as well as 81% for Family Planning service
the information delivered about after male sterilization officer.
services. The rest 73.1% received the information. Type
of information received after procedure varied. The least Discussion
known by the respondents was about after surgical side As many as 1379 or 68.9% of the targetted 2001 male
effects (4.4%), prohibition to scratch surgical wound sterilization potential acceptors were included in this
(8.8%), semen examination (8.8%), and wearing special study. The number of male sterilization acceptors was
underwear to support scrotum (17.6%). Other informa- lower than planned, due to socio-cultural, gender and en-
tion were received more commonly, such as the use of vironmental issues. Socio-cultural aspects are commonly
condoms when having sex (88.2%), taking medication associated with beliefs, social norms, and the client’s sta-
until it dissolved (72.1%), avoid lifting heavy loads tus in the family and society. Socio-cultural and environ-
(69.1%), shower 24 hours after surgery and not wetting mental chalenges include misperceptions about male ste-
the wound (69.1%), wearing plaster on the surgical rilization such as that is similar to castration.5,6 Similar
wound and did not open for three days (57.4%). barriers also occur in Khatmandu Nepal, where misper-
ceptions about male sterilization were still deeply root-
Male Sterilization Service Satisfaction ed.7 Barriers to participation include environment, so-
In terms of ratings of male sterilization satisfaction ciety and families who may be less supportive to male
services received, respondents gave a good judgment. sterilization as a choice in family planning.
Nine out of ten respondents rated the operation as quick Those who have a limited knowledge and under-
and 6% as good and skilfully done. Almost all respon- standing of sterilization may be particularly susceptible to
dents rated the doctor’s serving attitude as kind and non-supportive influences from their community and
friendly; while only 1.5% rated as common. Further- family. Most men strongly objected to male sterilization,
Figure 1. Percentage of Male Sterilization Receiving by Type of Information
Table 3. Relation between Respondents and Spouses Characteristics, Family Planning Participation and
Counseling with Number of Children When Deciding to Participate in Male Sterilization
Variable β Standard Error Significance Odd Ratio
Age of father -0.740 0.227 0.001 0.477

Education of father 0.063 0.172 0.716 1.064
Age of mother -0.391 0.186 0.036 0.676
Education of mother -0.089 0.175 0.609 0.914
Family Planning participation -0.243 0.145 0.093 0.784
Family Planing counselling provision 1.030 0.518 0.047 2.800
Constant 0.625 0.268 0.020 1.868
Note :
Dependent Variabel:
1 Participate in MS, no of children ≥ 3
0 Participate in MS, no of children <3
Independent Variables :
Age of father, mother, 1 young (<35 years) 0 old (≥35 years)
Education of father, mothetr 1 low (≤junior high school) 0 high (> junior high school)
Family Planning partcipation, counselling 1 yes 0 no
149
Figure 2. Percentage of Respondents by Information Received after Male Sterilization Procedure
and conveyed that family planning is the wife’s responsi- Terms of male sterilization clients must absolutely ful-
bility.5,8 Another potential barrier is the concern of both filled by every prospective family planning client.
husband and wife of impotency and weakened physical Results of this study showed that most of male sterili-
strength after the procedure.8-10 zation wives were old, age ranged from 51 to 62 years
Similar barrier was also found in several countries in (1.3%), and the youngest was 19 years (0.1%). This da-
Asia such as Nepal and Iran, as well as Tanzania and ta was not in accordance with male sterilization require-
Nigeria.7,11-15 Even medical personnels such as gyneco- ments and rational reference for Family Planning method
logist resident in Nigeria had a very low acceptance of va- elections.18 This showed that there were momentum
sectomy because of the psychological, social, cultural and male sterilization services were less carefull in the re-
religious issues, although they had high knowledge of va- cruitment aspects of male sterilization candidate.
sectomy.16 Officer was less careful in performing screening
Studies in Pakistan presented a different picture, prospective male sterilization clients. One of the require-
where people were more aware and open to male sterili- ments for male sterilization was eligibility criteria for the
zation. Clients who are satisfied with male sterilization wife, that were still in childbearing age or at least 30
can aid in dissemination of family planning methods.17 years. Criteria for screening potential male sterilization
This study found that most of participants’ wives participants need to be improved and adjusted, since
were older, ranging from 51 to 62 years old (1.3%), women fertility was naturally decrease along the age.19
while the youngest was 19 years old (0.1%). These data Besides, there was related recruitment problem found
were not matched with the requirements of recruitment such as very young woman (19 years). Hence, more ex-
male sterilization and reference for rational Family ploration towards the number of children and age of the
Planning method election.18 The findings showed that last child of the potential client was needed.
momentum male sterilization services were not ensuring Age of respondent and wife were significantly associ-
that all candidates met the inclusion criteria. ated with requirements of male sterilization participant.
One of the inclusion criteria was that the wife should In the future, recruitment of the male sterilization candi-
be within childbearing age and with a minimum age of 30 date is expected to mention age of respondent and his
years. Screening for male sterilization candidates needs spouse to avoid recruiting too young candidate aside
to be improved, since fertility decreases with age.19 On from number of children and age of the youngest child as
the other hand, there are recruitment issues, such as a the major factor. One aspect in quality measurement was
wife who was below the minimum age (19 years). Hence, information provided to clients regarding contraception
it is necessary to scrutinize the number of children and selection.20 In this study, information disseminated from
the youngest child. The requirement that the youngest the provider to the client include providing IEC on male
child is above five years is because upon reaching that sterilization, counseling, informed consent, and post ope-
age, there is a high chance of surviving into adulthood. rative information. Counseling materials about male
The data informed that 81.2% had three or more living sterilization had apparently not been fully received by the
children, and 18.8% had 1-2 children. respondent. This finding was similar to IDHS 2012, that
It was also found that there were male sterilization the Family Planning client received less counseling.
participants who had 1-2 children with the youngest Similarly, information received through counseling such
child aged <5 years (6.3%). This findings suggested that as on side effects (36.5%) and on action in case of side
male sterilization requirements using the number of chil- effects (29.4%).3 Hence, provision of counseling materi-
dren and age of the youngest child were less fulfilled by als for momentum male sterilization family planning
male sterilization participants. Applicant screening as- services require more attention and improvement.
pect of male sterilization program requires attention. Counseling from health care and family planning officers
150
to the prospective male sterilization acceptors are in- quality ICC depends on the trust developed in the rela-
tended to have the candidates better understand, confi- tionship between officer and client. So that officer re-
dent, secure and steady on selecting family planning ceived information about contraception wanted by the
methods.21,22 client, and the client believe and understand the infor-
Interaction between providers and clients in counsel- mation received. Positive thinking was also needed.
ing is more emphasized for the benefit of the client; and Positive thinking would give comfort to the client,
provision of fully informed choice is the right counseling through provision of complete information, encourage
client.6,21 Complete and clear information, will provide clients to ask questions and taking the time to answer the
flexibility to a client and family to decide or choose con- client’s questions and concerns. Positive thinking for
traception. Another counseling principle is that the coun- clients meant that the client could receive and under-
selor should be able to identify potential barriers to se- stand information, comfortably and open.22,23
lection and subsequent use of contraception. The clerk A limitation of this study is that it did not analyze the
did confirm rumors about the truth of the issue of con- medical aspect, and only examined the social aspects.
traception, ask the origin of the rumors, and help clients Also because the study was conducted in Medan, which
think in dealing with the issues rumor.22,23 Counseling is an urban area, generalizability of results to all of North
officers are expected to help the client to make a deci- Sumatera province and other provinces may be limited.
sion, understand the client’s needs, offer choice matching The findings were only intended to aid in evaluation of
method, fill the gaps in the knowledge of the client, and the momentum male sterilization service in Medan. Also,
assist clients in determine the choice of contraceptive.5 a limitation of the quantitative analysis was the limited
Information provided after male sterilization proce- number of variables.
dure action is still imperfect. Information about the use
of condoms after male sterilization was quite good, but Conclusion
the information about the examination of semen three Momentum male sterilization service has been well
months after the operation was not good. This informa- prepared in planning, mobilization, service and post-ser-
tion was very important in order to avoid unwanted preg- vice. Mobilization may be a weak point in terms of
nancies, because a period of time must pass after the pro- screening/recruitment male sterilization candidate. There
cedure before sterility is achieved. Sterility (zero sperm) is a significant relation between age of the respondent
is achieved after 20 ejaculations or three months after the and wife and participation in male sterilization. Young
sterilization. Examination should be conducted to con- respondent and wife, aged <35 years are significantly as-
firm sterility.24 sociated with the participation in male sterilization
Still related to family planning IEC and male sterili- among those who do not meet the requirements. In coun-
zation counseling aspects, Family Planning manager or seling, information regarding male sterilization received
officers need to ensure the timeliness of the provision of are limited. Counseling shows a significant relationship
IEC and family planning counseling. Decision to accept with the decision to accept male sterilization among re-
male sterilization after having many children, was not spondents who have many children (three or more).
profitable birth control program, because it had not The signing of the informed consent is almost uni-
much impact on fertility decline. This situation implied formly performed in all male sterilization acceptors.
that the provision of family planning information and Information after male sterilization is not consitently pro-
family planning counseling should be planned and im- vided. In the recording aspect, the reference criteria for
plemented from the beginning, at the time a couple is the new male sterilization acceptor is different with that
planning a family or whenever a couple still have few in the field. In general, assessment satisfaction towards
children.18 the Family Planning services are good.
The analysis showed a contradiction between the
signing of informed consent and IEC/counseling received Recommendation
by respondents. A high percentage of male sterilization Recommendations are addressed to the Family
respondents signing informed consent was not in line Planning managers and executors in the field who are in-
with the low ICC received. Acceptance towards ICC sup- volved with the recruitment of male sterilization clients.
posed to be proportional to the signatories informed con- The provision of services should comply with the criteria
sent. The signing of the agreement was easy to remember, for male sterilization candidate, and need supervision, so
while the male sterilization ICC provided was difficult to that the criteria set for male sterilization participant can
understand and remember for the respondent. The qua- absolutely be met by the target. Recruitment of male
lity of the ICC needed to be addressed, to help the sterilization candidate in the future are expected to pay
respondents clearly receive and understand the materials more attention to the age of the respondent and his wife,
presented. In the counseling process, ability to provide aside from other major factors such as number of chil-
151
dren and age of the youngest child. Indonesia. Global Science and Technology Forum Journal of Nursing
The quality of the ICC provided for male sterilization and Health Care (JNHC). 2015; 2 (1): 56-60.
needs to be improved and the time for Family Planning 10. Novianti S, Gustaman RA. Faktor persepsi dan dukungan isteri yang
officers and health workers must be adequate to provide berhubungan dengan partisipasi KB pria. Jurnal Kesehatan Komunitas
all information related to male sterilization. ICC provi- Indonesia. 2014; 10 (2): 1017.
sion must be carried out early, because the client’s deci- 11. Dayanand G, Singh S, Baruwal C. An assessment of knowledge and at-
sion to accept male sterilization may require considerable titude of vasectomy in adult males: a cross-sectional study from Pokhara,
time. In future literation, inclucion criteria for new Western Nepal. Medical Science. 2014; 2 (4): 164 – 70.
Family Planning acceptor should apply the standards de- 12. Keramat A, Afsanah Z, Masoumah A. Barriers and facilitators affecting
veloped by all involved parties. Momentum male sterili- vasectomy acceptability (a multi stages study in a sample from north
zation services momentum can be continued in the fu- eastern of Iran), 2005-2007. Asia Pacific Family Medica. 2011; 10 (1):
ture, with improvements. However, it is suggested that 5.
future family planning programs do not aim to achieve a 13. Bunce A, Guest G, Searing H, Frajzyngier V, Riwa P, Kanama J, et al.
MURI record because it detracts from the quality of the Factors affecting vasectomy acceptability in Tanzania. International
service. Family Planning Perspectives. 2007; 33 (1): 13-21.
14. Akpamu U, Nwoke EO, Osifo UC, Igbinovia ENS, Adisa AW.
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152
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Kesmas

National Public Health Journal

Volume 11, Issue 3, February 2017 p-ISSN 1907-7505

Effect of School Community Empowerment Model towards Handwashing Implementation

Acceptance of Medical Resume Completion at Dr. Radjiman Wediodiningrat Lawang Psychiatric

Risk Factors of Premature Rupture of Membrane............................................................................. 133-137

Evaluation of Momentum Male Sterilization Service Effectiveness as an Attempt to Reach

Nationally Accredited by Director General of Higher Education Ministry of Education and

Volume 11, Issue 3, February 2017 p-ISSN 1907-7505

Dear Editorial Team,

Please make a bank transfer payment to:

Then please send the proof of payment to:

Impact of National Health Insurance Policy towards the

Dampak Kebijakan Jaminan Kesehatan Nasional terhadap Implementasi

Mochamad Iqbal Nurmansyah, Bulent Kilic

health centers in Indonesia. Kesmas: National Public Health Journal. 2017;

11 (3): 103-110. (doi:10.21109/kesmas.v11i3.1262)

Introduction tative approach. The study was conducted in South

and equipments, human resource and implementation of Center in Rural Area)

Effect of School Community Empowerment Model

Pengaruh Model Pemberdayaan Komunitas Sekolah terhadap Penerapan

Health Journal. 2017; 11 (3): 111-116. (doi:10.21109/kesmas.v11i3.1171)

Introduction promote school health, and also an effective place where

pared to before intervention, for both little doctors and Discussion

Table 3. Frequency Distribution of Handwashing with Soap Patterns of Students

Before Intervention After Intervention

Handwashing with Soap Month 1 Month 2 Month 3

377 100 0 0 21 5.6 356 94.4 0 0 377 100 0 0 377 100

Z -18.868(a) -19.416(a) -19.416(a) -4.583(a) -4.583(a) ,000(a)

Acceptance of Medical Resume Completion at

Penerimaan Pengisian Resume Medis di Rumah Sakit Jiwa Dr. Radjiman

Silvia Shinta Devi, Aryo Dewanto, Lukman Hakim

Introduction information forms. The behavior of doctors in charge of

Figure 1. Partial Least Square Line Diagram

Exogenous Med1 Med2 Endogenous Direct Indirect Total Grand Total

PEU PU 0.297* - 0.297 0.297

timely manner. form of medical resumes made the doctors complete

Risk Factors of Carpal Tunnel Syndrome among Food-

Faktor Risiko Carpal Tunnel Syndrome pada Pekerja Pengepakan Makanan

Introduction cross sectional study. Samples were 50 of 67 food-pack-

CTS Severity Category (N/%)

Age Old > 40 years 11 (57.9%) 7 (38.8%) 1 (5.3%) 19 (100%) 0.001

Psychosocial Determinants of Risky Sexual Behavior

Determinan Psikososial Perilaku Seksual Berisiko pada Siswa Sekolah

Fenny Etrawati*, Evi Martha**, Rita Damayanti***

Variables Category Risky Unrisky Total p Value RP

Table 4. Multivariable Modeling Stage

RP RP ∆ RP RP ∆RP RP ∆RP RP ∆RP RP ∆RP

not have. health.16,17 Communication between parents and chil-

Risk Factors of Premature Rupture of Membrane

Faktor Risiko Ketuban Pecah Dini

Maryuni, Dedeh Kurniasih

Midwifery Studies Institute of Health Science Binawan, Jakarta, Indonesia

Introduction fetal malposition, younger than 20 years and older than

Table 1. Bivariate and Multivariate Results

Age Risky 71 62.3 87 38.2 0.000 2.676 (1.683 – 4.254)

Table 2. Analysis Results of Logistic Regression Multivariate Model in Every Variable

Age .945 .250 .000 2.573 1.577 4.199

Constant -3.830 .689 .000 .022

Fenny Etrawati, Evi Martha, Rita Damayanti