Dengue Prevention and Control in Indonesia

A case study in Yogyakarta City

Sulistyawati

Department of Epidemiology and Global Health

Umeå 2020

This work is protected by the Swedish Copyright Legislation (Act 1960:729)

Dissertation for PhD

ISBN: 978-91-7855-382-2 (print)ISBN: 978-91-7855-383-9 (PDF)ISSN: 0346-6612Possible series title

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Electronic version available at: http://umu.diva-portal.org/

Printed by: Cityprint i Norr ABUmeå, Sweden 2020

To God—Allah SWT

‘O mankind, there has to come to you instruction from your Lord and healing for what

is in the breasts and guidance and mercy for the believers.’

Wahai manusia! Sungguh, telah datang kepadamu pelajaran (Al-Qur'an) dari Tuhanmu,

penyembuh bagi penyakit yang ada dalam dada dan petunjuk serta rahmat bagi orang yang

beriman

(QS. Yunus, 57)

Also, for Suyanto, Cicha, Dito and my Parents…

with love and gratitude.

i

Table of Contents

Table of contents ................................................................................................................... i

Abstract................................................................................................................................. iii

Abbreviations ...................................................................................................................... iv

Summary in Bahasa ...............................................................................................................v

Original papers .................................................................................................................... vi

Introduction ........................................................................................................................... 1

Background ............................................................................................................................ 4 Current dengue fever situation in Indonesia .................................................................. 5 Dengue prevention and control in Indonesia ................................................................. 5 Dengue diagnostics enforcement tool ............................................................................. 8 Dengue diagnostics workflow, case management and case reporting .......................... 9 Integrated surveillance and outbreak preparedness .................................................... 11 Integrated vector management ...................................................................................... 11

Study aim and objectives .................................................................................................... 13 Overall aim ..................................................................................................................... 13 Specific objectives ........................................................................................................... 13

Materials and methods........................................................................................................ 14 Study location ................................................................................................................. 14 Study design ................................................................................................................... 14 Data collection and analysis ........................................................................................... 15

Community knowledge, attitudes and practices as a foundation for intervention

development (Objective 1) ............................................................................................ 15 Executing the control card as a vector control intervention (Objective 2) ...................... 16 Exploring the implementation of the ‘Jumantik’ vector control programme (Objective 3)

................................................................................................................................... 17 Assessing the hospital dengue surveillance system: Case management and reporting

(Objective 4)................................................................................................................ 18 Ethical considerations..................................................................................................... 20

Results .................................................................................................................................. 21 Dengue and vector control knowledge, attitudes and practices in Yogyakarta

(Objective 1) .................................................................................................................... 21 Control card feasibility study (Objective 2) ................................................................... 30 Implementation of the ‘Jumantik’ vector control programme (Objective 3) ............... 30

Perceived roles and responsibilities ............................................................................... 34

ii

People´s perception of dengue ....................................................................................... 35 Perceived benefits of the ‘Jumantik’ and PSN programmes ............................................ 35 Perceived barriers to LMCs’ tasks ................................................................................ 36 Perceived willingness to participate in the ‘Jumantik’ programme ................................. 36 Perceived capacity and self-efficacy .............................................................................. 37 Possible improvements for vector control in the future .................................................. 37

Hospital-based dengue surveillance system: Case management and reporting

(Objective 4) .................................................................................................................... 37 Challenging disease diagnostics ................................................................................... 39 Mismatch in regulatory frameworks and interplay with regulatory bodies ..................... 40 Unequal internal prerequisites for dengue management ................................................ 41

Discussion ............................................................................................................................ 43 Consequences of insufficient dengue prevention and control knowledge .................. 44 Complex interplay of the stakeholders involved in dengue prevention and control . 47 Inconsistent and incomplete standard operating procedures ...................................... 49 Insufficient support for diagnosis and case management ............................................ 51

Study limitations and strengths ......................................................................................... 52 Study limitations ............................................................................................................ 52 Study strengths ............................................................................................................... 53

Conclusions and recommendations ................................................................................... 54

Acknowledgements ............................................................................................................. 56

References ............................................................................................................................ 58

iii

Abstract

Background: Integrated efforts that involve many public health sectors are required to

combat dengue in any setting. Hospitals are responsible for providing accurate diagnosis

and reporting confirmed dengue cases to the health authorities, which serves as an alarm

for increasing preventive measures. Community participation in dengue vector control is

essential because it affects sustainability and cost-effectiveness of preventive and control.

This thesis aimed to provide an in-depth understanding of dengue prevention and control

in Yogyakarta, Indonesia, in order to contribute to strengthening the country’s health

system and the implementation of standardized and well-accepted dengue control

strategies. Several aspects have been studied in term of dengue prevention and control

(case management and reporting, surveillance and vector control) in a dengue-endemic

region of Indonesia—namely, Yogyakarta.

Methods: This thesis comprises four individual research studies: Knowledge, Attitude

and Practice (KAP) survey, control card intervention, implementation of the Jumantik

programme and dengue case management and reporting in hospital. Descriptive and

analytic studies, followed by a pre-post assessment, was performed in the community. A

mixed-method approach was used for assessing the Jumantik programme and a

qualitative study was conducted for the hospital study.

Results: The findings indicated that: (i) KAP regarding dengue vector control were

sufficient but certain aspects still had weaknesses; (ii) level of community participation in

vector control was not satisfactory for several reasons, including lacking time, being busy

with work and member of the community feel that vector control was not their

responsibility; (iii) the Jumantik programme dealt with various obstacles, especially those

related to public acceptance; (iv) coordination between the district health office and

hospitals for early dengue detection did not run optimally. We also found that standard

operating procedures for dengue management differed between hospitals.

Conclusions: The results suggest that dengue prevention and control efforts in

Yogyakarta face certain challenges that must be addressed. While many World Health

Organization recommendations are being followed, the weaknesses reported in some

aspects of the implementation, as well as the lack of integration for various dengue

prevention and control elements, need to be promptly addressed.

Keywords: dengue, control and prevention, community empowerment, diagnostic and

case reporting

iv

Abbreviations

BPJS

DENV

DF

DHF

CHO

DHO

EI

GPs

HBM

IgG

IgM

Jumantik

KAP

KDRS

Km2

LFR

LMC

MRO

NS1

PSN

RT-PCR

RW

SOP

WHO

Badan Penyelenggara Jaminan Sosial (Indonesian

National Insurance)

Dengue Virus

Dengue Fever

Dengue Haemorrhagic Fever

City Health Office

District Health Office

Epidemiological Investigation

General Practitioners

Health Believe Model

Immunoglobulin G

Immunoglobulin M

Juru Pemantau Jentik (Larva Monitoring Cadre)

Knowledge, Attitudes and Practices

Kewaspadaan Dini Rumah Sakit (Hospital Early

Warning)

Square kilometres

Larva Free Rate

Larva Monitoring Cadre

Medical Record Officer

Non-Structural Protein 1

Pemberantasan Sarang Nyamuk (Mosquito Nest

Eradication)

Reverse Transcription Polymerase Chain Reaction

Rukun Warga (Residence Group)

Standard Operating Procedure

World Health Organization

3M Menutup, Menguras and Mengubur (Covering,

Cleaning and Burying)

v

Summary in Bahasa

Latar Belakang: Upaya terpadu yang melibatkan berbagai sector diperlukan untuk

menangani Demam Berdarah Dengue (DBD). Rumah sakit bertanggung jawab untuk

melakukan diagnosis yang akurat dan melaporkan kasus DBD kepada otoritas kesehatan

untuk kewaspadaan dini. Partisipasi masyarakat dalam pengendalian vektor DBD sangat

penting untuk keberlanjutan program. Tesis ini bertujuan untuk memberikan

pemahaman yang mendalam tentang pencegahan dan pengendalian demam berdarah di

Yogyakarta, Indonesia, dalam rangka berkontribusi pada penguatan sistem kesehatan

nasional dan penerapan strategi pengendalian demam berdarah yang terstandarisasi dan

diterima dengan baik oleh pihak yang terlibat. Beberapa aspek dipelajari dalam hal

pencegahan dan pengendalian DBD antara lain (manajemen kasus dan pelaporan,

surveilans dan pengendalian vektor) di daerah endemis DBD di Indonesia yaitu Kota

Yogyakarta.

Metode penelitian: Tesis ini meliputi 4 penelitian yaitu survey KAP, uji coba kartu

kendali pembersihan larva, penelitian implementasi program Jumantik dan manajemen

kasus serta pelaporan kasus dengue di rumah sakit. Analisis deskriptif dan analitik diikuti

dengan penilaian pre-post dilakukan di masyarakat pada study KAP dan kartu kendali.

Mixed-method digunakan pada penilaian program Jumantik dan kualitatif - content

analisis digunakan dalam studi di rumah sakit.

Hasil penelitian: Penelitian ini menunjukkan (i) pengetahuan, sikap, dan praktik

pengendalian vektor DBD sudah memadai tetapi masih terdapat kelemahan; (ii) tingkat

partisipasi masyarakat dalam pengendalian vektor kurang memuaskan karena beberapa

alasan: seperti waktu, sibuk bekerja dan merasa bahwa itu bukan tanggung jawabnya; (iii)

Jumantik mengalami berbagai kendala dalam implementasinya, terutama dalam hal

penerimaan masyarakat; (iv) kesenjangan antara dinas kesehatan dan rumah sakit

menyebabkan deteksi dini DBD tidak berjalan optimal, selain itu SOP yang tidak seragam

antar rumah sakit perlu dikontrol agar dapat menjamin kualitas pelayanan.

Kesimpulan: Tesis ini secara jelas menunjukkan bahwa upaya pencegahan dan

penanggulangan DBD di Yogyakarta menghadapai tantangan, yang berimplikasi juga

pada program nasional. Meskipun rekomendasi WHO telah dijalankan, masih terdapat

kelemahan dibeberapa bagian. Integrasi berbagai elemen pencegahan dan pengendalian

DBD masih belum memadai.

Kata kunci: demam berdarah, kontrol dan pencegahan, pemberdayaan masyarakat,

diagnostik dan pelaporan kasus

vi

Original papers

This thesis is based on the following three individual papers:

I. Sulistyawati S, Astuti FD, Umniyati SR, Satoto TBT, Lazuardi L, Nilsson

M, Holmner A. Dengue Vector Control through Community

Empowerment: Lessons Learned from a Community-Based Study in

Yogyakarta, Indonesia. Int J Environ Res Public Health. 2019; 16(6): 1013.

Available from: https://www.mdpi.com/1660-4601/16/6/1013

II. Sulistyawati S, Nilsson M, Ekasari MP, Mulasari SA, Sukesi WS,

Padmawati RS, Holmner Å. Untapped potential—A qualitative study of

a hospital-based dengue surveillance system. Am J Trop Med Hyg. 2020;

103(1): 120–131. Available from:

http://www.ajtmh.org/content/journals/10.4269/ajtmh.19-0719

III. Sulistyawati S, Nilsson M, Carlisle K, MacLaren D, Wibowo TA,

Whittaker M, Holmner A. Challenges in vector control programme

implementation in Indonesia: a mixed-method study. (Manuscript).

1

Introduction

Dengue fever is a mosquito-borne viral disease that is transmitted by female

Aedes aegypti. This disease has spread rapidly in recent decades, both in terms of

geographical distribution as well as in relation to the increase in the number of

cases reported worldwide (1,2). The dengue virus (DENV) is a member of the

Flavivirus genus of the Flaviviridae family and is responsible for dengue infections

in humans. Currently, there are four serotypes of DENV 1–4 identified globally.

While the distribution of these serotypes was uneven in 1970, confirmed DENV

1-4 cases were found spread across the entire globe by 2004 (3). DENV is

transmitted to humans by Aedes mosquitoes when they feed. These mosquitoes

dwell in tropical and subtropical countries because they need warm weather to

accelerate their growth (4). Aedes are mostly found in urban and suburban areas

that are associated with high population densities and the availability of

containers and stagnant water locations in which these mosquitoes to breed

(1,2,5).

Globally, the World Health Organization (WHO) estimates that 3.9 billion people

are at risk of being infected with the dengue virus in more than 100 countries

(6,7,8). Annually, around 500,000 people are hospitalised as a result of severe

dengue infection, leading to 12,500 (1). However, dengue is an underreported

disease and many cases are misclassified (1,9). Consequently, the actual dengue

burden is unknown. The situation resembles the iceberg phenomenon, where

current reported cases represent the tip of the iceberg while even more cases

remain invisible or unreported—despite enormous diagnostic endeavours of

physicians and community disease surveillance procedures (10).

Combatting dengue fever is challenging because of the complex interplay

between human, mosquito, viral and environmental factors. In addition, there is

no medication available to treat the disease and the existing vaccine intended and

currently used for dengue prevention has turned out to actually pose a significant

problem for preventing and controlling the spread of this disease instead. Hence,

the best current dengue prevention methods are avoiding being bitten by Aedes

mosquitoes and reducing their population. For infected people, mortality can be

prevented by early symptom recognition and subsequent proper treatment

2

provision. Finally, a robust surveillance system can offer early warnings and

enhance the dengue control capacity through a timely approach.

In 2012, the WHO released global strategy guidelines to assist countries around

the world with reducing their dengue burden (11). These guidelines are not the

only document issued by the WHO—various efforts to eradicate dengue have

continuously been initiated over numerous decades. Five technical elements

compose the 2012 WHO strategy: diagnosis and case management, integrated

surveillance and outbreak preparedness, sustainable vector control, future

vaccine implementation and basic operational and implementation research

(Figure 1). This thesis focused on three of these elements—diagnosis and case

management, integrated surveillance and outbreak preparedness as well as

sustainable vector control—while operational research constituted a cross-

cutting element.

Hospitals, both primary and referral, play a significant role in reducing dengue

transmission because hospitals are responsible for providing accurate diagnosis

and reporting positive cases for early warning purposes (12). Hospitals must

ensure detection of early and severe cases, increase in health services and

building of capacities, provision of dengue prevention courses and preparation

of vaccines (11). According to the WHO surveillance guidelines, standard case

investigation should be performed within 24 hours of the initial case notification

(13). This notification is used to perform surveillance activity through

epidemiological investigation (EI), which needs to be conducted within a 100-

metre radius from the home of a confirmed dengue case in order to seek the

presence of other people with a suspected dengue infection. Furthermore, this

activity also investigates the search for larvae existence in potential breeding

places (14). Consequently, such activity serves to inform decision-makers who

are responsible for determining the interventions that aim to stop transmissions

and prevent outbreaks.

3

Figure 1. The framework of the thesis follows the WHO global strategy for

dengue burden reduction (50% mortality) (11).

The WHO encourages sustainable dengue control, considering it to be a low-cost

intervention with long-term effects on both health and environment (15). Their

recommendations include using integrated and sustainable vector control to

reduce human-vector contact, which can be performed through environmental

management and chemical and biological control (16). Community participation

is fundamental for running the mentioned approach and to guarantee the

programme’s sustainability (7,17).

At the national level, Indonesia follows and implements the WHO’s

recommendations for dengue prevention and control. However, it is unknown

to what extent these strategies are implemented and followed from the local

perspective in Indonesia—the quality of diagnosis and case management is

unknown, information regarding surveillance and outbreak prevention is

lacking and little evidence for how and if vector control programmes work exists.

Thus, the completeness and degree of implementation of dengue control

strategies needs to be evaluated at the local level.

4

Background

Indonesia is a large archipelago state in Southeast Asia, where the transmission

of dengue has become hyperendemic (18,19) in recent decades. Dengue

underreporting is also evident in Indonesia, where it is potentially influenced by

the country’s geographical characteristics as well as its epidemiological, clinical,

laboratory and health system challenges (20). A segregated reporting and

recording system has exacerbated this situation among districts (21). The

performance of clinical surveillance is vital for effective disease management and

underreporting can directly aggravate an outbreak situation (22). Some

prevention efforts were developed to mitigate outbreaks, such as involving the

community in dengue prevention programmes and building a national report

system tiered according to all health sectors involved, e.g. hospitals. However,

assessment of how these programmes are implemented to support integrated

vector control has not yet been performed. Consequently, in this thesis, the focus

is on certain dimensions of dengue prevention and control, such as case

management and reporting, surveillance system and vector control.

Figure 2. Actors involved in vector control in Indonesia.

Note: Continues line: authority

Dotted line: technical supervision

5

Figure 2 illustrates the various actors involved in controlling dengue vectors in

Indonesia. The Ministry of Health controls all dengue programmes, which are

then implemented in stages (Provincial Health Offices, District Health Offices

and Primary Health Centres [Puskesmas]), although different regions are given

freedom to develop their own programmes. The Puskesmas is at the lowest level

of health care, directly dealing with the community. In addition, these centres

collaborate with other actors at the same level to run dengue programmes.

Current dengue fever situation in Indonesia

Indonesia is an archipelago in Southeast Asia and was the fourth most populous

state in the world in 2018 (23), with 266,794,980 inhabitants (24). In 2017, 57% of

the population was concentrated on Java Island (25), making Java the most

densely populated part of the country. Accordingly, Java has the highest number

of dengue cases in Indonesia. In January 2019, it was reported that more than 50%

of dengue cases in Indonesia—out of a total of more than 10,000 cases—were

found on Java (26). However, underreporting of cases may disguise the real

dengue incidence situation.

Indonesia has been dengue-endemic for the past five decades, almost since the

first cases were discovered in Jakarta and Surabaya on Java island in 1968. During

the first outbreak in Indonesia, 58 dengue cases were reported and 24 of them led

to patient death (27). During the initial outbreak period, dengue spread rapidly

across the country, leading to dengue transmission quickly becoming

hyperendemic in the country (27,28,29), with cases continuing to increase sharply

as time passed. By the 2000s, the number of dengue cases continued to increase

(30,31) and four DEN Viruses, 1–4, came to be identified in Indonesia, with most

cases resulting from DENV-3 infection (29).

Dengue prevention and control in Indonesia

The government of Indonesia, through the Ministry of Health, has built vertical

programmes that are implemented in a tiered approach, from the top (national)

level to the bottom levels—i.e. provincial, district and sub-district—with the aim

to synchronously control and prevent the spread of dengue between levels. These

programmes integrate epidemiology surveillance, vector control, public health

campaigns as well as education, training and research (32). Dengue programmes

6

were immediately initiated as soon as the dengue virus was first discovered in

Indonesia in 1968. In a situation in which there is absence of routine vaccination

and specific antivirals to combat the disease, the vector control approach is the

best way to mitigate transmission. Figure 3 illustrates the history of dengue

vector control programmes in Indonesia from their inception to the present.

Figure 3. The Indonesian dengue vector control journey: 1968–2020.

In the 1970s, a dengue vector control strategy—called the ‘firefighting’ strategy—

was established. This strategy involved perifocal spraying of the area within a

100-metre radius from the houses of positive dengue cases and it also included

health education and case management. Perifocal spraying was conducted only

when an outbreak was in progress, targeting adult mosquitoes (33). Health

education was conducted in several ways and through the involvement of

various sectors, with the aim to change the behaviour of people (34,35). Case

management was undertaken at health facilities to prevent dengue fatalities,

such as diagnosis, laboratory tests and triage management decisions (11).

In the 1980s, the use of larvicides was implemented on a massive scale to

complement the perifocal spraying method. This programme was modified

during the 1986–1999 period to a selective larviciding, which was only

implemented in cities that had dengue haemorrhagic fever cases for three

consecutive years in order to avoid resistance development in the mosquitoes. To

strengthen selective larviciding, it was complemented by two cycles of fogging

(weekly intervals) in villages with a high prevalence of dengue haemorrhagic

fever cases in 1990–1991 (31).

7

In 1992, the Ministry of Health initiated the so-called 3M programme, where the

three Ms stand for Menutup, Menguras and Mengubur, meaning water container

covering, water container cleaning and discarded water container burying. This

was later followed by the 3M plus programme, which included specific activities

that aimed to reduce mosquito breeding places and to educate people about

protective behaviours. The 3M programme was implemented together with the

so-called Jumantik programme—a community-based programme in which ‘larva

monitoring cadres’ (LMCs) or ‘Jumantik’ were employed at the village level to

monitor and support local cleaning activities in private as well as public areas.

Larva monitoring cadres continue to be recruited from communities and

typically tend to be women. LMCs have the responsibility to perform door-to-

door visits in order to inspect for larvae presence at residential houses and to

perform health education activities (36,37).

In 2004, the government introduced the Communication for Behavioural Impact

(COMBI) programme as one possible dengue control approach, where education

activities are conducted that aim to change behaviour in relation to mosquito nest

eradication (PSN) implementation through local socio-cultural activities. Three

years later, the COMBI was combined with PSN to strengthen the programme

and promote community participation in it (38). In 2015, the Indonesian

government further introduced the One-House One-Jumantik (1 rumah 1

Jumantik) program, as a form of community participation in dengue control, to

complement the Jumantik programme that had run previously. This program

required every house to actively participate in monitoring for larvae existence in

their homes by implementing the 3Ms (39,40).

The Indonesian government responded to the release of WHO guidelines in 2012

by strengthening its previously built control and prevention system, directing it

towards the WHO’s target of reducing the dengue burden (50% mortality) by

2020. In addition, the government aimed to strengthen not only vector control

but also hospitals, surveillance systems and early warning systems but also to

encourage research that aims to provide input on dengue control policies in this

country.

8

Dengue diagnostics enforcement tool

According to the 2012 WHO guidelines, in order to reduce 50% of dengue

mortality by 2020, two major paths should be taken by each country: 1)

improving case management and diagnosis to prevent dengue mortality and 2)

improving technical capacity, building at organizational and individual levels

(11).

For the provision of accurate and efficient diagnosis, rapid laboratory tests and

early dengue response are essential elements of clinical care, corresponding to

the WHO path. In addition, clinical incidence data are important for preparing

outbreak control, particularly in relation to early recognition of a clinical

problem. Laboratory testing using non-structural protein 1 (NS1), as well as both

antigen and Enzyme-linked immunosorbent assay (ELISA), can provide early

diagnosis in febrile patients as a marker of severe dengue infection (41). Using

NS1 disease surveillance can be performed effectively to also act as an effective

control measure.

The WHO states that several examinations can be performed to confirm dengue.

During the early stage of infection—or up to the first six days of illness (febrile)—

virus isolation and viral nucleic acid or antigen detection are the best methods

for diagnosing dengue infection. At the end of the acute phase, on the other hand,

immunological tests are the method of choice for diagnosis (42,43). Hence,

recognizing the febrile phase is essential for a doctor to determine the supporting

diagnosis examination. The problem arises because some people still have low

awareness of fever as a dengue symptom (44). This problem occurs in practically

any country in which many infectious diseases are found with similar symptoms,

such as malaria and influenza, that causes acute febrile illness (45).

Virus culture assays are generally conducted through the inoculation of samples

(serum, plasma or buffy coat) into mosquito cell lines, such as C6/36 and AP61,

or mammalian cell lines, such as Vero and LLC-MK2 (46). Virus RNA detection

can be discovered through the polymerase chain reaction (PCR) from tissues,

blood or sera gathered during the acute phase of the infection using primers

(47,48). These two assays require specialized expertise, a long period of time and

are expensive. Furthermore, an RT-PCR (Reverse Transcription Polymerase

Chain Reaction) can also be conducted, however, this test is costly. Serology (anti-

9

dengue IgG and IgM) and routine hepatology tests are commonly used today.

Unfortunately, these examinations have the disadvantage of not being able to

detect dengue early on because new sufferers can only have blood samples taken

for the above test starting from the third to the fifth day of experiencing a fever

(49,50).

Dengue diagnostics workflow, case management and case reporting

Diagnosis begins when a patient attends a health facility with symptoms that

correspond to febrile symptoms. A doctor first records the patient’s medical

history (anamnesis) by asking for chronology, symptom recognition and fever

onset. The assessment further guides the doctor to decide whether to use

laboratory testing or the rapid NS1-test to confirm the disease. Clinical judgment

is made to determine the degree of infection severity and the course of treatment

as well as whether or not the patient needs to be hospitalised or can be sent home

with observation after educating the patient.

The Indonesian health system implements a tiered order, from the local to the

national levels, as shown in Figure 4. Health data go from a Primary Health

Centre (PHC), called Puskesmas, or a relevant health facility to a District/City

Health Office (DHO/CHO), then continue on to a Provincial Health Office (PHO),

ultimately reaching the Ministry of Health. In DHO and PHO levels, the hospitals

have a position equal to the health office.

According to Indonesian health regulations, once a patient is diagnosed as

dengue positive, the so-called hospital early warning report (KDRS) must be sent

to a DHO within the first 24 hours for prevention purposes, which is in line with

the WHO guidelines. The KDRS should be reported ultimately, accurately and in

a timely manner (51). As soon as they receive the KDRS, the DHO coordinates

with the PHC to conduct an EI.

A PHC officer visits the dengue patient’s address to inspect 20 houses in the

neighbourhood—or within a 100-metre radius—to seek other people who have a

fever without a clear cause. Furthermore, this officer inspects potential breeding

places in the area for the presence of larvae. These two pieces of information must

be reported to the DHO immediately so that the prevention policy can be

executed. If one or more persons in the vicinity are found with a dengue infection

10

or more than three people are suspected to have dengue—and if there are ≥ 5%

of larvae found in containers—fogging, education, larvae cleaning activities

should be undertaken (14,38).

Figure 4. Illustration of the Indonesian health system.

Source: The Republic of Indonesia Health System Review (2017) (52).

11

Integrated surveillance and outbreak preparedness

The WHO states that dengue surveillance can be conducted in passive and active

forms for both entomological and epidemiological surveillance (11). In order to

achieve the WHO goal of reducing the dengue burden by 50% by 2020, a robust

surveillance system for improving dengue reporting, prevention and control is

needed. The primary purpose of dengue surveillance is to identify early signs of

outbreaks and allow timely prevention measures to be applied. Surveillance is

closely related to effective and accurate dengue diagnostics in clinical care, as

mentioned in the previous section. A responsive surveillance system is able to

avoid disease outbreaks by recognizing occurring cases as early as possible. Case

surveillance is performed by recognizing fever and dengue haemorrhagic fever

cases and then reporting these cases to health authorities (53), while the objective

of vector surveillance is to observe the Aedes population (39) under the umbrella

of Indonesian regulation Kepmenkes No. 581 of the year 1992 (38).

Success of dengue surveillance depends on the active participation of many

different stakeholders, including health authorities, health facilities,

communities and individuals. In Indonesia, dengue surveillance is conducted in

a tiered mode, from the lowest to the highest levels. Community participation

means engaging people, both individuals and groups, so that they become

involved in decision-making as well as in practical activities that concern their

health and well-being (54). In disease control, community participation usually

implies that people are included in actions that have a positive impact on their

health (55).

Integrated vector management

In the current challenge of vaccine development (56), integrated vector control is

an effective and efficient approach for reducing the burden. Controlling dengue

vectors is approached by eliminating sources—such as containers that could

potentially be mosquito breeding places—by covering containers or, in some

cases, using insecticides to kill the mosquitoes in their aquatic stage of

development (11). All resources should be deployed, such as vector control

integration within the health system, adaptive management of vector control and

cooperation with other sectors (34).

12

In line with this, dengue vector control in Indonesia is developing in two ways—

through chemical treatment and environmental management. Chemical

treatment is effective for a short period of time (57), thus environmental

management—elimination of mosquito breeding sites—is the preferred option

(58). Community participation in dengue prevention is implemented through the

3M programme, as mentioned before. This programme was complemented with

the Jumantik programme, which employed cadres to monitor larvae presence in

communities. The cadres then report back to the village office and PHC

(Puskesmas) (21). Recently, this programme has been enhanced to ‘One-House,

One-Jumantik’ (‘Satu Rumah Satu Jumantik’) (59).

13

Study aim and objectives

Dengue is a severe global threat because transmission escalates quickly and

produces enormous costs, requiring many resources for its control. The WHO

encourages the reduction of the dengue burden through five technical elements,

four of which are implemented in Indonesia: diagnosis and case management,

integrated surveillance and outbreak preparedness, sustainable vector control

and implementation research. However, evidence regarding how these elements

are implemented and interact at the local level is lacking.

Overall aim

To provide in-depth understanding of dengue prevention and control in

Yogyakarta, Indonesia, in order to contribute to strengthening the country’s

health system and the implementation of standardized and well-accepted

dengue control strategies.

Specific objectives

1. To assess knowledge levels, attitudes and practices towards dengue and

vector control in Yogyakarta in order to support development and

implementation of vector control strategies;

2. To study the feasibility of using a control card to engage the community

in vector control activity;

3. To assess the implementation of the ‘Jumantik’ vector control

programme;

4. To investigate the hospital-based dengue surveillance system from the

perspective of clinical and administrative staff in order to explore

potential reasons for case underreporting.

14

Materials and methods

Study location

Yogyakarta, where the study was conducted, is a city on Java Island, which is

part of Indonesia. This city covers 32,5 Km² (60) and has 413,961 inhabitants (data

from 2018) (61) (Figure 5). Yogyakarta is a city with good quality of services,

consisting of 14 sub-districts and 45 village administrations. Health services in

this city are provided by 25 PHCs and 9 general hospitals.

The health system in Yogyakarta is tiered, from the DHO to the PHCs and then

the community. The DHO is the community’s advisor for disease prevention and

control programme. The PHCs execute the programme in collaboration with the

community.

Figure 5. City of Yogyakarta on Java Island in Indonesia.

Source: https://www.google.com/maps/place/Yogyakarta.

Study design

The research undertaken for this thesis employed multiple methods, including

quantitative, qualitative, and mixed-method approaches. First, a quantitative

study was performed to assess the knowledge, attitudes and practices of people

in relation to dengue (Objective 1). Second, a quasi-experimental study was

conducted to study the feasibility of using a control card (Objective 2). Third, a

15

mixed-method approach was employed to assess the opinions of various

stakeholders about the Jumantik programme (Objective 3). Finally, a qualitative

approach was applied to explore dengue case management and reporting

practices at local hospitals (Objective 4). The location of the objectives in relation

to the thesis framework is presented in Figure 6.

Figure 6. Positions of research objectives within the thesis framework.

Data collection and analysis

Community knowledge, attitudes and practices as a foundation for

intervention development (Objective 1)

A total of 521 households in two Yogyakarta villages—namely, Mantrijeron and

Demangan—participated in this study. Convenience sampling was applied to

select households due to resource limitations. Each household was represented

by one family member who was selected based on the following inclusion

criteria: (1) people of productive age (≥ 15 years of age) (62,63), having lived in

the study area for more than one year, (2) being able to communicate verbally

and in written form. People who had lived in the villages for less than one year

were excluded from the survey.

During the Knowledge, Attitude and Practice (KAP) survey, participants were

asked to answer a total of 29 questions, which were divided into four main

categories: 1) socio-demographics of respondents (sex, age, education,

occupation); 2) knowledge (disease, agents, symptoms, transmission, treatment);

2 4

3

1

16

3) attitudes (who's at risk, importance of container cleaning, seriousness of the

disease) and 4) precautionary practices (container cleaning, protective

behaviour). The questions related to knowledge and practices were designed as

multiple-choice items. The questions related to attitudes were designed as

statements and the responses were measured using a 4-point Likert scale, from

‘strongly disagree’ to ‘strongly agree’, which also included an optional ‘I do not

know’ answer. Correct answers on knowledge and practice questions were

scored with 1 point, except for one especially important practice question

addressing container cleaning practices. This item was scored from 0 to 3, with 3

representing the best practices and 0 the worst practices. Maximum possible

knowledge and practice scores were 8 and 11, respectively. Attitudes were scored

from 0 to 4, where the highest score represented the most proper or positive

attitude with respect to the topic. The lowest score (0) represented the least

proper or the most negative attitude. The maximum possible score for attitude

was 32.

The first analysis was descriptive, presenting total and mean scores for each

element—knowledge (K), attitudes (A) and practices (P)—according to the socio-

demographic characteristics of respondents. Bivariate logistic regression was

used to analyse the association between K, A and P scores and the socio-

demographic characteristics. The KAP total scores were divided into either poor

or good—it was considered good when participants obtained a score that was ≥

80% of the overall score and poor when their score was < 80% (64,65).

Executing the control card as a vector control intervention (Objective 2)

This vector control intervention was performed after the KAP survey. The trial

involved the same research area with the KAP survey, which was divided into

one intervention and one control site. Mantrijeron was selected as the

intervention location and Demangan as the control location. The control card

feasibility study began on June 1, 2014 and ran for eight consecutive weeks.

Prior to starting the study, 76 volunteer field workers—representing different

geographical sub-areas (called RW) within the Mantrijeron village region—were

informed about how the study should be monitored. Subsequently, they

distributed control cards to 2,440 households in their respective RW. Container

cleaning practices were regularly monitored by these field workers, who checked

17

the water containers and the card usage through random visits to 10 households

on a weekly basis. During the second month of the study, this monitoring was

executed every second week.

To evaluate whether control cards enhanced people’s cleaning practices, this

feasibility study had a pre-post intervention-control design. Pre and post the

number of larvae infested houses and containers were executed through random

sampling in both Mantrijeron and Demangan. All potential indoor and outdoor

mosquito breeding places were checked in the selected homes. The sample size

was calculated using Statcalc Epi Info 7.

The outcome of the feasibility study was evaluated by comparing the number of

positive containers/houses for larvae pre and post the intervention between the

intervention group and the control group using a Poisson regression model. This

analysis used time parameters (pre/post) and group parameters

(intervention/control) to estimate additional changes over the study period

resulting from the intervention by interacting the time variable with the group

variable longitudinally.

At the end of the control card study, a short survey was conducted among the

team of field workers who conducted the monitoring in order to assess their

experiences and opinions about control cards and their feasibility as a stand-

alone intervention.

Exploring the implementation of the ‘Jumantik’ vector control programme

(Objective 3)

This study originated from the previous study in which we identified weaknesses

in vector control engagement level in the community. This investigation was

directed to the working areas of the PHC (Puskesmas) Umbulharjo 1 (UH 1). This

centre is responsible for four villages: Warungboto, Pandean, Sorosutan and

Giwangan. According to Puskesmas UH 1 data, during the 2009–2017 period,

Sorosutan village had the highest average number of dengue cases, while

Giwangan had the lowest. Hence, the study was conducted in Giwangan village,

under the assumption that they were implementing good dengue vector control.

18

The study population consisted of 42 larva monitoring cadres in Giwangan. For

the quantitative approach, the study instrument was a questionnaire that

addressed the work of larva monitoring cadres—inspired by the Health Belief

Model perspective. This model predicts the health-related behaviour of people

through various constructs: perceived susceptibility, severity, motivation, benefit

and barrier (66,67). Our instrument used a 5-point Likert scale. Before data

collection began, the study instrument was tested with larva monitoring cadres

outside of the research area. After testing, 4 out of 20 questions were removed

and the overall Cronbach’s alpha for the 16 remaining items and the final

instrument was 0.81—and was thus considered to be reliable. SPSS Data Entry

Station release 24.0.0.1 was used to calculate data obtained from 35 larva

monitoring cadres participating in the survey. Data checks were performed for

consistency and descriptive statistics were calculated.

To complement the information gathered from survey answers, in-depth

interviews were conducted with the stakeholders involved in dengue vector

control—namely, 2 larva monitoring cadres, 2 community members, 1 head of a

community group and 1 surveillance officer from the Yogyakarta DHO. The

interviews aimed to further explore the opinions of people about the work of

larva monitoring cadres in order to identify potential weaknesses in the

programme. Interviews were transcribed verbatim, followed by familiarisation

with the material. Qualitative thematic analysis was used to analyse the data.

Manual coding was done by two researchers, grouping of codes into sub-themes,

re-coding iteratively and last was reporting the result.

Assessing the hospital dengue surveillance system: Case management and

reporting (Objective 4)

This study was based on in-depth interviews with a total of 16 informants: 4

paediatricians, 5 general practitioners, 3 internists and 4 medical record officers.

Purposive sampling was applied to select respondents, according to the

following criteria: 1) had worked in the hospital for more than 1 year, 2) was a

health professional and 3) was involved in dengue case management and

reporting. The sample consisted of respondents from both private and state

hospitals and aimed to obtain rich material about the current situation in

Yogyakarta. We sent invitations to 4 hospitals—asking potential respondents to

join the study—and ended up with a total of 16 participants that fulfilled the

19

necessary criteria—1 participant per profession and hospital. In the end, 1

participant could not participate because of lack of time and 1 hospital sent 2 GPs

to 1 interview.

Face-to-face interviews were conducted at the informants’ offices using a semi-

structured interview guide. The guide was developed on the basis of preliminary

results from a previous questionnaire study, conducted among GPs at private

and public hospitals in Yogyakarta (unpublished work). The preliminary results

indicated some potential weaknesses in dengue diagnostics, as well as reporting

routines and practices, at both system and individual levels. Hence, the guide

consisted of 20 open-ended questions that aimed to explore the informants’

experiences regarding all major processes that rule diagnostics, treatment and

reporting of confirmed dengue cases to the health authorities. The guide covered

the following themes: i) experience in dengue treatment, including raising the

alarm about dengue cases at the hospital, ii) procedures for diagnosing a dengue

patient, iii) efforts to improve and update their dengue knowledge, iv) case

reporting routines and practices (called Kewaspadaan Dini Rumah Sakit [KDRS] in

the local language) and v) how dengue management relates to health insurance

(financing). Written informed consent was requested from participants prior to

beginning the interviews. The interviews lasted for 30 to 60 minutes and were

audio-recorded and transcribed verbatim. Field notes were taken during the

interviews and were afterwards summarised to the participants. SS performed

the interviews in Bahasa, Indonesia. Follow-up questions were posed to further

probe for information that could increase the understanding of the system under

study. Saturation was reached after fifteen interviews were performed.

Qualitative content analysis was used to capture the manifest content in the data.

All transcripts were converted into rich text format and imported into the Open

Code software 4.03 for analysis. Open Code is an open-source software,

developed by Umeå University, Sweden (http://www.phmed.umu.se/enheter/

epidemiologi/forskning/open-code/). The analysis was conducted in four steps:

i) contextualization, ii) re-contextualization, iii) categorisation and iv)

compilation [18]. Four researchers, with a public health background, performed

the coding simultaneously to maintain trustworthiness during the data analysis.

As part of this process, the researchers met and held a discussion every second

week.

20

Ethical considerations

Participation in the research study was voluntary. Data collection took place at

participants’ houses or in their work settings.

Prior to the data collection, a written informed consent form was given to the

participants. The researcher verbally explained the research purpose before

signing. All participants were free to withdraw from participating in the research

at any time and without having to present a reason for doing so. All necessary

approval protocols followed and the consent forms were approved by the Ethical

Board of Universitas Ahmad Dahlan, Indonesia. Data were saved in a computer

that was protected by a password and only the research group could access them.

Data were presented so that no informants or their individual information could

be identified.

21

Results

This chapter presents the most critical findings, organized according to specific

aims.

Dengue and vector control knowledge, attitudes and practices in

Yogyakarta (Objective 1)

Community is an essential element of dengue prevention and control. A proper

understanding of dengue can increase the awareness of people about outbreak

prevention. In this study, low levels of knowledge and engagement were

reported.

In total, 521 individuals participated in the knowledge, attitudes and practices

survey (Table 1). More than half (50.7%) of the respondents were female. This

group obtained better knowledge, attitudes and practices scores than the male

respondents. More than 30% of the respondents were 45–59 years old. People 30–

44 years of age acquired the best mean score on knowledge, attitudes and

practices in comparison to other age groups. Almost 60% of our respondents had

graduated from secondary school. People who held a university degree had

better scores for knowledge, attitudes and practices than other education groups.

Many of the participants (36.1%) worked in the private sector. People who

worked in the government sector had better mean scores for knowledge and

attitudes than other occupations. Retired people and housewives obtained the

highest scores for practices.

22

Tab

le 1

. P

arti

cip

ant

char

acte

rist

ics

and

mea

n (

SD

) sc

ore

s fo

r d

eng

ue

con

tro

l k

no

wle

dg

e, a

ttit

ud

es a

nd

pra

ctic

es.

Var

iab

le

N (

%)

Mea

n S

core

Kn

ow

led

ge

(SD

) A

ttit

ud

e (S

D)

Pra

ctic

e (S

D)

All

par

tici

pan

ts

521

(100

%)

3.7

2 +

1.59

25

.64

± 3.

55

9.18

+ 1

.25

Sex

Mal

e 23

4 (4

4.9)

3.

62 (

1.47

) 25

.09

(4.1

0)

8.97

(1.

41)

Fem

ale

287

(55.

1)

3.80

(1.

68)

26.1

2 (2

.97)

9.

36 (

1.08

)

Ag

e g

rou

p (

yea

rs)

15–2

9 71

(13

.6)

3.97

(1.

43)

26.4

6 (2

.71)

9.

04 (

1.35

)

30–4

4 14

2 (2

7.3)

4.

16 (

1.59

) 26

.72

(3.8

0)

9.39

(1.

16)

45–5

9 18

0 (3

4.5)

3.

59 (

1.64

) 25

.16

(3.4

0)

9.07

(1.

36)

>

60

128

(24.

6)

3.28

(1.

47)

24.7

3 (3

.53)

9.

20 (

1.12

)

Occ

up

atio

n

Go

ver

nm

ent

sect

or

27 (

5.2)

4.

67 (

1.17

) 27

.63

(2.7

3)

8.89

(1.

71)

Pri

vat

e se

cto

r

188

(36.

1)

3.74

(1.

56)

25.9

6 (3

.42)

9.

13 (

1.38

)

Stu

den

t

25 (

4.8)

3.

80 (

1.47

) 25

.92

(2.8

7)

8.36

(1.

18)

Sea

son

al w

ork

er

16 (

3.1)

3.

19 (

1.97

) 24

.19

(1.6

0)

8.44

(1.

93)

Ret

ired

46

(8.

8)

3.57

(1.

53)

25.5

2 (2

.69)

9.

43 (

0.95

)

Ho

use

wif

e 16

0 (3

0.7)

3.

83 (

1.73

) 25

.94

(3.1

7)

9.42

(0.

99)

Un

emp

loy

ed

59 (

11.3

) 3.

15 (

1.)2

0 23

.41

(5.1

8)

9.20

(1.

01)

Ed

uca

tio

n

Pri

mar

y

61 (

11.7

) 2.

67 (

1.54

) 23

.75

(3.8

2)

9.05

(1.

62)

Sec

on

dar

y

311

(59.

7)

3.79

(1.

54)

25.8

0 (3

.55)

9.

24 (

1.10

)

Un

iver

sity

deg

ree

126

(24.

2)

4.25

(1.

50)

26.5

9 (3

.19)

9.

15 (

1.36

)

Illi

tera

te

23 (

4.4)

2.

74 (

1.25

) 23

. 65

(2.0

1)

8.91

(1.

47)

T

able

so

urc

e: S

uli

sty

awat

i et

al.

(201

9) (

44).

23

Knowledge questions had a low number of correct answers from respondents

regarding potential breeding places for Aedes and having prolonged fever as one

of the dengue symptoms. This is shown in Table 2.

Table 2. Knowledge regarding dengue agents, symptoms,

transmission and treatment.

Study Population Mantrijeron

N = 257

Demangan

N = 264

Total

N = 521

Knowledge Item Correct Answer N (%)

Dengue agents, symptoms, transmission,

treatment

- DHF is an abbreviation for Dengue

Haemorrhagic Fever.

93 (36.2)

109 (41.3)

202 (38.8)

- Using repellent from morning until evening

is one way to prevent dengue. 72 (28.0) 71 (26.9) 143 (27.4)

- Having high and continuous fever for

several days is one dengue symptom. 71 (27.6) 72 (27.3) 143 (27.4)

- Paracetamol and sponging with tepid water

are types of first aid when infected with

dengue.

72 (28.0) 65 (24.6) 137 (26.3)

- Discarded material and bathtubs are

potential Aedes aegypti breeding sites inside

the house.

156 (60.7) 145 (54.9) 301 (57.8)

- Aedes aegypti biting time is from morning

until evening. 99 (38.5) 96 (36.4) 195 (37.4)

- Dengue cannot be transmitted by direct

contact with a dengue patient. 210 (81.7) 216 (81.8) 426 (81.8)

- Ditches are not potential breeding sites for

Aedes. 75 (29.2) 72 (27.3) 147 (28.2)

Table source: Sulistyawati et al. (2019) (44).

All questions related to attitudes received adequate responses, meaning that

most of the respondents had a positive attitude regarding dengue prevention and

treatment, such as reducing mosquito breeding places and treating family

members who have a fever (Table 3).

Table 3. Attitudes towards dengue fever (DF) prevention and

treatment.

Study Population Mantrijeron

N = 257

Demangan

N = 264

Total

N = 521

Attitude Statement N (%)

I don’t bother with larvae in the indoor water container.

Strongly agree 7 (2.7) 6 (2.3) 13 (2.5)

Agree 4 (1.6) 11 (4.2) 15 (2.9)

Disagree 125 (48.6) 129 (48.9) 254 (48.8)

24

Study Population Mantrijeron

N = 257

Demangan

N = 264

Total

N = 521

Strongly disagree 120 (46.7) 116 (43.9) 236 (45.3)

Don’t know 1 (0.4) 2 (0.8) 3 (0.6)

I need to take my family member to the hospital immediately if infected with DF.

Strongly agree 143 (55.6) 131 (49.6) 274 (52.6)

Agree 110 (42.8) 121 (45.8) 231 (44.3)

Disagree 1 (0.4) 6 (2.3) 7 (1.3)

Strongly disagree 2 (0.8) 4 (1.5) 6 (1.2)

Don’t know 1 (0.4) 2 (0.8) 3 (0.6)

It is not necessary to clean the bathtub routinely if it is not dirty.

Strongly agree 4 (1.6) 4 (1.5) 8 (1.5)

Agree 32 (12.5) 43 (16.3) 72 (14.4)

Disagree 164 (63.8) 166 (62.9) 330 (63.3)

Strongly disagree 56 (21.8) 49 (18.6) 105 (20.2)

Don’t know 1 (0.4) 2 (0.8) 3 (0.6)

It is necessary to brush bathtubs to eliminate mosquito eggs.

Strongly agree 108 (42.0) 112 (42.4) 220 (42.2)

Agree 133 (51.8) 138 (52.3) 271 (52.0)

Disagree 6 (2.3) 4 (1.5) 10 (1.9)

Strongly disagree 8 (3.1) 8 (3.0) 16 (3.1)

Don’t know 2 (0.8) 2 (0.8) 4 (0.8)

I leave unused plastic mineral water cans outside my house.

Strongly agree 4 (1.6) 5 (1.9) 9 (1.7)

Agree 9 (3.5) 14 (5.3) 23 (4.4)

Disagree 149 (58.0) 148 (56.1) 297 (57.0)

Strongly disagree 93 (36.2) 95 (36.0) 188 (36.1)

Don’t know 2 (0.8) 2 (0.8) 4 (0.8)

I don’t need to monitor larvae in my environment.

Strongly agree 3 (1.2) 3 (1.1) 6 (1.2)

Agree 22 (8.6) 31 (11.7) 53 (10.2)

Disagree 160 (62.3) 168 (63.6) 328 (63.0)

Strongly disagree 66 (25.7) 59 (22.3) 125 (24.0)

Don’t know 6 (2.3) 3 (1.1) 9 (1.7)

If I have a fever for three consecutive days without any other symptoms (influenza, cough,

diarrhoea), then I suspect that I have DF.

Strongly agree 46 (17.9) 49 (18.6) 95 (18.2)

Agree 182 (70.5) 174 (65.9) 356 (68.3)

Disagree 23 (8.9) 34 (12.9) 57 (10.9)

Strongly disagree 4 (1.6) 3 (1.1) 7 (1.3)

Don’t know 2 (0.8) 4 (1.5) 6 (1.2)

In my opinion, everyone has the same risk to get infected by DF.

Strongly agree 73 (28.4) 80 (30.3) 153 (29.4)

Agree 161 (62.6) 160 (60.6) 321 (61.6)

Disagree 19 (7.4) 14 (5.3) 33 (6.3)

Strongly disagree 2 (0.8) 6 (2.3) 8 (1.5)

Don’t know 2 (0.8) 4 (1.5) 6 (1.2)

Table source: Sulistyawati et al. (2019) (44).

25

Finally, different answers were provided by the respondents regarding dengue

prevention practices. For example, the usage of mosquito spray and coil received

the lowest response percentage from the participants (Table 4).

Table 4. Practices regarding DF prevention.

Study Population Mantrijeron

N = 257

Demangan

N = 264

Total

N = 521

Practice Items Good Practice N (%)

- I pay attention to larvae

existing in indoor water

containers.

238 (92.2) 248 (93.2) 486 (92.7)

- I clean and brush water

containers if there are any

larvae inside.

236 (91.5) 251 (94.4) 487 (92.9)

- I clean my containers one to

three times a week. 239 (92.6) 242 (91.0) 481 (91.8)

- I always keep the water

containers at my house closed. 174 (67.4) 166 (62.4) 340 (64.9)

- I discard, cover or sell

discarded material outside the

house.

255 (98.8) 258 (97.0) 513 (97.9)

- All my family members are

responsible for cleaning water

containers.

254 (98.4) 262 (98.5) 516 (98.5)

- I clean water containers by

draining and brushing them. 246 (95.3) 259 (97.4) 505 (96.4)

- I use mosquito repellent. 161 (62.4) 160 (60.2) 321 (61.3)

- I use repellent, mosquito coil or

mosquito spray in mornings

and evenings.

60 (23.3) 53 (19.9) 113 (21.6)

Table source: Sulistyawati et al. (2019) (44).

Binary logistic regression analysis shows the factors that influence knowledge,

attitudes and practices towards dengue prevention, respectively. There was no

difference in knowledge between women and men (OR = 1.46, 95% CI: 0.33–6.44)

or between age groups (Table 5).

Regarding attitudes, women had a lower score on attitude (< 80% total score)

than men (OR = 0.45, 95% CI: 0.27–0.76). Age and attitude were also found to be

significantly associated. People aged 30–44 and 45–59 were 3.18 times (95% CI:

1.37–7.36) and 2.59 times (95% CI: 1.39–4.82), respectively, more likely to have a

higher score on attitude in comparison to the youngest age group (P = 0.05).

Those working in the private sector and housewives had 11.08 times and 2.50

26

times, respectively, higher score on attitude in comparison to people working in

the government sector (P = 0.05) (Table 6).

There was no difference in dengue practices by gender. However, those aged 45–

59 had two times better dengue prevention practices (P = 0.05). People who

worked in the private sector, seasonal workers and retirees had 72%, 82% and

78%, respectively, higher risk of worse practices than people who worked in the

government sector—the result was statistically significant (Table 7).

27

Tab

le 5

. B

inar

y l

og

isti

c re

gre

ssio

n a

nal

ysi

s o

f fa

cto

rs a

sso

ciat

ed t

o k

no

wle

dg

e o

n d

eng

ue

pre

ven

tio

n

So

cio

-de

mo

gra

ph

ic c

ha

ract

eri

stic

To

tal

resp

on

se N

(%)

Kn

ow

led

ge

ca

teg

ory

OR

(9

5%

CI)

P-v

alu

e

Po

or

(<8

0%

) G

oo

d(≥

80

%)

N (

%)

N (

%)

All

Pa

rtic

ipa

nt

52

1 (

100

) 5

07

(9

7.3

3)

14

(2.6

7)

Sex

M

ale

2

34

(4

4.8

5)

22

8 (

97

.4)

6 (

2.6

) 1

F

emal

e

28

7 (

55

.15

) 2

79

(9

7.2

) 8

(2

.8)

1.4

6(0

.33

-6.4

4)

0.6

1

Ag

e

1

5 –

29

71

(1

3.5

5)

69

(9

7.2

) 2

(2

.8)

1

3

0 –

44

14

2 (

27

.29

) 1

36

(9

5.8

) 6

(4

.2)

2.7

1(0

.10

-72

.14

) 0

.55

4

5 –

59

18

0 (

34

.54

) 1

75

(9

7.2

) 5

(2

.8)

5.6

9(0

.38

-84

.57

) 0

.20

6

0 –

84

1

28

(2

4.6

2)

12

7 (

99

.2)

1 (

0.8

) 4

.43

(0.3

4-5

7.3

0)

0.2

5

Occ

up

atio

n

G

ov

ern

me

nt

sect

or

27

(5

.34

) 2

7 (

10

0.0

) 0

(0

.0)

1

P

riv

ate

se

cto

r

18

8 (

2.6

7)

18

2 (

96

.8)

6 (

3.2

) *

S

tud

ent

2

5 (

4.7

7)

24

(9

6.0

) 1

(4

.0)

*

S

easo

nal

wo

rker

1

6 (

33

.21

) 1

5 (

93

.8)

1 (

6.3

) *

R

etir

ed

4

6 (

3.0

5)

45

(9

7.8

) 1

(2

.2)

*

H

ou

sew

ife

1

60

(3

.78

) 1

55

(9

6.9

) 5

(3

.1)

*

U

nem

plo

ye

d

59

(4

2.1

8)

59

(1

00

.0)

0 (

0.0

) *

Ed

uca

tio

n

P

rim

ary

6

1 (

11

.64

) 6

0 (

98

.4)

1 (

1.6

) 1

S

eco

nd

ary

3

11

(5

9.6

4)

30

6 (

98

.4)

5 (

1.6

) *

G

rad

uat

e /

Po

st G

rad

uat

e

12

6 (

24

.43

) 1

18

(9

3.7

) 8

(6

.3)

*

Il

lite

rate

2

3 (

4.3

9)

23

(1

00

) 0

(0

.0)

*

*N

ot

po

ssib

le t

o e

stim

ate.

OR

: O

dd

s ra

tio

. C

I: C

on

fid

ence

in

terv

als

28

Tab

le 6

. B

inar

y l

og

isti

c re

gre

ssio

n a

nal

ysi

s o

f fa

cto

rs a

sso

ciat

ed t

o a

ttit

ud

e o

n d

eng

ue

pre

ven

tio

n

So

cio

-dem

og

rap

hic

ch

arac

teri

stic

To

tal

resp

on

se

N (

%)

Att

itu

de

cate

go

ry

OR

(95

%C

I)

P-v

alu

e P

oo

r (<

80%

) G

oo

d (

≥80%

)

N (

%)

N (

%)

All

Par

tici

pan

t 52

1 (1

00)

263

(50.

76)

258

(49.

24)

Sex

M

ale

23

4 (4

4.85

) 14

1 (6

0.3)

93

(39

.7)

1

F

emal

e

287

(55.

15)

122

(42.

5)

165

(57.

5)

0.45

(0.

27-0

.76)

0.

00

Ag

e

15

– 2

9 71

(13

.55)

22

(31

.0)

49 (

69.0

) 1

30

– 4

4 14

2 (2

7.29

) 48

(33

.8)

94 (

66.2

) 3.

18 (

1.37

-7.3

6)

0.00

45

– 5

9 18

0 (3

4.54

) 11

0 (6

1.1)

70

(38

.9)

2.59

(1.

39-4

.82)

0.

00

60

– 8

4

128

(24.

62)

83 (

64.8

) 45

(35

.2)

0.89

(0.

50-1

.60)

0.

71

Occ

up

atio

n

G

ov

ern

men

t se

cto

r 27

(5.

34)

4 (1

4.8)

23

(85

.2)

1

P

riv

ate

sect

or

18

8 (2

.67)

89

(47

.3)

99 (

52.7

) 11

.08

(2.8

9-42

.34)

0.

00

S

tud

ent

25

(4.

77)

9 (3

6.0)

16

(64

.0)

1.97

(0.

89-4

.36)

0.

09

S

easo

nal

wo

rker

16

(33

.21)

12

(75

.0)

4 (2

5.0)

1.

36 (

0.37

-5.0

1)

0.64

R

etir

ed

46 (

3.05

) 24

(52

.2)

22 (

47.8

) 1.

03 (

0.25

-4.1

0)

0.96

H

ou

sew

ife

160(

3.78

) 78

(48

.8)

82 (

51.3

) 2.

50 (

0.96

-6.5

0)

0.05

U

nem

plo

yed

59

(42

.18)

47

(79

.7)

12 (

20.3

) 1.

35 (

0.54

-3.4

1)

0.51

Ed

uca

tio

n

P

rim

ary

61

(11

.64)

50

(82

.0)

11 (

18.0

) 1

S

eco

nd

ary

31

1 (5

9.64

) 14

9 (4

7.9)

16

2 (5

2.1)

0.

62 (

0.18

-2.1

6)

0.46

G

rad

uat

e /P

ost

Gra

du

ate

126

(24.

43)

46 (

36.5

) 80

(63

.5)

1.93

(0.

66-5

.69)

0.

22

Il

lite

rate

23

(4.

39)

18 (

78.3

) 5

(21.

7)

2.52

(0.

81-7

.89)

0.

11

OR

: Od

ds

rati

o.

CI:

Co

nfi

den

ce i

nte

rval

s

29

Tab

le 7

. B

inar

y l

og

isti

c re

gre

ssio

n a

nal

ysi

s o

f fa

cto

rs a

sso

ciat

ed t

o p

ract

ice

on

den

gu

e p

rev

enti

on

So

cio

-de

mo

gra

ph

ic c

ha

ract

eri

stic

To

tal

resp

on

se

N (

%)

Pra

ctic

e c

ate

go

ry

OR

(9

5%

CI)

P-

va

lue

Po

or

(<8

0%

) G

oo

d (

≥8

0%

)

N (

%)

N (

%)

All

5

21

(1

00%

) 1

30

(2

5.3

8)

39

1 (

74

.62

)

Sex

M

ale

2

34

(4

4.8

5)

68

(2

9.1

) 1

66

(7

0.9

) 1

F

emal

e

28

7 (

55

.15

) 6

2 (

21

.6)

22

5 (

78

.4)

0.6

6(0

.38

-1.1

3)

0.1

3

Ag

e

1

5 –

29

71

(1

3.5

5)

23

(3

2.4

) 4

8 (

67

.6)

1

3

0 –

44

14

2 (

27

.29

) 2

6 (

18

.3)

11

6 (

81

.2)

1.3

7(0

.57

-3.3

3)

0.4

7

4

5 –

59

18

0 (

34

.54

) 4

9 (

27

.2)

13

1 (

72

.8)

2.0

0(1

.00

-3.9

9)

0.0

4

6

0 –

84

1

28

(2

4.6

2)

32

(2

5.0

) 9

6 (

75

.0)

1.1

9(0

.65

-2.1

8)

0.5

6

Occ

up

atio

n

G

ov

ern

me

nt

sect

or

27

(5

.34

) 1

1 (

40

.7)

16

(5

9.3

) 1

P

riv

ate

se

cto

r

18

8 (

2.6

7)

49

(2

6.1

) 1

39

(7

3.0

) 0

.28

(0.0

9-0

.87

)

0.0

2

S

tud

ent

2

5 (

4.7

7)

12

(4

8.0

) 1

3 (

52

.0)

0.5

2(0

.23

-1.1

5)

0.1

1

S

easo

nal

wo

rker

1

6 (

33

.21

) 8

(5

0.0

) 8

(5

0.0

) 0

.18

(0.0

5-0

.66

) 0

.01

R

etir

ed

4

6 (

3.0

5)

7 (

15

.2)

39

(8

4.8

) 0

.22

(0.0

6-0

.75

) 0

.01

H

ou

sew

ife

1

60

(3

.78

) 3

0 (

18

.8)

13

0 (

81

.3)

1.5

6(0

.52

-4.6

1)

0.4

2

U

nem

plo

ye

d

59

(4

2.1

8)

13

(2

2.0

) 4

6 (

78

.0)

0.6

3(0

.24

-1.6

4)

0.3

4

Ed

uca

tio

n

P

rim

ary

6

1 (

11

.64

) 1

4 (

23

.0)

47

(7

7.0

) 1

S

eco

nd

ary

3

11

(5

9.6

4)

74

(2

3.8

) 2

37

(7

6.2

) 2

.17

(0.7

4-6

.33

) 0

.15

G

rad

uat

e /

Po

st

Gra

du

ate

12

6 (

24

.43

) 3

3 (

26

.2)

93

(7

3.8

) 1

.91

(0.7

4-4

.92

) 0

.17

Il

lite

rate

2

3 (

4.3

9)

9 (

39

.1)

14

(6

0.9

) 1

.63

(0.5

8-4

.57

) 0

.34

30

Control card feasibility study (Objective 2)

In total, 2,440 control cards were circulated—approximately 30 cards per sub-

area. We found that the level of community participation in the intervention was

insufficient. Our intervention using control cards to monitor community activity

in relation to cleaning action received low engagement from the community.

Following the intervention, the number of containers infested with larvae

significantly increased in the intervention group in comparison to the control

group (IRR = 1.71; 95% CI: 0.87–3.36). Correspondingly, the number of larvae-

positive houses increased in the intervention group (IRR = 1.42; 95% CI: 0.69–

2.92), although not significantly.

According to the community, some reasons given for low participation included

lack of time due to work as well as the opinion that larvae monitoring should be

done by cadres or the government and not by them.

Implementation of the ‘Jumantik’ vector control programme (Objective

3)

Most of the 35 respondents in the quantitative study survey were females,

generally 33 to 69 years of age—with more than half between 33 and 45 years of

age. More than half (51.4%) had graduated from senior high school and 30% had

graduated from junior high school. The majority (> 70%) of the respondents were

housewives. Most of the participants came from families with low- or medium-

income levels (Table 8).

31

Table 8. Larva monitoring cadre’s socio-demographic characteristics.

Demographic Characteristic Number of Participants

N (%)

Age Group (year)

- 33-45 18 (51.4)

- 46-50 6 (17.2)

- 51–69 11 (31.4)

Education Level

- Primary education 2 (5.7)

- Junior high school education 12 (34.3)

- Senior high school education 18 (51.4)

- Diploma education 1 (2.9)

- Bachelor/Master education 2 (5.7)

Occupation

- Labour/seasonal worker 1 (2.9)

- Housewife 25 (71.4)

- Entrepreneur 9 (25.7)

Income Level

- High-income level 8 (22.9)

- Medium-income level 12 (34.2)

- Low-income level 15 (42.9) Table source: Sulistyawati et al (Manuscript).

Table 9 presents the characteristic of our qualitative informants. Of the 6

informants, five were female and one was male—all informants were more than

40 years old. Two informants were larva monitoring cadres and another two

informants represented the community. A community group leader also

participated in this study, who had graduated with a diploma in education. The

last informant was a DHO staff, with a bachelor’s degree, and was the person

responsible for the dengue programme in Yogyakarta City.

Table 9. Characteristics of qualitative phase informants.

Code Sex Age

(year)

Education Occupation Subject

Role

W01 Female 46 Senior high

school

Not working

(housewife)

LMC

W02 Female 49 Senior high

school

Private sector

(clinic

administration

staff)

Community

32

Code Sex Age

(year)

Education Occupation Subject

Role

W03 Female 62 Senior high

school

Not working

(housewife)

Community

W04 Female 42 Primary

school

Not working

(housewife)

LMC

W05 Female 57 Diploma Not working

(housewife)

Community

group

leader

D06 Male 54 Bachelor Civil servant DHO staff Table source: Sulistyawati et al (Manuscript).

From the survey, it was found that, generally, LMCs thought of dengue as a

dangerous illness that could infect everyone. Respondents answered that they

were able to take the time to exchange information and track larvae in their

habitat. More than 60% of LMCs agreed that everyone has a similar risk of

contracting dengue fever. Although more than half of the respondents indicated

that they agreed with the benefits of the Jumantik and PSN programmes, several

LMCs argued that dengue education did not increase community knowledge.

Approximately 11% of the LMC did not consider free levels of larvae (LFR)—a

proportion of houses without mosquito larvae—to be one of their job outputs.

Larva free rate is a measure that compares the number of houses without larvae

detected with the number of houses inspected. The Indonesian government is

setting the target for LFR to 95% in order to control dengue.

LMCs generally stated that they have not identified any barriers to performing

their duties in terms of time or salary. This was also reinforced by their

declarations of intent and willingness to perform their duties. The majority of the

respondents disagreed with the argument that limitations impaired their ability

to do their jobs. However, a limited number of LMCs shared having time

constrains for public education and routine LMC sessions. Approximately 70%

of LMCs indicated that they could develop dengue information to be shared with

the public. They also said that they could find the time to operate as LMCs. The

majority suggested that they could fulfil their duties as LMC even without being

paid. However, 14% of LMCs did not express their opinion or their neutrality

regarding this comment. In addition, LMCs claimed that they did not agree with

the argument that they do not recognize dengue, although 17% of LMCs also

indicated that they did not have adequate information to do so (Table 10).

33

Table 10. The opinions of larva monitoring cadres about their dengue vector

control tasks

Statements Strongly

Disagree

Disagree

Neutral

Agree

Strongly

Agree

N (%)

Opinions regarding dengue

infection susceptibility.

Everyone, at any age—including

me—is susceptible to dengue

infection.

0 (0.0) 2 (5.7) 0 (0.0) 22 (62.9) 11 (31.4)

Opinions regarding benefits of

the vector control programme.

- Dengue counselling will

increase the community’s

knowledge about dengue.

2 (5.7) 0 (0.0) 4 (11.4) 19 (54.3) 10 (28.6)

- The higher the larva free rate,

the higher the possibility of

reducing dengue cases is.

1 (2.9) 4 (11.4) 1 (2.9) 22 (62.9) 7 (20.0)

- If everyone finds time to

conduct mosquito breeding

place elimination, dengue cases

could be reduced.

0 (0.0) 0 (0.0) 0 (0.0) 19 (54.3) 16 (45.7)

Understanding of the severity.

I think dengue is a deadly disease. 1 (2.9) 5 (14.3) 0 (0.0) 21 (60.0) 8 (22.9)

Opinions regarding LMC action

barriers.

- I do not have time to talk about

dengue with the community.

8 (22.9) 26 (74.3) 0 (0.0) 1 (2.9) 0 (0.0)

- I do not have time to monitor

larvae at the houses in my

community.

14 (40.0) 19 (54.3) 1 (2.9) 0 (0.0) 1 (2.9)

- I do not have enough time to

attend LMC meetings at the

village office regularly.

8 (22.9) 24 (68.6) 1 (2.9) 2 (5.7) 0 (0.0)

- LMC salary is small, so I will

work as I want.

10 (28.6) 22 (62.9) 1 (2.9) 2 (5.7) 0 (0.0)

Opinion regarding willingness to

act as an LMC.

- I frequently attend LMC routine

meetings to update my

knowledge.

0 (0.0) 0 (0.0) 2 (5.7) 26 (74.3) 7 (20.0)

- I share my knowledge about

dengue with the community to

remind them about dengue.

0 (0.0) 0 (0.0) 0 (0.0) 27 (77.1) 8 (22.9)

- I monitor larvae in the

community regularly.

0 (0.0) 0 (0.0) 0 (0.0) 28 (80.0) 7 (20.0)

Perception of self-efficacy.

34

Statements Strongly

Disagree

Disagree

Neutral

Agree

Strongly

Agree

N (%)

- I am able to transfer my

knowledge about dengue to the

community.

0 (0.0) 1 (2.9) 0 (0.0) 28 (80.0) 6 (17.1)

- I am able to spare my time to

monitor larvae in the

community.

0 (0.0) 1 (2.9) 0 (0.0) 28 (80.0) 6 (17.1)

- I am able to fulfil my

responsibility as an LMC even

without any salary.

- I do not have enough

knowledge about dengue.

0 (0.0)

5 (14.3)

0 (0.0)

24 (68.6)

5 (14.3)

0 (0.0)

24 (68.6)

6 (17.1)

6 (17.1)

0 (0.0)

Table source: Sulistyawati et al (Manuscript).

In the qualitative study, several sub-themes emerged from the data. These sub-

themes are perceived roles and responsibilities, people perception of dengue,

perceived benefits of the Jumantik and PSN programmes, perceived barriers of

the LMCs task, perceived willingness to participate in the ‘Jumantik’ programme,

perceived capacity and self-efficacy as well as possible improvements for vector

control in the future.

Perceived roles and responsibilities

The ‘perceived roles and responsibilities’ sub-theme defines the expectation of

respondents that success in vector control requires the support of partners, such

as LMCs, the government, the village office, the sub-district office, the primary

health centre, the sub-districts and the city health office. These stakeholders

highlight the complexities of the current vector control structure and the various

functions they perform, as stated by the DHO officer.

With respect to the position of LMCs, one LMC reported that one of their duties

was to provide health education for the community. This was reiterated by the

community group leader and the DHO officer, both of whom confirmed that, in

their area, LMCs carried out larvae checks and provided health education for the

general public on the basis of the awareness reports they obtained at LMC

meetings. The DHO officer expanded on the duties of an LMC related to

supporting the PSN programme. LMCs also act as data suppliers for the DHO,

35

in terms of reporting on larvae present in the population, which are, thus, a

variable for the measurement of the larva free rate.

From the interviews, we learned that this role had not properly been carried out

by LMCs. For example, larvae inspections should be carried out at least once a

week; however, in practice, there are those that perform them only once a

month—that is, before data reporting. This provision is conveyed by DHO

officers.

This study also revealed the role of the PHC—namely, as a community group

supervisor and providing knowledge updates to the LMC. What is very

important about the role of the PHC is that it becomes a mediator between LMCs

and the community when LMCs have difficulty conducting larvae inspections.

People´s perception of dengue

This sub-theme reflects people's views on the severity of dengue fever.

Participants were concerned about possible mortality as a result of infection.

Society and LMCs both agree that dengue is a serious disease. The LMC survey

shows that 60% claim that dengue can cause death. The community group leader

stated that, even though the community members were aware of the seriousness

of dengue, this was not fully reflected in the community level of concern because

the community stated that they were tired of hearing information related to

dengue. More than half of the respondents said that dengue can infect anyone.

However, LMCs expressed concern because the community ignores fever as a

symptom of dengue.

Perceived benefits of the ‘Jumantik’ and PSN programmes

This sub-theme focuses on the opinions of informants about the ‘Jumantik’ and

PSN programmes. In general, there was a consensus among respondents that

vector control through mosquito nest eradication (PSN) was the best approach

for controlling dengue spread. This was revealed by some participants in this

study, including the informant from DHO and members of the public.

The leader of the community group said that, until now, the ‘Jumantik’

programme has run less than optimally; however, the value of the ‘Jumantik’

36

programme in raising global understanding of dengue was reiterated. The

informant stressed that the effectiveness of the ‘Jumantik’ programme relied on

the multi-cooperation between all stakeholders, such as the government (DHO,

PHC) and the society. LMCs made the same point in the quantitative session,

where more than half of them (54.3%) claimed that vector management is

everyone's role and duty.

Perceived barriers to LMCs’ tasks

The survey results showed that more than 70% of respondents stated that they

did not experience problems in carrying out their duties as LMCs. However, a

few of them also stated that they did not have time to attend regular meetings

(5.7%) and conduct larvae inspections (2.9%). This was also raised in an interview

session with an LMC.

LMCs also stated that it was difficult to reach some members of the community

to carry out their duties and they reasoned that these members were embarrassed

by the condition of their bathroom so that they did not allow LMCs to enter and

carry out inspections.

From the survey results (Table 10), it can be concluded that LMCs have no

objection to continue working as LMCs without payment. This was also

conveyed during the in-depth interview sessions.

Perceived willingness to participate in the ‘Jumantik’ programme

This sub-theme defines the perceived willingness of each LMC and the entire

group to fulfil their duties. LMCs have the following duties, among others: to

conduct larvae inspections once a week, to update their knowledge and to attend

regular meetings. On the other hand, to support LMC performance, the public

needs to actively participate in mosquito nest eradication (PSN).

In the in-depth interviews it was reported that LMCs were compensated by the

redistribution of the village office budget. Even though LMCs were paid for their

work, getting someone to replace them was not easy because many people

refused to be LMCs. Hence, existing LMCs kept their role because no one else

was willing to take their position.

37

Perceived capacity and self-efficacy

In the interviews, the community group leader and community members shared

their opinion that LMCs had an adequate understanding of dengue because the

health authorities had educated them. The community group leader explained

that many LMCs had outstanding communication skills for coping with different

members of society and education—but some may fail to do that.

Possible improvements for vector control in the future

Community members and LMCs expressed their desire for dengue prevention

and vector control. They expected that the ‘Jumantik’ and PSN programmes

would perform well in the future. They expected to work together with all

stakeholders involved and did not feel like fighting dengue alone.

The community group leader underlined the importance of synergizing the

current ‘Jumantik’ programme with the new government policy—namely, ‘One-

House One-Jumantik’, which will be the foundation of dengue vector control in

the future.

Hospital-based dengue surveillance system: Case management and

reporting (Objective 4)

Generally, dengue prevention and control in Indonesia—including

Yogyakarta—is performed at two levels: the PHCs and the hospitals. The PHCs

are directly connected to the DHOs because the 2 institutions have the same

structure. The hospitals contribute to the success of dengue control and

prevention by reporting dengue positive cases within 24 hours of diagnosis to

the DHO. This acts as a starting point for conducting surveillance management

at the community level and, thus, for avoiding an outbreak.

Figure 7 shows how dengue case management in Yogyakarta, Indonesia is

conducted. Generally, prevention programmes use a syndromic surveillance

approach based on hospital and PHC reports. Patients with a fever can be

admitted to the health care facility (hospital or PHC) to get advice from a medical

doctor. Based on febrile phase symptoms, the doctor decides whether to use an

NS1 or a routine blood sample test. Platelets serve as an indicator for a suspected

dengue case to be hospitalised or sent home.

38

Figure 7. Dengue diagnostics, case management and reporting in Yogyakarta

Indonesia.

However, from this study, different challenges among the stakeholders involved

in dengue diagnosis and case reporting were observed. Some issues were related

to dengue diagnosis, including the low community awareness of dengue

symptoms—sometimes they could not explain the febrile phase history, which is

essential for clinicians to determine what tests to run and further treatment

course. Concerns about atypical symptoms and an increase in what they called

39

‘expanded dengue’ were raised, especially in children, among clinicians. The

rapid NS1 test was considered to support early and accurate dengue detection

and to, thus, reduce the risk of fatality. However, the use of the NS1 test was

arbitrary and considered to be an economic challenge.

Early warning reports (KDRS) from hospitals were not always submitted,

according to requirements, in the first 24 hours after diagnosis for various

reasons—including lack of regulation awareness, regulatory mismatches and

coordination challenges between hospitals and the local health authorities. There

were implications of a weak connection between hospitals and DHOs as

regulators of dengue prevention. In addition, inequalities in different hospitals’

prerequisites for dengue management, including updated knowledge about the

disease, were found.

The next section briefly describes the categories—and their sub-categories (in

bold)—that developed from the qualitative analysis and illustrates them with

certain selected quotations. Figure 8 shows the themes and categories of this

study.

Figure 8. Sub-categories and themes developed from the analysis.

Picture source: Sulistyawati et al. (2020) (68)

Challenging disease diagnostics

Challenges to disease diagnostics came from three sub-categories: ‘an ambiguous

and changing disease’, ‘varying prerequisites for NS1 utilisation’ and

40

‘inconsistent community attentiveness’. All three relate to the problem

concerning dengue diagnosis as a result of the changing dengue disease pattern,

which requires greater awareness about possible manifestations of this disease.

The following selected citations from the participants illustrate this case.

Currently, we are dealing with expanded dengue. Perhaps this

phenomenon makes it difficult for us to recognize dengue or we can say that

diagnosing dengue, without classic symptoms, is a challenge. So, in my

opinion, if we found a patient with classical dengue, it would be easy to

diagnose. (Ped-1)

If every single patient with suspected dengue was tested using NS1, it

would improve awareness because, nowadays, not every dengue patient

comes with classic dengue symptoms. However, the problem is the high

NS1 cost. Now, we use NS1 for patients because there is support from the

‘Eliminate Dengue Programme, which provides NS1 for free. Otherwise,

outpatients would have to pay IDR 300.000, which is expensive…. (Ped-

1)

…if I meet children, who have a fever, on the first day of the fever, but the

parents say that they don't have a thermometer, then I recommend for them

to go to the drugstore to buy a thermometer. Fever cannot be judged only

by feeling and by touching with the hand….’ (GPs-1)

Mismatch in regulatory frameworks and interplay with regulatory bodies

This category comprises several sub-categories: ‘immature insurance system’,

‘arbitrary documentation traditions and inappropriate workarounds’ and

‘friction between regulator and operator’. This category discusses the challenges

that dengue prevention and control face, specifically related to the regulation

discrepancy in several related agencies: hospitals, DHOs and national insurance

providers.

In BPJS, the NS1 antigen is covered but the result must be positive. If it is

negative—if negative—it is not covered. I do not know if this rule comes

from the BPJS or the hospital. I do not know. It's just that we are informed

that if NS1 is negative, it cannot be (covered). So, fortunately all patients

41

whom we have examined, the results of NS1 were positive so BPJS could

be claimed. (GPs-3)

NS1 is expensive. One, it is expensive, uh, and we will see the condition

first. Now, we have support from the ‘Eliminate Dengue’ programme. In

the past, there was no support. We do not have the heart. It is 300,000

(rupiah) for one patient. And for outpatients, this amount of money is a lot.

BPJS does not cover that. (Ped-1)

The DOH gives us, what do you call it, uh, a time period, if possible not

report it more than a week, but it is better to deliver it the first 24 hours.

(MRO-2)

What I dislike about them is that they schedule a meeting at the last minute;

for example, there is a meeting tomorrow and I am informed today. For

them, perhaps, three days is not the last minute for sending the invitation.

Yet, for us in the field, calling at night, ‘Doc, there will be a meeting

tomorrow…’. (Ped-1)

Unequal internal prerequisites for dengue management

This category represents the situation among hospitals at the research site. Two

sub-categories emerged from the interviews: ‘standard operating procedure not

standardised’ and ‘inconsistent conditions for knowledge updates’. We found

some variations among the hospitals in relation to dengue management as well

as regarding keeping staff informed and updated.

There is no SOP from [hospital name], but my guidelines are from the

WHO. Book, uh, WHO children service standard…. (GPs-3)

Also, about different SOP in different hospital. The GPs allows to practice

in three places. Something like that. If it happens here, we warn them. They

said, ‘Usually in hospital A, the patient is not hospitalised, Doc’. It turns

out that they also work at other hospitals and they have different

regulations there. (Ped-2)

42

Perhaps, most doctors, maybe, there are some who tend, uh, I know more

about the old ones. That’s number 1, number 2, perhaps too lazy to update.

(Ped-1)

I mean, my suggestion is that this hospital should support its doctors to

update their knowledge. We do not need to use, no need to send us to

seminars outside, we can use our internal doctors; for example, the

internists and the paediatricians…Not just the doctors, it can also be the

nurses, can be everyone. (GPs-3)

43

Discussion

This thesis studied dengue control and prevention in Yogyakarta, Indonesia. The

researcher assessed the status of dengue knowledge, the level of community

engagement and participation in vector control as well as dengue case

management and reporting routines in hospitals. The rationale behind this

research was that the community might play an essential role in reducing the

dengue burden because, through their participation and engagement, the dengue

prevention and control programme would be sustainable. Hospitals are a critical

pillar of surveillance because they generate the statistics about the actual dengue

burden, which is useful for health prevention authorities when planning the

dengue prevention and control programme. Likewise, it is beneficial for the

community to perform vector preventive measures. However, the system does

not support a control programme if it is not responsive.

This study explored the role played by the community in dengue vector control

and prevention. Some previous studies agreed that this approach was the

primary key to controlling dengue fever, as mentioned by the WHO in 2012—

namely, sustainable vector control. This activity is also part of surveillance and

outbreak preparedness. Larva monitoring cadres, as partners of the programme,

practically conformed to the current dengue guidelines, as did the hospitals in

their function as the vanguard for preventing dengue-related death resulting

from their responsibility to diagnose and manage cases. Hospitals, in addition,

were also part of the surveillance system by providing data input for the

prevention of transmission and dengue outbreak preparedness. Nevertheless, it

cannot be denied that there were weaknesses found in several aspects of dengue

prevention and control in Yogyakarta, Indonesia.

This discussion focuses on the most critical findings of this thesis, which are

presented in the following order. First, the consequences of insufficient

knowledge about dengue prevention and control that were identified among

various target groups during the studies are presented. Second, the complex

interplay between the stakeholders involved in dengue prevention and control is

elaborated because it threatens the effectiveness of community interventions as

well as the disease surveillance system. This is followed by a discussion on the

apparently inconsistent and incomplete standard operating procedures. Finally,

44

insufficient support for diagnosis and case management is touched upon,

followed by a look at the limitations and strengths of this study as well as

recommendations for future research and policy development directions.

Consequences of insufficient dengue prevention and control

knowledge

Knowledge is the foundation for people making decisions. Knowledge helps

someone understand and act to find a solution for a particular problem (69). It

was confirmed that the level of knowledge contributes to infectious disease

prevention behaviour (70). This thesis found knowledge gaps related to dengue

fever and control in all studied target groups—the community, LMCs and

hospital staff.

In the community, the overall knowledge, attitudes and practices related to

dengue were considered to be relatively adequate. However, we need to pay

attention to several aspects of vector control. First, awareness regarding the

mosquito outdoor breeding places and the importance of managing discarded

material outside the house were inadequate. In Indonesia, this might be the result

of ongoing dengue campaigns that are focused on mosquito breeding places

inside the house and seldom on those outside the house. On the other hand, the

waste disposal and recycling behaviour in Indonesia is still not sufficient in terms

of low knowledge levels about solid waste management (71,72). The link between

solid waste and dengue has widely been studied in the world, which has shown

that neglected solid waste has the potential to become a breeding site for Aedes

mosquitoes (73-75). The findings of this study are in line with those of some

previous research and reinforce that handling dengue vectors requires

multisectoral collaboration (11,76,77). The community needs to continuously be

accompanied, monitored and provided with good leadership in all sectors that

are involved in dengue prevention activities. In this manner, the community

would hopefully conduct dengue prevention through vector control voluntarily

because its members would realize that this is a shared need and responsibility.

Second, this study revealed that the community had low awareness when it came

to viewing fever as a dengue symptom. Doctors often received patients at late

stages of the disease because the community considered fever to be a common

disease symptom and delayed visiting a health care facility. Low awareness of

45

the community towards fever onset as a symptom prevents doctors from

establishing a timely diagnosis, thus posing a challenge. In the 2009 WHO

guidelines, it is written that fever onset is part of the general observations that

must be considered when accepting patients or suspected dengue persons (78).

This onset is used to calculate the estimated incubation period of the dengue

virus in the body of a patient and then to help determine further patient handling.

Our findings are supported by a study in Pakistan, which found that only 52% of

the respondents recognized that having prolonged fever could be a dengue

symptom (79). A similar study in Jamaica also reported that less than 50% of

people recognized this prominent symptom (80). In addition, the implication of

improper dengue symptom knowledge influences people’s health-seeking

behaviours (81) and many dengue cases can consequently be missed.

Knowledge gaps were also found among LMCs, particularly with respect to their

understanding of the larva free rate (LFR), which is an essential vector control

parameter. To the best of our knowledge, this thesis might constitute the first

study that elaborates on the challenges of that LMCs face in relation to vector

control as part of the ‘Jumantik’ programme. Previous studies have focused on

the effectivity of LMCs to improve the LFR (82,83) or on the level of LMCs’

knowledge regarding dengue (84). In this study, it was shown that LMCs did not

understand well the meaning and usefulness of the activities they carried out in

that role—even though having a good understanding of what one’s goal is can

motivate people to have higher job performance (85). In our study, it was

confirmed that some LMCs reported incorrect data about larvae inspections.

Lack of accurate data can contribute to a poor dengue integrated surveillance

system because wrong decisions could be made. Local authorities, in this case the

Yogyakarta District Health Office (YDHO), have tried to solve this issue. Thus,

to determine the LFR, the LMC larvae reports did not constitute all data but the

YDHO also utilized other data types, such as data obtained from epidemiology

investigation and periodic larva monitoring by a dengue operational working

group. Furthermore, in 2015, the central government launched the ‘One-House

One-Jumantik’ policy to strengthen existing programmes and to embrace

community involvement in monitoring the larvae in their respective homes,

aiming to reduce the central role of LMCs (86).

46

The gap between knowledge and practices that was found in the results of the

community-based KAP survey implies that people might be poorly motivated to

engage in vector control activities despite having good awareness of the practices

that health authorities recommend. Several studies have shown that knowledge

levels might directly influence dengue preventive practices (64,87). However,

there are other studies that have failed to establish a direct correlation between

knowledge and practices (70,88,89). Hence, we also need to look at people’s

motivation and not only at their knowledge levels. According to the so-called

Health Belief Model (HBM), people would not engage in healthy behaviour

unless they value the outcome related to that behaviour. Moreover, they need to

believe that that specific behaviour is likely to result in the desired outcome (90).

From the results of this study, it seems that people have learnt at least some

behaviours that can prevent the dengue disease—for example, how to get rid of

mosquito larvae. However, do they believe that their cleaning practices will

result in a mosquito larva decrease and, in the end, in a reduction of dengue

cases? Or do they feel that their work is meaningless? This depends on their level

of knowledge about the risks of getting dengue and how they perceive the risks

of not doing the work. This possibility is supported by a study by Wong et al.,

who found that people's perception of their susceptibility to dengue influenced

their dengue preventive behaviours (87). The motivation of people also depends

on whether they believe that their work has any effect—for example, that regular

cleaning will, indeed, result in a reduction in the larvae population and the

number of dengue cases. This requires feedback from the local authorities and,

therefore, it is essential to assess whether or not people have received any

feedback from them regarding their work. If the answer is yes, then how was this

information delivered and was it received as intended? Feedback from

authorities is valuable because the results of this study revealed that some people

often refused LMCs to conduct larvae inspections in their house.

Critical knowledge gaps were found among the doctors at the hospitals. The first

gap is related to the reports that should be sent to the DHO (KDRS), which is a

first step for preventing dengue transmissions and outbreaks. Some doctors did

not acknowledge the importance of this procedure for prevention activities in the

field. For example, one respondent said that the person in charge of this report

was the medical report officer and not themselves. The next gap is related to the

47

finding that not all doctors had updated knowledge about the current dengue

situation and management, which could influence their competence, capacity to

perform an accurate diagnosis and minimize the occurrence of infection in the

patient, as stated in an Ecuadorian study (91). There were additional differences

between the sampled hospitals, with some providing the opportunity for their

staff to update or share their knowledge both within the hospital—through

routine gatherings—or in external forums—through conferences and scientific

meetings. It is important to remember that strengthening the competency of

health workers, including doctors, is one of the mandates of the 2012 WHO

guidelines (11). To overcome the potential imbalance of knowledge possessed by

doctors, as mentioned, competencies can gradually be built with individual

certificates for those doctors who are allowed to treat dengue.

Dengue diagnosis has always been compared to other diseases that have almost

the same symptoms, such as influenza, typhus and leptospirosis. At the same

time, doctors are faced with changes in dengue virus strains in some Indonesian

cities that can confound dengue diagnosis (92-94). This might explain why some

doctors claim to encounter different symptoms in their patients. Again, doctors

must continuously update their knowledge about both the shifting dengue

disease itself and how patients are treated in order to avoid misdiagnosis.

Complex interplay of the stakeholders involved in dengue prevention

and control

Efforts to prevent and control dengue cannot be made separately by the parties

involved but a synergy between them is required. Sometimes, due to the

complexity of the party structure, communication is not smoothly delivered

between them and the aims of the dengue prevention and control programme

are not conveyed and understood correctly. The WHO clearly states that, to

establish a healthier future for people, effective, integrated and coordinated

communication between the parties involved is needed (95). Communication is

also an essential aspect of well-being, including disease prevention, health

promotion and quality of life (96). What people say influences their risk

perceptions (97), emotions (97,98) and uncertainties (99) about health behaviours.

Communication also aims to engage stakeholders from all decision-making

levels—from individual to organizational. For instance, a valuable experience

48

was given by the Ugandan government in relation to fighting malaria, where a

harmonized communication framework for malaria control was implemented

(100).

This thesis elaborated that communication challenges compromise the complex

interplay of the stakeholders involved in dengue prevention and control on

several levels. This includes the interplay between health authorities and

hospitals as well as between various stakeholders involved in the community-

based vector control initiatives.

Communication is a crucial aspect of delivering knowledge and understanding

to other people with the aim to engage them in behavioural change. Based on our

study, the ‘Jumantik’ programme did not run optimally partly due to

communication challenges that led to community resistance to programme

participation. The LMCs’ communication process with the community did not

seem to attract the audience’s attention and, as a consequence, a lack of

engagement in the ‘Jumantik’ programme and a low trust in the capability of

LMCs by the community may have been created.

According to the WHO, community engagement not only refers to involvement

or participation but also to ownership and action in a particular health

programme. This action requires many aspects of life to be addressed, such as

cultural, social, political and economic, with communication playing a vital role

in this process (101-103). The lack of ownership may reflect Indonesia’s policy

direction history, which largely uses a top-down approach that fails to capture

community opinions. Accordingly, urban communities’ voluntary participation

in vector control needs to be intensified, especially by promoting the

participation of all stakeholders.

Community refusal of LMC inspections also appeared to relate to the

community’s low trust in their working capacity. This situation is most likely

closely connected to the specific context mainly related to the economic and

educational status. In the urban area, most residents have higher education levels

and are at a higher economic level in comparison to LMCs themselves. Due to

these gaps, some community members did not respect LMCs and ignored their

message. Even though the goal of health communication is to generate change,

49

including health behaviour change (104), this may not be achieved unless the

receiver has an interest in and trusts the message sender—in this case, LMCs.

Increasing trust should be done from both sides: the community and LMCs. In

the community, the massive campaign about the importance of 3M and

‘Jumantik’ should be scaled up using proper media. Assessment of what popular

media should be chosen for this setting is needed, especially at this time when

social media has become a trend in health communication. Correspondingly,

social media could be an alternative tool for sending health messages and

information in real time (105). From the LMC side, capacity building to improve

the competence of LMCs is required, as mentioned earlier.

At the same time, the success of dengue prevention and control is not only

determined by communication at the bottom level but also at the top level.

Hospitals send dengue case information to DHOs, who are the entities

responsible for the community’s prevention policy. When this connection is not

working correctly, the prevention path is disturbed, which might lead to an

outbreak occurrence.

Communication challenges were also experienced between hospitals and health

authorities. The majority of the respondents said that they did not receive any

feedback from the DHO about dengue—even though these data were needed for

doctors to increase their awareness and for hospitals to be prepared logistically.

This weak link between the two sectors may illustrate the fragmented health

system of Yogyakarta. This situation might be not visible but it nevertheless

results in unintended consequences, such as inefficiency and ineffectiveness

(106,107). Indeed, the Indonesian government has implemented several reforms

in recent decades, including the move from a centralized to decentralized health

system, particularly in the budgetary aspect (108). After more than two decades

of implementation, some improvements in the performance of the health system

have been reported. However, there are also reports about structural challenges

that make overall management problematic (109).

Inconsistent and incomplete standard operating procedures

Standard operating procedure (SOP) refers to a document that defines current

operations to certify that procedures are performed correctly and with

consistency (110). Public health practice requires timeliness, consistency,

50

technical excellence and accountability (111). Accordingly, in the SOP, it is

important to avoid a misleading procedure. This thesis report that there were

challenges with the existence, implementation and compliance of various

standard operating procedures in the system under study.

At the community level, of which LMCs are a part, it was found that they did not

always provide accurate larva monitoring reports. This can be an indication of

low feelings of ownership of the programme or of a failure to understand the

long-term consequences that may arise from the false or inaccurate reports that

they provide, such as unknown priority DHF vector control areas due to poor

data (112). However, this should be recognized as a weakness of the existing

reporting system and not solely as an LMC failure. Monitoring and evaluating

the effectiveness, efficiency and acceptability of the ‘Jumantik’ programme is

suggested to be carried out by following the input, process, output and outcome

logic model (113,114). This logic model is commonly used in some countries

when a particular health programme is executed. For example, in Iran, this model

was used to assess the performance of the public health and primary care system

(115). According to the Indonesian Ministry of Health, every year the local

government must conduct an evaluation of the DHF control programme (116);

however, to what extent this is done and how this process impacts the

programme itself are areas that need to be explored further. Several studies in

Indonesia have assessed the ‘Jumantik’ programme (117-119). However, this is

not routinely done, so these studies cannot catch the inter-period problems due

to the community's dynamic.

The SOP challenge was also reported in the hospital setting. Two main problems

were identified regarding the KDRS SOP and patient-handling SOP. The

procedures for sending KDRS reports from the hospital to the DHO were not

always followed. Referring to Figures 2 and 3, the position between the health

office and the hospital is parallel. They have a partnership function, which

neither of them can force. A hypothesis is that this may be one main reason why

their collaboration is not functioning well. Indeed, they carry out different

functions—while the hospital carries out a curative function, the DHO carries out

tasks related to prevention and population education. However, this does not

mean that the two are separate; instead, they should support one another.

51

Some hospitals developed their own SOPs, while others did not have an SOP for

dengue in place. Indeed, the central government provides guides for the

treatment of patients, which some hospitals then translate into SOPs. This lack of

standardisation and synchronisation makes the system not function well, posing

serious risks for patients and reducing the quality of services. In fact, the presence

of SOPs for clinical practice is required in order to maintain a higher level of

patient treatment in critical circumstances (120). The competent authorities must

overcome this problem—namely, the non-standardization of SOPs in existing

hospitals. This SOP gap can potentially impact the opportunity for patients to

receive excellent, proper and safe services that follow the quality of care principle

established by the WHO, which states that quality of care must underlie

universal health coverage (121).

Considering that SOPs are either lacking or inconsistent at several levels,

reorientation between the actors involved is needed to achieve good

collaborative governance (122,123). The actors must have the motivation,

principles and capacities to carry out joint actions and have a positive impact on

the existing system.

Insufficient support for diagnosis and case management

Having an accurate diagnosis while in clinical care, followed by a proper

reporting system, is mandatory for achieving early detection, outbreak

prevention and adequate surveillance. To obtain an accurate diagnosis, a

combination of proper judgment—based on the patient’s medical history and a

valid test instrument—is required. Our results suggest that some doctors had

difficulties diagnosing dengue when a patient came with complications,

especially in paediatric patients. Moreover, the usage of NS1 as a rapid diagnostic

test is still limited by the national insurance system and is thus arbitrarily used

among clinics. The situation may get worse due to the community’s low

awareness of the fact that fever is one of dengue symptoms.

The NS1 antigen test is an instrument test that has been confirmed as useful in an

endemic setting for early dengue detection (124,125), which means that this tool

may also be beneficial in an Indonesian setting. However, the usage of NS1 faces

an important limitation—it is costly. In addition, doctors seem not to share the

same views regarding its value or which patient groups should have access to it.

52

Study limitations and strengths

Study limitations

In the KAP study, the validity test for the instrument was rather low (0.6), which

could lead to an underestimation of the knowledge score. But it was still in the

reliable category.

In the eight-week control card test, this was not enough time for a test that

involved behavioural changes. In addition, it was conducted during a

transitional period, when the number of dengue cases was not very high. Hence,

the community's awareness of dengue could still be low. In addition, after our

test was completed, we were informed that our control area had just finished

receiving treatment from other researchers. Thus, this could potentially bias the

results of our test.

In the ‘Jumantik’ programme study, we used the respondents’ self-reported

answers, which means that the answers cannot be confirmed. Second, there is a

risk of courtesy bias—on the part of LMCs—in selecting an answer on the basis

of an assumption and in order to have a positive response. Indonesia is a large

country with hundreds of districts/cities. Although, in general, they have the

same dengue programme, the achievements and problems that each face can be

different because each region has its own characteristics and differences. Hence,

it is necessary to be careful when generalizing the results of this study.

In the hospital-based study, neither respondents nor hospitals in the sample were

randomized. Hospitals were identified by the researcher and hospital

administration was named by the respondents. However, saturation was

attained and content was found to be rich in complexity, covering many essential

facets and viewpoints. Another possible drawback is that the content was

translated and interpreted in two distinct languages—thus, some essential

concepts could have been lost in translation.

53

Study strengths

This research contributes to the dengue programme in Indonesia, in general, and

in Yogyakarta, in particular. Thus far, there have been many studies about

dengue control but they are often conducted in relation to one aspect only.

Therefore, the fact that this study can provide a more comprehensive picture of

the public health context is considered to be its strength.

54

Conclusions and recommendations

This thesis presented several challenges related to dengue prevention and control

efforts in Yogyakarta, Indonesia, from the perspective of community

empowerment in vector control and hospital-based diagnosis and reporting.

These potential challenges include: insufficient knowledge, ineffective

communication due to the complexity of the system structure and absence of

SOPs at some levels. Given these challenges, the following recommendations are

given.

First, some weaknesses were found in the foundation of integrated dengue

prevention and control—such as community empowerment—and in the accurate

diagnosis and reporting system. Several stakeholders involved did not have

appropriate knowledge and motivation to achieve the programme’s goals.

Improving the knowledge of the community and LMCs through proper health

promotion media could be a good alternative. Community involvement through

the ‘One-House One-Jumantik’ program may strengthen community

empowerment and reduce dependency on current LMCs.

Second, at the hospital level, the hospital authorities need to standardize the

SOPs and certify doctors to treat dengue patients while maintaining

professionalism and securing the quality of health services. Finding a capacity

building mechanism that is easily accessible and up to date for physicians is

essential, given that they are very busy with service activities.

Future studies could further elaborate on the community’s desire to participate

in vector control. Also, simplifying the system structure to avoid a

communication gap—bidirectionally (cases from hospitals and disease burden

from health authorities to clinicians)—is recommended for decision-making

purposes.

Fourth, there was good support for vector control. But, it is important to establish

clear rules or SOP that LMCs must follow when reporting their activities. PHCs

and DHOs are recommended to assess LMCs performance regularly to monitor

their effectiveness.

55

Last, the potential for the NS1 test to be used as a first assessment for dengue

suspected cases is undeniable. Further studies could assess the effectiveness of

the NS1 test on reducing the number of hospitalized dengue patients and its cost

effectiveness.

56

Acknowledgements

This dissertation is the culmination of work and learning over a period of several

years. It would not have been possible to complete without the support of many

people. I am fortunate to have had a supervisory team whose members

complement one another. I am very thankful to them.

Åsa Holmner—my principal supervisor on this PhD journey. I am blessed and

lucky to have you as my mentor. Thank you for your time and for the motivation

and dedication you provided. Your feedback was always optimistic and positive

and you guided me to look at my research from different perspectives. You are

not only my supervisor but also my friend. Thank you!

Maria Nilsson—my first co-supervisor. I thank you for your support when I

found myself in tough situations. You always listened to me and helped as much

as you could, with your calm and expertise. Thank you for being like a second

mother to me when I was far away from my family.

Lutfan Lazuardi—my co-supervisor. It was a pleasure to work with and learn

from you when I began my PhD journey. Thank you for your thoughtful

feedback.

Miguel San Sebastian—my examiner. I am grateful for the time you dedicated

to listening to me and to discussing possible solutions when I was in a tough spot.

I will never forget all your valuable advice.

To my PhD colleagues at Epi (current and former)—thank you for your

friendship and support. Even though I cannot mention you all by name here,

believe me when I say that I enjoyed all the time we spent together during this

journey. I am fortunate to know you all both personally and professionally.

To my colleagues at UAD—Rahma, Yuni, Yanti and Tutik—thank you for your

friendship and support throughout our career development journeys.

To my family in Umeå—Nawi Ng, Ailiana Santosa and Septi Kurnia—thank

you for your kindness throughout the duration of my visit to Umeå.

57

Finally, to my family. First, to my husband—Suyanto—words will never be

enough to express my love for and gratitude to you. I thank you for always

supporting me in difficult situations. You always remind me that God—Allah—

is the greatest helper in all hardships. Thank you for taking care of our children

during my stay in Umeå, as well as during day-to-day activities when I was

focused on my writing. Second, to my children—Anindya Keisha Putri and M.

Bisma Hanindito—you are always in my heart. Thank you for being sweet kids

throughout my absence even though I was not always there to take care of you.

My prayers always accompany you. Third, to my parents—Sugimin and

Ramini—there are no words that can represent how grateful I am to have you. I

thank you for your constant prayers. I love you!

58

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