MONITORING and EVALUATION of the INTEGRATED

COMMUNITY-BASED INTERVATION for the PREVENTION of NONCUMMUNICABLE DISEASES in

DEPOK, WEST JAVA, INDONESIA

General contacts information for this study : Ekowati Rahajeng Phone : 6221 – 4244693 Email : ekowatir@ yahoo.com ekowati@litbang.depkes.go.id nunikk@yahoo.com nunik@litbang.depkes.go.id i

This Study was funded by :

WHO Regional Office – APW No : SE/ICP/NCD/003/XK/02 WHO Headquarters – Priject NMH/NPH/BRS – 13 September 2002 WHO Country Office APW No : C2-AMP-05-004 18 August 2005 Who searo, HQ, WHO Kobe Centre

Acknowledgements We wish to gratefully acknowledge many individuals and institutions who contributed and participated for the success of the study, among other things : Mayor of Depok Municipality West Java Indonesia Depok Municipality Health Office Healthy Depok City Forum Abadijaya Health Center PKK (Women Welfare Movement) in Abadijaya Village Center for Health Promotion – MOH Directorate Genderal of Medical Services – MOH Directorate Genderal of Health Community – MOH Center for Diabetes & Lipid Faculty and Division of Metabolic & Endocrinology Faculty of Medicine University of Indonesia/Tjipto Mangunkusumo Hospital Center for Healthy Heart Medicine University of Indonesia/Harapan Kita Hospital Indonesia Healthy Heart Association Indonesia Smoking Controlling and Stoping (LM3)

ii

Principal Investigator:

Ekowati Rahjeng, PHD

Co-Investigator:

Nunik Kusumawardhani, MSc

Consultant:

Stephanus Indradjaja, MD. PHD

Institutional Address : National Institute Health Research and Development Ministry of Health Indonesia Jalan Percetakan Negara 23 A Jakarta Pusat Indonesia Telpon/Fax : 6221 – 4244693 General contacts information for this intervention study: Ekowati Rahjeng Email: ekowati@litbang.depkes.go.id ekowatir@yahoo.comNunik Kusumawardani Email : nunik@litbang.depkes.go.id nunikk@yahoo.com

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ABBREVIATION

AC Air Conditioning

BKKBN Family planning board

BMI Body Mass Index

Puskesmas (CHC) Community Health Center

DM Diabetes Mellitus

DPRD Local Peoples Representative Assembly

HDL High Density Lipoprotein

LDL Low Density Lipoprotein

PSP (KAP) Knowledge Attitude and Practice

MSG Mono Sodium Glutamate

NGO Non Governmental Organization

Kabupaten District

Kelurahan City Block (in rural areas : Village)

Kota City /Municipality

PTM (NCD) Non Communicable diseases

Posbindu Integrated Health Service and Promotions Post

RT City neighborhood (under RW)

RW Village Block (under kelurahan)

SD Elementary School

SLTP Junior High School

SLTA Senior High School

Tuak Traditional alcohol drink of Indonesia

WHR Waist Hip Ratio

Yandu PTM An integrated of health post for common risk factors NCD in community health center services

iv

List ofContent ABBREVIATION List of Content List o Table List of Atachment ABSTRACT

Page iv v

vii ix xi

1. INTRODUCTION 1.1 Background 1.2 The purpose of the study 3. The benefit of study 2. STUDY DESIGN 2.1 Goal and objectives 2.1.1 Goal 2.1.2 Objectives 2.2 Type of study design 2.2.1 The intervention area 2.2.2 Target population 2.2.3 Evaluation design 3. PLANNING 3.1 Situation analysis 3.1.1 Geographic aspect 3.1.2 Demographic aspect 3.1.3 Socioeconomic condition 3.1.4 Socio-cultural aspect 3.1.5 Health system development 3.1.6 Local health office program 3.1.7 Health seeking behaviour of the community 3.1.8 Health city forum of Depok 3.2. Community diagnosis 3.3. Intervention strategy. 3.3.1 Concept development of strategy 3.3.2 The main of strategy intervention 3.3.3 Frame work of CBI 4. IMPLEMENTATION

1 1 2 3

3 3 3 3 3 4 4 4

16 16 16 17 18 19 20 21 22 24 25 25 26 29

31 31 32

44 44 44 44 45 47

4.1 Program and activities 4.2 Monitoring programs and activities 5. EVALUATION 5.1 Result of process evaluation 5.1.1 NCD RF Surveillance in 2003 5.1.1.1 Sampling and Response Proportions of surveillance 5.1.1.2 Risk Factors of NCD in 2003 5.1.1.3 Utilization of surveillance risk factors NCD information. v

5.1.2 Policy Development and Coordination 5.1.2.1 Policy and program in surveillance 5.1.2.2 Policy and program in health promotion 5.1.2.3 Policy and program in health service management 5.1.2.4 Policy and program in industry sector 5.1.3 Strengthening individual skill 5.1.4 Enhancing social environment and enabling community actions 5.1.5 Reorienting Health Services 5.1.5.1 Posbindu PTM 5.1.5.2 Integrated ’Yandu PTM’ in PHC 5.1.6 Constraints in NCD control program implementation 5.2 Effect/Outcome Evaluation 5.2.1 Behavior Risk Factors 5.2.2 Physical Risk Factors 5.2.3 Biochemical Risk Factors 6. CONCLUSION 7. RECOMMENDATION

48 49 49 49 50 51 51 53 53 57 60 61 62 64 65

66 67

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List of Table

Table 1. Difference of mean score of knowledge test in pre and post training 2004 Table 2. Difference of mean score of knowledge test in pre and post training 2005 Table 3. Ratio of ‘Posbindu PTM’ at the selected Villages in Depok……………... Table 4. Target achievement of Posbindu PTM by budgeting system applied ……… Table 5 Target achievement of Posbindu PTM by Constraints which found in implementation…………………………………………………………… Table 6. Target achievement of Posbindu PTM by Constraints which found in Counseling activity…………………………………………………………. Table 7 Target achievement of Posbindu PTM by Knowledge and Skill of Health volunteers……………………………………………………………………… Table 8. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2003 ………………… Table 9. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2004 …………………. Table 10. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2005 …………………. Table 11 . Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2006 …………………. Table 12. Percentage who currently smoke tobacco daily ……………………… Table 13. Average age started smoking (years) for those who smoke tobacco daily Table 14. Average years of smoking ……………………………………………. Table 15. Percentage smoking manufactured cigarettes ………………………… Table 16. Mean number of Cloves manufactured cigarettes smoked per day ……. Table 17. Mean number of Non-Cloves manufactured cigarettes smoked per day Table 18. Percentage of Abstainers (who did not drink alcohol in the last year) … Table 19. Mean number of servings 0f fruit consumed per day ………………….. Table 20. Mean number of servings of vegetable consumed per day ……………. Table 21. Percentage who ate 5 or more combined servings of fruit & vegetables per day ……………………………………………………………….. Table 22. Percentage with low levels of activity (defined as <600 MET-minutes/ Week …………………………………………………………………. Table 23. Median time spent in work-related physical activity per day (minutes) Table 24. Median time spent in transport-related physical activity per day (minutes) ……………………………………………………………… Table 25. Median time spent in recreation physical activity per day (minutes) Table 26. Mean body mass index – BMI (kg/m2) ………………………………. Table 27. Percentage who are overweight or obese (BMI ≥ 25 kg/m2) ………… Table 28. Percentage who are obese (BMI ≥ 30 kg/m2) ……………………….. Table 29. Average waist circumference (cm) ………………………………….. Table 30. Mean systolic blood pressure - SBP (mmHg) ……………………….. Table 31. Mean diastolic blood pressure - DBP (mmHg) ………………………. Table 32. Percentage with raised BP (SBP ≥ 140 and/or DBP ≥ 90 mmHg) ……. Table 33.Percentage with raised BP (SBP ≥ 170 and/or DBP ≥ 100 mmHg) ……. Table 34. Mean fasting blood glucose (mmol/L) …………………………………

69 69 70 70

71

71

72

73

74

75

76 77 77 78 78 79 79 80 80 81

81

82 82 83

83 84

84 85 85 86 86 87 87 88

Table 35. Percentage with raised blood glucose (≥ 7.0 mmol/L) ………………… 88 vii

Table 36. Mean fasting blood glucose (mmol/L) ………………………………… 89 Table 37. Percentage fasting blood glucose (≥11mmol/L) ………………………. 89 Table 38. Prevalence diabetes …………………………………………………… 90 Table 39. Mean total blood cholesterol (mmol/L) ……………………………….. 90 Table 40. Percentage with raised total cholesterol (≥ 5.2 mmol/L) …………….. 91 Table 41. Percentage with raised total cholesterol (≥ 6.5 mmol/L) ……………… 91 Table 42. Percentage with low risk (less then three of the risk factors *) ……….. 92 Table 43. Percentage with raised risk (three or more of the risk factors*) ……… 92 Table 44. Percentage of who Raised Risk of NCD by achievement of their “Posbindu PTM” ……………………………………………………… 93

viii

List of Attachment

Attachment 1: Figures and Graphs of General Description of Geographical and

Demographic Aspects of Depok

Figure 1.Map of Depok).

Figure 2. Map of village and sub district in Depok,

Graph 1. Number of Population per sub district

Graph 1. Distribution of land use in Depok

Graph 2. Population Size of 6 Sub District in Depok

Graph 2a Development parameter progress

Graph 3. Consumption per capita (in thousand)

Graph 4. Income distributions

Graph 5. Depok regional/district revenue expenditure budget-

regional/district income

Graph 6. Depok District revenue expenditure budget

Graph. 7.National revenue expenditure budget for Depok

Attachment 2 Steps Instrument Depok Indonesia

Attachment 3 Operationl standard prosedure

Attachment 4 Interview guidance and questionnaire guidance

Attachment 5 Form consent

Attachment 6 Consent information

Attachment 7 Invitation letter

Attachment 8 Posbindu PTM

Attachment 9 Form evaluation of Posbindu PTM program

Attachment 10. Courses topics/material for health volunteer and health workers

Attachment 11 Fact sheet 2003

Attachment 12 Fact sheet 2006

Attachment 13 Data Book 2003

Attachment 14 Data Book 2006

ix

ABSTRACT Background:

World Health Organization (WHO) central and regional office in collaboration with

other member countries have developed an intervention program to control risk factors

of major NCDs through an integrated community based program, as well as building

regional networking for the program. In 2001-2002, SEARO had selected three

countries, Indonesia, India, and Bangladesh, to carry out a pilot study of NCD

intervention program. In Indonesia, Depok municipality had been selected as

“Demonstration Area” to develop NCD control program for the municipal area based

on several considerations.As a result of two workshops (on 22nd to 26th of April 2002 in

Thailand, and on 27th to 31st of January 2003 in India), WHO agreed to develop an

extension study, which involves larger sample size (approximately 2000 respondents).

Intervention program also need to be prolonged for approximately 3 years (year 2003 to

2005), and it requires more focus on comprehensive and sustainable activities based on

community based intervention.

Objectives:

To assess the intervention effects on prevention and control the prevalence of NCD and

its risk factors such as smoking, fruit and vegetable consumption, low physical activity,

obesity, hypertension, hyper-cholesterol, hyperglycaemia, diabetes and determine

means value of risk factors of major NCD risk factors (such as blood pressure, body

mass index, waist hip ratio, and blood glucose and blood cholesterol) in the population

Method :

To assess the intervention effects on prevention and control NCD risk factors

surveillance activity using WHO STEPS approach had been conducted in February

2003 (sample size: 1806 respondents). The surveillance activity had been followed by

the implementation of Community Based Intervention on prevention and control of

NCD risk factors program in Depok starting from April 2004 and completed on May

2006. Monitoring and evaluation had been done on June-July 2006, which include

STEPS survey (sample size: 1927 respondents) and facility based survey (“Posbindu

PTM, PHC, Health Office, and other related institutions).

x

Findings:

Process evaluation showed that the CBI approach brings ‘Posbindu PTM’ as

potential activities for NCD control and prevention program. But for sustainability

those program need technical facility, partnership, and social support. Outcome

evaluation resulted that the community based intervention of NCD prevention and

control program that had been conducted for three years had significantly reduced the

prevalence of several common risk factors, such as obesity, hypertension,

hyperglycemia, hyper cholesterol, and high risk or combined risk factors (having three

or more risk factors) and also considerably reduced the prevalence of diabetes mellitus.

Meanwhile, smoking, less physical activity, and fruits and vegetable consumption also

decreased but not significantly.

The main effective strategies of CBI on PC of NCD and its risk factors

program, which are essentially need to be conducted in coordinated approach and

integrated (not in systematic or sequence way). Implementation at district level requires

structural policy support and coordination forum which can stimulate the

implementation of NCD prevention control program and advocacy to get the policy.

The messages that should be address to the policy makers are not the risk factors but

the burden of diseases. For the sustainability the program must be linked to

achievement of the increasing HDI in community.

Key words: Non-communicable diseases, prevention, risk factors, community-based,

health behaviours, developing countries, surveillance.

xi

1. INTRODUCTION 1. 1 Background

World Health Organization (WHO) predicted that non-communicable diseases (NCD) have caused about 60% of mortality and 43% of morbidity in the world. These mortality and morbidity rate are commonly occurring in low social economy community.11, 28 In line with the fact mentioned above is NCD gradually also increases in Indonesia recently. Data from Indonesia Household Health survey showed that the prevalence of hypertension rose from 8.3% in 1995 to 21 % in 2001, the prevalence of diabetes mellitus increased from 1, 2% in 1995 to 7.5% in 2001, and the morbidity of cardiovascular and circulation diseases rose from 3 among 1000 people in 1995 to the prevalence of 4.2% in 2001. In Indonesia, the pattern of cause of death has changed from communicable diseases to non-communicable diseases. Indonesia Household Health Survey shows that the percentage of communicable diseases as cause of death decreased from 69.49% in 1980 to 44.57 % in 2001, meanwhile the percentage of non-communicable diseases as cause of death increased from 25.41% in 1980 to 48.53% in 2000.4,15,28

World Health Organization (WHO) central and regional office in collaboration with other member countries have developed an intervention program to control risk factors of major NCDs (cardiovascular diseases, diabetes mellitus, and particular cancer) through an integrated community based program, as well as building regional networking for the program. In 2001-2002, SEARO had selected three countries, Indonesia, India, and Bangladesh, to carry out a pilot study of NCD intervention program. In Indonesia, Depok municipality had been selected as “Demonstration Area” to develop NCD control program for the municipal area based on several considerations. Depok is one of the fast growing city in Indonesia, where has already started to apply decentralization approach in local government system. Area characteristic of Depok is varies, part of it is urban areas including exclusive residential areas such as real estate, and slump areas, educational area, industrial and trading areas. The other part of Depok is rural areas, which include village areas, farm and poultry areas. Depok has heterogeneous community with variety of social, cultural and economical condition. As the closest city from Jakarta the capital city of Indonesia, Depok is very responsive to psychosocial problems as result of modern life style, including non-communicable diseases problems.

Result of NCD risk factors surveillance in Abadijaya village in 2001 showed that prevalence of NCD was relatively high in comparison with national figure. The study revealed that 12.7 % of population had diabetes mellitus, 24.9% suffered from stress, 25.6% had hypertension. Several NCD risk factors that had been found from the study were 53.7% had high LDL cholesterol, and only 35.3% had high HDL cholesterol, 37.8% were overweight, and smoking prevalence was 36.7% among males and 2.9% among

2

females.15 Numerous intervention programs had been accomplished. However, NCD risk factors base line survey in 2002 (after 8 months intervention program) explained that the community still had the same health problem concerning NCD risk factors. As a result of two workshops (on 22nd to 26th of April 2002 in Thailand, and on 27th to 31st of January 2003 in India), WHO agreed to develop an extension study, which involves larger sample size (approximately 2000 respondents). Intervention program also need to be prolonged for approximately 3 years (year 2003 to 2005), and it requires more focus on comprehensive and sustainable activities based on community based intervention.

NCD risk factors surveillance activity using WHO STEPS approach had been conducted in February 2003 (sample size: 1806 respondents), in which funded by WHO SEARO-New Delhi, WHO Head Quarter-Geneva, and Endocrine Unit, RSCM-FKUI hospital Jakarta. The surveillance activity had been followed by the implementation of Community Based Intervention on prevention and control of NCD risk factors program in Depok starting from April 2004 and completed on May 2006, which was funded by WHO Jakarta Office. After that, monitoring and evaluation had been done on June-July 2006, which include STEPS survey and facility based survey (“Posbindu PTM, PHC, Health Office, and other related institutions), and they were supported financially by WHO Kobe Center and also the Endokrin unit RSCM-FKUI hospital Jakarta.

This report consists of information about implementation process and results of process evaluation, effect/outcome evaluation of community based intervention program, which represent the Depok municipality governmental system. Meanwhile the NCD risk factors proportion represents to Depok population age 25 to 64 years. Results and experiences in this report are expected to be usefully for district health office and community which have similar characteristics in other provinces in Indonesia. This report will describe further about basic strategy and conceptual model development, implementation process and result of evaluation, conclusion and recommendation for the future plan.

1.2 The purpose of the study

The aim of the study is to obtain experiences for lesson learnt and to gather good evidence about effective approach of community-based intervention programmes on prevention and control of the major NCD risk factors in Depok municipality that had been applied since 2003 to 2006 which seek to prevent NCDs by reducing the prevalence and mean of the risk factors in the population,

3

3. The benefit of study

1) For government, it will be beneficial to develop the prevention and control program of risk factors of major NCD in Indonesia.

2) For WHO, it will be a good evidence about effective approach of community-based intervention programmes on prevention and control of the major NCD risk factors program

3) For community, household, and individual, it will be useful to gain their knowledge about healthy life style and to develop their ability and awareness to prevent and control of the major NCD risk factors.

4) For NGO and private sector, it will increase their interest and motivation to participate in NCD risk factor intervention programs. On the other hand, it will gain their public health view without any disadvantages.

2. STUDY DESIGN

2.1 Goal and objectives 2.1.1 Goal

The goal of this study is to obtain evidence about effective approach of community-based intervention programmes on prevention and control of the major NCD risk factors that had been applied since 2003 to 2006 in Depok municipality, West Java, Indonesia.

2.1.2 Objectives

1) To assess the intervention effects on prevention and control the prevalence of NCD and its risk factors of major NCD (such as smoking, fruit and vegetable consumption, low physical activity, obesity, hypertension, hyper-cholesterol, hyperglycaemia, and diabetes) in the population.

2) To assess the intervention effects on prevention and control determine means value of risk factors of major NCD risk factors (such as blood pressure, body mass index, waist hip ratio, and blood glucose and blood cholesterol) in the population.

2.2 Type of study design This is a follow up community base intervention study on prevention and control of

major NCD and its risk factors program (before after without control). The evaluation study is comparing the result of two cross-sectional before and after intervention and following of the implementation intervention to local government, health provider, and community (individual, family, group or organization, and industry/ private sector) since 2003 to 2006.

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2.2.1 The intervention area This intervention study had been conducted in Depok City West Java Indonesia,

meanwhile the evaluation effect of NCD risk factors had been taken in one village (village of Abadijaya in Sukmajaya sub district in Depok) which is selected by two Stage Clusters Random Sampling (sub district and village cluster) and specific criteria.

2.2.2 Target population The target population for outcome evaluation of community based intervention on

prevention and control of NCD and its risk factors were all citizens aged 25 to 64 years old in Depok, West Java, Indonesia

2.2.3 Evaluation design

The evaluation have purpose to assess whether each program can be applied sufficiently and had achieved its target and objectives. The evaluation required important information to explain several questions, such as what necessary further intervention required if the program yet unable to achieve the target, whether the main objective of CBI had been accomplished, and what necessary further action required to accommodate the problem if it was not accomplished, what program that most important in achieving the main objective of CBI on prevention and control of major NCD and its risk factors program and for program sustainability.

Although programs and activities of CBI had been applied for all related stakeholders and Depok community, the process and outcome evaluation were taken only within the Abadijaya village, where the intervention activities had carried out more intensively, and the outcome indicator was monitored. However, in regard to structure and mechanism, the program, policy support, and NGO activity was up to the district level, the process evaluation for those aspects was done in the level of Depok municipality level 2.2.3.1 Process evaluation

The process evaluation of CBI was focused on quality, interaction, and comprehensiveness of the particular elements below: 1) The intervention activities had met the objective according to the process and impact

indicator 2) Structure, working mechanism, and performance of Depok Health Office and Depok

Government office, that related to planning and implementation of NCD prevention and control program, including the NCD risk factor surveillance activity to obtain evidence based information.

3) Policy support from Depok Government, that includes social support, regulation, program development, human resources as well financial resources for the NCD prevention and control.

5

4) Roles and capacity of PHC, as the most direct government health service institution which to the community, in planning, advocacy, social action and information dissemination of NCD prevention and control program.

5) Roles and capacity among the health professional (GP, paramedics, nutritionist) in NCD prevention and control program.

6) Capacity and Participation of community (individual, organization, private), in planning, advocacy, and social action in NCD prevention and control as well as information dissemination.

7) Roles and capacity of communication media in NCD prevention and control program. 8) Program implementation/activity of NCD prevention and control program including

community access to health services, particularly in primary level (PHC and private clinic) and in community health post (“Posbindu PTM”).

9) Social environmental condition that related to NCD risk factors, such as accessibility to sport facility, exposure to negative-positive health promotion, healthy diet, etc.

2.2.3.2 Effect/outcome evaluation The evaluation of CBI outcomes was focused on change in proportion/prevalence

and mean value of NCD risk factors (behaviour, biology, and biochemical), and compared the results of NCD risk factors surveillance in 2003 (before the CBI applied intensively) to results of NCD risk factors surveillance in 2006, and tried to relate them with process evaluation.

Frame of evaluation design

Process Evaluation

Effect/outcome Evaluation

O 1 :

• Policies that consist of NCD control program at the local government and health office of Depok in 2003.

• Social environments include structure and infrastructure in government that are related to NCD control program in Depok in 2003.

• Programs and budget concerning NCD from the local government in 2003.

O 1 O2

Community Based Intervention

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• Involvement of community organization and industries on prevention and control of major NCD risk factors program in 2003.

• Participation of community on prevention and control of major NCD risk factors program in 2003.

• “Posbindu PTM” coverage as a community based health measures in early monitoring and counselling of NCD risk factors in 2003..

• Public Health Centre coverage as a primary and secondary health care in following up the NCD cases in community in 2003.

• Prevalence, proportion, and means value of major NCD risk factors before intervention (result of NCD risk factors surveillance in 2003).

O 2 :

• Policies that consist of NCD control program at the local government and health office of Depok in 2006.

• Social environments include structure and infrastructure in government that are related to NCD control program in Depok in 2006.

• Programs and budget concerning NCD from the local government in 2006. • Involvement of community organization and industries on prevention and control of

major NCD risk factors program in 2006. • Participation of community on prevention and control of major NCD risk factors

program in 2006. • “Posbindu PTM” coverage as a community based health measures in early monitoring

and counseling of NCD risk factors in 2006. • Public Health Centre coverage as a primary and secondary health care in following up

the NCD cases in community in 2006. • Prevalence, proportion, and means value of major NCD risk factors before

intervention (result of NCD risk factors surveillance in 2006).

Community based intervention (CBI):

The intervention in this project is program on prevention and control of the major NCD risk factors in Depok municipality which is conducted in integrated and comprehensive approach with the focus to community based intervention and supported by cross programs and cross sectors to control risk factors of major NCD. CBI material, strategy, and approach implemented in this project had been developed according to general condition, local tradition and resources and its community.

7

2.2.3.3 The method of information collection

Process evaluation was done by assessing of the monitoring results of each program indicator. Monitoring method of each activity can be seen on attachment 1. Effect evaluation was done by result of implementation surveillance of risk factors NCDs.

The surveillance of risk factors NCD:

Implementation of the surveillance of risk factors NCDs was applied on one village. Abadijaya village was selected by use Two Stage Clusters Random Sampling (sub district and village cluster). A sample of risk factors NCD had been selected by simple random sample. A sample unit of 2200 individual was selected in ‘proportional stratified random sampling’ based on age interval of 25-34, 35-44, 45-54, 55-64 and sex (550 respondents for each strata). In this case, this study used list of citizen according to age group and sex available from the Abadijaya village office, as a sampling frame. More detail description of sampling design can be seen on scheme below

Sampling Design

Village of Abadijaya (60 000 people)

Village of Abadijaya (37. 000 people age 25-64 y o)

2200 people or 550 for each stratum

Male Female

25-34 y o 35-44 y o 45-54 y o 55-64 y o

Depok City (1,200,000 people)

Sub district (6 sub districts)

Village (63 villages)

Individual

8

Risk factors Data Collection

Data were collected using WHO Steps approach, which is a data collection approach for NCD risk factors developed by WHO based on surveillance system concept. The instrument is expected to obtain data that fulfill medical standard requirement, flexible in representing variety of information from different areas or countries, and flexible to be modified according to local condition and resources.

Data collection method were applied according to the guidance and steps recommended by the WHO Steps approach. Since the risk factors of NCD are very complex and comprehensive, this approach is divided into 3 steps, which are step (1) collecting the data of NCD risk factors by interviewing the respondents using questionnaire; step (2) collecting more complex data, which requires physical measures; and step (3) biochemical measures. Matrix 1 describes more detail about data that collected in Depok using WHO Steps approach for surveillance of risk factor NCD.

Matrix 1

WHO Steps Application on Surveillance of NCD Risk Factors in Depok

Core Expanded Additional

Demography Age (25-64 y o) Sex Education

Ethnic, level of education, and occupation

Family size, household income

Smoking

Age when start smoking, frequency, length, etc

Quantity, type , when start to stop smoking

Alcohol % alcohol in last 12 months

Volume

Nutrition Frequency of fruit and vegetable consumption

Consumption of some food (egg, meat, milk, etc)

Physical Activity

%, and length of sedentary activity

Type of activity (vigorous, moderate, etc)

Duration of physical activities

Obesity Height, Weight, waist circumference

Hip circumference

Blood Pressure Systolic and Diastolic

Hypertension history and medication

Fasting blood glucose

2 hours blood glucose after glucose load

Diabetes

Total cholesterol Triglyceride HDL cholesterol

Risk Factors in Step 1

Risk Factors in Step 2

Risk Factors in Step 3

9

Translation of instrument, field Manual and summary of WHO Steps

The WHO Steps Approach main materials which consist of the Questionnaires, Field Manual and Summary of the WHO Steps Approach were translated into Indonesian language, and then the translation were edited by a senior researcher is a biologist who has an excellent power writing and does not know anything about the WHO Steps approach. The draft of the questionnaires in Indonesian language were translated back again into English by a professional sworn translator from Translation Plus Agency. There are no any significant differences detected between the original and the translated back document. The purpose of using both neutral editor and back translator is to prevent the translation from any bias and influence from their previous experiences and to make the translation easily understandable by layman without any distortion.

Trial of Instrument

The activity on trial had been conducted through train 25 interviewers in using the questionnaires of Steps, trial with inter rating on interview 100 respondents , discussion with expert and field trial team, and revision of the instruments after trial Result of trial the instrument was as follow:

1) Several potential difficulties faced during interviewing were asking questions of physical activities, dietary pattern, household income, diabetes mellitus history, and hypertension history.

2) Most of participants said that asking questions of physical activities and dietary pattern required more time.

3) Investigation team agreed to provide the interviewer with the questionnaire guideline in more detail and clear explanation, especially for physical activity and dietary pattern.

4) Particular questions required to be amended, which include question about household income, physical activities, dietary pattern, and traditional medication.

5) The pathway instructions in the questionnaire required to be revised into more clear and appropriate instruction.

Calibration of the Digital Scales Instrument for body weight measurement used electronic personal weighing scale

(model SECA 843, Volgel and Halke and Co Germany), which has capability of maximal weight up to 140 Kg. Before the data collection started, all the weighing scale was given identity number and calibrated with several standard weight (10 Kg, 20 Kg, 30 Kg, 40 Kg, 50 Kg, 60 Kg, and 70 Kg. Standard deviation value and mean value of the calibration results was used as standard value as a correction factors of each weighing scale.

10

Training for data collections and physical measurement

Prior to data collection implementation, all the personnel of data collection team were trained. Training course contents for interview were STEPS instruments questions guide, interview skill, and recording information. Training method include lecture, discussion, and simulation. Detail activities and time frame of the training can be seen on matrix 2 below.

Matrix 2: Training Agenda and Time Frame

Activity Participant Stepwise Duration • Introduction to STEPS, data

collection activities (registration and informed consent)

• simulation

• Community leader • Health volunteer

Step 1 1 day

• Introduction to STEPS • STEPS instrument, question

by question guide, and show card.

• Interview simulation • Evaluation and discussion of

simulation

• Nurse or other health professional

• General Practitioner (GP)

• Nutritionist

Step 1

2 days

• Taking and recording the physical measures, and blood pressure.

• Simulation of physical measures and blood pressure

• Evaluation and discussion of simulation

• Paramedics • Health volunteers

Step 2 1 days

• Explanation of standard method blood glucose examination, cholesterol, etc.

• Simulation of blood test • Evaluation and discussion of

simulation

Laboratory analyst Step 3 1 days

Data Collection Preparation

To obtain successful data collection implementation as well as to increase response rate within the limited time and budget, the STEP 1, 2, and 3 had been carried out at the same time and venue/post, which was mostly at the each administrative unit (RW) area or respondent’s residential area. Data were collected on week end and holiday at one post, starting from 8 am to 2 pm and number of respondent was limited up to 100 people per day. Respondent, who was not able to participate on the scheduled day, was invited to

11

participate on next data collection date at different area or RW. There were several stakeholders involved in the preparation process. Those were local health office, health centre, and head of village, local community health organizations, public figure, and head of block village (RW). The activities of data collection preparation were as follow:

1) Inform the activities plan (including aim and benefits), administering the permission for the study, and preparing the data collection location.

2) In collaboration with local health centre, head of village conducted meeting with public figures (religious, health organization, females association, etc) and head of block village (RW). The aim of this meeting is to explain the activities plan to the local community. It is expected that the people involved in the meeting can give further explanation about the benefits and objectives of the activities to the local community.

3) Invitation sent at one week before the activity to individual who was selected to become respondent. The selected individuals were invited to participate in first health examination, which required respondents to fast. Fasting procedure was explained in detail on the invitation letter that also resend one day before the activity.

4) Invitation letter was sent via public figures and head of local block village (RW).

Data Collection Process Data was collected using WHO STEPS instrument for NCD risk factors

Surveillance that had been translated into Indonesian language and had been trial tested (Attachment 2). All the interviewer personnel had interview guidance and questionnaire guidance (see attachment 4), and operational standard procedure for whole activities of data collection (see attachment 3). Beside the investigator team, other people who involved in this activity were local health workers, public figure, and local community activist. Number of data collector per day and detail of interview and health examination process, including time spent for each respondent were as follow:

1) Registration and sign in the inform consent form involved 4 persons (3 public figure and 1 administration staff). Length of time was 5 minutes per respondent.

2) Data of biochemical risk factors were collected by blood examination. Respondent had to fast for 8 – 10 hours prior to blood test. Blood measurement was taken to measure blood glucose and blood lipid level. Blood was analyzed using wet chemistry by the laboratory analysts. Blood was taken from the vena. Blood volume required for the test was 5 cc. Blood collection was conducted met the requirement for blood collection. Respondent’s blood was placed in specimen tube which was labeled with respondent’s identification number. Blood measurement procedure and analysis were used Randox kit. All the blood specimens were analyzed at the same day. Fasting blood glucose measurement, two hours blood

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glucose measurement and fasting blood cholesterol measurement were taken by 3 laboratory personnel with chemical analyst education background from “Prodia Laboratory”. Length of time was 10 minutes per respondent.

3) 75 gram of dextrose monohydrate dissolved in 300 mg drinking water was given orally to the respondent, for glucose load. Trained workers from local community organization prepared it. Duration per respondent was 5 minutes.

4) 4 trained paramedics (2 males and 2 females) took blood pressure measurement (Step 2). Length of time was 15 minutes per respondent. Procedure of blood pressure measurement as follow : − Equipment used is the OMRON Digital Automatic Blood Pressure Monitor

(DABPM) and type of OMRON digital is M1-4. The batteries were replaced after every 100 measurement.

− Blood pressure was measured after the registration (five minute rest period) − The subject was seated and pressure was measured on the right arm, with the

appropriate cuff size. − The right arm should be free of any clothing and the lower edge of the cuff

should be placed 1.2 to 2.5 cm above the inner side of the elbow joint. − Keep the level of the cuff at the same level as the heart during measurement. − The first reading will be displayed followed by the second after a one-minute

interval. − Record blood pressure was only the first and second readings and not the

average pressure reading as displayed. If the difference between the first and second readings is 10 mm Hg or more then a third reading is required.

5) Anthropometry measurements were taken to obtain the nutritional status and abdominal obesity. The measurement was conducted following the WHO recommendation on the STEPS manual. There were four trained health volunteers who took anthropometrics measurement (Step 2), measurement duration was 10 minutes per respondent. The measurement included height, weight, waist and hip circumference, and had been carried out in private room. All the personnel were ladies. A poster of anthropometry measurement was in on the wall inside the room to make easier for the personnel to remind the correct procedure. .

Procedure of weight measurement as follow : − Weight was measured with electronic personal weight scale (model SECA 843,

Volgel and Halke and Co Germany). Capability of weight maximal is 140 Kg − The instrument was checked each day with standard weight preferably − The subjects have wear light clothing − Weight was recorded to the nearest 0,1 kg

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Procedure of height measurement as follow : - Height was measured with aluminum scale (model SECA 222, Volgel and Halke

and Co Germany). Length of scale is 0 cm - 230 cm. - Height was measured without shoes - The subjects was standing fully erect on a flat surface - Measurement is to the nearest 0.1 centimeter

Procedure of Waist and Hip circumference as follow : - Waist and Hip circumference were measured using a plastic dressmaker’s

measuring tape - The subject was standing and breathing normally - Waist and Hip circumference were measured to the nearest of centimeters

6) Interview process to obtain data about social demography, health history (diseases, medication, diet), smoking, drinking, stress, health knowledge, and physical activities (Step 1), was conducted by 10 interviewers who had been trained, have bachelor degree, and works at local health office, and some of local health activist. Length of time was 30 minutes per respondent.

7) Two administration staffs coordinated the flow of the data collection process.

8) Two investigators from NIHRD supervised the activities. The supervisors were responsible for the whole process including the preparation process, data collection process, and data editing process directly in the location of data collection process.

Flow of data collection activity can be seen on the diagram below:

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Flow Chart of Data Collection Process

Invite the respondents

• Weight • Height • Waist & hip

circumference (2 health workers)

Biochemical examination • Fasting blood glucose • Blood cholesterol

(2 analyst)

Waiting room I

Health interview (10 interviewer) Waiting room II

(2 staff)

Snack (food & drink) distribution

Registration and Sign in the inform consent form

(4 staffs)

Blood pressure measurement

( 2 paramedics)

Checking and editing of answers and completeness (2 Investigators/supervisors)

Finnish

2 hours Blood Glucose after glucose load (2 analyst)

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Data management and analysis

Data editing was conducted directly during the data collection activity in the survey post. Data entry was done by double entered, using Epi Info version 6, while data cleaning and analysis used Epi Info 2000.

Diseases and risk factors were diagnosed on the basis of the WHO recommendations, 11which are as follow: 1) Low physical activity defined as < 600 minutes/week 2) Obesity, which is calculated by body mass index was categorized as follow:

− Normal range BMI 18.5 - 24.9 kg/M2 − Overweight BMI 25.0 – 29.9 kg/M2 − Obesity BMI >= 30.0 kg/M2

3) Central obesity, which is calculated by waist-hip ratio (WHR), was defined as WHR >= 1 for men and WHR >= 0.85 for women.

4) Hypertension was determined as systolic blood pressure >=140 mg/Hg and/or diastolic blood pressure >= 90 mm Hg.

5) Hypercholesterolaemia was defined as a total cholesterol concentration of >= 6.5mmol/L, while borderline hypercholeterolaemia was defined as a total cholesterol concentration of >= 5.2mmol/L.

6) Diabetes mellitus was defined on the basis of measurement of venous blood glucose concentration, after on overnight fast of 10-14 hours which was >= 7mmol/L, and measurement of two hours after a 75 gr. oral glucose load which was >=11mmol/L.

Weighting process was applied to calculate the mean value and prevalence/proportion of NCD risk factors. Weight was calculated according to: 1) Cluster (village) inclusion probability out of all clusters available in Depok city (W1) 2) The non response rate for each strata of STEPS (W2S1-3) 3) Sample proportion to population was based on stratum of age group and sex (W3).

In weighting data analysis for outcome evaluation, all data was calculated base on standard population size, which was taken from Depok population on stratum of age group and sex distribution on the middle years of intervention time period it was on 2004. Level of Confidence Interval 95% was used to estimate the significance of deference of the intervention result. The whole process of data management and analysis used WHO STEPS Data Analysis Manual. Primary Sampling Unit (PSU) was determined base on inclusion probability of RW (block village unit), while the stratum was determined base on age group and sex.

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3. PLANNING

3.1 Situation analysis

3.1.1 Geographic aspect

Depok is one of 433 districts in Indonesia and one of the fast growing cities in West Java Indonesia, The location of Depok is directly under boundary of Jakarta, and as a buffer area to alleviate the high population growth in Jakarta, the capital city. The distance between and Jakarta is approximately 30 Km (see attachment 1 figure 1.Map of Depok). Depok, as a new autonomy city, was established on April 27, 1999 and has already started applying decentralization approach for local government system. Previously, Depok was part of Bogor district. In administrative point of view, the location of Depok is a strategic, especially in consideration of political aspect, economy, social cultural, and safety. Depok is directed to be a residential area in which working opportunity is more equally distributed, as stated in the President’s instruction number 13 in 1976, regarding the area development of Jakarta-Bogor-Tangerang-Bekasi. Instead of residential area, Depok was now growing into trading city, centre of education and services as well.17

Geographically, Depok is located on the coordinate of 6o19’00” - 6o28’00” South and 106o43’00”- 106o55’30” East side, with area of 200,29 km2. Borderline of the Depok area consists of :

- Northern area : in the border with DKI Jakarta and sub district of Ciputat, District of Tangerang.

- Southern area : in the borderline to sub district of Bojong Gede and Cibinong in Bogor district.

- Western area : in the borderline to sub district of Gunung Sindur and Parung in Bogor district.

- Eastern area : in the borderline with sub district of Gunung Putri, Bogor dan Pondok Gede in Bekasi

Depok consists of 6 sub districts, which in total has 63 villages, 801 administrative units and 4200 neighborhoods block. The 6 sub districts include Sukmajaya, Beji, Pancoran Mas, Cimanggis, Limo, and Sawangan. Sub district of Swingman has the largest number of villages, 14 villages, followed by coming’s which has 13 villages, Sukmajaya and Pancoran Mas each has 11 villages, Limo has 8 villages, and Beji has 6 villages. Those number of villages shows that the population distribution in each village in Depok has not equally distributed, as well as the number of population in each sub district. Although, almost all the villages have became a self-determining village, and each village has similar characteristic. (see attachment 1, Figure 2. Map of village and sub district in Depok, and Graph 1.number of Population per sub district). The location of NCD risk factor surveillance was in village of Abadijaya, which was located in sub district of Sukmajaya.

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Area characteristic of Depok is varies. Depok has urban areas including exclusive residential areas such as real estate, and rural areas, educational area, industrial and trading areas. Meanwhile, some part of Depok is rural areas, which include village areas, farm and poultry areas (see attachment 1, Graph 1. Distribution of land use in Depok) . 3.1.2 Demographic aspect

Demographically, based on data from Statistical Bureau during 2000-2004 the population size and density of Depok are as follow:

− In 2000 : 973.036 people; population density : 4.858 people/Km2. − In 2001 : 1.204.684 people; population density : 6.015 people/Km2. − In 2002 : 1.247.233 people; population density : 6.227 people/Km2. − In 2003 : 1.335.734 people; population density : 6.669 people/Km2. − In 2004 : 1.369.461 people; population density : 6.837 jiwa/Km2.

Population in Depok has significant migration level, and the population size was bigger every year. The descriptions of migration in Depok are as follow:

− In year 2000, number of new comers was 52.383 people, while number people who migrate was 8892 people.

− In year 2001, number of new comers was 7066 people, while number people who migrate was 2721 people

− In year 2002, number of people who move in was 9418 people, while number people who migrate was 2753 people

− In year 2003, there was 19950 people move in and 7419 people migrate. − In year 2004, there was 11899 people move in and 4503 people migrate

Life expectancy in Depok was 71.8 years in 2002, which was the highest compare to other districts in West Java. The high achievement of life expectancy is closely related to the decline of Infant Mortality Rate (IMR) in Depok. The IMR, that indirectly calculated by the Depok Statistical Bureau, was 24.90/1000 life birth in 2004. During 2001 to 2004, the IMR in Depok was a significantly decreased. The IMR was decline from 44.67/1000 life birth in 2001 to 44.20/1000 life birth in 2002, 33.38/1000 life birth in 2003, and 24.90/1000 life birth in 2004.

In 2003, the education participation was fairly high in Depok. The percentage of junior high school was 75.1% among the population age 10 years above, while the average school year was 10 years. Most of the Depok citizen was working as a government employee. Recent policy of early retirement lead to productive or potential retired population, who able to voluntarily working on health development as well on economy and education in their area.

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3.1.3 Socioeconomic condition

A report by Indonesia Statistical Bureau, Institute of National Development, and UNDP in 2004, the Human Development Index (HDI) in Depok in 2002 was in the highest rank among other districts in West Java, and in number 11 compare to national level. However, the purchasing power index was lower than the other HDI (such as education and life expectancy). This is showed by very low consumption capacity per capita, as showed on attachment 1, Graph 3. Meanwhile, the economy growth rate of Depok was increasing, based on the development parameter as shown on Graph 3. However, the biggest contribution of economy growth rate was on consumption, not infestation. Population distribution based on GINI ration was 0.152 on 2001, 0.121 on 2002, and 0.281 on 2003 (see attachment 1, Graph 2a). In this case, the purchasing power parity was fairly hard in purchasing other life standard commodity.

Local commodity for economic development in Depok are food and drink industries, textile industries, house ware industries, machinery industries. During 2000-2003 chemical industries had given most vital contribution to Depok’s economic development. Meanwhile, textile industry was the biggest industry during 2003 – 2004. There are several types of market in Depok, modern market (16 units), traditional market (9 units), and open market (4 units). Regarding district budgeting for Depok, the financial sources were from real district income, and other income including tax, non tax, general allocation budget, specific allocation budget, provincial budget, national budget and other official district income.

In 2003, the highest regional/district income was from public budget allocation, as much as Rp 209.550.000.000,00, with the total income was Rp389.586.439.710,16. In 2004 the total income was Rp458.730.058.473,53, which mostly from district budget income (Rp.264.268.717.275,00). The budget was mostly spent for public need (education, health, economy, infrastructure, and others) and for government necessity. Highest amount of budget allocated from the Regional Expenditure Revenue for District level in 2003 was on health sector (Rp.39,722,000,-) while the lowest amount was for education sector (Rp 13.841.682,00). In 2004 the biggest amount was allocated for education (Rp. 7.825.429.200,00), while it was lower (Rp260.992.000,00.) for health. Meanwhile the budget from National Expenditure Revenue in 2003 for Depok, the biggest was for education (Rp4.293.078.000,00), and only Rp. 70.580.000,00 for health, while in 2004 the budget for health was higher than 2003 (Rp 5.500.000.000,00). The detail figure of budget allocation for Depok can be seen on attachment 1(Graph5,6,7)

3.1.4 Socio-cultural aspect

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Depok has heterogeneous community with variety of ethnic and cultural. Approximately 90% of 26 ethnics in Indonesia were available in Depok. The highest proportion was Java, Sunda, Betawi, and Minang. Cultural aspect is one of the important parts in city development. As typical of metropolitan city, Depok is open city and has specific economic power for investor and visitor. From the ethnic point of view, Depok has various kind of ethnicity. Mainly, there are two different groups, local or native citizen and visitor. Visitors are differed by migration motivation. There were some people migrate from Jakarta to Depok due to economy condition or known as socio urban movement. Other type of visitors was those who move to Depok because of their demand to live in Depok as they work mostly in Jakarta.

Based on those typical characteristic, it can be determined that the native population is from Dutch generation while the first type of visitors are from Betawi ethnic in Jakarta and the 2nd type is from out side Jakarta with huge variation of ethnicity (suku jawa, sunda, minang etc). Those three groups are basically influenced by social cultural development of metropolitan city. Relationship within the community in Depok still remains close to each other and help each other as one big family. Alike Indonesian tradition in general, Depok society like to have group activity for any social or religious event, such as religious club, neighborhood club, elderly association, sport association, or particular Indonesian ethnic association, and others. Influences of cultural aspect on health and economic that is specifically felt by the community in Depok were behavior aspect and motive of achieving wellbeing for all. Sense of belonging as a Depok citizen can be as a measure to achieve wellbeing for all. For example, activities on poverty elimination not actually involve cohesive social intra strata. For those who have higher economy status was able to help the poor and vice versa. Helping each other is a cultural basis which is in fact become very rare at the moment.

Indonesian women culturally have equal position to men in improving family welfare. This also occurred among Depok women, especially a housewife, who has a vital role in the family and the neighborhood environment. In the family, a housewife can also be a household educator, household planner, and manager for the household financial. Within the neighborhood environment, women have significant contribution in community welfare through actively involve and organize the neighborhood activities and organization.

The famous women association that available almost in every village in Indonesia is “PKK” (Family Welfare Educator). All women can joint the ‘PKK” group, and usually the “PKK” is coordinated by the wife of government and military employee. Leadership structure of this organization is based on the structural position of their husband in all administrative level of the government office, starting from district level, sub district, village, administrative unit, and neighborhood block. The organization has routine monthly

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meeting in village level, when all members participate for the coordination meeting and capacity building training. The capacity building mostly consists of knowledge and skill improvement for family welfare includes family health status improvement. Women who actively joint the “PKK” usually have better capacity in enhancing community welfare and well known in the surrounding community. Therefore, this organization has been utilized as the entry point of promoting health including community based NCD risk factors prevention and control program.

3.1.5 Health system development

Indonesia Health Development corresponding to country basic constitution 1945 (UUD 45) which states that health is a basic human right, and according to national health legislation number 23/2004, which says that health is under responsibility of government as well as community including private sectors. Measures of health development should be sustainable and comprehensive with considering promotion, curative, and rehabilitative aspects. Also, the measures is based on Healthy Indonesia 2010, which consists health policy formed by the Ministry of Health, parliament legislative, as well as intermediate term of planning development, and directed to increase quality of life and human resources. National health development has been formed according to National Health System, which had been developed since 1982. In conjunction with the application of district autonomy in 1999, government has established Regional/District Health System, which consists of Province Health System and District/City Health System. Regional Health System is a guideline for health development in the regional or local level, which is part of National Health System, and should be implemented by all health development providers in government sector as well as in community including private sectors.26

According to government policy on decentralization system of health sector and district autonomy, the Ministry of Health had established the decentralize system on health policy and strategy (MOH decree number 004/2003). The main goal of the decentralize system in health sector is to develop health system which accommodates community aspiration and initiative using several approach. The approach includes community empowerment, integrating, and optimize the local potential to accomplish local or district needs and to achieve national priority targeting Healthy Indonesia 2010, which includes to build a healthy city/district promptly based on point of time target determined by each district/city.14, 20 With considering the decentralization policy, the strategy and program on health in Depok have been focused on several important points as follow: 1) The program have been implemented addressing the main issue in community of all

social economy status and using available resources, community demand and ability with the supports of management, knowledge and technical medic from local health

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office. The program should be monitored and supervised by local provincial health office.

2) The program have been carried out within the local capacity, but still using standardized method (measurement and diagnostic) and services (diagnostic and treatment), which are accurate and liable in medical point of view.

3) Implementation program, particularly for treatment service (service fee, health workers authority, etc), have been in line with the regulation in the local district applied and not against the national regulation.

4) Regional/District Legislative Organization has substantial contribution or responsibility in the implementation prevention and control program in their own district/city, in the mater of legislation function, supervision, and financial.

5) Ministry of Health, have obligation to facilitate the prevention and control program in district/city level, with the focus on capacity building on knowledge , advocacy, health promotion, diagnostic technique, treatment, and case management.

6) Guidance or assistantship on health management, referral system development, outbreak management, disaster management, and other urgent health issue, are also potential to be done as contribution to prevention and control program.

3.1.6 Local health office program

Several of Public Health Centers (PHC) had been provide by the district government to overcome the public health issues in Depok community. There were 27 PHC in 6 sub districts (on average 4 PHC in each sub district), 7 assisting PHC, and 93 midwives who work in the PHC. Private health service networking, includes mother and child hospital, has provided obstetric and neonatal emergency service which available evenly in every villages. A general district hospital was still under construction, and it will be utilized as a referral hospital to accommodate demand of further health treatment among cases from the PHC. Approximately 75% RW (administrative unit) in Depok has developed variety of community participation activities on health aspect, such as integrated health post for under five children (“Posyandu Balita”), elderly health post (“Posyandu lansia”), NCD integrated health post (“Posbindu PTM”), Indonesian Cancer Association, Healthy Health Club, and other sport or exercise clubs). Also, some non government organizations (NGO) have positively supported health development (medical doctor association, midwives association, dentist association, Green Depok, Lempalhi, Mitra Bunda Foundation and other).

Budget allocation for health sectors was substantially lower than it was proposed ($2 per capita vs. $5 per capita). The budget was mostly spent for office facility use and very less for the community development and programs. Other limitation in health services were as follow:

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1) Unavailability of clear strategy on roles or functions of private sector in Depok health system.

2) Health workers in PHC still had limited skill in providing services on obstetric emergency, disaster management, NCD case management, and drugs addict case management.

3) Limited number of professional workers in health services (PHC) as well in health administration (Health Office). This lead to less optimum program implementation.

4) Some health care activities and cross sector activity that not yet supported by district regulation or law aspect that may lead to more satisfaction services for the community. In example, improvement in Public Health Center fee and availability of specific health treatment, private PHC, and more better contribution of health insurance from PT ASKES.

The local health office and primary health care don’t have specific unit which is represent for NCD control program neither the NCD is not the health priority issue. Because of that, the information on the magnitude of NCD problem and risk factors was very important in giving inputs to decisions maker as regard to order who capable to concern in NCD control program, support policy and planning program for NCD risk control in the city of Depok. As NCD is not priority in health development, it is important to obtain policy support in prevention and control of NCD in Depok. Therefore, the strong and sustainable advocacy to decision makers to overcome NCD issues in Depok is strongly required.

3.1.7 Health seeking behaviour of the community

Results of pilot study in Depok that had been conducted in 2001 – 2002 showed some findings as following, most community has perception that NCD is assumed as unpreventable degenerative diseases and occurred mostly among higher income population. NCD is known as elderly diseases, and genetic factor. Observation of the health seeking behaviour has been found that the people, who never check their health in 1 year was 52.2 %, never check their blood pressure was 51.3 %, never check their blood glucose was 8.8 %, and never check their blood cholesterol was 90.4 %. Beside that, most of the cases that found are not aware of having the risk factors (51.7 %, DM, 38.2 % hypertension, 98.2 % Hypercholesterol). In general, NCD prevalence and NCD risk factors prevalence in Depok, are higher than national prevalence. Most of the NCD cases and people with high risk were not aware of the diseases and even they didn’t realize of having the diseases or the risk, that because of the community knowledge of NCD and its risk factors, but they have high interest to prevent the NCD and its risk factors. Community is never check their health because afraid of knowing the diseases because of inability to pay the treatment

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There was community’s habit in Depok that they ate in their office or bought on food seller especially the young’s family didn’t eat at home because they worked all day. Most of family who cooked at home, used to utilize MSG as little as food seller. A part of the community has used to do the disease prevention or take care of their body by consuming vitamin, food supplement, etc. Eat more and provide more food are symbol of prosperity in the family and overweight means wealthy. However, as the goal of lifestyle’s change on diet, it will be effective if the intervention do to both of food seller and housewife. Because of that, we will use to change the lifestyle by PKK (Woman’s welfare) activity, especially for the housewife.

Most of them, especially the teenager had to use smoking in heavy category (> 4 cigarette/day}. Commonly that community known the effect of smoking is bad. Part of them wanted to stop smoking but it’s difficult to begin and they didn’t know how the way it. The goal of changing health’s lifestyle (to stop smoking) is priority on teenagers or risk group. The changing strategy was being done systematically with paying attention on goal’s segmentation. We also think several options on stop smoking. The promotion can be held by dialog, individual or group consulting, sport activity and by radio broadcasting.

Most of the community used to do physical exercise at least one time a week. A part of them also spends their money for sport like gymnastic. The kind of sport was variety according to community group. The teenager and male’s adult like volleyball, football, badminton, and basketball. Female’s teenager and adult used to do gymnastics sport {aerobic gym, etc} and jogging. There was a field for sport in each block village, sport’s club like gymnastic, health’s heart club, badminton’s club, football’s club, basketball’s club. The promotion can use sport club to change the lifestyle. The strategy that can do, involves sport’s instructor by adding the knowledge of lifestyle healthy and medical to them. The Healthy Heart Club and others sport clubs are can be gotten an embryo or entry point development to make community like sport. The clubs existed and had many members who want to spend the money to the club. However, this organization must be involving to controlling risk factors of NCD.

There are some potential community figures and health volunteers interest to promote healthy lifestyle. Beside, the community figure has had enough knowledge and prevention of some NCD risk factors. The appropriate ways to promote healthy lifestyle are promotion, create cadres, and involve the community figure to set an example is. The goal of change should be appropriated promoters characteristic and material promotion. We will use the organization/club that it exists, such as Healthy Heart Club or others clubs/gathering. If the new way will be informed, it should be taken negotiation among community. Represent by the community figure and the board will be taken by community who lives there. The changing will be appropriated gradually on material promotion.

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Beside it also are informed health’s cadres to promote it, to involve the community figure to set an example for healthy lifestyle properly.

3.1.8 Health city forum of Depok

Health City Forum of Depok (“FKDS”) is an umbrella organization of activity across sector and program beyond Healthy Depok in 2009 with legitimating from the major. There are many stakeholder in Depok Municipality which consists of representative from local government, Health NGO, industry, private business and community figures.

3.2 Community diagnosis

To keep of the sustainability of NCD prevention and control program, it is potential to consider the concept ‘supply creating demand approach’ and ‘demand creating supply approach’, currency flow as a kind of fuel which should be always available to maintain the activity running, and the success will depends strongly on the driver, which is usually applied by private business and community resources (self funding and self managing) are more exceptional. Based on the concept mentioned above, people are economically better to spend their money, especially for those who prefer to private institution, on services and goods offered by positive health market e.g. fitness centre, self-defense club and dance machine. However for the low segment social class and some unprofitable business of risk factor prevention, smoking, role of NGO and health services are still required and funding should be always allocated by the local parliament accordingly.

Therefore, the activity for prevention and control on risk factors of NCD could be conducting by a combination of the two approaches (‘supply creating demand approach’ and ‘demand creating supply approach’) should be conducting through ‘FKDS’ by synergistic and integrated. Base on situation analysis as regard to condition of health in community include the health seeking behavior of community, their limitation and potential resources, intervention program which are required and possible to be effective and also applicable for integrated prevention and control of NCD risk factors are: 1) Facilitating the Healthy Heart Clubs and others of sport clubs in physical activities 2) Capacity building of the ‘PKK’ member skill and knowledge in diet and stop smoking

programs 3) Developing a gathering/clubs in community to be “Posbindu PTM” as an integrated

health post for monitoring and early prompt counseling on common risk factors of NCD by community participant)

4) Increasing the active roles of private sector in program for physical activities and reducing body weight

5) Reorienting a health services program in PHC to be “Yandu PTM” as integrated health care for common risk factors of NC, which also integrated with the general health care.

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3.2. Intervention strategy

3.2.1 Concept development of strategy

It is known that the prevalence of particular non-communicable diseases tends to increase due to environmental changes such as age structure, life style, and social cultural. An effective and efficient prevention and control of NCD should be developed through promotion and prevention to control the risk factors (primary prevention), and through an effective curative action to prevent further complication diseases (secondary prevention), and through rehabilitative programs to manage the disability resulted by NCD for better quality of life. It will be less effective if the programs don’t involve the community itself, as an individual, household, or community including private sector, non-government organization, and others. Based on the result of pilot study, the promotion programs and providing facilities for NCD programs at local health centre had not achieved the target. This is because the programs mostly depend on skill and availability of health workers of the local health centre, meanwhile, community sometimes feel healthy and doesn’t fully aware of their health need. In that case, community should be proactively participate in an intervention program. 8,13, 27,33, 37-40

Besides, health behavior changes in community related to government policy and other non-health sectors policy, and it will need a cross program approach as well to gain their view point on public health. Therefore, it is very important to increase motivation and education of community health behavior by involving individual, household, organization, private, and other related sector. It is very crucial to have commitments from local government, local parliament, and other related sectors to manage NCD problems. These include: NCD control programs and its operational responsibility at health office and health centre level; adequate facilities for NCD control programs; legitimating for community participation in primary prevention program; and policy and regulation which give opportunity for the community to apply healthy life style (for instance: free tax for fitness centre, restriction for tobacco advertisements by high tobacco tax ). In other word, the community must proactively involve in health care even though it is government responsibility, and on the other hand the government has to give more concern to public health problems and gives necessary support to health programs. However, commitment from local government and parliament will not accrue without evidences for policy support regarding NCD control program. Therefore facilitation is needed to improve health worker’s skill and ability at local health office to evaluate NCD problems and its determinants in the environment and then should be disseminate of adequate information for policy makers through advocacy and planning for comprehensive NCD control programs. 14, 18, 23, 24

Unhealthy life style strongly influences the increasing of NCD risk factors, in the meantime, recent community life style closely relates to social economy cultural status.

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Therefore, by improving community participation, we can conduct more integrated community-based intervention program and effective NCD risk factors control program. In this case, the community should be given responsibility in improving their health behavior and life style through ‘community based development’. By gaining the community participation, the community will participate and capable to proactively improve their life style and controlling NCD risk factors independently. Hence, the NCD control programs should be focused on integrated measures as well as involve the community themselves in planning, operating, monitoring and evaluating activities. Consequently, it requires health workers who have adequate skill and capability to motivate the community and to give optimum health care concerning NCD. However, the community and health providers basically cannot work effectively unless supported by conducive environment including adequate facilities.

3.2.2 The main of strategy intervention

In regard to its definition, it is described that community-based prevention program as being integrated (across risk factors and diseases, across services and disciplines), and comprehensive across levels of prevention and care, and are not limited to clinical care settings. They use multiple interventions, target change among individuals, groups, and organizations, and often incorporate strategies to create policy and environmental changes. The role of the community is target of change, the community as agent with developmental capacity, and the community as resource with a high degree of ownership and participation. Accordingly, strategy and activity that had been applied in the CBI of NCD risk factor prevention and control program, were basically addressed to solve community problems, and developed by involving community in adjusted to local need, available resources and community readiness.

The strategy was developed using conceptual framework of health promotion strategy of Ottawa Charter.29 Six strategies had been applied in Depok, started with NCD risk factors surveillance activity. The NCD risk factors surveillance results were utilized as evidence based for program development. Providing evidence base program is substantially important in the CBI strategy and results of NCD risk factors surveillance can be a starting point or baseline for program plan and as evaluation of intervention programs.

The CBI on NCD prevention and control program in Depok has been developed in line with the community setting and available government system from the lowest administrative unit until the district government level. The development of health service system and management of NCD involved all sectors in community, PHC, hospitals, and health administration in Depok Health Office. Several activities regarding NCD prevention and control program had been carried out. Those activities included exploration, trial and development of STEPS survey and intervention strategy during 2001 to 2002.The intervention for NCD risk factors control programs requires a comprehensive program

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with the focus on common risk factors control, which needs to be supported by several aspects such as policy, social environmental aspect, community participation, individual capability, and health service function.

The strategy of CBI was developed in line with decentralization system in Depok, which is also applied in other districts in Indonesia. This study is expected to obtain effective CBI model for the NCD prevention program, which is can be adopted by other districts or village in Indonesia, by applying integrated strategy of community and market based approach. The study has been conducted base on structure that has been provided in their community. At the end, it is expected that the prevalence of non-communicable diseases can be controlled continuously.

Health Promotion strategy from Ottawa Charter is used as a concept which emphasizing on local potential resources and its limitation. There strategies include:

1) NCD risk factors Surveillance

Implementation of NCD risk factors Surveillance and mortality survey are required to carry out regularly to obtain accurate information as an evidence base and to gain awareness among the policy makers at the local government and parliament. Data from the surveillance activities is used for the baseline and evaluation data of the intervention strategy. The STEPS survey implementation should be conducted to completely. (Step1,2,3), to obtain information of non communicable diseases, because information of risk factors only, was not sufficient to get the policy support from to the policy makers.

2) Coordinating policy

Information from the NCD risk factors surveillance activity have been utilized for advocacy to integrate NCD control program to other sectors at the local government to support policy to accelerate Healthy Depok 2009. Integrating policy for NCD control program and local government policy for Healthy Depok through activities on a forum of healthy city of Depok This means ‘linking’ the healthy life style program and orienting health services for NCD on health service management to increase Life Expectancy and Human Development Index. This strategy should be done to obtain a policy support for NCD program and to make it sustainable.

3) Strengthening individual skills

Several activities had been done to strengthening the individual skills include capacity building of the health workers, volunteers, and local community. This is aimed to increase individual skill to perform healthy life style and strengthening individual capability in controlling NCD’s risk factors independently, by conducting series of training for health workers, volunteers, and other interested community member. Also, this strategy gives focus on gaining skill of health workers in NCD control management program, including

28

physician’s and paramedic’s skill, conducting public seminars on NCD and its risk factors control programs, and distributing poster of health behavior.

4) Enhancing social environment

This substantially means certifying that social organization increase wellbeing. The strategy is aimed to create supportive environment in regard to prevent the occurrence of NCD and its risk factors and to increase people awareness of healthy behavior by involving several NGO such as local healthy heart club, workers association, health insurance, etc. Motivating and facilitating community organization and private sectors to actively participate in controlling NCD and developing ‘Posyandu Usila’ (integrated health post for elderly) to become ‘Posbindu PTM’ (integrated health post for NCD). ‘Those activities must have legitimacy from local government, and guided by local health centre, and facilitated by local health office for the implementation and program development. Other activity, includes build an active partnership between government, non-government organization and the local community to increase community awareness concerning NCD and its risk factors. It also activates ‘Healthy and Clean Friday’ activity, which is a routine activity of cleaning the workplace environment among the government institutions on every Friday, that have been applied since several years ago, but less active recently

5) Enabling strong community action

Activities in this strategy were intensive community campaign, public seminar, poster distribution, and publish a book. As a health extension material to arise community knowledge about integrated NCD risk factors control, “CERDIK” poster (The meaning is SMART behavior which contain message for controlling risk factors of NCD)” and guidance book “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, were created. Some of public seminars were aimed to increase people awareness to NCD and its risk factors. The target is local community, especially the high risk age group (25 to 64 years old), diabetes patient and hypertension.

6) Reorienting health services

Previously, the Public Health Centre in Depok is only provided a basic/general of health services. Considering potential resources and some limitations, there are two main aspect of health service that need to be focused on, which are: a) Improve and facilitate the function of the gathering activities in community to become

‘Posbindu PTM’ (integrated health post for NCD). ‘Posbindu PTM’ is an outcome of community participation in promotion and preventive measure for early detection of NCD risk factors (hypercholesterolemia, hypertension, hyperglycaemia, unhealthy diet, and smoking), which includes risk factors monitoring activities, gaining knowledge of NCD risk factors preventions by health counseling, and refer of cases who have risk factors of NCD to PHC. Those activities are conducted by community (trained health

29

volunteer) and for community, which have legitimacy from local government, guided by local public health centre, and facilitated by local health office for the implementation and program development. Management and financial support of ‘Posbindu PTM’ are arranged according to agreement among the community of ‘rembug warga’, and reported to the public health centre. ‘Posbindu PTM’ is a generic name for the activity that can be carried out either at residential environment, working environment, or other public places. Detail information of ‘Posbindu PTM, monitoring procedure, and forms, can be seen on attachment 8.

b) Improve of health services function in PHC to providing clinical health service for controlling of risk factors of NCD. The program called a ‘Yandu PTM’ (integrated curative for patient with common of risk factors of NCD). The ‘Yandu PTM’ is an activity that is managed by local public health centre for curative and rehabilitative aspects to control NCD risk factors (hypertension, hyperglycaemia, hypercholesterolemia, obesity, unhealthy diet, and smoking) by counseling therapy and medication. This also includes improving referral system and collaboration with the general hospital that has been providing services by internists. The activities have been supported by the legitimacy, fund adequate and facilities from the local government. The price for activities in ‘Yandu PTM’ are managed by the health centre board, and how much the patient should pay for the health service at ‘Yandu PTM’ was decided by the agreement among the community of what it called ‘rembug warga’ or community agreement.

3.2.3 Frame work of CBI

The frame work of CBI on prevention and control of NCD and risk factors, can see diagram 1 as bellow.

30

• Smoking • Diet • Low activity

• Blood pressure • Blood cholesterol • Overweight • Blood Glucose

Public Primary Health Cervices

and

Private Primary Health Cervices

Diagram1. Frame work of Community Based Intervention Strategy on Prevention and Control of Risk Factor of NCD Program

Social Structure

• Social status • Age • Gender

• Geographic • Access • Work Place • Housing

Environment

Life style

Physiology

In te gra ted N C D’s Pro gram and Po licy

A D V O C A C Y

Surveillance Risk Factors Of Major NCDs

Information of NCD’S and Risk Factors

EVALUATION BASE

PROCESS EVALUATION IMPACT EVALUATION EFFECT/OUTCOME EVALUATION

MONITORING

Organization

and

Community

Enabling Strong Community Action Enhancing Social Environment Strengthening Individual Skills Reorienting services

N E T Work ing for Co or dina ting

31

4. IMPLEMENTATION 4.1 Program and activities

In the process of program development and activities we carried out series of meetings with policy makers, local health office, other sector related, FKDS as forum of stake holder in Depok, and experts from Ministry of Health, involving directorate of health promotion, directorate of medical service, directorate of community health, as well as from Cipto Mangunkusumo general hospital, Harapan Kita hospital, and from NGOs such as Healthy Heart Club, Cancer Association, and Stop Smoking Association. During the project implementation we develop several activities, which were arranged according to the intervention strategy. The programs/activities which had been plan, target intervention and objectives each program can be find in Matrix 3.

The implementation of community based intervention (CBI) of NCD risk factors prevention and control program had been initiated since February 2003 and completed on July 2006. The activities of CBI was in collaboration with several related institutions at central level, province level, as well as district level of government office. Institutions involved from the central level were:

a. Ministry of health (Center of Health Promotion, Directorate of Medical Service, Directorate of Community, and National Institute of Health Research and Development).

b. RSCM – Faculty of Medicine University of Indonesia General Hospital c. Cardiology unit, Harapan Kita Hospital d. Center of Indonesia Healthy Heart e. Smoking Control Organization f. Ministry of Education g. Ministry of Agricultural

Institutions involved from the Province level were as follow:

a. Sub unit of Surveillance system in West Java Health Office b. Sub unit of Health Promotion in West Java Health Office c. Sub unit of Primary Health Service, West Java Health Office

Institutions involved from the District level were as follow:

a. Depok Health Office and other related sectors (education, agriculture, city planning, and demography).

b. Depok Government Office (City Major and District Development Office) and District Parliament for Depok.

c. Public Health Centers (intensively with Abadijaya PHC) d. Health and non health NGOs

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e. Industry and Business Association in Depok f. Local community member, health volunteer, public figure in Depok,

particularly in Abadijaya village. 4.2 Monitoring programs and activities

The indicator of each activity and the monitoring methods can see in Matrix 4. Program/activities were conducted simultaneously, as in the agenda or time frame (see Matrix 5).

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Matrix 3 : Objectives, targets, and facilitators of the activities on each Strategy

Strategies Activities Objectives Targets Fasilitator

Socialization of goals and benefits of NCD risk factors surveillance to stakeholders and community

Increasing community response to the NCD RF surveillance

• Community • Stakeholders in Depok

Training of NCD RF surveillance for local health workers

Transfer knowledge and skill in NCD RF surveillance, coordinated by Depok Health Office

• Health workers in Depok Health Office

• NGO in Depok

Implementation of NCD RF surveillance

To provide evidence based of NCD and its risk factors

• Community age 25 to 64 years old.

Surveillance of risk factor of NCD

Dissemination of NCD RF surveillance to the related stakeholders and community

To give inputs to policy makers and decision makers, and coordinator of PC NCD programs.

• District policy makers • Program coordinator for

PC of NCD

NIHRD (National Institute of Health Research and Development, Ministry of Health )

Establishment of Healthy Depok City Forum

To provide forum for communica tion and coordination to integrated action to support NCD prevention and control.

All stakeholders and NGOs in Depok

• NIHRD • Health office • Center of HP

Workshop to develop of programs/ activities for PC of NCD and risk factors in Depok

• to develop comprehensive a PC of NCD and its risk factors program according to local community condition, needs, and resources

• Program coordinator at Depok health office.

• FKDS • District Development Office

• NIHRD • Local health

office • Center of Health

promotion

Policy development and Coordinating

Advocacy about NCD and its risk factors as public health problem in Depok

• To gain awareness to get policy suport of NCD problems among policy makers and stakeholders in Depok.

City major, District parliament , local health official, statistical bureau, and other related sectors, FKDS

• NIHRD-MOH • Dir general of

Medical Services • Center of HP

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Round table discussion of the implementation of NCD health service (“Yankes PTM”) in the public health center and integrated health post of NCD (“Posbindu PTM”) in the community.

• To expose other regions with success and constraints of NCD control programs in Abadijaya village.

• To motivate other regions to actively develop of NCD control programs.

• To build collaboration and commitment in developing NCD risk factors control program with other district health office in West Java.

• Program coordinator at Depok health office.

• Healthy Depok City Forum • District Development Office • Abadijaya Public Health

Center (PHC) • Other PHC in Depok • Coordinator of “Posbindu

PTM” in Abadijaya village • Coordinators of other

“Posbindu PTM”

• NIHRD-MOH • Directorate

general of Medical Services

• Center of Health promotion

• Directorate of Communities MOH-RI

• NIHRD-MOH • WHO

Round Table Discussion of building commitment to PT ASKES (health insurance) in Depok

To accomplish the NCD medicines requirement in Public Health Center.

Decision makers from PT Askes in Depok and Central office, head of local Public Health Center, local district health office, local government of Depok.

• NIHRD-MOH • Dit.general of

Medical Services • Center of Health

promotion • Dit Communitas

MOH-RI • NIHRD-MOH • WHO

Conducting forum of communication and coordination of stakeholders and health workers in NCD control programs in Depok.

Strengthening the networking and collaboration for sustainability of PC of NCD and its risk factors.

Local health official, statistical bureau, and other related sectors (health, education, industry, agricultural, city planning, demography, health insurance, private hospitals), and FKDS

• NIHRD-MOH • Dit.general of

Medical Services • Center of Health

promotion • Dit Communities

MOH-RI • NIHRD-MOH • Local Health

35

office • WHO

Round Table Discussion of Diet and Physical Activity

Develop plan of action for Diet and Physical Activity program in related to NCD prevention and control program

District Health Office District Education Office City Planning Office NGOs Depok Government Office

• District Health Office

Training program of controlling risk factors (primary prevention) and clinical case management for cardiovascular diseases, diabetes mellitus, and cancer (secondary prevention), for physician, nurse, and dietitian.

Gaining knowledge and skill of physician, nurse, and dietitian in controlling major NCDs (cardiovascular diseases, diabetes mellitus, and cancer) through promotion, preventive and curative.

Physicians, nurses, and dietitians in Depok (priority for health workers of public health center and health volunteer in Abadijaya)

• Center of Lipid and Dibates Mellitus, e of Ciptomangunkusumo hospital

• Social cardiology of Harapan Kita hospital.

• Social Oncology of Dharmais Cancer hospital

Training in management of “PosBindu PTM” and “Yandu PTM” for the health workers

Increasing health worker’s ability in developing UKBM in services for NCD and its management.

• Health worker in Depok health office.

• FKDS • Health workers from PHC

Training in management of “PosBindu PTM” and for potential and active volunteer.

Gaining community’s skill in managing “PosBindu PTM”

Active and potential individual in community

Strengthening Individual Skills

Training for potential health volunteers, with the topics of

anthropometry measurement, and blood pressure measurement. Healthy diet, Exercise for healthy

Gaining the health volunteer’s skill knowledge and capability early detection of risk factors of NCD and to become health educator in healthy diet , physical

Active of health volunteers with educational background of minimum of three years health diploma.

• Dit. General of Community MOH-RI

• Health insurance safety (JPKM)

• Healthy heart association

• Other health association (Persadia, LM3)

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heart and Diabetes mellitus., Stop smoking program

activity stop smoking program.

Training program of controlling risk factors (primary prevention) and clinical case management for cardiovascular diseases, diabetes mellitus, and cancer (secondary prevention), for physician, nurse, and dietitian.

Gaining knowledge and skill of physician, nurse, and dietitian in controlling major NCDs (cardiovascular diseases, diabetes mellitus, and cancer) through promotive, preventive and curative aspects.

Physicians, nurses, and dietitians in Abadijaya PHC and medical doctors from private clinics in Abadijaya village in Depok.

• Center of Lipid and Dibates Mellitus, RSCM Hospital

• Social cardiology of Harapan Kita hospital.

• Social Oncology of Dharmais Cancer hospital

Training for potential health volunteers, with topics of anthropometry measurement, and blood pressure measurement, healthy diet, Exercise for healthy heart and Diabetes mellitus., Stop smoking program, management of “PosBindu PTM”

Gaining the health volunteer’s skill knowledge and capability early detection of risk factors of NCD and to become health educator in healthy diet , physical activity stop smoking program.

Active health volunteers of “Posbindu PTM

• Dit. General of Community MOH-RI

• Health insurance safetiness(JPKM)

• Healthy heart association

• (Persadia, LM3)

Enhancing Social Environment

Workshop on PC of NCD by industries and development of partnership program in controlling major NCD’s risk factors

• To develop surveillance program and control program for NCD’s risk factors in working environment.

• To develop of partnership in NCD’s promotion and preventive programs

• Industrial sectors in Depok • Private sectors in Depok,

which relate to NCD’s risk factors (fitness center, restaurants, etc)

• Entrepreneur Association • Trade Association Depok

• Center of Occupational health, MOH-RI

• Center of Health Promotion, MOH-RI

• NIHRD-MOH-RI Enabling Strong Community

Free distribution of poster to gain individual and community skill about NCD risk factors, at schools, working places, health centers, and

• Enhancing community awareness of healthy life style.

• Improving community’s

• Community, health volunteer • City forum of healthy Depok

• Depok health office

37

Action other public places. Free distribution of guidance book, which has title of “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, to community.

knowledge in controlling NCD’s risk factors in integrated approach.

Reorienting services

Improve and facilitate the function of the gathering activities in community to become ‘Posbindu PTM’ as integrated health post for monitoring, early detection and control of risk factors NCD regularly

To gain community awareness to monitor NCD risk factors periodically and routine, to enable community preventing NCD by healthty diet, adequate physical activity and avoid smoking.

“Posbindu PTM” in Abadijaya village

• NIHRD • City forum of

healthy Depok • Depok health office • Intervention team

Improve of health services function in PHC to providing clinical health service for controlling of risk factors of NCD in integrated approach

To meet community need on effective health services for NCD case in PHC

Abadijaya PHC • Center of Lipid and Dibates Mellitus, RSCM Hospital

• Depok health office

Publication Posbindu PTM to other villages.

Motivate other districts or villages to develop ‘Posbindu PTM’

38

Matriks 4 : Indicator of Intervention Activities Monitoring

Indikator Activities

Input Impak/Output OutCome

Monitoring Method

Socialization of goals and benefits of NCD risk factors surveillance to stakeholders and community

WHO STEPS wise approach for surveillance risk factors of NCD and facilitation

Respon rate of NCD RF surveillance

Prevalence/proportion and mean value of NCD RF

Training of NCD RF surveillance for local health workers

WHO STEPS wise approach for surveillance risk factors of NCD and facilitation

Capacity of District Health Office in implementing the NCD RF Surveillance

Prevalence/proportion and mean value of NCD RF

Implementation of NCD RF surveillance

WHO STEPS wise approach for surveillance risk factors of NCD and facilitation

Availability of evidence based of NCD and its risk factors.

Prevalence/proportion and mean value of NCD RF

Dissemination of NCD RF surveillance to the related stakeholders and community

Results if NCD RF surveillance PTM

Implementation of dissemination

Presentation method

Utilization of Information from NCD RF survey for planning and program development of NCD prevention and control and/or determine the health program prioriy.

Prevalence/proportion and mean value of NCD RF

WHO STEPS wise approach for surveillance risk factors of NCD

Report Documentation

Establishment of Healthy Depok City Forum

Number of Healthy Depok City Forum participants Meeting agenda Time, venue, and budget of the meeting

Number of meeting per year Number of social action per year Number of advocacy activity per year Proportion of stake holder member involved in the activity

Prevalence/proportion and mean value of NCD RF

Report Documentation

Advocacy by Round Table Discussion about NCD factors as public health problem in Depok

Time, Venue,type of information Method of teaching Target proportion of audience

• Policy of NCD’s risk factors control program available.

• Support from other sectors

Prevalence/proportion and mean value

Report Documentatio

39

• Amount of local government budget for NCD’s programs.

• Number of policy regarding NCD’s control programs.

of NCD RF n, planning

Workshop to develop of programs/ activities for PC of NCD and risk factors in Depok

• Appropriate structure for NCD’s programs

• Availability of coordinator for NCD’s program.

• Appropriate infra structure of NCD’s program.

• Appropriate of medication facilities at local health center

• Availability of budget • Facilitation

• Agreement of strategy, program, and activities and its intervention targets

• Number of applied NCD’s programs

• Number of planning program of NCD’s PC programs

Prevalence/proportion and mean value of NCD RF

Report Documentation

,planning, report of institution survey

Round table discussion of the implementation of NCD health service (“Yankes PTM”) in the public health center and integrated health post of NCD (“Posbindu PTM”) in the community.

Time, Place Discussion process

Proportion of target audience Adequate facility Quality of moderator/facilitator

To Prevalence/proportion and mean value of NCD RF

Report Documentation

Round Table Discussion of building commitment to PT ASKES (health insurance) in Depok

Agreement on type and quantity of medicine of NCD patients covered by health insurance of ASKES

Adequate availability of medicines for NCD case who were covered by the health insurance

Prevalence/proportion and mean value of NCD RF

Conducting forum of communication and coordination of stakeholders and health workers in NCD control programs in Depok.

Time, Place Discussion process

Proportion of target audience Adequate facility Quality of moderator/facilitator

NCD sustainable program plans had been done program related to NCD prevention and control program in other sector

Prevalence/proportion and mean value of NCD RF

•

Training program of controlling risk factors (primary prevention) and clinical therapy for cardiovascular diseases, diabetes mellitus, and

Time, Place Discussion process

Proportion of target audience Adequate facility

• Knowledge of health workers concerning community participation and its management.

Prevalence/proportion and mean value of NCD RF

40

cancer (secondary prevention), for physician, nurse, and dietitian.

Quality of facilitator Material

Training in management of “PosBindu PTM” and “Yandu PTM” for the health workers

• Community knowledge concerning management of “PosBindu PTM & YanduPTM.

Prevalence/proportion and mean value of NCD RF

Training in management of “PosBindu PTM” and for potential and active volunteer.

Increasing knowledge of NCD among industries and private sectors.

Prevalence/proportion and mean value of NCD RF

Training for potential health volunteers, with the topics of

anthropometry and blood pressure measurement, healthy diet, Exercise for healthy heart and Diabetes mellitus., Stop smoking program

Increasing of community knowledge about NCD’s risk factors and its control program.

Prevalence/proportion and mean value of NCD RF

Training program of controlling risk factors (primary prevention) and clinical therapy for cardiovascular diseases, diabetes mellitus, and cancer (secondary prevention), for physician, nurse, and dietitian.

Increasing health worker’s skill in controlling risk factors of cardiovascular diseases, diabetes mellitus, and cancer.

Prevalence/proportion and mean value of NCD RF

Training for potential health volunteers, with the topics of anthropometry and blood pressure measurement, healthy diet, Exercise for healthy heart and Diabetes mellitus., Stop smoking program, management of “PosBindu PTM”

Volunteer’s skill in promoting healthy diet, gaining physical activity, and stop smoking habbit.

Prevalence/proportion and mean value of NCD RF

Workshop on PC of NCD by industries and development of partnership program in controlling

• • Prevalence/proportion and mean value of NCD RF

Report Documentation

41

major NCD’s risk factors

Free distribution of poster to gain individual and community skill about NCD risk factors, Free distribution of guidance book, which has title of “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, to community.

• Material • Area of distribution

Increasing of alertness and knowledge

Prevalence/proportion and mean value of NCD RF

Observation

Improve and facilitate the function of the gathering activities in community to become ‘Posbindu PTM’ as integrated health post for monitoring, early detection and control of risk factors NCD in regular base

Implementation of “Posbindu PTM” activity in regular and periodic. Increasing of “posbindu PTM” ratio to number of RW (administrative unit)

Increasing coverage of who participated in NCD risk factor monitoring periodically

Prevalence/proportion and mean value of NCD RF

Rekapitulasi “Posbindu” Record, phone communication Field visit Survey

Improve of health services function in PHC to providing clinical health service for controlling of risk factors of NCD in integrated approach.

Implementation of NCD integrated health service in PHC. Sufficient facilities and medicine for NCD patient in PHC

Increasing number of NCD case who were followed up by PHC

Prevalence/proportion and mean value of NCD RF

Recapitulation of results Recording and reporting of NCD case in PHC

Publication of Posbindu PTM to others villages

Frequency of publication on “Posbindu PTM”. Abadijaya ‘Posbindu PTM” had been visited by other villages

Implementation of “Pobindu PTM” activity in routine and periodic time in other villages in Depok.

Prevalence/proportion and mean value of NCD RF

Report documentation

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Matrix 5 : Activities Schedule in 2003-2006

2003-2004 2004-2005 2005-2006 Activities

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

15

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

Socialization of goals and benefits of NCD risk factors surveillance to stakeholders and community

Training of NCD RF surveillance for local health workers

Implementation of NCD RF surveillance

Dissemination of NCD RF surveillance to the related stakeholders and community

Establishment of Healthy Depok City Forum

Advocacy NCD and its risk factors as public health problem in Depok

Workshop to develop of programs/ activities for PC of NCD and risk factors in Depok

Training for potential health volunteers, with the topics of

Healthy diet, Exercise for healthy heart and Diabetes mellitus., Stop smoking program

43

Training program of controlling risk factors (primary prevention) and clinical therapy for cardiovascular diseases, diabetes mellitus, and cancer (secondary prevention), for physician, nurse, and dietitian.

Workshop in controlling NCD for industries and potential private sectors and discussion of partnership program development in controlling major NCD’s risk factors

Free distribution of poster to gain individual and community skill about NCD risk factors, “CERDIK”

Improve and facilitate the function of the gathering activities in community to become ‘Posbindu PTM’ as integrated health post for monitoring, early detection and control of risk factors NCD regulary

Improve of health services function in PHC to providing clinical health service for risk factors of NCD integratedly.

Publication of Posbindu PTM to other villages

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5. EVALUATION

5.1 Result of process evaluation

All the programs and activities had been accomplished as planed, however not all the activities could be done promptly as in the schedule. During the last Depok Government Office, especially Depok Health Office has plenty of programs and activities. Parliament election and Indonesian President Election occurred in 2004, while Depok Major Election was on 2005. Those important agenda took lots of energy and time of most people in Depok, particularly the government employee. The next few sections will present the results of process evaluation of each program.

5.1.1 NCD RF Surveillance in 2003

5.1.1.1 Sampling and Response Proportions of surveillance

Data was collected by inviting respondents to the two places, Abadijaya Public Health Cervices (PHC) and Abadijaya village office. Particularly for respondents who were living quite far from the PHC, the data collection was conducted in the local administrative unit (RW). Respondent who was not able to attend were not replaced, but they got second invitation to attend on the following week. Home visit was performed when the respondent could not attend after the third invitation. Although this strategy requires more time, funds and human effort, but it leads to greater response rate.

Out of 2200 respondents, who were stratified randomly selected by sex and age group in the Abadijaya village using two stage cluster random sampling, there were 847 men respondents (77%) and 959 women respondents (86.9%) had been interviewed for Step 1 and Step 2 approach. Meanwhile, 686 men respondents (62.36%) and 934 women respondents (84.9%) participated for Step 3 approach (measurement of fasting blood glucose and two hours pp blood glucose, and total blood cholesterol) and 161 men and 25 women were not eligible for the blood examination because they didn’t complete the fasting requirement. The lowest respondent’s response was among man age 25 – 34 years old, while the highest was among women age 55 – 64 years old. (See attachment 13 Data Book 2003 table 1.1 up to 1.3).

Results of the survey showed that older age group and females had higher response rate than younger age and males. Higher response rate among older age and women is most likely because of older respondents tend to give higher concern on health, and usually, women have more self-aware on health. Generally, man respondents feel more apathetic to check their health due to economical aspect. They think that it would be useless if they found their sickness but they can not afford to cure it. Besides, due to man natural typical, man mostly ‘feels’ more strong and healthy than

45

women, which make them deny their health problems. In the mean time, respondent’s response proportion that above the targeted respondents, might due to sampling error. Because, sampling frame was performed based on the data from the previous year (year 2002), which lead to age group alteration. Approximately 30 respondents (1.6%) had categorized into older age group. As it mentioned above, the respondent distribution were mainly women and older age group. However, the different in age and sex was not proportionally significant, which was 1 – 8.6 % (< 10 %).Therefore; the data was representative to describe risk factors based on age and sex.

Prevalence of NCD (diabetes and hypertension) in Depok was generally higher than the national figures, in which mostly found among males.15, 31 Those described that Depok society especially males had bigger chance to have higher NCD prevalence. In the case of diabetes mellitus and hypertension, it was known that it was not the number one cause of death diseases in Indonesia, but the acute complication of diabetes mellitus and hypertension may lead to higher mortality rate, while the chronic complication can lead to other diseases such as stroke, blindness, coronary heart diseases, chronic kidney diseases, gangrene, and impotent, which those would lead to great issue on survival, disability, and less productivity, as well as costly health expenditure for the community. The health problems not only had negative impact to individual or community, but also for the government, as it would influenced economy status, especially when diabetes occurred among those who still economically productive.31 Because of that, we concern more to those diseases in prevention and control program.

5.1.1.2 Risk Factors of NCD in 2003

More detail figures of NCD risk factors surveillance results on 2003 can also be seen on Data Book 2003, which attached and in fact sheet 2003 at attachment 11. Data of tobacco use can be seen on table 2.1 up to table 2.8. In general, the prevalence of daily smokers was 32.9% among men and 3,8% among women. Women mostly started smoking at older age than men (mean age were approximately18.4 years old in men and 22.9 years old in women). Table 3.1 describes alcohol consumption in last 12 months, it shows that the prevalence of current consumers was higher (6.1%) in men than in women (0.2%). The average number serving per day of fruit intake was about 1.8 serving among men and 1.8 among women. Then, the average number serving per day of vegetables intake was about 1.7 serving among men and also women (Table 4.1). The prevalence of fruits and vegetables consumption > 5 servings per day was 11% for men, and 14.5% for women, while prevalence of not consume fruits and vegetable everyday was higher for men (19.5%) than women (9.8%) (see table 4.2). Regarding type of oil consumption, it shows that most of respondents consume palm oil. Table 5.1 to table 5.7on Data Book 2003, was illustrate physical activity status at work, during transportation, and during leisure time, by age and sex. The prevalence of low level activity was 19.5% in men and 12.3% in women (see Table 5.1), while the median time

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of total physical activity per day was 94.3 minutes among men and 138.3 minutes among women (see Table 5.2). Other physical activity descriptions can be seen in several other tables 5.3 up to 5.7 in Data Book 2003).

Raised blood pressure and diabetes history is described on table 6.1 to table 6.5 on Data Book 2003, and also fact sheet. Regarding the time elapsed since most recent blood pressure measurement of less than 12 month among men were 72.7%, and 15.8% for time elapsed of 1 to 5 years, and 11.5% for time elapsed of more than 5 years. While among women were 73.5% for time elapsed of less than 12 months, 16.4% for time elapsed of 1 to 5 years, and 10.1% for time elapsed of more than 5 years. While confirmed diagnosis of raised blood pressure by health workers during past 12 months was slightly higher among men (16.4%) than women (15.6%) and confirmed diagnosis was 3.6 % among men and 2.3% among women. Other description of raised blood pressure history and diabetes can be seen on several other tables.

As can be seen on data book on table 7.2 the mean value of Body Mass Index was slightly higher in women (24.8) than in men (23.6). The prevalence of obesity was also higher among women than men. The prevalence of high waist-hip ratio (WHR > 1) was 0.8 % in men and 17.7 % in women (WHR > 0.85). Table 7.6 shows that average systolic blood pressure was 122.5 mmHg for men and 117.6 mmHg for women. Prevalence of raised blood pressure (SBP >= 140 and/or DBP >= 90 mmHg) was 9.2 % among men and 7.9 % among women. While the prevalence of raised blood pressure (SBP >= 170 and/or DBP >= 100 mmHg) was 4.5 % among men and 2.9 % among women.

Table 8.1 to table 8.6 illustrate the result of biochemical measurement, including blood glucose, blood cholesterol and triglyceride measurement. As can be seen on table 8.1 the mean value of fasting blood glucose among men was 4.9 mmol/L and women 4.8 mmol/L, similarly, the prevalence of high blood glucose (≥ 7 mmol/L) for fasting blood glucose was 5.3 % for men and 5.2% for women. The mean value of 2 hours of blood glucose after glucose load was 7.8 mmol/L in men and 7.7 mmol/L in women, while the highest blood glucose level was 11.7 mmol/L. The prevalence was rather higher among men (11.7 %) than women (8.8%). Based on diabetes mellitus diagnosis criteria (fasting blood glucose >= 7 mmol/L and or 2 hours of blood glucose after glucose load >=11.7), the prevalence of diabetes in Depok was 9.8% for men and 10.1% for women. Concerning the fasting blood cholesterol, the figures show that the mean value and the prevalence were slightly greater among women than men. Table 8.4 and 8.5 explain that mean value of blood cholesterol was 4.6 mmol/L among men and 4.8 among women, while the prevalence of high blood cholesterol ( ≥ 5.2 mmol/L) was 28.8% in men and 31.3% in women. Similarly, the prevalence of high blood cholesterol ( ≥ 6.5 mmol/L) was 5.6% in men and 5.5% in women.

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5.1.1.3 Utilization of surveillance risk factors NCD information Community based surveillance of NCD risk factors had been applied in Depok.

The data collection method in the surveillance was interview, physical measurement, and blood measurement. Personnel in data collection activity was health workers who had education background at least one year diploma, and member of Healthy Depok City Forum who had education background at least three years diploma. Coordinator of Health Service Unit Depok Health Office, was involved the activity. Technically, capacity of Depok Health Office in conducting the NCD risk factors surveillance was inadequate. That was because of the limited capacity of the human resources. Not all the trained personnel got involved in the surveillance activity. There was lack of commitment consistency among the health workers who had been trained as data collection personnel in the NCD risk factor surveillance. The health workers who had been trained sometime had to move to other unit and could not participate in the date collection activity. In the future, selection of surveillance personnel should involve more health workers at all unit in Depok Health Office.

Strong commitment from local government, parliament, and from other related sectors such as health insurance company are necessary to make sustainable program on NCD prevention and control. The commitments include policy on program implementation, financial support; provide adequate diagnostic facilities and other technical medical necessity, legitimating the community based program, district government regulation on health services, and district government policy on healthy life style environment that enable community to get more access on health living, such as giving free tax for fitness center or sport club, restriction on smoking advertisement, or use the cigarette tax for health promotion program.

The commitment and policies mentioned above could not be achieved without accurate and representative information as evidence based for advocacy to the policy makers in Government Office.14,18,26,29 As it was occurred in Depok, the decision makers gave more concern on morbidity data of certain NCD such as diabetes mellitus, heart diseases, and hypertension by rather than the information of NCD risk factors. Therefore, additional information such as diseases severity and further complicated diseases, disability, and mortality, in association with human development index, were effective to get more attention to prioritize the NCD prevention and control program.

Adequate information as evidence based was obtained by the NCD risk factors surveillance and mortality surveillance. Information from the surveillance was substantially necessary in NCD prevention and control program. In the planning stage, the information was used to determine the program strategy and target, while in the implementation stage the information was utilized as monitoring instrument of program benefits. In the evaluation stage, results of the surveillance were used to assess program effectiveness. Community based surveillance was more effective to identify community

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NCD problems than the hospital based surveillance.11 Hospital based surveillance was more effective only to assess the working performance of health institution, because not all cases of NCD were hospitalized or visited hospital.

5.1.2 Policy Development and Coordination

Several programs that related to policy development had been performed step by step. Forum of healthy city of Depok (FKDS) had been established and facilitated by health official. It is an integrated and coordinated forum involving local community organizations, NGO, other related non-health sectors, and related private sector which potentially support the promotion of healthy life style. Networking had been developed and it was an advanced collaboration between local health government and FKDS, in planning and managing public health program. The FKDS had motivated the community and local government officials to develop local and regional government policy by creating social environment that conducive for NCD risk factors prevention and control program. High prevalence of diabetes mellitus had taken into account by the Depok Health Office and already put it as input in policy and program advocacy. Evidence based information, frequent advocacy activities such as hearing, round table discussion, and public seminars resulted good progress.

Workshop of PC of NCD Program in Depok City and audiences about NCD problem in Depok City were agreed that for controlling NCD risk factors in Depok city government needed some programs and structure. A comprehensive of strategies for NCD control programs had been developed, and will be integrated through routine activities. Previously, Depok Health Office didn’t have specific program structure for NCD. Funding of the NCD risk factors control program in Depok were mostly supported by World Health Organization (WHO). After one-year intervention program that is in 2004, it had some progress on several aspects below: 1) The local government would contributed funding for small programs such as

seminars, routine meeting for every 3 months 2) The local government could give of the facility (funding, policy, and office room)

for ‘FKDS’ as a working group for co-coordinating and communicating activities to perform healthy Depok 2006, which included NCD risk factors control programs in community.

3) Structure and working mechanism of different unit and coordinator for NCD program had been determined by Depok Health Office.

4) The policy support and programs plan for NCD from the local government, which were previously not available, have been initially developed.

The information below is policy support, activities that had been done and programs plan for NCD and its risk factors control program in Depok, up to December

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2004. The activities are focused on three main programs for NCD in Indonesia, which are Surveillance, Health Promotion, and Health Service Management.

5.1.2.1 Policy and program in surveillance

• Information of NCD risk factors surveillance in 2003 had been used by the local government in planning health development strategy for Depok municipality.

• Information of NCD risk factors surveillance in 2003 had been utilized by the local health office to improve drugs availability the local community health centre.

• Funding for surveillance activities in 2003 was from WHO. Endocrine unit of Ciptomangunkusumo Hospital had given additional funding specifically for implementation of Step 3 approach.

• Coordinator for surveillance program at Depok health office has made plan to conduct training of NCD surveillance implementation for health worker.

• Plan of action of surveillance risk factors NCD for the next term have not been developed yet by the surveillance program coordinator at the Depok health office.

5.1.2.2 Policy and program in health promotion

• Implementation of health promotion activities were partly facilitated by personnel form central health office (Ministry of Health)

• Coordinator for health promotion program had planed to conduct baseline survey for health behavior within family and review all the community health program which had been conducted NCD control program in the community, as well as to develop regulation for ‘no smoking area’ program in public places, monitoring the activities of integrated health post of NCD, and built strong adequate collaboration with the health service program division/unit.

• Coordinator of health promotion program at the health office and half of the health promotion personnel at the public health centre had been successfully carried out their function as facilitator of ‘Posbindu PTM’ activities in other village in Depok.

5.1.2.3 Policy and program in health service management

• Head of the local health office agreed to decide that the coordinator for NCD control program is the head of health service division in the Depok health office.

• Depok health office has applied policy to develop integrated health service for NCD (‘Yandu PTM’) at the community health centre in which patients have to pay the services which is determined by the community and affordable for most of the community. This has been supported by a decree from the head of the local government.

• Depok health office has developed new policy concerning the number of days of medicine supply to patients with NCD at the public health centre. The medicine is given for two weeks period, while previously it was only given for 3 days.

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• Adequate distribution and more type of NCD medicine was available in PHC compare tin previous year. Health service division in the Depok health office planed to provide additional health instrument such as Sphygmomanometer and weighing scale for ‘Posbindu PTM’ at every village, and had developed referral system for specific NCD cases to community health centre.

• Health service division in the Depok health office had arranged supply for laboratory instrument (Spectrophotometer) at the sub district public health centre.

5.1.2.4 Policy and program in industry sector

A workshop Involving industries in controlling NCD risk factors programs among workers was attended by representative from 28 industries in Depok, most of them has a minimum of 1000 employees. The chairman of industries association (Apindo) in Depok, supported future collaboration with local health office in managing NCD control program, especially for workers. This workshop resulted in several agreements, as follows: • Establishment of working group for occupational health and safety among workers

in Depok, under co-ordination of Depok health office. • Commitment to conduct health education particularly for controlling NCD risk

factor in working environment • Promotion on occupational health will be socialized in work places and will be one

of the substantial health programs. Occupational health programs that relate to NCD, are: implementation of physical activities at least 10 minutes in every 4 hours at work for all workers; no smoking area; and provide health food in the cafeteria.

• Developing plans to carry out NCD risk factors surveillance periodically in the work places.

However, a coordinator at Health Office was substantially needed to create a sustainable NCD prevention and control program. The coordinator was expected to manage planning, implementation, and evaluation, of three main strategies of NCD prevention and control program determined by Ministry of Health, which includes surveillance, health promotion, and health service management. Coordinator, who specifically for NCD, was not available yet in Depok Health Office, and the three main strategies were under three different unit in Depok Health Office, which were: 1) Surveillance activities were under responsibility of Diseases Prevention and Control

unit, which was usually working for communicable diseases. 2) Health promotion was under responsibility of Family Health unit, which given more

work on maternal and child health. 3) Health service management was under responsibility of Primary Health Service

Unit.

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The experience learn from Depok, showed that basically coordination between related unit had been done, however, the coordination was not sufficiently taken due to responsibility to complete other task than NCD. The NCD prevention and control program need to be under responsibility of one section to make the program implementation more effective and well improved. 5.1.3 Strengthening individual skill

All the training activities were conducted by Depok health office, and the intervention team played as facilitators (steering committee). This activities were taken in both 2004 and 2005. The participants were health workers (general practitioners, nurse, dietician), health volunteers, and other community member. Almost all the targeted activities were accomplished, except the clinical training for general practitioners (GP) of the community health centre. The percentage of GP who participated was only about 50% of the targeted number of GP. That was because miss information about participant criterion and subjects of the training. After the training, GPs who did not attend were enthusiastic to suggest that there will be similar training in the near future.

Almost all training activities were beneficial for the participants. They expect that those activities will be followed and supported by concrete NCD control programs. The activities increased knowledge among health workers and health volunteers, specifically about NCD and its risk factors control program, as well as about how to develop health services as required. The topic given in the training can be seen on attachment10. Table 1 and Table 2 describe result of knowledge test among the participants before and after the training.

5.1.4 Enhancing social environment and enabling community actions

Some of NCD risk factors like sport, diet (cholesterol, blood glucose and salt) and smoking was intervened by integrated program on “Healthy Lifestyle Promotion”. Intervention activity was done by giving priority to community and private empowerment and by “community based development.” As a health extension material to arise community knowledge about integrated NCD risk factors control, “CERDIK” poster (The meaning is SMART behavior which contain message for controlling risk factors of NCD)” and guidance book “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, were created.

“CERDIK” poster stands for :

“C” is Ciptakan lingkungan yang aman nyaman indah dan sehat (Create a safe, comfortable, beautiful and healthy environment) ”E” is Enyahkan asan rokok dan polusi udara lainnya (Evade cigarette smoke and other smoke pollution) ”R” is Rangsang aktifitas dengan gerakolah raga dan seni

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( Stimulate activities by sports, work and art) “D” is Diet yang sehat dengan gizi yang cukup dan seimbang ( Have a healthy and balanced diet ) “I” is Istirahat yang cukup ( Have adequate rest) “K” is Kuatkan iman dalam menghadapi stress (Strengthen your spiritual life for managing stress)

Campaign activities had been held by local health office in collaboration with “Health Depok City Forum” (FKDS) and facilitated by Ministry of Health, such as:

• Organized “NCD in Depok City” seminar, that was attended by deputy Mayor of Depok; head of local health government, head of E commission of DPRD (assembly at municipal level), delegation of other sectors, government organizations and NGOs in health sectors

• Disseminated “CERDIK (Smart)” poster and guidance book freely to community. • Organized interactive dialogue of health lifestyle and controlling integrated NCD

by activity groups (regular social gathering, Islamic gathering, DM’s patient gathering, etc).

• Arranged interactive dialogue of health lifestyle on controlling NCD by local electronic mass media (FM “Ria” Radio)

• Campaign for health lifestyle (assembling street banner and dissemination poster/sticker)

• Seminar ‘Protect Depok Community of DM Threat” that was attended by head of local health government, Secretary of Mayor of Depok , Head of E commission of DPRD, some of government organizations and NGOs in health sector, DM’s patient and public community (about 250 persons)

• Activates ‘Healthy and Clean Friday’ activity, which is a routine activity of cleaning the workplace environment among the government institutions on every Friday

• Reward the community organization that held control activity on NCD risk factors • Give awards to the model of cadres who has proactively in health promotion

activity • Give awards to the healthy elderly who have healthy lifestyles • Give reward the good of restaurants that always prepare healthy menu and healthy

food processing • Give award to fitness centre which have a large amount of members and have no

smoking area. • Facilitated and motivated the implementation of “Posbindu PTM” by established

communication forum of “Posbindu PTM” at village level. The communication forum had function to develop coordination which was performed every three month. This forum also used for sharing experience in conducting “Posbindu PTM” between coordinators and health volunteers.

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NCD prevention and control program definitely required an integrated and comprehensive policy support., especially in regard to improve the human development index (Education index, purchasing power, life expectancy). Integrated policy was more feasible to develop rather than exclusive policy. Therefore, it will need a forum for communication and coordination of all the related stakeholders at District level. The forum will also important for the planning an evaluation program. Depok was fortunate to have such forum, a Healthy Depok City Forum, which was very potential to integrated the NCD prevention and control program. One of the missions of Healthy Depok City Forum was to create a healthy city which means support healthy life style environment.

5.1.5 Reorienting Health Services

5.1.5.1 Posbindu PTM

Posbindu PTM is activities of NCD monitoring and controlling program, include activities of counseling, sharing experience and knowledge, and early detection which is organized by community and develop for the community. Although the initiative of establishing ‘Posbindu PTM’ originally will be implemented in Abadijaya, it is expected that ‘Posbindu PTM’ will be available in every administrative block (RW). There were 30 ‘Posbindu PTM’ representing 6 villages in Depok participated in the training activities. ‘Posbindu PTM’ have been established in 6 villages out of 6 sub-districts, that already have trained health volunteers to conduct ‘Posbindu PTM’ . It is expected that the ratio of number of “Posbindu PTM” and number of block village (RW) is 100%. Ratio of number of ‘Posbindu PTM’ in each village compare to number of administrative block (RW) in each village are presented on table 3 , it shows that the ratio of ‘Posbindu PTM’ and RW at the each village, the highest is at the village of Abadijaya, the second highest was village of Tugu, followed by village of Beji. The highest ratio in village of Abadijaya most probably because this village was the study area of surveillance and intervention program, that made the community and the health workers more well prepared and more eager to develop ‘Posbindu PTM. For village of Beji, the high ratio might be caused by involvement of active and professionalism of health workers from the public health centre in developing ‘Posbindu PTM’. Meanwhile, high ratio in village of Tugu is related to the participation of substantially active public figures in applying ‘Posbindu PTM’.

In Abadijaya village there are several potential resources in the development of integrated health post for NCD or ‘Posbindu PTM’ among the 30 “Posbindu PTM’, as regards of financial and human resources, facilities, and community group. All of the 30 posts have already involved Family Welfare Organization and “Arisan Warga” (a neighborhood social gathering group). Meanwhile, 25 integrated health posts have involved Moslem Community Groups, 14 posts in collaborated with Healthy Heart

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Club, and only 1 post has involved Diabetes Community Association. There were 6 posts had financial contribution from ‘Dana Sehat’ (community health insurance for low income community). Among the 30 posts, 22 posts have already had particular place for the activities and have provided Waist Hip Ratio measurement, while 20 posts have conducted body weight measurement.

Several forms and recording-reporting tools to assess the target achievement, capacity and benefits of “Posbindu PTM” in community, had been developed. The achievement of each activity was categorized into 4 grades (Pratama, Madya, Purnama, and Mandiri). Detail forms and recording-reporting procedure of ‘Posbindu PTM’ as well as definition of each grade and activity indicators can be seen on form Posbindu PTM monitoring in attachment 8‘Pratama’ is the lowest level of Posbindu, it means the most basic or newly developed Posbindu, the second level was ‘Madya’, which means ‘Posbindu’ that had more activities, coverage and resources than the previous level (Pratama), and the next level was ‘Purnama’, which was at moderate level in implementing the Posbindu, and the highest level was ‘Mandiri’, which had the most complete activities, coverage, and resources.

Results on “Posbindu PTM” monitoring activity (questionnaire attached on attachment 9) showed that the progress achievement of “Posbindu PTM” in Abadijaya village was increasing in every year. In 2003, Pratama level has been reached by 96.7% Posbindu PTM and only 3.3% reached “Madya” (see Table 8). In 2004, development level of ‘Posbindu PTM’ was 46.7%” for Pratama level, 30% for Madya, 16.7% for Purnama, and 6.7% of “Posbindu PTM was on level Mandiri (Table 9). In 2005, ‘Pratama’ level of ‘Posbindu PTM’ decreased to 40%”, for Madya, 20% for Purnama, and 20%, and for ‘Mandiri’ level was 20%. (Table10). Recent data in 2006 (see table 11) described more better figure of “Posbindu PTM”, there were only 13.3% in Pratama and Madya level, 33.3% reached Purnama, and 40% had reached Mandiri.

Although the evaluation of the training showed an impressive result in knowledge, however, progress evaluation taken during 2004, 2005 and 2006 by field visits, communication by phone, and evaluation on report documentation of communication meeting which was done every three month, found that there were few limitations in the of ‘Posbindu PTM’, which are: 1) Lack of skill of NCD risk factors and its prevention among the health volunteers,

which make them feel less confident to run the activities. 2) Lack of skill in recording and reporting system. 3) Lack of supporting facilities for the activity 4) Limited number of medics/paramedics in the residential area who were willing to

participate in the activity. . 5) Low awareness of NCD risk factors prevention among the community.

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Those information mentioned above, was found from the quantitative study which was done in 2005. Results of the study presented that there was significant different of target achievement of “Posbindu PTM” development level, between skilled health volunteer in blood pressure measurement with “Posbindu PTM” development level. There was 86.4% of “Posbindu PTM” who had better skill in blood pressure measurement had increased the progress become Purnama and Mandiri. (p < 0.05). The same of result also was found that there was significant different of target achievement of “Posbindu PTM” development level, between skilled health volunteer in diet maintenance. Meanwhile, health volunteer knowledge and limited facility had not significantly relate to the “Posbindu PTM” progress. (see Table 7 ). Limited number and quality of human resources showed significant association to the “Posbindu PTM” progress (p = 0.01). Particular amount of money that agreed by the community tend to show higher progress of “Posbindu PTM” (Purnama-Mandiri). It was found 88.2 % of ”Posbindu PTM” had managed the budget by fix amount of money that agreed by community (p 0.01). Oppositely, “Posbindu PTM” that managed the budget by voluntary donation significantly mostly was on Pratama and Madya level. (see Table 5).

Limited number of human resources had significantly related to “posbindu PTM” progress development (p =0.01), but the facility resources had not significantly associated to the progress development (p 0.08). The implementation of ‘Posbindu PTM’ still needs to be supported by health workers from the local public health centre. In the point of partnership indicator and community health safety insurance, which in general still under the level of ‘Pratama’ and ‘Madya’, it is important to increase health volunteers and health worker’s capability as well as to increase partnership. Those two indicators (partnership and community health safety insurance) are substantially important for sustainability of the community based health programs.

Health workers from the community health centre suggested that the training can be conducted at the community health centre, therefore it is necessary to provide adequate medicine and health diagnostic facilities to support the activity. In general, the health centers only have limited health facilities. Recording and reporting activities for ‘Posbindu’ were still confusing for the health volunteers and health workers. However, method in recording and reporting system is useful for the monitoring and evaluation activities of ‘Posbindu PTM’ in the community. It is suggested to conduct training and practice directly for monitoring and evaluation activities of ‘Posbindu PTM’ in the community

Recording and reporting activities for ‘Posbindu’ were still confusing for the health volunteers and health workers. However, method in recording and reporting system is useful for the monitoring and evaluation activities of ‘Posbindu PTM’ in the community. It is suggested to conduct training and practice for monitoring and evaluation activities of ‘Posbindu PTM’ in the community. This condition shows that

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training and technical assistant for health volunteer, in particular for reporting-recording and counseling of cases, are substantially important and need to conducted in the near future for better performance of “Posbindu PTM” implementation.

The implementation of ‘Posbindu PTM’ still needs to be supported by health professional. This was because the community preferred of getting more health information or educated by health professional rather than getting it from health volunteer. Value of health volunteer was not sufficiently change the community awareness on healthy life style. Referring to the ‘health believe model’ in the behavior study, it was obvious that community tend to trust their health condition to the health professional or health experts.21,26 Series of meeting had been carried out to encounter this problem. Limited number of health professional from PHC made it less possible for them to guide or assist in every “Posbindu PTM” activity. More possible way to address this issue was trying to motivate any health professionals living in the working area of “posbindu PTM” or health professional who worked in private hospital or health clinic to participate in the activity. This approach had been applied in Depok, and in fact not all “Posbindu PTM” coordinator could manage this approach due to personal communication point of view. Therefore, increasing health volunteers and health worker’s capability and partnership are still intensely needed. The evaluation showed that medical aspect and partnership with health professional were significantly related to the ‘Posbindu PTM’ progress development (see Table 6 and Table 7).

Experiences gained by investigator team when they directly involved in building the partnership, it was found that detail and clear explanation that the benefits were not only community health, but also give benefits to the private health clinics. Firstly, the activity could be used to promote their clinics to the community. Secondly, ‘Posbindu PTM’ might found some people who had NCD risk factors, in which there would be more chance for them to visit the private health clinics they knew from the “Posbindu PTM” activity. The concept of ‘supply creating demand approach’ and ‘demand creating supply approach’ could naturally developed in this partnership approach. This approach resulted positive results in sustainability of “Posbindu PTM”. There were nine “Posbindu PTM” (30%) that could performed actively every month with supports from health professional of local private health clinic in their area. Supports that had been given included medical tools such as blood pressure measurement tool, weighing scale, and sometimes they also brought vitamin and medicine

Partnership with pharmaceutical industry also had been developed. As a result of the partnership with PT Merck and PT Roche digital blood test company, some “Posbindu PTM” got free digital blood test tools for blood glucose and cholesterol. This supports enabled ‘Posbindu PTM’ to provide blood test to monitor hiperglicemia and hypercholesterol. Similar partnership had also developed with the health insurance company, but it didn’t give significant results yet. Two indicators (partnership and

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community health safety insurance) are substantially important for sustainability of the community based health program. Therefore, it is important to develop the two indicators for more effective partnership strategy.

Socialization and publications of the positive impact of Posbindu PTM was sufficiently achieved. A local middle up well known magazine March 2006 edition in Jakarta had covered success story of “posbindu PTM” activity, in six full pages. Also, a FM radio (RIA FM) had broadcasted interactive dialog about ‘Posbindu PTM’ and other NCD risk factors issues. This local radio could reach Depok area as well other areas including Jakarta. As a result, supports from Depok Health Office had dramatically increased. The budget allocation for NCD from the Depok Government Office was sharply increased from Rp.200,000,000,- in 2004-2005 to Rp.500,000,000,- in 2005-2006, although the amount was not sufficient compare to other programs. Most of budget was used for ‘Posbindu PTM’ and other related programs, such as training for health volunteers, medical doctors, and paramedics, was well as providing measurement equipment such as stethoscope and spigmomanometer. Currently, there were 360 health volunteer working for ‘Posbindu PTM’, 50 medical doctors and paramedics had been trained for PC of NCD and it risk factors program in Depok.

5.1.5.2 Integrated ’Yandu PTM’ in PHC

Public Health Center (PHC) is the technical unit of District Health Office, that responsible to manage health development for sub district area. One of the Health Office missions is achieving healthy sub district/healthy village to support Healthy Indonesia with considering the local community need and resources as well as working area. Basically, the concept of healthy sub district or healthy village is to create healthy life style among the community that supported by healthy environment, and more qualified and adequate health access that equal for all community member to improve community health status optimally. Functions of PHC are as initiator or motivator for health development in PHC working area; center of family and community empowerment and in health aspect; and provide primary health services focusing on individual health program as well as on public health program.26, 31-33

Function of PHC

Initiator for health development in PHC working area

Centre of family and community empowerment

Center of health services in level 1

Health service

Medical service

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The structure of PHC in Health System is stated on the following:

1. On the National Health System, as a primary health service facility at the first level of health system.

2. On the District/City Health System, as technical operational unit of District Health Office.

3. On the District Health System, as a structural unit of District Government on health aspect for the sub district level.

4. First level of health facility, in which PHC plays as a partner for various first level health care facilities, as well as educator or facilitator of community based health program.

In the management of PHC, some important aspects below are needed to be considered

1) Aspect of responsibility for health status of community in the working area of PHC (district or village)

2) Aspect of community empowerment that covers community in PHC working area.

3) Aspect of integrated approach. 4) Aspect of referral health services (particularly for further health treatment)

There were 18 basic health care programs in PHC. Generally, the programs include: individual health care (private Good), and public health care (public goods). Government has tried to reduce the programs into 6 obligatory programs, which will added with local needs which will be varied depend on local PHC capacity. The 6 obligatory programs are as a health promotion, environmental health, maternal and child health including birth control, nutrition, communicable diseases control, basic medication

Several possible additional program development are as adolescent health, mental health, over nutrition, injury, non-communicable diseases (degenerative diseases), and improving services, such as 24 hours service, appointment service for better service quality, etc. Several additional roles and functions have been applied in PHC to implement the NCD prevention and control program through community based program. The additional roles and function are as follow: 1) Organize NCD risk factors surveillance in PHC working area. 2) Referral facility of NCD risk factor case which was referred from the NCD risk

factor monitoring activity in “Posbindu PTM”. 3) Educate or improve community based program, such as “Posbindu PTM”, NCD

club, exercise or sport club, etc. 4) Planning and Conducting NCD prevention and control program, with strengthening

promotion and prevention aspects and also concerning the curative and rehabilitative aspects, fulfilling the community need and adjusted to PHC capacity.

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5) Develop adequate partnership with related institutions and stakeholders in the PHC working area, such as make collaboration with local general hospital for capacity building on NCD case management and referral system, as well as develop partnership with private sectors of non-government organizations, to improve community based health program.

Revitalization is very important to enable PHC successfully running its roles and functions, particularly in implementing NCD prevention and control program. The revitalization programs are as the following: 1) Improve PHC concept direct to recent district autonomy policy. , 2) Obtain policy support and regulations to enable the operational of “Yandu PTM”

(integrated health services for NCD) in PHC. 3) Enhance health workers capacity in PHC to provide qualified NCD case

management as well as NCD prevention and control in integrated approach. 4) Provide PHC with facilities (required laboratory or measurement equipments) for

NCD case management and prevention program. 5) Provide PHC with sufficient medicines required for NCD case treatment, 6) Improve reporting and recording system in PHC, particularly for NCD cases. 7) Develop referral system of NCD case from “Pobsindu PTM” to local PHC and vise

versa.

At present, the activity of ‘Yandu PTM’ could only be performed in a public health centre of village of Abadijaya. The operation of ‘Yandu PTM’ has been supported by a decree from the City Mayor and local Health Office. The activities were carried out once a week, on every Monday. The average number of patient was 10-20 patients. The number of patient was still limited, because the visiting hour was only from 8 am to 12 am. When we tried to apply longer office hour the total number of patient reached 20 in maximum. This implies there is a greater patient’s need regarding NCD medication and care. The community proposed that the frequency of service should be added become twice a week (Saturday and Monday) instead of once a week. It is important to be considered that most of the people work on Monday to Friday, and Saturday is the best time for them to visit ‘Yandu PTM’. Public Health Center coverage for NCD case was still relatively low, which was approximately 10% compare to prevalence of NCD case in Depok.

The implementation of ‘Yandu PTM’ had several limitations, as follow :

1) Limited number of medical doctors and paramedics as well as limited skill of NCD case management

2) Patient who had NCD preferred to go to general hospital, because they could not used insurance for medicine and laboratory test in PHC.

3) Reporting and recording system had not sufficiently applied.

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4) Limited availability of quantity and type of medicine and health diagnostic facilities

This condition shows that training of NCD clinical management and technical assistant for reporting-recording, required to be gained. This issues had been discussed in the coordination meeting between PHC, Depok Health Office, and other stakeholders. Health workers from the community health centre suggested that the programs can be conducted at the community health centre; therefore it is necessary to provide adequate medicine and health diagnostic facilities to support the activity. In general, the health centers only have limited health facilities. It had been agreed that the integrated health service of NCD would not only provided by local PHC, but also would applied in other private health clinics. Obviously, the health service provided by private health clinics was better than in PHC, even though it would be more costly. Therefore, in the future the training will involve health professionals from private sectors as well.

PHC could not optimally support ‘posbindu PTM’ in community due to limited capacity and resources. This evaluation showed that good progress or performance of this community based approach required stronger personal awareness and commitment among the health professionals involved in the program, both from PHC and Health Office. Monitoring and technical guidance from Depok Health Office addressed to PHC were very vital. The Health Office should give more attention to PHC that didn’t show qualified performance or progress on NCD prevention and control program. However, working mechanism and system showed that PHC was under the Government Office not Health Office, which made Health office had less authority to supervise or monitor the PHC.

Inputs or community response might significantly effective to the health service policy when community felt unsatisfied with the health service. Nevertheless, culturally and traditionally criticizing health services still assumed as impolite manner because some of the community still believed that medical professionals, especially doctors, was their life saver that made them felt inappropriate to show non-satisfaction of the services. Coordination meeting was expected to encounter this situation. However, the Government Office had given huge financial support to the intervened PHC, more than one billion rupiah for improving the PHC facilities only not for improving the service performance quality. This issue will be discussed and managed at the coordination meeting of Healthy Depok City Forum at the end of year 2006. .

5.1.6 Constraints in NCD control program implementation

In general, Community base intervention on prevention and control NCD program implementation had been performed successfully. However, several conditions

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in the local government office and recent health care system brought some constraints for NCD control program implementation. Those are:

1) NCD is still low priority despite the growing interest of the local government and community. This is reflected by low allocation of funding from the local government. Meanwhile, NCD control program is kind of new programs which require additional budget allocation and it has not been used as an indicator of minimum health care standard.

2) Basically, Depok health office showed positive response to NCD control program, however, some administrative function, in regard of decentralization system, took more working time of the health workers, who was supposed to run NCD control program. As a result, co-ordination and intervention of NCD control program were a little bit slow up.

3) Collaboration of NCD control program between Province level and District level was not established yet thus caused less support from the Depok health office to conduct NCD control program.

4) Limited human resources and drugs facilities in the community health centre, as well as limited knowledge of NCD control program among health workers.

5) Non-conducive social environment condition for NCD risk factors control program. Promotion of unhealthy products, such as tobacco advertisements, fast food, soft drinks, is extremely assertive.

6) Decision-makers in the local health office still not given priority for Non Communicable Diseases. One significant reason is because there is no sufficient information regarding mortality data of NCD as cause of death in Depok.

5.2 Effect/Outcome Evaluation

The NCD risk factor surveillance had been carried out in 2006, which was applied with same data collection method to 2003 survey (considered as baseline survey). The 2006 survey was aimed to evaluate the community based intervention program that had been done since 2003. Out of 2200 respondents, there were 909 men respondents (86,63%) and 1018 women respondents (92.54 %) had been interviewed for Step 1 and Step 2 approach. Meanwhile, 891 men respondents (81 %) and 1017 women respondents (92.45%) participated for Step 3 approach (See attachment 12 and 14 Data Book 2006 Table 1.1 up to 1.3 and fact sheet). Respondent response rate in 2006 increased compare to 2003 survey. This was because the community was more aware to the benefits and objectives of the survey. The surveillance activity applied different service intensity and different system compare to other countries. The surveillance activity in 2006 had pointed out several aspects below: 1) The implementation of STEP 1,2, and 3 had been carried out in same day,

assumed as general health check up. .

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2) The surveillance activity or data collection activity was done in one post which was located close to the respondent’s residential area.

3) The activities always involved local community leader or member. The community was treated as subject of the surveillance instead of the object.

4) The activities were prepared at least one month prior to the data collection, and respondent had invited at least one week before the health examination.

5) Respondents had been adequately informed to fast for the blood test. 6) Local health volunteers reminded respondent to come to the post and compulsory

to fast for the blood test, one day before the data collection. 7) Results of health examination were distributed immediately in one week time after

the data collection date. 8) Referral mechanism or follow up for the NCD case found during the data

collection activities had been prepared in collaboration with local PHC or health clinic.

Detail figures of prevalence and mean value of NCD risk factors can be seen on book 2006 (Attachment 14), while the brief description of NCD RF can be seen on fact sheet 2006 on attachment 13. The NCD risk factors prevalence and mean value significantly decreased, especially hypertension, compare to 2003 survey, except for smoking, alcohol consumption, and physical activity. Data on 2003 and 2006 could not be directly compared as there were some changes in population distribution and size. Therefore, intervention effect evaluation had done based on standard population size, which was taken from Depok population data on the middle years of intervention time period it was on 2004. Depok population distribution by sex and age group (25-34, 35-44,45-54, 55-64) in 2004 was used in weighting data analysis. Level of Confidence Interval 95% was used to estimate the significance of deference of the intervention result. Table 12 up to Table 43 showed prevalence and adjusted mean of NCD risk factors in 2003 and 2006.

5.2.1 Behavior Risk Factors

Prevalence of daily smokers had not significantly decreased (26% ; 95% CI 22.8%– 29% for men and 3.9%;95% CI 2.5%–5.2% for women) in comparison to 2003 data (32.5 % ; 95% CI 28.1 % – 36.8% for men, and 4.2%;95% CI 2.7%–5.7% for women ), both in men and women. The detail figure of smoking prevalence can be seen on Table 12 up to Table 17. Data on average age when started smoking, smoking duration, and average number of cigarette per day, as well as alcohol consumption during last 12 months (Table 18), were not significantly decreased. Significant lower prevalence of daily smoking in Depok had not yet achieved. This is most probably because of anti smoking promotion was not as huge as smoking prevention in Depok. Obviously, the cigarette advertising was shown in every famous and crowded public places in Depok. There were plenty of sport events and entertainments were sponsored

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by the tobacco industry. These unhealthy advertising and sponsorship were quite common in other parts or districts in Indonesia. Meanwhile, regulation on smoking restriction and tobacco advertising ban were not yet developed in Depok.

Several intervention activities, coordinated by Healthy Depok City Forum, had been undertaken. The activities included anti smoking campaign, promote non smoker City Major on the election campaign, who finally won the election on 2006. Previous Major in 2005 had not yet made any changes on smoking issues. A round table discussion with related sectors resulted agreement on cigarette advertising restriction. In fact, unavailability of national policy on tobacco control in Indonesia, give significant influence on unsuccessful to reduce smoking prevalence in Depok. Anti smoking activities that have been done until recently are develop smoking control program by promoting ‘rooms without astray’ in the house and public places, changing the tradition of using words ‘cigarette money’ for tip, into the word ‘fruits or milk money’, put note or announcement of ‘no smoking area’ in public places, and make smokers feel inconvenient to smoke by get away from them when they smoke. The future plan has emphasized more intensive on tobacco control policy development. Definitely, community will raise the selected new Major for his promise and commitment to support tobacco control program in Depok.

The fruits consumption was slightly increase, but not significant, between 2003 data and 2006 data. The average fruits consumption was ranging from 1.8 to 1.9 serving per day, which increased in 2006 (1.9 to 2.1 serving per day). Similar trend was occurred for vegetable consumption. Percentage of those who consumed vegetables 5 servings or more had significantly increased from 14% to 17.5% for both men and women, from 13% to 18.2% for men, and from 15.3% to 16.4% for women. Detail figure of fruits and vegetables consumption can be seen on Table 19 up to Table 21.

Information gained from in depth interview and focus group discussion of dietary behavior found that Availability of fruits and vegetable in the local market in Depok is relatively sufficient in variety as well as in quantity. People consume less fruits and vegetable consumption due to some reasons, such as low knowledge on the health benefits of fruits and vegetables, some myths on negative effects of particular fruits, and low skill in serving vegetable among the housewives. Beside, it is also important to gain local fruit production by encourage community to use the backyard to grow fruit and vegetable plant. Government and related sectors also need to consider to control the fruits and vegetable price adjusting the community purchasing power. Therefore, several activities have to be done are increase knowledge on health impact of fruits and vegetable consumption, improve skill among housewives to prepare vegetable in healthy way, fast, and interesting. Also it will need improvement in local fruits production by utilizing home yard and control fruits and vegetable price to be more affordable.

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Data of physical activity, showed that the percentage of sedentary physical activity significantly decrease in both sexes from 33% in 2003 to 22.4% in 2006. A sharp decreased was found among women, which decreased from 33.5% to 14.3%, but the percentage was not significantly decreasing among men (from 32.6% to 28.7%). Median time spent in work increased not significantly from 25.7 minutes per day in 2003 to 60 minutes per day in 2006. Similar trend occurred for median time spent during transportation and leisure time. More detail figures can be seen on Table 22 up to Table 25).

In fact, in regard to physical activity, community had high motivation and spirit to take exercise and physical activity, especially walking. Most of the people are aware of the health benefits of physical activity. Inadequate physical activity is mostly because of non conducive environment, such as lack of sport and physical activity facility provided by the local government, traffic jam, and unavailability of pedestrian path. Results of in depth interview and focus group discussion showed that community need on physical activity, there are sufficient support of availability and maintaining the sport facilities for public in each RW (administrative unit) from local Government Office, repairing and providing safe and convenient pedestrian path, increase motivation to exercise.

Regular physical activity which could be done by almost all people was walking. All groups stated that walking was the most convenient physical activity. This can be seen from community greater enthusiasm to walk in the open areas (in the area of University of Indonesia campus) or new road (real estate area) during the week end or holiday. Particularly for less than 1 kilometer distance, walking is still convenient among the community; however there were some constraints. There was assumption among the community that walking in the daily activity for travel from one place to other places considered as ‘broke’ (‘bokek’) or doesn’t have enough money to pay for transportation. And the walking facilities or pedestrian area in public areas was limited or not constructed specifically for pedestrian, and not suitable for walking (dirty, smell, mud-covered, etc).

Several activities and programs of community based intervention had been undertaken to work out the issues mentioned above. Depok Government Office had tried to encounter community need regarding health environment. Pedestrian path had been provided to enable community to walk safely. However, the pedestrian path areas were mostly occupied by the street vendor. Therefore people have to walk on the road, which is actually unsafe and lead to greater risk of traffic accident. Plans for the future to promote physical activity in community include:

1) Motivate government to provide adequate pedestrian path which is safe, healthy and comfortable.

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2) Government should be able to provide ‘city garden’ in each the village which is also suitable for walking activity.

3) A big event of walking together for all Depok citizens is allocated at least once a year, to motivate and gain walking tradition among the community

Physical Risk Factors

Mean value of BMI significantly decreased for both men and women. The mean value declined from 24,3 in 2003 to 23.4 in 2006. The mean value of BMI declined from 23.9 in 2003 to 23.0 in 2006 among men, and from 24.9 in 2003 to 23.9 in 2006 among women. Similar trend also found on prevalence of overweight (BMI >= 25 kg/m2) and obesity (BMI >= 30 kg/m2). The detail of BMI showed on Table 26 up to Table 28 . The intervention program for diet was focused on promoting healthy diet by balance calorie intake. The program was targeted for health volunteer so that can be socialized to the community, particularly housewives. Although the fruits and vegetables consumption were not significantly improved, the community had more skills on dietary management for more balance and healthy diet. Further analysis will be needed to assess the relationship of community skill and awareness in diet and BMI.

Table 30 up to Table 33 were disseminate the prevalence and mean of systolic and diastolic blood pressure decreased significantly after the intervention. The prevalence of raised blood pressure (SBP >= 140 and/or DBP >=90) considerably decreased from 9% in 2003 to 4.5% in 2006, specifically, from 9.2% in 2003 to 5% in 2006 for men and from 8.6% to 4.9% for women. Similarly, grade 2 raised blood pressure (SBP >= 170 and/or DBP >=100 mm/Hg) significantly declined from 3.8% in 2003 to 1.2% in 2006; from 4.3% to 1.4% among men, and from 3.1% to 1% among women.

This quite good improvement on blood pressure related to improvement in community awareness to monitor their blood pressure regularly and to follow it up immediately when the blood pressure got higher, as it was suggested in ‘Posbindu PTM’. Information from PHC report showed that number of hypertension case increased in the last few years. In addition, more sufficient availability of medicine in PHC leads to adequate treatment for hypertension patients. Improvement on community knowledge and awareness of NCD issues and its related diseases might contribute to the decreasing figures. This assumption can not be analyzed as the questions on individual knowledge were not available in STEPS instrument but we can add optional questions on that aspect for the next STEPS survey in the future.

Biochemical Risk Factors

Mean of fasting blood glucose decreased considerably from 4.9 mmol/L in 2003 to 4.6 mmol/L in 2006. Specifically, the mean value declined from 5 mmol/L to 4.6 mmol/L in men and from 4.9 mmol/L to 4.6 mmol/L in women. Meanwhile, prevalence

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of raised blood glucose (>=7 mmol/L ) also declined from 5.8% to 3.2% for both sexes, from 5% to 3.7% for men and 6.1% to 2.6% for women. The significant decline also occurred for two hours blood glucose load as well as diabetes prevalence. More clear figure can be seen on Table 34 up to Table 38.

Mean blood cholesterol also showed significant improvement after the intervention, except for men (Table 39). The prevalence of raised total cholesterol (>=5.2mmo/L) reduced considerably from 31.6% in 2003 to 19.6% in 2006 for both sexes; and it declined from 29.7% to 20.9% for men, and from 34% to 18.9% for women (Table 40). The prevalence of raised total cholesterol (>=6.5 mmol/L) also decreased from 5.9% in 2003 to 3.9% in 2006 for both sexes; and it reduced from 5.3% to 3.1% for men and from 6.7% to 3.6% for women (Table 41). The decrease was likely related to more adequate services and medication treatment from PHC, early detection in the community, knowledge and awareness to reduce high cholesterol food intake, as well as routine monitoring in ‘Posbindu PTM’.

This study found that combined risk factors or those who had high risk (having three of more risk factors) decreased significantly by age group and sex after the intervention (Table 43). The percentage of those who had lower risk was increase significantly. Detail percentage can be seen on Table 42. This significant improvement of NCD risk factors after the intervention concluded that the community based intervention of NCD prevention and control program has achieved the main goal. In general, ‘Posbindu PTM’ gave vital contribution to reduce the NCD risk factors prevalence and mean value. As showed on Table 44 the higher risk group mostly who stayed in area where the ‘Posbindu PTM’ development level was on Pratama and Madya, while for those who had lower risk factors mostly stay in the area where the ‘Posbindu PTM’ level was Purnama-Mandiri. (p< 0.05). 6. CONCLUSION 1) The community based intervention of NCD prevention and control program that

had been conducted for three years had significantly reduced the prevalence of several common risk factors, such as obesity, hypertension, hyperglycemia, hyper cholesterol, and high risk or combined risk factors (having three or more risk factors) and also considerably reduced the prevalence of diabetes mellitus. Meanwhile, smoking, less physical activity, and fruits and vegetable consumption also decreased but not significantly.

2) Three main effective strategies of CBI on PC of NCD and its risk factors program, are surveillance of risk factors of NCD, development policy and coordinating, strengthening individual skill, enabling strong community action, enhancing social environment, and re-orienting health service, which are essentially need to be conducted in coordinated approach and integrated (not in systematic or sequence

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way). Implementation at district level requires structural policy support which can stimulate the implementation of NCD prevention control program. In this case, it is vital to provide program coordinator for province level and district level to monitor and to integrate program achievement. Other contribution to ineffective support from the Depok Health Office was employee mutation which occurred frequently and unpredictable. This leads to ineffective working performance among the coordinators. The mutation should be done after specific working time period, so that enable the employee to complete the task, and prepared adequate time for hand over so that the program can still be taken optimally and sustain.

3) Health City Forum of Depok (“FKDS”) as a partnership coordinating institution in Depok Municipality, which consists of people from local government, Health NGO, industry, private business and community figures. FKDS is an effective forum for co-ordination and advocacy to policy makers. The activity on controlling risk factors of NCD by a combination of the two approaches (‘supply creating demand approach’ and ‘demand creating supply approach’) had been conducting through ‘Health City Forum of Depok’ by synergistic and integrated.

4) Information of diseases which was obtained from the NCD risk factors surveillance activity can motivate the policy makers to develop policy for NCD control program. Information dissemination of NCD risk factors issues in related to human development index during the advocacy process was more effective to motivate the policy makers rather than the information of NCD risk factors only.

5) Activities in ‘Posbindu PTM’ have been well developed and run in the community, although some of educators still are not confidence enough to give counseling. Community organizations that can be potentially developed are integrated health post for elderly (‘Posyandu Usila’), healthy heart exercise group, and community group (‘Arisan’). Activities in ‘Posbindu PTM’ are not necessarily only monitoring and counselling of NCD risk factors in community. If the activities are conducting in routine period, it can be as a partnership media and knowledge transfer media in NCD risk factors control program in primary level. NCD risk factors was considerably reduced among the community that had ‘Posbindu PTM’ at Purnama and Mandiri level.

6) Coverage of ‘Yandu PTM’ (integrated health service for NCD) in PHC was relatively still low. Participation of private health clinic, partnership with pharmaceutical industries and media, gave substantial contribution to accelerate progress level of Posbindu PTM, as well as for its sustainability.

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7. RECOMMENDATION 1) Surveillance activity for NCD risk factors and/or mortality surveillance is important

to be linked on community base intervention strategy for evidence base line and evaluation programs/activities. Policy development for further specific programs and sustainability on NCD control program are considerably required to be done.

2) To gain awareness of NCD issues among the policy makers as well as to obtain policy support for sustainable NCD prevention and control programs, it is very substantial to associate the outcome of the NCD program with the increasing human development index (HDI), such as life expectancy illiteracy rate, average school years, and purchasing power index. NCD problem identification and its relation to human development index were used during the advocacy to the policy makers.

3) To supportive social environment, it will be beneficial to develop similar concept of NCD control program in different setting, such as workplaces and schools. Motivation and facilitation through encouraging health system and networking, as well as flexible operational guideline, are substantially important for NCD control program. Activities of ‘FKDS’ need to be done with more intensive technical support especially for administrative activity, as well as build partnership with pharmaceutical industry and media.

4) Activities of ‘Posbindu PTM’ ideally should be performed by established community health organisation; such as integrated health post for elderly and healthy heart exercise group. The health promoter should be carried out by family welfare association. Support and active participation of the health professional still important for ‘Posbindu PTM’ until they are completely independent, while partnership with private health clinic also have to be maintained.

5) Depok still need to develop programs to improve capability of health workers and health volunteer in NCD control program, in particular capacity to promote physical activity, diet, and stop smoking. It is also substantially necessary to perform appropriate training or courses specifically for recording and reporting system of ‘Posbindu PTM’ for health workers as well as for health volunteer.

6) Routine meeting (once every 3 months) among health workers and among health volunteers concerning NCD control activities require to be performed in minimum at the sub-district level. Therefore, it is expected that health workers can share experiences and develop co-ordination for the activities.

7) Community base intervention approach on PC of NCD and its risk factors are necessary to be applied in other district or village area in Indonesia to control and reduce the NCD risk factors in different setting of community. Process evaluation need to be undertaken annually, while the outcome evaluation should be done in at least every 5 years.

8) ‘Posbindu PTM’ as operational activity of community based intervention at the lowest community setting as part of integrated NCD prevention and control program requires further analysis and study using quasi experimental design to accessing its effectiveness and cost effectiveness.

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Table 1 : Difference of mean score of knowledge test in pre and post training 2004

4.3 Topic of training n Means of

Pre Test Means of Post Test

t value p

Controlling NCD risk factors and clinical therapy for physician, nurse, dietician.

35 56.7 84.6 -15.07 0.00

Improving community participation in developing ‘Posbindu PTM’ and ‘Yandu PTM’ , for the health workers

30 62.17 85 -11.57 0.00

Healthy diet, exercise and stop smoking program for community.

44 62.39 84.43 -13.54 0.00

Management of ‘Posbindu PTM’ for potential and active volunteer

30 56.5 83.6 -13.57 0.00

Method of healthy diet, exercise and stop smoking program for selected cadre

30 66.75 87.5 -8.69 0.00

Table 2 : Difference of mean score of knowledge test

in pre and post training 2005 4.4

Topic of training n Means of Pre Test

Means of Post Test

t value p

Controlling NCD risk factors and clinical therapy for physician, nurse, dietician.

30 70.68 88.60 -17.02 0.00

Improving community participation in developing ‘Posbindu PTM’ and ‘Yandu PTM’ , for the health workers

30 75.71 88.82 -13.09 0.00

Healthy diet, exercise and stop smoking program for community.

30 68.35 85.21 -16.86 0.00

Management of ‘Posbindu PTM’ for potential and active volunteer

60 77.50 87.53 -10.04 0.00

Method of healthy diet, exercise and stop smoking program for selected cadre

30 70.15 87.24 -17.09 0.00

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Table 3. Ratio of ‘Posbindu PTM’ at the selected Villages in Depok

Village Number of RW Number of ‘Posbindu PTM’

Ratio

Abadijaya 27 15 0.55

Cinangka 15 3 0.20

Cinere 10 2 0.20

Beji 9 4 0.44

Ratujaya 10 2 0.20

Tugu 10 4 0.40

Table 4. Target achievement of Posbindu PTM by budgeting system applied

Pratama-Madya Purnama- Mandiri Variables Number % Number %

Routine fixed donation Yes No

Pearson 8.123 df 1 p 0.00

2 8

11.8 61.5

15 5

88.2 38.5

Voluntary donation Yes

No

Pearson 3.750 df 1 p 0.05

4 6

66.7 25.0

2 18

33.3 75.0

Sponsor Yes No

Pearson 3.000 df 1 p 0.08

0 10

0

40.0

5 15

100.0 60.0

From Posbindu Service Fee Yes No

Pearson 1.697 df 1 p 0.19

4 6

23.5 46.2

13 7

76.5 53.8

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Table 5. Target achievement of Posbindu PTM by Constraints which found in implementation

Pratama-Madya Purnama- Mandiri Variables Number % Number %

Limited number of human resources Yes No Pearson 6.429 df 1 p 0.01

10 0

47.6 0

11 9

52.4 100.0

Limited quality of human resources Yes No Pearson 6.429 df 1 p 0.01

10 0

47.6 0

11 9

52.4 100.0

Limited facility Yes No Pearson 3.000 df1 p 0.08

10 0

40.0

0

15 5

60.0 100.0

Unwilling to pay Yes No Pearson 7.500 df1 p 0.00

10 0

50.0

0

10 10

50.0 100.0

Table 6. Target achievement of Posbindu PTM by

Constraints which found in counseling activity

Pratama-Madya Purnama- Mandiri Variables Number % Number %

No opportunity Yes No Pearson 0.085 df 1 p 0.77

3 7

37.5 31.8

5

15

62.5 68.2

Less self confident Yes No Pearson 10.000 df 1 p 0.00

10 0

55.6

0

8

12

44.4

100.0

Less skills Yes No Pearson 10.000 df 1 p 0.00

10 0

55.6

0

8

12

44.4

100.0

Less facility Yes No Pearson 10.000 df 1 p 0.00

10 0

55.6

0

8

12

44.4

100.0

Not trusted Yes No Pearson 10.000 df 1 p 0.00

10 0

55.6

0

8

12

44.4

100.0

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Table 7 Target achievement of Posbindu PTM by Knowledge and Skill of Health volunteers

Pratama-Madya Purnama- Mandiri Variables Number % Number %

Knowledge of NCD Sufficient Less sufficient Pearson 0.714 df 1 p 0.39

8 2

38.1 22.2

13 7

61.9 77.8

Knowledge of ‘Posbindu’ Sufficient Less sufficient

Pearson 0.714 df 1 p 0.39

8 2

38.1 22.2

13 7

61.9 77.8

Skill in motivate community Sufficient Less sufficient

Pearson 0.714 df 1 p 0.39

8 2

38.1 22.2

13 7

61.9 77.8

Knowledge of NCD Prevention Sufficient Less sufficient

Pearson 0.000 df 1 p 1.00

8 2

33.3 33.3

16 4

66.7 66.7

Skill to measure blood pressure Sufficient Less sufficient

Pearson 1.667 df 1 p 0.00

2 8

11.8 61.5

15 5

88.2 38.5

Skill to measure anthropometry Sufficient Less sufficient

Pearson 14.403 df 1 p 0.10

8 2

44.4 16.7

10 10

55.6 83.3

Skill in diet maintenance Sufficient Less sufficient

Pearson 2.500 df 1 p 0.00

3 7

13.6 87.5

19 1

86.4 12.5

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Table 8. Achievement of Development Level of Integrated Health Post for NCD

(‘Posbindu PTM’) by Indicator in Abadijaya in 2003

Development Level of Posbindu PTM ( N= 30) ‘Pratama’ ‘Madya’ ‘Purnama’ ‘Mandiri’

No

Indicator

n % n % n % n %

1 Activities implementation 27 90 2 6.7

2 Obesity monitoring coverage 27 90 2 6.7

3 Blood pressure monitoring coverage 27 90 2 6.7

4 Blood glucose monitoring coverage 28 93.3 1 3.3

5 Blood cholesterol monitoring coverage 28 93.3 1 3.3

6 NCD education 28 93.3 1 3.3

7 Counseling 28 93.3 1 3.3

8* Exercise coverage/ Physical Activity once in a week

10 33.3 13 43.3

9 Participant Coverage : Age > =55 y old Age 45 – 54 y old Age 35 – 44 y old Age 25 – 34 y old

3 3

22 27

10 10

73.3 90

27 27 8 0

90 90

26.7

10 Activities personnel 25 83.3 5 16.7

11 Health safety insurance 27 90 3 10

12 Independent participant 29 96.7 1 3.3

13 Partnership 29 96.7 1 3.3

All Indicator 29 96.7 1 3.3

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Table 9. Achievement of Development Level of Integrated Health Post for NCD

(‘Posbindu PTM’) by Indicator in Abadijaya in 2004

Development Level of Posbindu PTM ( N= 30) ‘Pratama’ ‘Madya’ ‘Purnama’ ‘Mandiri’

No

Indicator

n % n % n % n %

1 Activities implementation 17 56.7 7 23.3 4 13.3 2 6.7

2 Obesity monitoring coverage 17 56.7 7 23.3 4 13.3 2 6.7

3 Blood pressure monitoring coverage 17 56.7 7 23.3 4 13.3 2 6.7

4 Blood glucose monitoring coverage 17 56.7 7 23.3 4 13.3 2 6.7

5 Blood cholesterol monitoring coverage 20 66.7 5 16.7 4 13.3 1 3.3

6 NCD education 27 90 2 6.7

7 Counseling 27 90 2 6.7

8 Exercise coverage/ Physical Activity once in a week

10 33.3 13 43.3 4 13.3 3 10

9 Participant Coverage : Age > =55 y old Age 45 – 54 y old Age 35 – 44 y old Age 25 – 34 y old

3 3 5

20

10 10

16.7 66.7

15 15 15 5

50 50 50

16.7

12 12 10 5

40 40

33.3 16.7

10 Activities personnel 10 33.3 5 16.7 15 50

11 Health safety insurance 27 90 3 10

12 Independent participant 15 50 5 16.7 10 33.3

13 Partnership 20 66.7 7 23.3 3 10

All Indicator 14 46.7 9 30 5 16.7 2 6.7

75

Table 10. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2005

Development Level of Posbindu PTM ( N= 30)

‘Pratama’ ‘Madya’ ‘Purnama’ ‘Mandiri’

No Indicator

n % n % n % n %

1 Activities implementation 7 23.3 10 33.3 8 26.7 5 16.7

2 Obesity monitoring coverage 7 23.3 10 33.3 8 26.7 5 16.7

3 Blood pressure monitoring coverage 7 23.3 10 33.3 8 26.7 5 16.7

4 Blood glucose monitoring coverage 7 23.3 10 33.3 8 26.7 5 16.7

5 Blood cholesterol monitoring coverage 7 23.3 10 33.3 8 26.7 5 16.7

6 NCD education 10 33.3 12 40 4 13.3 4 13.3

7 Counseling 10 33.3 12 40 4 13.3 4 13.3

8 Exercise coverage/ Physical Activity once in a week

8 26.7 8 26.7 5 16.7 9 30

9 Participant Coverage : Age > =55 y old Age 45 – 54 y old Age 35 – 44 y old Age 25 – 34 y old

3 3 5

13

10 10

16.7 43.3

7 7 7 8

23.3 23.3 23.3 26.7

12 12 10 5

40 40

33.3 16.7

8 8 8 4

26.7 26.7 26.7 13.3

10 Activities personnel 10 33.3 5 16.7 10 33.3 5 16.7

11 Health safety insurance 23 76.7 4 13.3 3 10

12 Independent participant 12 40 5 16.7 8 26.7 5 16.7

13 Partnership 18 60 7 23.3 3 10 2 6.7

All Indicator 12 40 6 20 6 20 6 20

76

Table 11 . Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2006

Development Level of Posbindu PTM ( N= 30)

‘Pratama’ ‘Madya’ ‘Purnama’ ‘Mandiri’

No Indicator

n % n % n % n %

1 Activities implementation - - 2 6.7 8 26.7 20 66.7

2 Obesity monitoring coverage 3 10 3 10 15 50 9 30

3 Blood pressure monitoring coverage 3 10 3 10 15 50 9 30

4 Blood glucose monitoring coverage 3 10 3 10 15 50 9 30

5 Blood cholesterol monitoring coverage 3 10 3 10 15 50 9 30

6 NCD education 3 10 3 10 15 50 9 30

7 Counseling 3 10 3 10 17 56.7 7 23.3

8 Exercise coverage/ Physical Activity once in a week

- 2 6.7 8 26.7 20 66.7

9 Participant Coverage : Age > =55 y old Age 45 – 54 y old Age 35 – 44 y old Age 25 – 34 y old

3 3 5

10

10 10

16.7 33.3

3 6 4 5

10 20

13.3 16.7

15 12 12 9

50 40 40 30

9 9 9 6

30 30 30 20

10 Activities personnel 30

11 Health safety insurance 3 10 3 10 19 63.3 5 16.7

12 Independent participant 8 26.7 22 73.3

13 Partnership 12 40 6 20 4 13.3 8 26.7

All Indicator 4 13.3 4 13.3 10 33.3 12 40

77

Table 12. Percentage who currently smoke tobacco daily

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years (adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 19.9 15.5 32.5 26.1 4.3 2.4 (15.0-24.8) (11.9-19.1) (24.3-40.8) (20.0-32.2) (1.2-7.4) (0.5-4.3) 35-44 years 24.9 18.1 35.8 27.4 2.1 6.9 (18.1-31.7) (14.5-21.8)) (26.4-45.2) (21.4-33.4) (0.2-4.0) (3.8-10.0) 45-54 years 21.5 16.7 32.1 31.2 5.7 3.9 (16.6-26.5) (13.5-19.9) (23.3-40.9) (25.4-37.1) (2.8-8.6) (1.7-6.2) 55-64 years 18.0 14.5 29.0 19.4 2.8 0 (14.5-21.5) (10.2-18.8) (24.1-33.9) (13.7-25.1) (0.6-5.0) 25-64 years 21.0 16.3 32.5 26.0 4.2 3.9 (18.3-23.6) (14.4-18.3) (28.1-36.8) (22.8-29.0) (2.7-5.7) (2.5-5.2)

Table 13. Average age started smoking (years) for those who smoke tobacco daily

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=308) (N=308) (N=272) (N=239) (N=36) (N=35)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 18.2 16.3 18.0 16.3 20.1 16.1 (17.0-19.5) (15.7-17.0) (16.7-19.3) (15.7-13.6) (16.5-23.7) 35-44 years 17.9 17.6 17.7 16.6 25.2 22.8 (16.5-19.4) (16.4-18.9) (16.3-19.2) (15.3-17.8) (17.4-33.0) 45-54 years 20.0 20.9 19.4 20.2 24.9 26.2 (18.6-21.4) (19.0-22.9) (18.0-20.9) (18.3-22.1) (20.3-29.5) 55-64 years 19.9 21.1 19.6 21.1 24.6 0 (18.6-21.7) (18.5-23.7) (18.3-20.9) (18.5-23.7) (17.5-31.6) 25-64 years 19.0 18.2 18.6 17.8 23.0 21.9 (18.3-19.7) (17.5-18.9) (17.9-19.4) (17.1-18.5) (20.6-25.5)

78

Table 14. Average years of smoking

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=308) (N=308) (N=272) (N=239) (N=36) (N=35)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 12.5 12.8 12.8 12.6 8.9 15.6 (11.0-13.9) (11.8-13.7) (11.4-14.3) (11.6-13.6) (5.4-12.4) 35-44 years 22.7 21.9 22.9 22.8 13.6 17.3 (21.2-24.1) (20.5- 23.3) (21.5-24.4) (21.4-24.4) (6.4-20.8) 45-54 years 28.8 28.3 29.5 29.2 22.9 22.3 (27.1-30.6) (26.4- 30.2) (27.6-31.4) (27.3-31.0) (18.5-27.3) 55-64 years 39.7 36.9 40.0 37.0 35.0 0 (38.1-41.2) (34.3- 39.7) (38.4-41.5) (34.3-39.7) (26.3-43.7) 25-64 years 23.8 21.7 24.3 22.1 18.3 18.0 (22.5-25.2) (20.3- 23.1) (22.9-25.8) (20.6-23.6) (14.8-21.7)

Table 15. Percentage smoking manufactured cigarettes Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=308) (N=274) (N=272) (N=239) (N=36) (N=35)

% % % % % %

Results for adults aged 25-64 years (adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 67.7 14.9 69.6 14.7 50.0 17.8 (52.6-82.9) (5.6-24.1) (53.4-85.9) (5.0-24.3) (2.8-97.2) (-16.2-51.7) 35-44 years 82.3 21.0 83.6 24.4 40.0 4.5 (72.7-92.0) (11.7-30.3) (73.7-93.5) (13.3-35.5) (-10.4-90.4) (-5.2-14.3) 45-54 years 79.7 21.6 85.7 23.5 28.5 7.9 (71.9-87.4) (12.1-31.0) (77.6-93.8) (13.1-33.9) (-0.8-57.9) (-8.3-24.2) 55-64 years 92.2 26.2 91.7 26.2 100 0 (86.5-97.9) (10.5-41.9) (85.5-97.8) (10.5-41.9) 25-64 years 78.1 19.5 81.0 20.8 45.7 8.5 (72.1-84.2) (14.0-25.1) (74.6-87.5) (14.8-26.8) (23.3-68.1) (-2.5-19.5)

79

Table 16. Mean number of Cloves manufactured cigarettes smoked per day Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=245) (N=55) (N=227) (N=52) (N=18) (N=)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 11.0 13.1 11.1 13.3 9.0 0 (9.1- 12.9) (11.5-14.7) (9.2-13.1) (11.6-15.0) (6.2-11.8) 35-44 years 12.3 12.7 12.4 12.6 8.0 0 (9.9- 14.7) (11.9-13.5) (10.0-14.8) (11.7-13.4) (-0.9-16.9) 45-54 years 12.5 12.4 12.6 12.4 9.0 0 (9.9- 15.0) (1.8-13.0) (10.0-15.3) (11.8-13.1) (3.1-14.9) 55-64 years 9.4 12.0 9.7 12.0 6.1 0 (8.1- 10.7) (8.2-11.1) (3.8-8.4) 25-64 years 11.5 12.6 11.7 12.6 8.2 0 (10.4- 12.7) (12.1-13.2) (10.5-12.9) (12.1-13.2) (6.2-10.3)

Table 17. Mean number of Non-Cloves manufactured cigarettes smoked per day Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=65) (N=219) (N=47) (N=187) (N=18) (N=32)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 12.5 8.5 12.8 8.7 10.6 4.8 (9.2-15.7) (6.7-10.2) (9.0-16.5) (6.9-10.6) (5.7-15.5) 35-44 years 10.4 9.2 11.0 10.1 4.0 6.0 (8.0-12.7) (7.7-10.8) (8.4-13.6) (8.4-11.8) (1.5-6.5) 45-54 years 9.4 10.5 10.0 11.3 8.5 6.1 (6.3-12.6) (8.5-12.6) (6.0-14.0) (8.9-13.7) (2.8-14.2) 55-64 years 8.2 11.0 8.2 11.0 0 0 (4.6-11.7) (7.1-15.0) (4.6-11.8) (7.1-15.0) 25-64 years 11.0 9.4 11.5 9.9 8.9 5.7 (9.0-13.0) (8.4-10.4) (9.2-13.8) (8.8-11.0) (5.1-12.7)

80

Table 18. Percentage of Abstainers (who did not drink alcohol in the last year) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 94.5 97.6 90.1 95.8 100 100 (91.6-97.5) (96.2-99.1) (85.3-94.9) (93.2-98.4) 35-44 years 97.5 98.2 96.2 96.8 100 100 (95.1-99.8) (97.0-99.5) (92.8-99.7) (94.5-99.1) 45-54 years 96.2 99.1 94.2 98.0 99.2 100 (03.8-98.5) (98.2-100) (90.1-98.2) (96.0-100) (98.0-100.3) 55-64 years 99.2 99.4 98.8 99.2 100 100 (98.3-100.3) (98.3-100.5) (97.0-100.6) (97.7-100.7) 25-64 years 96.3 98.3 94.0 97.1 99.7 100 (95.0-97.7) (97.6-99.0) (91.7-96.3) (95.8-98.3) (99.4-100.1)

Table 19. Mean number of servings 0f fruit consumed per day Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=755) (N=748) (N=304) (N=349) (N=451) (N=399)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 1.9 2.0 1.7 2.2 2.0 1.9 (1.7-2.0) (1.8-2.2) (1.4-2.0) (1.8-2.5) (1.8-2.2) (1.6-2.1) 35-44 years 1.9 2.1 1.8 2.1 1.9 2.0 (1.7-2.0) (1.9-2.2) (1.6-2.0) (1.9-2.4) (1.8-2.1) (1.8-2.2) 45-54 years 1.9 2.0 1.9 1.9 1.8 2.1 (1.8-2.0) (1.8-2.1) (1.8-2.1) (1.7-2.1) (1.7-1.9) (1.9-2.3) 55-64 years 1.9 2.0 1.9 2.1 1.9 1.6 (1.8-2.1) (1.8-2.2) (1.7-2.1) (1.9-2.4) (1.7-2.2) (1.4-1.9) 25-64 years 1.9 2.0 1.8 2.1 1.9 1.9 (1.8-2.0) (1.9-2.1) (1.7-2.0) (1.9-2.3) (1.8-2.0) (1.8-2.0)

81

Table 20. Mean number of servings of vegetable consumed per day

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1223) (N=1242) (N=500) (N=579) (N=723) (N=663)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 1.7 1.7 1.7 1.7 1.7 1.7 (1.7-1.8) (1.6-1.8) (1.5-1.8) (1.6-1.9) (1.6-1.8) (1.6-1.8) 35-44 years 1.6 1.7 1.6 1.6 1.7 1.7 (1.5-1.8) (1.6-1.7) (1.5-1.8) (1.6-1.8) (1.6-1.8) (1.5-1.8) 45-54 years 1.8 1.7 1.8 1.6 1.8 1.7 (1.7-1.9) (1.6-1.7) (1.6-1.9) (1.5-1.7) (1.7-1.9) (1.6-1.8) 55-64 years 1.8 1.7 1.8 1.7 1.7 1.6 (1.7-1.8) (1.6-1.8) (1.7-1.9) (1.6-1.8) (1.6-1.8) (1.4-1.8) 25-64 years 1.7 1.7 1.7 1.7 1.7 1.7 (1.7-1.8) (1.6-1.7) (1.6-1.8) (1.6-1.8) (1.7-1.8) (1.6-1.8)

Table 21. Percentage who ate 5 or more combined servings of fruit & vegetables per day Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1751) (N=1806) (N=808) (N=909) (N=943) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 12.5 17.7 7.9 20.6 18.1 14.0 (9.1-15.9) (14.1-21.3) (3.5-12.3) (15.1-26.1) (13.0-23.1) (9.8-18.3) 35-44 years 9.4 17.4 8.5 16.7 11.3 18.2 (5.8-13.0) (13.9-20.9) (3.5-13.5) (11.5-22.0) (6.8-15.8) (13.4-22.9) 45-54 years 16.4 17.8 19.0 15.4 12.5 19.9 (12.8-20.0) (14.0-21.5) 14.3-23.8) (10.7-20.1) (7.5-17.4) (14.7-25.0) 55-64 years 16.7 16.6 16.1 18.0 17.5 12.5 (13.4-20.0) (11.9-21.4) (12.1-20.1) (12.1-23.9) (11.8-23.1) (6.1-18.9) 25-64 years 14.0 17.5 13.0 18.2 15.3 16.4 (12.0-15.9) (15.3-19.6) (10.3-15.7) (15.2-21.2) (12.5-18.0) (13.9-19.0)

82

Table 22. Percentage with low levels of activity (defined as <600 MET-minutes/week Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 29.9 25.9 30.8 28.7 28.9 22.4 (23.6-36.3) (21.5-30.3) (20.7-40.9) (22.5-34.9) (21.9-35.8) (16.9-28.0) 35-44 years 27.5 24.6 31.5 34.4 19.0 12.7 (19.7-35.2) (21.1-28.1) (20.1-43.0) (22.8-40.1) (13.6-24.3) (8.8-16.6) 45-54 years 31.7 14.6 28.3 25.3 36.7 5.1 (26.0-37.4) (11.3-17.8) (19.9-36.8) (19.8-30.8) (29.9-43.5) (2.3-7.9) 55-64 years 47.3 18.6 46.0 23.0 49.2 5.8 (43.5-51.1) (14.0-23.3 (41.5-50.4) (17.2-28.8) (42.4-56.0) (0.9-10.6) 25-64 years 33.0 22.4 32.6 28.7 33.5 14.3 (29.7-36.2) (20.2-24.7) (27.7-37.5) (25.4-32.0) (29.7-37.3) (11.7-16.9)

Table 23. Median time spent in work-related physical activity per day (minutes) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1559) (N=1378) (N=705) (N=595) (N=854) (N=783)

median median median median median median

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 21.4 60.0 34.3 60.0 17.1 68.6 (10.7-42.8) (30.0-180.0) (12.8-68.6) (25.7-180.0) (8.6-42.8) (34.3-205.7) 35-44 years 25.7 72.8 34.3 68.6 25.7 77.1 (10.7-51.4) (34.3-180.0) (12.8-68.6) (25.7-205.7) (8.6-42.8) (38.6-180.0) 45-54 years 23.7 85.7 31.1 111.4 25.7 72.8 (11.9-45.0) (30.0-180.0) (15.0-51.4) (25.7-214.3) (8.6-42.8) (30.0-150.0) 55-64 years 17.1 51.4 25.7 51.4 17.1 51.4 (8.6-42.8) (18.2-120.0) (8.6-51.4) (17.1-120.0 (8.6-34.3) (20.0-120.0) 25-64 years 25.7 60.0 25.7 60.0 17.1 60.0 (8.6-42.8) (30.0-180.0) (12.8-51.4) (25.7-180.0) (8.6-42.8) (30.0-180.0)

83

Table 24. Median time spent in transport-related physical activity per day (minutes) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1130) (N=1250) (N=477) (N=563) (N=653) (N=687)

median median median median median median

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 23.2 23.6 20.0 25.7 25.7 20.0 (10.0-45.0) (10.0-60.0) (10.0-45.0) (10.0-60.0) (12.8-42.8) (10.7-51.4) 35-44 years 21.4 20.0 20.0 17.1 25.7 25.7 (12.8-51.4) (10.0-60.0) (11.8-51.4) (10.0-60.0) (14.3-60.0) (11.4-60.0) 45-54 years 25.3 25.7 21.4 25.7 25.7 30.0 (12.8-42.8) (15.0-60.0) (14.6-42.8) (12.1-60.0) (11.4-34.3) (17.1-60.0) 55-64 years 17.1 30.0 20.7 30.0 17.1 25.7 (10.0-42.8) (12.8-60.0) (10.0-50.7) (14.3-60.0) (8.6-34.3) (10.0-60.0) 25-64 years 21.4 25.7 20.0 25.7 25.0 25.7 (12.8-45.0) (12.8-60.0) (12.8-51.4) (11.4-60.0) (12.8-42.8) (12.8-60.0)

Table 25. Median time spent in recreation physical activity per day (minutes) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1385) (N=1927) (N=671) (N=909) (N=714) (N=1018)

median median median median median median

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 17.1 8.6 17.1 8.6 17.1 8.6 (8.6-25.7) (8.6-27.5) (8.6-25.7) (4.2-30.0) (8.6-25.7) (8.6-25.7) 35-44 years 17.1 12.8 17.1 12.8 17.1 12.8 (8.6-25.7) (8.6-30.0) (8.6-17.1) (5.7-27.8) (8.6-25.7) (8.6-30.0) 45-54 years 17.1 17.1 17.1 12.8 17.1 30.0 (8.6-17.1) (8.6-30.0) (8.6-17.1) (8.6-23.6) (8.6-17.1) (17.1-30.0) 55-64 years 17.1 30.0 17.1 8.6 12.8 30.0 (8.6-25.7) (8.6-30.0) (8.6-25.7) (4.3-30.0) (8.6-25.7) (30.0-30.0) 25-64 years 17.1 17.1 17.1 8,6 17.1 25.7 (8.6-25.7) (8.6-30.0) (8.6-25.7) (6.4-25.7) (8.6-25.7) (8.6-30.0)

84

Table 26. Mean body mass index – BMI (kg/m2)

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 23.9 23.4 23.4 22.8 24.4 24.1 (23.4-24.3) (23.1-23.7) (22.7-24.1) (22.5-23.2) (24.0-24.9) (23.7-24.6) 35-44 years 23.8 23.1 23.2 22.7 24.9 23.5 (23.3-24.3) (22.8-23.4) (22.5-24.0) (22.3-23.1) (24.4-25.4) (23.1-23.9) 45-54 years 25.0 23.6 24.6 23.2 25.5 23.9 (24.5-25.4) (23.3-23.9) (23.9-25.3) (22.8-23.6) (24.9-26.1) (23.5-24.3) 55-64 years 24.4 23.6 24.2 23.5 24.6 24.0 (24.0-24.8) (23.1-24.2) (23.8-24.7) (22.8-24.2) (23.9-25.2) (23.3-24.7) 25-64 years 24.3 23.4 23.9 23.0 24.9 23.9 (24.0-24.5) (23.2-23.6) (23.5-24.2) (22.8-23.2) (24.5.25.2) (23.6-24.1)

Table 27. Percentage who are overweight or obese (BMI ≥ 25 kg/m2) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years (adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 29.6 30.3 26.7 18.9 33.2 44.6 (24.8-34.5) (26.3-34.4) (19.0-34.5) (13.8-24.0) (27.3-39.1) (38.5-50.7) 35-44 years 35.2 29.0 31.0 24.1 44.0 34.9 (28.5-41.9) (24.7-33.3) (20.9-41.1) (18.3-30.0) (38.1-49.8) (28.8-40.9) 45-54 years 42.1 31.4 40.0 27.0 45.3 35.3 (37.6-46.6) (27.6-35.2) (33.9-46.1) (21.5-32.6) (39.0-51.6) (30.0-40.7) 55-64 years 39.8 25.9 37.9 22.4 42.4 36.5 (34.9-44.6) (20.7-31.1) (31.3-44.5) (16.2-28.5) (35.1-49.6) (26.6-46.5) 25-64 years 36.3 29.5 33.7 22.2 40.1 38.9 (33.7-38.9) (29.9-37.5) (19.4-25.1) (36.6-43.5) (35.4-42.5)

85

Table 28. Percentage who are obese (BMI ≥ 30 kg/m2)

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 7.8 2.4 6.4 1.7 9.5 3.3 (5.3-10.2) (1.1-3.8) (2.8-10.0) (0.0-3.5) (6.4-12.6) (1.1-5.4) 35-44 years 5.9 1.4 4.8 0.4 8.2 2.5 (3.4-8.4) (0.3-2.5) (1.6-8.0) (-0.4-1.3) (4.3-12.1) (0.3-4.7) 45-54 years 9.6 2.0 8.7 1.8 11.0 2.1 (6.6-12.7) (0.6-3.3) (4.1-13.4) (0.0-3.6) (7.7-14.3) (0.4-3.8) 55-64 years 5.4 4.2 5.2 4.3 5.6 3.8 (3.4-7.4) (1.6-6.8) (2.3-8.1) (1.0-7.6) (3.0-8.2) (0.5-7.2) 25-64 years 7.7 2.3 6.7 1.9 9.1 2.8 (6.2-9.1) (1.5-3.1) (4.5-8.8) (0.8-3.0) (7.4-10.9) (1.7-4.0)

Table 29. Average waist circumference (cm) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 77.4 71.9 77.9 74.3 76.7 69.0 (76.2-78.5) (70.9-73.0) (76.1-79.6) (72.9-75.7) (75.2-78.2) (67.7-70.3) 35-44 years 78.5 75.2 78.4 77.4 78.9 72.5 (76.8-80.3) (74.3-76.0) (75.9-80.9) (76.1-78.6) (77.2-80.5) (71.4-73.7) 45-54 years 81.9 78.5 82.6 80.1 80.7 77.0 (80.3-83.4) (77.4-79.5) (80.3-85.0) (78.7-81.6) (79.1-82.3) (75.6-78.3) 55-64 years 80.3 80.8 80.5 82.6 80.0 75.7 (78.9-81.6) (79.4-82.2) (78.4-82.5) (81.0-84.1) (78.5-81.5) (73.3-78.0) 25-64 years 79.5 75.3 80.0 77.6 78.8 72.4 (78.7-80.3) (74.7-75.9) (78.8-81.1) (76.8-78.4) (77.9-79.7) (71.6-73.1)

86

Table 30. Mean systolic blood pressure - SBP (mmHg) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 115.3 99.0 118.2 103.5 111.7 93.5 (112.2-118-3) (97.5-100.6) (113.5-122.9) (101.2-105.8) (108.4-115.0) (91.8-95.1) 35-44 years 118.3 104.0 120.3 106.0 114.3 101.6 (115.2-121.5) (102.4-105.6) (115.8-124.8) (103.7-108.3) (111.6-117.0) (99.3-103.9) 45-54 years 124.0 115.3 124.0 114.7 123.9 115.9 (121.6-126.4) (113.3-117.4) (120.5-127.5) (111.8-117.6) (121.1-126.8) (112.8-119.0) 55-64 years 134.8 123.7 136.5 123.2 132.5 125.4 (132.7-137.0) (120.5-126.9) (133.7-139.3) (119.2-127.1) (129.1-135.9) (120.9-129.9) 25-64 years 121.8 107.0 123.5 109.7 119.5 103.5 (120.3-123.4) (105.9-108.1) (121.2-125.7) (108.1-111.3) (117.6-121.4) (101.9-105.2)

Table 31. Mean diastolic blood pressure - DBP (mmHg) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 70.9 61.2 71.0 62.5 70.7 59.4 (69.4-72.4) (60.1-62.2) (68.8-73.3) (61.0-64.1) (68.8-72.5) (58.4-60.5) 35-44 years 72.7 64.4 73.3 65.5 71.5 63.1 (70.5-74.9) (63.3-65.6) (70.1-76.4) (63.9-67.3) (69.7-73.4) (61.5-64.6) 45-54 years 74.6 69.1 74.1 69.1 75.3 69.1 (73.1-76.1) (67.9-70.4) (71.9-76.3) (67.4-70.9) (73.5-77.1) (67.4-70.9) 55-64 years 76.1 7.04 76.6 70.4 75.5 70.2 (74.8-77.4) (68.7-72.1) (74.7-78.4 (68.4-72.4) (73.8-77.2) (67.4-73.1) 25-64 years 73.2 64.9 73.4 65.9 73.1 63.6 (72.4-74.1) (64.2-65.5) (72.1-74.6) (65.0-66.8) (72.0-74.1) (62.6-64.5)

87

Table 32. Percentage with raised BP (SBP ≥ 140 and/or DBP ≥ 90 mmHg)

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 5.8 1.8 6.4 2.9 5.2 0.4 (3.6-8.1) (0.5-3.1) (3.0-9.8) (0.7-5.2) (2.3-8.0) (-0.4-1.3) 35-44 years 9.6 2.2 10.7 1.9 7.3 2.5 (5.9-13.2) (0.9-3.4) (5.4-15.9) (0.1-3.6) (4.5-10.2) (0.6-4.4) 45-54 years 9.4 6.8 8.3 7.7 11.0 6.0 (6.5-12.3) (4.6-9.0) (4.2-12.4) (4.3-11.1) (7.0-15.0) (3.0-9.0) 55-64 years 13.9 6.7 14.9 6.4 12.4 7.7 (11.1-16.6) (4.1-9.4) (11.1-18.7) (3.2-9.6) (8.6-16.2) (3.0-12.4) 25-64 years 9.0 3.5 9.2 4.0 8.6 2.9 (7.5-10.4) (2.6-4.4) (7.1-11.4) (2.8-5.3) (6.7-10.4) (1.7-4.0)

Table 33.Percentage with raised BP (SBP ≥ 170 and/or DBP ≥ 100 mmHg) Both Sexes Males Females

2003 2006 2003 2003 2006 2003 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 2.5 0.3 3.5 0.5 1.3 - (1.0-4.0) (-0.3-0.8) (1.1-5.9) (-0.5-1.5) (-0.1-2.7) - 35-44 years 5.4 1.7 6.4 1.9 3.4 1.5 (1.9-9.0) (0.5-2.8) (1.2-11.6) (0.1-3.6) (1.3-5.5) (-0.0-2.9) 45-54 years 3.4 1.7 2.9 1.8 4.1 1.7 (1.8-4.9) (0.6-2.9) (1.0-4.8) (0.0-3.6) (1.5-6.7) (0.2-3.2) 55-64 years 5.5 2.2 6.0 2.3 4.8 1.9 (3.4-7.6) (0.5-3.9) (2.8-9.3) (0.2-4.4) (2.4-7.2) (-0.6-4.5) 25-64 years 3.8 1.2 4.3 1.4 3.1 1.0 (2.8-4.8) (0.7-1.7) (2.8-5.8) (0.6-2.2) (1.9-4.2) (0.3-1.6)

88

Table 34. Mean fasting blood glucose (mmol/L)

Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1631) (N=1788) (N=691) (N=891) (N=940) (N=897)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 4.6 4.4 4.7 4.4 4.5 4.3 (4.5-4.8) (4.3-4.5) (4.5-5.0) (4.3-4.5) (4.3-4.7) (4.2-4.4) 35-44 years 4.6 4.5 4.6 4.6 4.5 4.5 (4.4-4.7) (4.4-4.6) (4.4-4.8) (4.4-4.7) (4.3-4.7) (4.4-4.6) 45-54 years 5.2 4.9 5.1 4.8 5.3 4.9 (5.0-5.4) (4.7-5.9) (4.9-5.4) (4.6-4.9) (5.0-5.6) (4.7-5.1) 55-64 years 5.4 5.0 5.3 5.0 5.5 4.9 (5.2-5.6) (4.8-5.2) (5.1-5.6) (4.8-5.2) (5.2-5.8) (4.6-5.2) 25-64 years 4.9 4.6 5.0 4.6 4.9 4.6 (4.8-5.0) (4.5-4.7) (4.8-5.1) (4.5-4.7) (4.8-5.1) (4.5-4.6)

Table 35. Percentage with raised blood glucose (≥ 7.0 mmol/L) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1631) (N=1788) (N=691) (N=891) (N=(940) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 3.6 1.1 4.4 1.3 2.7 0.4 (1.4-5.9) (0.0-2.1) (0.6-8.2) (-0.2-3.3) (0.8-4.6) (-0.4-1.2) 35-44 years 3.6 2.8 3.6 3.3 3.5 2.3 (1.6-5.5) (1.3-4.3) (1.1-6.2) (1.0-5.5) (0.5-6.5) (0.5-4.1) 45-54 years 7.3 5.4 6.1 5.4 8.7 5.4 (4.3-10.2) (3.5-7.4) (2.1-10.2) (2.5-8.3) (4.7-12.8) (2.8-8.0) 55-64 years 9.4 7.0 8.6 7.1 10.5 6.7 (6.6-12.2) (4.0-10.1) (4.9-12.2) (3.2-11.0) (6.0-15.0) (2.0-11.4) 25-64 years 5.8 3.2 5.5 3.7 6.1 2.6 (4.4-7.1) (2.4-4.0) (3.5-7.6) (2.4-5.6) (4.4-7.8) (1.7-3.6)

89

Table 36. Mean fasting blood glucose (mmol/L) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1631) (N=1788) (N=691) (N=891) (N=940) (N=897)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 7.2 5.9 7.5 6.0 6.9 5.8 (6.8-7.7) (5.8-6.1) (6.9-8.2) (5.8-6.3) (6.5-7.3) (5.7-5.9) 35-44 years 7.1 6.3 7.0 6.4 7.4 6.2 (6.7-7.6) (6.1-6.6) (6.4-7.5) (6.1-6.8) (6.8-8.0) (6.0-6.4) 45-54 years 8.3 7.1 8.0 6.7 8.6 7.4 (7.8-8.7) (6.8-7.4) (7.4-8.5) (6.3-7.1) (7.9-9.3) (6.9-7.9) 55-64 years 9.1 7.5 9.1 7.5 9.2 7.4 (8.6-9.6) (7.0-8.0) (8.5-9.7) (6.9-8.2) (8.3-10.0) (6.6-8.3) 25-64 years 7.9 6.5 7.9 6.5 7.9 6.4 (7.6-8.1) (6.3-6.6) (7.5-8.2) (6.3-6.7) (7.6-8.2) (6.2-6.6)

Table 37. Percentage fasting blood glucose (≥11mmol/L) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1631) (N=1788) (N=691) (N=891) (N=940) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 8.2 1.6 10.5 2.6 5.3 0.4 (5.6-10.8) (0.3-2.9) (6.3-14.7) (0.4-4.8) (2.6-8.1) (-0.4-1.2) 35-44 years 5.5 4.4 5.1 5.6 6.1 2.9 (2.7-8.3) (2.4-6.3) (1.6-8.6) (2.4-8.7) (1.5-10.8) (1.0-4.9) 45-54 years 13.8 11.0 13.8 8.4 13.7 13.3 (10.5-17.1) (8.4-13.6) (9.1-18.6) (4.8-11.9) (9.1-18.4) (9.4-17.2) 55-64 years 19.0 15.2 20.8 15.8 16.6 13.5 (15.2-22.8) (10.8-19.6) (15.7-25.9) (10.3-21.3) (10.9-22.3) (5.9-21.0) 25-64 years 11.5 6.1 12.5 6.9 10.1 5.1 (9.8-13.1) (5.0-7.2) (10.1-14.9) (5.1-8.6) (8.0-12.2) (3.7-6.4)

90

Table 38. Prevalence diabetes Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 7.1 2.2 7.5 3.3 6.5 0.8 (5.0-9.1) (0.8-3.6) (4.8-10.3) (1.0-5.7) (3.4-9.5) (-0.3-1.8) 35-44 years 5.7 5.7 5.3 6.7 6.5 4.6 (3.0-8.4) (3.6-7.9) (1.9-8.7) (3.4-10.0) (2.0-10.90 (2.1-7.1) 45-54 years 13.4 13.0 12.1 9.6 15.5 16.0 (10.6-16.3) (10.3-15.8) (8.4-15.7) (5.7-13.6) (11.2-19.8) (11.8-20.2) 55-64 years 21.0 21.5 21.4 22.9 20.4 17.3 (17.2-24.7) (16.8-26.2) (16.2-26.5) (16.8-29.0) (15.0-25.8) (9.8-24.8) 25-64 years 11.2 8.0 10.8 9.0 11.7 6.7 (9.8-12.6) (6.7-9.3) (9.0-12.7) (7.0-11.0) (9.6-13.9) (5.1-8.2)

Table 39. Mean total blood cholesterol (mmol/L) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1631) (N=1788) (N=691) (N=891) (N=940) (N=897)

mean mean mean mean mean mean

Results for adults aged 25-64 years

(adjusted *)

(95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) (95 CI %) 25-34 years 4.5 4.3 4.5 4.4 4.5 4.3 (4.3-4.6) (4.2-4.4) (4.2-4.7) (4.3-4.5) (4.4-4.7) (4.1-4.4) 35-44 years 4.6 4.4 4.6 4.5 4.6 4.3 (4.5-4.7) (4.4-4.5) (4.3-4.8) (4.4-4.6) (4.5-4.7) (4.3-4.4) 45-54 years 4.9 4.6 4.8 4.5 5.1 4.6 (4.8-5.0) (4.5-4.6) (4.7-4.9) (4.4-4.6) (4.9-5.2) (4.5-4.7) 55-64 years 5.0 4.6 4.8 4.6 5.2 4.6 (4.9-5.1) (4.5-4.7) (4.7-4.9) (4.5-4.7) (5.1-5.4) (4.3-4.9) 25-64 years 4.7 4.4 4.6 4.5 4.8 4.4 (4.6-4.8) (4.4-4.5) (4.5-4.7) (4.4-4.6) (4.7-4.9) (4.3-4.5)

91

Table 40. Percentage with raised total cholesterol (≥ 5.2 mmol/L) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1631) (N=1788) (N=691) (N=891) (N=940) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 24.2 16.4 25.4 18.0 22.7 14.5 (17.6-30.8) (12.5-20.3) (14.4-36.4) (12.5-23.4) (17.4-27.9) (9.9-19.1) 35-44 years 25.0 19.2 24.1 23.4 26.3 14.2 (19.7-30.2) (15.8-22.7) (15.8-32.4) (18.2-28.7) (21.7-30.9) (10.1-18.4) 45-54 years 38.6 22.0 35.9 19.6 42.1 24.0 (34.8-42.5) (18.2-25.7) (30.9-40.8) (14.3-24.9) (36.1-48.0) (18.9-29.2) 55-64 years 40.1 25.9 33.1 23.9 49.8 31.7 (36.2-44.0) (20.3-31.3) (28.0-38.2) (17.1-30.7) (44.2-55.4) (21.2-42.2) 25-64 years 31.6 19.6 29.7 20.9 34.0 18.0 (28.7-34.5) (17.4-21.8) (25.2-34.2) (17.7-24.1) (0.0-37.3) (15.3-20.6)

Table 41. Percentage with raised total cholesterol (≥ 6.5 mmol/L) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1631) (N=1788) (N=691) (N=891) (N=940) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-34 years 3.7 2.2 3.5 2.5 4.0 1.7 (1.8-5.6) (0.8-3.5) (0.8-6.2) (0.3-4.7) (1.5-6.5) (0.1-3.3) 35-44 years 5.3 1.8 7.3 1.4 2.2 2.3 (2.7-7.8) (0.6-2.9) (3.4-11.1) (-0.2-2.9) (0.4-3.9) (0.5-4.0) 45-54 years 7.6 3.4 5.6 3.8 10.0 3.0 (1.8-10.3) (1.6-5.2) (2.5-8.8) (1.1-6.6) (5.1-14.9) (0.8-5.3) 55-64 years 8.0 6.3 6.5 6.1 10.1 6.7 (5.7-10.3) (3.4-9.1) (3.7-9.3) (2.7-9.5) (6.2-14.0) (1.4-12.1) 25-64 years 5.9 2.9 5.3 3.1 6.7 2.6 (4.7-7.1) (2.1-3.7) (3.7-6.9) (1.9-4.3) (4.7-8.7) (1.6-3.6)

92

Table 42. Percentage with low risk (less then three of the risk factors *) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-44 years 85.8 92.7 83.9 91.0 88.5 94.8 (82.4-89.2) (91.0-94.4) (78.7-89.1) (88.5-93.6) (85.1-91.9) (92.9-96.9) 45-64 years 72.0 86.8 74.3 85.5 68.6 88.8 (68.7-75.3) (84.5-89.2) (69.6-79.1) (82.0-89.0) (64.3-72.8) (85.8-91.8) 25-64 years 79.0 90.2 79.2 89.1 78.8 93.0 (76.6-81.4) (89.4-92.2) (75.7-82.8) (87.2-91.1) (75.8-81.7) (91.2-94.8)

* Smoking, low level of activity, ate less 5 servings of fruit & vegetables per day, obesity, hypertension, hyperglycemia, and hypercholesterolemia

Table 43. Percentage with raised risk (three or more of the risk factors*) Both Sexes Males Females

2003 2006 2003 2006 2003 2006 (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897)

% % % % % %

Results for adults aged 25-64 years

(adjusted *)

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 25-44 years 14.2 7.3 16.1 9.0 11.4 5.2 (10.7-17.6) (5.6-9.0) (10.8-21.3) (6.4-11.5) (8.0-14.9) (3.1-7.2) 45-64 years 28.0 13.1 25.6 14.5 31.4 11.2 (24.7-31.3) (10.8-15.5 (20.9-30.4) (11.0-18.0) (27.2-35.7) (8.2-14.2) 25-64 years 20.9 9.2 20.7 10.6 21.2 6.9 (18.6-23.4) (7.8-10.6) (17.2-24.3) (8.9-12.8) 18.3 -24.2) (5.2-8.7)

* Smoking, low level of activity, ate less 5 servings of fruit & vegetables per day, obesity, hypertension, hyperglycemia, and hypercholesterolemia.

93

Table 44. Percentage of who Raised Risk of NCD by achievement of their “Posbindu PTM”

Pratama-Madya Purnama-Mandiri 2003 2006 2003 2006

N= 929 892 N=877 914 Results for adults aged 25-64 years (adjusted *) %

(95 CI) %

(95%) %

(95 CI) %

(95%)

25-34 years 16.6 4.2 13.1 6.9 (8.4-24.7) (1.9-6.5) (8.3-18.0) (3.7-10.1) 35-44 years 15.2 8.5 10.8 10.2 (8.6-21.9) (4.7-12.3) (6.2-15.5) (6.5-13.8) 45-54 years 26.6 11.0 21.3 11.8 (20.4-32.8) (7.7-14.4) (16.6-26.0) (7.7-15.9) 55-64 years 34.5 13.3 37.3 17.0 (27.7-41.3) (8.1-18.5) (30.8-43.7) (11.1-22.9) 25-64 years 23.0 8.1 18.8 10.2 (19.4-26.7) (6.3-9.9) (15.9-21.7) (8.1-12.3)

94

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1. Achmadi, Umar Fahmi. (2003) Mengembangkan Lingkungan Sehat Menuju Indonesia Sehat, Konferensi Nasional Promosi Kesehatan Ke 3, Yogyakarta.

2. Adisapoetra, Iskandar, Z. (2003). Promosi Kesehatan Peningkatan Aktifitas Fisik. Konferensi Nasional Promosi Kesehatan Ke 3, Yogyakarta.

3. Anwar, Choirul. (2003). Advokasi Dalam Pengembangan Program JPKM di Kota Yogyakarta. Konferensi Nasional Promosi Kesehatan Ke 3, Yogyakarta.

4. Ashton, J. (1988) The New Public Health George Allen and Unwin, London.

5. Atkins, R. (1984) A Comparative Analysis of the Utility of EIA Methods in Perspectives on Environmental Impact Assessment Clark et al. (ed) D Reidel Publishing Company. Dordrecht.

6. Baum, F. and Brown, V. (1989) Healthy Cities (Australia) Project: Issues of Evaluation for the New Public Health. Community Health Studies XIII 2, 140-149.

7. Baum, F., Fry, D. & Lennie, I. (ed) (1992) Community Health Policy and Practice in Australia. NSW: Pluto Press.

8. Baumann, A. (1989) An Epidemiology of Inequity In Workshop 2020: A Sustainable Healthy Future Commission For The Future and Latrobe University Melbourne.

9. Bracht, N. (ed) (1990) Health Promotion at the Community Level. CA: Sage Publications.

10. Boothroyd, P. (1992) “Managing Population – Environment Linkages: A General System Theory Perspective”. In Population – Environment Linkages: Toward a Conceptual Framework. P. Boothroyd (Ed.) Environmental Management Development in Indonesia Project. Jakarta and Halifax.

11. Bonita R, de Courten M, Dwyer T, Jamrozik K, Winkelmann R.(2001) Surveillance of risk factors for non communicable diseases: The WHO STEPwise approach. Summary. Geneva. World Health Organization, 2001

12. Brown, V. Ritchie, J. and Rotem A. Health Promotion and Environmental Management. A Partnership for the Future Health Promotion International 7, 3, 219-230.

13. Dachroni. (2003). Membumikan Promosi Kesehatan Dalam Berbagai Program dan Tatanan Menuju Indonesia Sehat 2010. Konferensi Nasional Promosi Kesehatan Ke 3, Yogyakarta.

14. Dewi. (2003). Menuju Kemandirian Masyarakat di Bidang Kesehatan Melalui Komite Kesehatan Dusun. Konferensi Nasional Promosi Kesehatan Ke 3, Yogyakarta.

15. Departemen Kesehatan, (2004) Survey Kesehatan Nasional. Laporan.Depkes RI Jakarta

16. Dinas Kesehatan Kota Depok. (2003). Rencana Pengembangan PTM di Kota Depok.

17. Dinas Kesehatan Kota Depok. (2003).Laporan Pertemuan Rembug Warga Dalam Rangka Pengembangan PTM di Kota Depok.

95

18. Dwyer, J. The Politics of Participation, Community Health Studies XII 1, 59-65.

19. Ewles, L. & Simnett, I. (1985) Promoting Health: A Practical Guide to Health Education . NY: John Wiley & Sons.

20. Fidiansjah. (2003). Promosi Kesehatan Dalam Masalah Kesehatan Jiwa, Konferensi Nasional Promosi Kesehatan Ke 3, Yogyakarta.

21. Green, L., W. and Kreuter, M.W. (1991) Health Promotion Planning An Educational and Environmental Approach (2nd Edition). Mayfield Publishing Co. Mountainview.

22. Hawe, P., Degeling, D; Hall, J. (1990) Evaluating Health Promotion. NSW: MacLennan & Petty Pty Ltd.

23. Hancock, T. (1993) Health, Environment, Economy Strategies for a Sustainable Future World Health Organization European Division.

24. Mamdy, Zulazmi. (2003). Promosi Kesehatan dan Sumberdaya Manusia : Sebuah Catatan dan Gangguan. Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

25. Markus, Soedibyo. (2003). Pemberdayaan Civil Society Dan Promosi Kesehatan Di Indonesia. Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

26. Mechanic, D dan Volkart, E. H (1961): Stress, Illness Behavior and The Sick Role, American Sociological review, 26: 51-58

27. Moeloek, Farid Anfasa. Promosi Kesehatan Di Era Desentralisasi (Menuju Indonesia Sehat 2010). Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

28. Milio, N. (1983) Promoting Health Through Public Policy, F.A. Davis Philadelphia.

29. Murray CJL, Lopez AD. The global burden of disease. Boston, Mass: Harvard School of Public Health 1996.

30. Ottawa Charter for Health Promotion. Can J Public Health 1986; 77: 425-30. Ottawa Charter for Health Promotion. Can J Public Health 1986; 77: 425-30.

31. Rahajeng Prevelensi Penyakit Tidak Menular di Kota Depok Jawa Barat. Laporan Penelitian. Badan Litbang Depkes RI. 2002.

32. Singgih, Renie. (2003). Promosi Kesehatan Dalam Penanggulangan Masalah Merokok. Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

33. Sumedi, Edith. (2003). Pedoman Umum Gizi Seimbang Sebagai Media Promosi Kesehatan. Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

34. Suryadi, Charles. (2003). Menuju Indonesia Sehat Melalui Pengembangan Kabupaten dan Kota Sehat. Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

35. Trihono. (2003). Model Pemberdayaan Keluarga Pada Proyek Kesehatan Keluarga Dan Gizi. Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

36. Wackernagel, M., McIntosh, J., Rees, W.E., and Wollard, R.W. (1993) How Big is our Ecological Footprint? A Handbook for Estimating a Community’s Carrying Capacity. A discussion draft prepared for the Task Force on Planning Healthy and Sustainable Communities. The University British Columbia. Vancouver.

37. Wadsworth, Y. (1988) Participatory Research and Development in Primary Health Care by Community Groups, Consumers Health Forum, Canberra.

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38. Wahyurini, Ernanti. (2003). Pemberdayaan Perempuan Menuju Pencapaian Indonesia Sehat. Konferensi Nasional Promosi Kesehatan Ke 3. Yogyakarta.

39. World Commission on Environment and Development (1987) Our Common Future. Oxford University Press. Oxford.

40. World Health Organization Healthy Cities Project, (1989) The New Public Health in an Urban Context Paradoxes and Solutions. WHO Healthy Cities Paper No. 4, FADL Copenhagen. Select Bibliography.

41. World Health Organization Healthy Cities Project, (1989) The New Public Health in an Urban Context Paradoxes and Solutions. WHO Healthy Cities Paper No. 5, FADL Copenhagen. Select Bibliography.

42. Yencken, D. (1989) Multifunction Polis: A Social Issues Study, DIT and C. AGPS.

Attachment 2

STEPS Instrument for NCD Risk Factors (Core and Expanded Version 1.3) Depok

The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS)

1

STEPS Instrument (V1.3)

• This is the generic template which countries use to develop their own Instrument. It contains the CORE (unshaded and in double lined boxes) and EXPANDED items (shaded and in single lined boxes) and response options for Step 1, Step 2 and Step 3.

• The introductory statements, questions and response options should be translated and adapted where necessary to suit local conditions. Italic typeface indicates where local examples should be inserted.

• All CORE items should be included in the country-specific STEPS Instrument. Wording and response options for CORE questions should not be changed.

• Relevant skip patterns are shown and should be carefully reviewed. Modifications to the skip patterns will be needed according to the final items included.

• Some countries may wish to expand the CORE questions. Recommendations for EXPANDED questions for the key risk factors are included in the shaded areas. These items may be modified but it is preferable to use them where possible.

• Additional questions can be added as OPTIONAL items to meet local needs. For example questions asked in previous surveys could be added to link to previous data.

• The use of the coding column (as is used in this Instrument) facilitates easy, fast and accurate manual data entry. Using this approach does not replace the need for double data entry for maximum quality control (see data coding manual).

EXAMPLE- for a current smoker who eats 8 servings of fruit on a typical day

Response Coding column

Skip

S 1a Do you currently smoke any tobacco products, such as cigarettes, cigars or pipes?

Yes No

Don’t know

1 2 7

If No, go to Next Section

D 1b How many servings of fruit do you eat on one of those days? USE SHOWCARD

Number of servings Don’t know

77

• "Do not know" or "Don’t remember" are response options indicated in CORE and EXPANDED questions where appropriate. These are coded as "7", "77" or "777" depending on the number of numerals in the other response options. Three other values are important to record: “refuse” and “not applicable” are coded as "8", "88", or "888". For example, if S 1a is recorded as “No”, then all remaining smoking questions will be set at “8”. Missing responses to any questions should be entered as "9", "99" or "999" at time of data entry.

• Interviewer training is essential to develop thorough knowledge of the instrument format, introductory statements, questions, skip patterns, response options, use of show cards and prompts (where needed). The STEPS Field Manual is a guide and resource for training sessions.

• Undertaking pilot work with the draft country-specific STEPS instrument is essential.

• Each country will need to prepare a list of the question numbers (e.g. D1a) and response code cross-referenced with the standard numbers and codes used in this generic template. This cross-referencing will facilitate communication and comparison.

This document is available electronically on the NCD Surveillance website: http://www.who.int/ncd/surveillance/surveillance_publications.htm

Other documents cross-referenced in above are available by contacting ncd_surveillance@who.int

0 8

1

2

3

Respondent Identification Number

Identification Information: Time interview start : _ _. _ _ . Time interview end : _ _ . _ _ Adjust how you will call the respondent to the local situation, you may ask them ‘anda’, ‘bapak’, ‘ibu’, ‘kakak’, ‘adik’, ‘mbak’, ‘abang’

I 1 Province

I 2 Country/district code

I 3 Centre (Village name)`:

I 4 Centre (Village code): (SEE NOTE BELOW)

I 5 Interviewer code

I 6 Date of completion of the questionnaire / / Day Month Year

No. RW : No.RT: Respondent Id Number

Consent

I 6 Consent has been read out to respondent

Yes 1 No 2 If NO, read consent

I 7 Consent has been obtained (verbal or written) Yes 1 No 2 If NO, END

I 8 Interview Language [Insert Language] English 1 [Add others] 2

I 9 Time of interview (24 hour clock) : I 10 Respondent’s full name

I 11 Respondent father’s name

Additional Information that may be helpful

I 12 Contact phone number where possible

I 13 Specify whose phone Work 1 Home 2 Neighbour 3 Other (specify) 4

Note: Identification information I6 to I13 should be stored separately from the questionnaire because it contains confidential information. Please note: village code (or household code) is required as part of main instrument for data analyses. Date of interview is required to calculate age. It will be necessary to record procedures that require quick reference checking. For example, whether Step 1, Step 2 and Step 3 have been completed, double data entry check boxes (or other checking procedures) are necessary. Again, these will need to be included in the main questionnaire if the Identification Information sheet is stored separately.

4

Respondent Identification Number

Step 1 Core Demographic Information

Coding Column

C1 Sex (Record Male / Female as observed ) Male Female

1 2

C2 What is your date of birth?

If Don’t Know, See Note* below and Go to C3 Day Month Year

C3 How old are you? Years

C4 In total, how many years have you spent at school or in full-time study (excluding pre-school)? Years

EXPANDED: Demographic Information C5 What is your [insert relevant ethnic group / racial group

/ cultural subgroup / others] background? [Defined according

to local demographic needs]

*)

No formal schooling 0 1 Less than primary school 0 2 Primary school completed 0 3

Secondary school completed 0 4 High school completed 0 5

College/University completed 0 6

C6 What is the highest level of education you have completed? [INSERT COUNTRY-SPECIFIC CATEGORIES] Post graduate degree 0 7

Government employee 0 1 Non-government employee 0 2

Self-employed 0 3 Non-paid 0 4

Student 0 5 Homemaker 0 6

Retired 0 7 Unemployed (able to work) 0 8

C7 Which of the following best describes your main work status over the last 12 months? [INSERT COUNTRY-SPECIFIC CATEGORIES] USE SHOWCARD Unemployed (unable to work) 0 9

C8a How many people, including yourself, live in your household? Number of people

C8b How many people older than 18 years, including yourself, live in your household? Number of people

Per week . .

OR per month . .

OR per year . .

C9 Taking the past year, can you tell me what the average earnings of each of the household member have been?

Refused 88 If Refused Go to C10

< Rp.1.800.000 01 Rp.1.800.000 to <Rp. 3.600.000 02 Rp.3.600.000 to <Rp.7.200.000 03 Rp.7.200.000 to Rp.14.400.000 04

More than Rp.14.400.000 05

C10 If you don’t know the amount, can you give an estimate of the annual household income if I read some options to you? Is it [READ OPTIONS] [INSERT QUINTILE VALUES] Refused 88

*) code: Betawi=1, Jawa=2, Sunda=3, Padang=4, Batak=5, Aceh=6, Palembang=7, Lampung=8, Madura=9, Bali=10, Menado=11, Bima/NTB=12, NTT=13, Ambon=14, Makasar=15, Kalimantan=16, Cina-17, Foreigner=18, Other=19 ∗Note: Coding Rule: Code “Don’t Know” 7 (or 77 or 777 as appropriate).

5

Respondent Identification Number

Step 1 Core Behavioural Measures

CORE Tobacco Use (Section S) Now I am going to ask you some questions about various health behaviours. This includes things like smoking, drinking alcohol, eating fruits and vegetables and physical activity. Let’s start with smoking.

Response Coding Column S 1a Do you currently smoke any tobacco products,

such as cigarettes, cigars or pipes? Yes No

1 2

If No, go to Next Section∗

S 1b If Yes, Do you currently smoke tobacco products daily?

Yes No

1 2

If No, go to Next Section∗

S 2a How old were you when you first started smoking daily?

Age (years) Don’t remember

7 7

If Known, go to S 3

In Years

Years

OR in Months

Months

S 2b Do you remember how long ago it was? (CODE 77 FOR DON’T KNOW or DON’T REMEMBER)

OR in Weeks

Weeks

On average, how many of the following do you smoke each day? Cloves cigarettes

Non Cloves cigarettes

(RECORD FOR EACH TYPE) Hand-rolled cigarettes

Pipes full of tobacco

(CODE 77 FOR DON’T KNOW CODE 88 FOR NOT APPLICABLE) Cigars, cheroots, cigarillos

S 3

Other (please specify):

EXPANDED: Tobacco Use S 4 In the past, did you ever smoke daily? Yes

No 1 2

If No, go to S 6a

Age (years) If Known, go to

S 6a S 5a If Yes,

How old were you when you stopped smoking daily?

Don’t remember 7 7 If 7 7, go to S 5b

Years ago Years

OR Months ago Months

S 5b How long ago did you stop smoking daily?

OR Weeks ago Weeks

Yes 1 S 6a Do you currently use any smokeless tobacco such as [snuff, chewing tobacco, betel] ?

No 2 If No, go to S 8

Yes 1 S 6b If Yes, Do you currently use smokeless tobacco products daily? No 2

If No, go to S 8

∗ Amend skip instructions if EXPANDED or OPTIONAL items are added to the Tobacco section ∗ Amend skip instructions if EXPANDED or OPTIONAL items are added to the Tobacco section

6

Respondent Identification Number

On average, how many times a day do you use …. (RECORD FOR EACH TYPE)

Betel + quid

Snuff, by mouth

Snuff, by nose

(CODE 77 FOR DON’T KNOW CODE 88 FOR NOT APPLICABLE) Chewing tobacco

S 7

Other (specify)

S 8 In the past, did you ever use smokeless tobacco such as [snuff, chewing tobacco, or betel] daily?

Yes No

1 2

CORE Alcohol Consumption (Section A) The next questions ask about the consumption of alcohol.

Response Coding Column

A 1a Have you ever consumed a drink that contains alcohol such as beer, wine, spirit, fermented cider or [add other local examples] ? USE SHOWCARD or SHOW EXAMPLES

Yes No

1 2

If No, Go to Next Section∗

A 1b Have you consumed alcohol within the past 12 months?

Yes No

1 2

If No, Go to Next Section*

A 2 In the past 12 months, how frequently have you had at least one drink? (READ RESPONSES) USE SHOWCARD

5 or more days a week 1-4 days per week 1-3 days a month

Less than once a month

1 2 3 4

A 3 When you drink alcohol, on average, how many drinks do you have during one day?

Number Don’t know

7 7

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

A 4 During each of the past 7 days, how many standard drinks of any alcoholic drink did you have each day? (RECORD FOR EACH DAY USE SHOWCARD) (CODE 77 FOR DON’T KNOW) Sunday

EXPANDED : Alcohol A 5 In the past 12 months, what was the largest number

of drinks you had on a single occasion, counting all types of standard drinks together?

Largest number

A 6a For men only: In the past 12 months, on how many days did you have five or more standard drinks in a single day?

Number of days

A 6b For women only: In the past 12 months, on how many days did you have four or more standard drinks in a single day?

Number of days

∗ Amend skip instructions if EXPANDED or OPTIONAL items are added to the Alcohol section

7

Respondent Identification Number

CORE Diet (Section D) The next questions ask about the fruits and vegetables that you usually eat. I have a nutrition card here that shows you some examples of local fruits and vegetables. Each picture represents the size of a serving. As you answer these questions please think of a typical week in the last year.

D 1a

In a typical week, on how many days do you eat fruit? USE SHOWCARD

Number of days

If Zero days, go to D 2a

D 1b How many servings of fruit do you eat on one of those days? USE SHOWCARD

Number of servings

D 2a In a typical week, on how many days do you eat vegetables? USE SHOWCARD

Number of days If Zero days, go to Section P

D 2b How many servings of vegetables do you eat on one of those days? USE SHOWCARD

Number of servings

EXPANDED : Diet

D 3 Do you usually prepare meal in your household? Yes No

1 2

Palm oil in packaging 0 1 Palm oil no packaging 0 2

Coconut oil in packaging 0 3 Coconut oil no packaging 04

Margarine 05 Butter 06

Other animal fat 07 Other 08

D 4

What type of oil or fat is most often used for meal preparation in your household? USE SHOWCARD SELECT ONLY ONE

(CODE 77 FOR DON’T KNOW)

D5 When you cook at home, how many times do you

usually re-use the cooking oil ………….times

D6 In typical week, how many days and how many portion (cup/glass/plate/spoon) in those days, do you eat several food below:

a. Chicken b. Animal organ (chicken, cow, sheep, pork,

etc) c. Fresh fish (from sea or river) d. Eggs e. Milk f. Instant noodles g. Canned food

Days Portion per per week day …….. ……… …….. ……… …….. ……… …….. ……… …….. ……… …….. ……… …….. ………

D7 Do you usually eat snack between meals?

Yes, always 1 Yes, often 2 Yes, occasionally 3 No 4

D8 Do you use monosodium glutamate for cooking at home?

Yes, always 1 Yes, often 2 Yes, occasionally 3 No 4 Don’t know 5

D9 In typical week, how many days and how many time in those days, do you usually drink the following:

a. Coffee b. Tea c. Soft drink(coca cola, pepsi, sprite, etc) d. Energy drink (kratingdaeng, M150, extra

joss, etc)

Days Portion per per week day …….. ……… …….. ……… …….. ……… …….. ………

8

Respondent Identification Number

9

Respondent Identification Number

CORE Physical Activity (Section P) Next I am going to ask you about the time you spend doing different types of physical activity. Please answer these questions even if you do not consider yourself to be an active person. Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, household chores, harvesting food, fishing or hunting for food, seeking employment. [Insert other examples if needed]

P 1 Does your work involve mostly sitting or standing, with walking for no more than 10 minutes at a time?

Yes No

1 2

If Yes, go to P6

P 2 Does your work involve vigorous activity, like [heavy lifting, digging or construction work] for at least 10 minutes at a time? INSERT EXAMPLES & USE SHOWCARD

Yes No

1 2

If No, go to P4

P 3a In a typical week, on how many days do you do vigorous activities as part of your work?

Days a week

In hours and minutes hrs : mins P 3b On a typical day on which you do vigorous activity, how much time do you spend doing such work?

OR in Minutes only or minutes

P 4 Does your work involve moderate-intensity activity, like brisk walking [or carrying light loads] for at least 10 minutes at a time? INSERT EXAMPLES & USE SHOWCARD

Yes No

1 2

If No, go to P6

P 5a In a typical week, on how many days do you do moderate-intensity activities as part of your work? Days a week

In hours and minutes hrs : mins P 5b On a typical day on which you did moderate-intensity activities, how much time do you spend doing such work?

OR in Minutes only or minutes

P 6 How long is your typical work day? Number of hours hrs

Other than activities that you’ve already mentioned, I would like to ask you about the way you travel to and from places. For example to work, for shopping, to market, to church. [insert other examples if needed]

P 7 Do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places?

Yes No

1 2

If No, go to P9

P 8a In a typical week, on how many days do you walk or bicycle for at least 10 minutes to get to and from places?

Days a week

In hours and minutes hrs : mins P 8b How much time would you spend walking or bicycling for travel on a typical day?

OR in Minutes only or minutes

The next questions ask about activities you do in your leisure time. Think about activities you do for recreation, fitness or sports [insert relevant terms]. Do not include the physical activities you do at work or for travel mentioned already.

P 9 Does your [recreation, sport or leisure time] involve mostly sitting, reclining, or standing, with no physical activity lasting more than 10 minutes at a time?

Yes No

1 2

If Yes, go to P 14

P 10 In your [leisure time], do you do any vigorous activities like [running or strenuous sports, weight lifting] for at least 10 minutes at a time? INSERT EXAMPLES & USE SHOWCARD

Yes No

1 2

If No, go to P 12

P 11a If Yes, In a typical week, on how many days do you do vigorous activities as part of your [leisure time]?

Days a week

In hours and minutes hrs : mins P 11b How much time do you spend doing this on a typical

day? OR in Minutes only

or minutes

10

Respondent Identification Number

P 12 In your [leisure time], do you do any moderate-intensity activities like brisk walking,[cycling or swimming] for at least 10 minutes at a time? INSERT EXAMPLES & USE SHOWCARD

Yes No

1 2

If No, go to P 14

P 13a If Yes In a typical week, on how many days do you do moderate-intensity activities as part of [leisure time]?

Days a week

In hours and minutes hrs : mins P 13b How much time do you spend doing this on a typical

day? OR in Minutes only

or minutes

The following question is about sitting or reclining. Think back over the past 7 days, to time spent at work, at home, in [leisure], including time spent sitting at a desk, visiting friends, reading, or watching television, but do not include time spent sleeping.

In hours and minutes hrs : mins P 14 Over the past 7 days, how much time did you spend

sitting or reclining on a typical day? OR in Minutes only

or minutes

11

Respondent Identification Number

EXPANDED : History of High Blood Pressure H 1 When was your blood pressure last measured by a

health professional? Within past 12 months

1-5 years ago Not within past 5 yrs

1 2 3

H 2 During the past 12 months have you been told by a doctor or other health worker that you have elevated blood pressure or hypertension?

Yes No

1 2

If No, skip to Next Section

Are you currently receiving any of the following treatments for high blood pressure prescribed by a doctor or other health worker?

H 3a Drugs (medication) that you have taken in the last 2 weeks

Yes No

1 2

H 3b Special prescribed diet Yes No

1 2

H 3c Advice or treatment to lose weight Yes No

1 2

H 3d Advice or treatment to stop smoking Yes No

1 2

H 3e Advice to start or do more exercise Yes No

1 2

H 4 During the past 12 months have you seen a traditional healer for elevated blood pressure or hypertension

Yes No

1 2

H 5 Are you currently taking any herbal or traditional remedy for your high blood pressure?

Yes No

1 2

EXPANDED : History of Diabetes H 6 Have you had your blood sugar measured in the last

12 months? Yes No

1 2

H 7 Have you ever been told by a doctor or other health worker that you have diabetes?

Yes No

1 2

If No, skip to Next Section

Are you currently receiving any of the following treatments for diabetes prescribed by a doctor or other health worker?

H 8a Insulin Yes No

1 2

H 8b Oral drug (medication that you have taken in the last 2 weeks

Yes No

1 2

H 8c Special prescribed diet Yes No

1 2

H 8d Advice or treatment to lose weight Yes No

1 2

H 8e Advice or treatment to stop smoking Yes No

1 2

H 8f Advice to start or do more exercise Yes No

1 2

H 9 During the past 12 months have you seen a traditional healer for diabetes?

Yes No

1 2

H 10 Are you currently taking any herbal or traditional remedy for your diabetes?

Yes No

1 2

12

Respondent Identification Number

Step 2 Physical Measurements

Height and weight Coding Column M 1 Technician ID Code

M 2a & 2b

Device IDs for height and weight (2a) height (2b) weight

M 3 Height

(in Centimetres) .

M 4 Weight If too large for scale, code 666.6

(in Kilograms) .

Waist

M 5 Technician ID

M 6 Device ID for waist

M 7 (For women) Are you pregnant?

Yes No

1 2

If Yes, Skip Waist

M 8 Waist circumference (in Centimetres) .

SELECTED EXPANDED ITEMS

M 7a Hip circumference (in Centimetres) .

Heart Rate (Record if automatic blood pressure device is used)

M 8a Reading 1 Beats per minute:

M 8b Reading 2 Beats per minute:

M 8c Reading 3 Beats per minute:

Blood pressure Coding Column M 9 Technician ID

M 10 Device ID for blood pressure

M 11 Cuff size used Small Normal

Large

1 2 3

M 12a Reading 1 Systolic BP Systolic mmHg

M 12b Diastolic BP Diastolic mmHg

M 13a Reading 2 Systolic BP Systolic mmHg

M 13b Diastolic BP Diastolic mmHg

M 14a Reading 3 Systolic BP Systolic mmHg

M 14b Diastolic BP Diastolic mmHg

M 15 Are you currently on treatment with drugs prescribed by a health professional?

Yes No

1 2

13

Respondent Identification Number

Step 3 Biochemical Measurements

CORE Blood glucose Coding Column B 1 During the last 12 hours have you had anything to

eat or drink, other than water? Yes No

1 2

B 2 Technician ID Code

B 3 Time of day blood specimen taken (24 hour clock) First blood specimen hrs : mins

B 4 Time of finish drinking glucose liquid (75 gr in 300 mk water) (24 hour clock)

hrs : mins

B 5 Time of day blood specimen taken (24 hour clock) two hours after drinking glucose liquid

Second blood specimen

hrs : mins

B 6 Fasting Blood glucose level mg/dl .

B 7 Two hours blood glucose level mg/dl .

CORE Blood Lipids B 8 Total cholesterol

mg/dl .

SELECTED EXPANDED ITEMS B 9 Triglycerides

mg/dl .

B 10 HDL Cholesterol mg/dl .

Attachment 3

Operational standard procedure

Preparation procedure : Community member which was supported by health workers from local health office and Public Health Center actively arrange the NCD risk factors surveillance activity. The activity was located in certain post, which was mostly in local public areas, such as PHC, mosque, integrated health post, etc. Several important procedures in survey preparation are as follow: 1) Respondent is community member was selected by stratified random sampling based

on age group and sex. Confirmation from the selected respondent to participate in the NCD risk factors surveillance was taken 7 days prior to the survey date. The invitation letter had to be received by the selected respondents at least 3 days before the survey date.

2) Other community member replaced respondents who were not able to participate. The substitute respondent’s name had to be available in the respondent list with consideration to sex and age group.

3) The invitation letter for responded was signed by the general practitioner who worked as the head of local Public Health Center (PHC) with acknowledgment from the head of the village, local head of district and head of neighborhood block. The activity was started on 08.00 am and the time in the invitation letter was arranged 15 minutes different for each 10 invited respondents to avoid long waiting time during the activity. Coordinator, who was from the local village office, had to make confirmed invitation list which include information on age, sex, and address.

4) Health volunteers kept reminded the respondents about the time and place of the survey post, as well reminded them to fast for blood examination.

5) Selection of post or data collection place was determined by agreement between coordinators and respondents. All the personnel involved in the data collection activity should prepare the selected post or place and facilities required, one day before the activity starts.

6) Flow of the activity were as follow: a) Registration b) First waiting room ( minimal for 20 sits) c) Laboratory or blood examination room. It should be next close to the registration. d) Second waiting room (minimal for 20 sits) e) Anthropometry and blood pressure measurement f) Interview room, that has at least 8 tables and 16 chairs. The tables should be

located in minimal 1 meter distance between each tables. g) Questionnaire editing room with three tables and 6 chairs

7) Data collection instrument, includes questionnaires (360 sets), one of digital blood pressure measurement, one of digital weighting scale, one microtoise (height measurement), and one of waist hip measuring tool.

1

Attachment 3

8) Other facilities and supporting equipment used are mineral drinking water, extra battery for blood pressure measurement and weighting scale. All the electronic devices must use new battery on the data collection activity.

Implementation Person in charge : 3 persons 1. Supervisor from the National Institute of Health Research and Development

(NIHRD) will be responsible for the quality of the data 2. Surpervisor from the local health office, who will responsible for the administration

aspect and activities flow. 3. General Practitioner who will responsible for the medical aspect and other necessary

professional health treatment. Standard Procedure: a) All personnel

i) All the personnel involved in the activity (include laboratory staffs or analist) must be available in the survey location or post on time at least 30 minute before the activity started.

ii) Supervisors have to make sure that all the personnel, especially the laboratory personnel, are well prepared and come on time.

iii) Supervisors and all the personnel should check the readiness of all the facilities, equipments, and room so that the activity can starts promptly.

iv) All the personnel are not allowed to eat during the physical measurement, blood measurement, as well as during the interview. Break time have to be arranged in flexible way to allow all the personnel able to eat or drink with respect to the respondents who are still fasting.

b) Task for Health Volunteers in the Registration desk i) Respondents have to give the original invitation letter to the health volunteer in

the registration desk and waiting to be called up in the first waiting room. ii) The invitation letter has to signed up by the health volunteers, and respondents

should keep it carefully, as they will need it to take the blood examination result. Only the person whose name is under the invitation letter or respondent list, who is allowed to participate in this activity.

iii) The personnel in the registration desk have to make sure whether the respondents have done 10 to 12 hours fasting before the blood will be taken. Any respondents, who don’t fast or fail to fast, should inform the GP or supervisor, and follow their instruction for the next step (interview, blood pressure, and physical measurement), and remind them to attend on other day available in the schedule for fasting blood test.

iv) Make sure that the respondents voluntarily agree to participate and signed up the informed consent. The informed consent form is included in the questionnaire book, which already has identification number. Then ask the respondent to wait for blood examination in the first waiting room.

2

Attachment 3

v) Respondents who come to the post later than 11 am cannot be accepted for blood examination, and should make appointment for blood examination on other day in the schedule as suggested by the GP or supervisors.

vi) The personnel in registration desk should working to assist all the activity until it is completed on that day.

vii) At the end of the activity, the registration person together with the supervisors check all the respondent list in registration list, blood measurement list, blood pressure list, as well in the interview list.

viii) If the registration person has completed the entire registration task, they can assists in other work in the activity.

c) Laboratory personnel task

i) Only respondent who completed fasting as recommended who will allowed having blood test.

ii) Before taking the respondent’s blood, obtain information whether the respondent has ever diagnosed having diabetes mellitus or not. Respondent who has ever diagnosed having diabetes can still take the blood test, but will be given standard meals as for substitution of glucose drink.

iii) The time of blood test is limited between 8 to 11 am for first blood test, so the second blood test will be on maximum of 12 am.

iv) Standard procedure for blood test that provided by the laboratory provider, have to approved by the principle investigator and distributed to all the supervisors for the data collection activity.

v) Information of time of taking glucose drink and time for the second blood test (two hours from the time of finishing the glucose drink) have to be written on the label which is attached to the respondent’s shirt, to make it easier in monitoring the second blood test.

vi) Laboratory workers should record their identification number and time of taking the blood on the questionnaire book in section of biochemical measurement.

vii) Laboratory workers should be watching the respondents when they drink the glucose drink to make sure they finish it completely.

viii) After complete the first blood test, respondents should wait in the second waiting room and while waiting for the second blood test (two hours), they can be called up for interview or physical and blood pressure measurement, as administered by the supervisors.

ix) Respondents are not allowed to hold or keep the questionnaire book, and it should be managed under supervisors for the next steps.

x) Registration and laboratory personnel, or other health workers, can ask or consult with the supervisors for any problems or difficulties during the activity.

xi) Respondents who may need medical treatment during the activity can be referred to the GP on duty to get further necessary medical treatment or advices.

3

Attachment 3

xii) Laboratory personnel should make a respondent list which will be useful for cross check the total number of participant as well as participant’s identification number.

d) Glucose drink preparation and procedure

i) Add glucose (75 g per sachet) with 300 ml of hot water and stir until it become solution.

ii) Respondent must drink the warm glucose drink immediately after the first blood taking and finish it completely.

iii) The survey staff need to explain the important of glucose drink in blood testing, particularly for the respondents who refuse or difficult to drink the glucose.

iv) Respondents who have ever diagnosed diabetes don’t drink the glucose but they have to eat a standard meal provided in the survey as a substitute of the glucose drink.

v) Exact time when the respondent finish the glucose drink and time for the second blood test have to written on the label (attached in the respondent’s shirt) and in the questionnaire book.

vi) After complete the first blood test, respondents should wait in the second waiting room and while waiting for the second blood test (two hours), they can be called up for interview or physical and blood pressure measurement, as administered by the supervisors.

e) Interviewer

i) Personnel who can be the interviewer in the data collection activity must have attended the training before, and they cannot be substituted by other person who has not been trained earlier.

ii) Each interviewer has their own id number. They must put in their name, id number, data and time of interview in the questionnaire book, as well as the time when interview starts and ends.

iii) Interviewer must put the questionnaire id on each page in the questionnaire book. Questionnaire id has already written on the top right hand corner on the cover page of the questionnaire book.

iv) Respondents should be between 25 to 64 years old. v) Interviewers have to make sure that respondent understand and answer all the

questions adequately. Interviewer may consults or asks the supervisors for any difficulties of the questions content or other problems during the interview.

vi) Interviewers should also pay attention on the second blood test time during the interview and prioritize the blood test. The second blood test may be taken in the middle of interview. The interview can be continued after the second blood test.

vii) Interviewer should refer the respondent who is feeling unhealthy or sick to the supervisors or GP on duty.

viii) Respondent’s answers in the questionnaire book have to be checked for its completeness and consistency. Always put the end time of interview in the questionnaire book.

4

Attachment 3

ix) Thank you and appreciation should be given to the respondent for their participation and request them to follow the next procedure.

x) The questionnaire book has to be remains on the desk and never give it the respondent. The supervisor or coordinator will take the questionnaire for further measurement activity.

xi) Each interviewer should have their own list of number of interview they had done in that day. This will be used for cross check of total number of respondent participate in the activity

f) Physical Measurement and Blood Pressure Measurement

i) Blood pressure measurement (1) Introduce yourself (2) Ask respondent to sit on chair and stay calm for 5 minute, and not to cross

the leg during the measurement process. (3) The measurement should be applied for the right arm, but we can use the

left arm if not possible to use the right arm. Give note about the reason using left hand, on the provided sheet in the questionnaire book.

(4) Put the right arm on the table with palm up. (5) Arm should be free from any material and put on the manset and make

sure that it touch directly the arm skin of the respondent. (6) Put on the manset on the upper right arm and the

ii) Height measurement

This measurement uses microtoise. (1) Place the microtoise on the flat walls and floor. (2) Pull out the microtoise and make sure the zero is on the floor surface

correctly. Attach the upper side (2 meter height from the floor) on the wall.

(3) We should check whether the zero still on the floor surface in each measurement.

(4) Respondents should not use shoes or sandals, and any head accessory such as hat, bandana, or other hair cover, except the Moslem scarf for ladies.

(5) Respondents should stand still exactly straight of the microtoise. (6) The position of head, back shoulder, arms, tumit, should be attached to the

wall under straight line of the mocrotoise. Both feet should be tightly close each other.

(7) Respondent should put their head up and look straightly ahead not looking downward or upward, and their both hand should be free on each right and left side.

(8) Pull down the microtoise until it reaches the most upper side of the respondent’s head.

(9) Read the number or scale where the red line position when it touches the upper respondent’s head from the front side or facing up the respondent. The person who read the number should not be standing in lower position than the respondent. He or she may need to stand above a chair if he/she is shorter than the respondent.

5

Attachment 3

(10) This measurement is taken once and it can be read with accuracy of 0.1 cm.

iii) Body Weight Measurement Weight measurement was taken using digital weight scale. (1) The weighting scale should be placed on the flat floor with adequate

light. (2) Respondents should take off their shoes, jacket, and empty all the clothes

pocket. (3) When the weight scale is ready, move your feet above the display monitor

without touching it, until it shows 0.0 and immediately ask the respondent to step on the weighting scale. Respondents should stand still with the head straight ahead, until the display monitor shows the body weight.

(4) This measurement is taken once and it can be read with accuracy of 0.1 cm.

iv) Waist Hip Circumference Measurement

6

Attachment 4

1

“ ABADIJAYA” Public Health Center Address: Kerinci Raya No.1 Depok 16417

Year : STATUS of NON COMMUNICABLE DISEASES

Medical Record/Status Number. :

NCD Identification Number : Name : Sex : 1. Male 2. Female Age (year) : Date of Birth : Place of Birth : ________________________ Address : _____________________________________________________________ RT: RW : Village : Sub district : Post code : City : Depok, West Java Telephone : Occupation : _______________________________ (Last occupation if retired or unemployed

Unemployed Civil servant Private Military Labor College student Others

1 2 3 4 5 6 99

For Housewife, is husband working ? Yes 1 No 2 Education : 1

2

3

4 5 6 7 8

Iliterate Incomplete Elementary School Complete Elementary School Complete Junior High Complete Senior High Diploma graduate Academy graduate University graduate Others

Ethnic : ____________________ Religion : ____________________ Date of first visit :

Attachment 4

2

Anamnesis Major symptoms : Diseases History : Have you ever informed that you have Diabetes Mellitus (DM) ? 1 yes 2 no If, “Yes” on which year? Recent medication taken : 1 no treatment 2 diet only 3 OHO Insulin 4 Herbs If OHO/Insulin dosage _____________________ Hypertension ? 1 yes 2 no 3 unknown If Yes since year ____________ Heart diseases ? 1 yes 2 no 3 unknown If Yes since year ____________ Hiperkolsterol ? 1 yes 2 no 3 unknown TBC ? 1 yes 2 no 3 unknown

Allergic ? 1 yes 2 no 3 unknown If “Yes” allergic to :…………………… Smoking ?

Never Ex smokers Smoke <10 stick /day Smoke 10-20 stick /day Smoke >20 stick /day

1 2 3 4 5

Sport/exercise Activity ? 1 Vigorous 2 Sedentary 3 Moderate Overweight ? 1 yes 2 no 3 unknown Diseases complication ? 1 yes 2 no 3 unknown a. ICU b. Shock c. Others : ________________

Attachment 4

3

FAMILY ANAMNESIS

Have any of your family members ever had diabetes mellitus? 1 yes 2 no 3 unknown If “yes” who?

1 Father 2 Mother 3 Brother/sister 4 Son/daughter 5 Grandparents Have any of your family members ever had hypertension ? 1 yes 2 no 3 unknown If “yes” who?

1 Father 2 Mother 3 Brother/sister 4 Son/daughter 5 Grandparents Have any of your family members ever had heart diseases? 1 yes 2 no 3 unknown If “yes” who?

1 Father 2 Mother 3 Brother/sister 4 Son/daughter 5 Grandparents Have any of your family members ever had other chronic diseases? 1 yes (specify…………..) 2 no 3 unknown

If “yes” who?

1 Father 2 Mother 3 Brother/sister 4 Son/daughter 5 Grandparents For Female Only : Have you ever delivered a baby who had birth weight of more than 4 kg ? 1 yes 2 no 3 unknown

If yes, on year ____________

Attachment 4

4

Physical Measurement

Height Cm Nutritio

n status Moderate

1 Body weight

Kg Over 2

BMI Kg/m2 Under 3 Hip Cm Obesity 4 Waist Cm Blood Pressure

mmHg Pulse / minute Regular 1

Irregular 2 RECALL DIET : CHEST Heart: Normal 1 Abnormal 2 IF abnormal, specify:

……………………..

Lung : Normal 1 Abnormal 2 IF abnormal, specify:

……………………..

Attachment 4

5

Abdomen: Y N Hepar : Enlarge Lien : Enlarge

LABORATORY MEASUREMENT

Peripheral blood Urine (routine) Hemoglobin :………………………… Protein :…………………. Leucosit :………………………… Sediment :…………………. Type amount :………………………… Reductio

n :………………….

LED :………………………… Bilirubin :…………………. Liver Function Kidney

Function

Albumin :……………….. mg/dl Ureum :………….. mg/dl Globulin :……………… mg/dl Creatinin :………….. mg/dl SGOT :……………… SGPT :……………… γ-GT :……………… Foafatase alcali :………………. Lipid Profile Total Cholesterol

:………………. mg/dl HDL cholesterol:……………….. mg/dl

Triglyceride :………………. mg/dl LDL cholesterol………………... mg/dl Blood Glucose Fasting :………… mg/dl OGTT (75 gram) 2 hours pp :………… mg/dl Fast

ing :…………. mg/dl

Not fasting

:………… mg/dl 2 hours :…………. mg/dl

Uric Acid :………... mg/dl

DIAGNOSIS Primary Diagnosis : DM 1 Type 1 2 Type 2 3 Other type 4 Gestational

Hypertension Obesity Dislipidemia

Attachment 4

6

THERAPY

Medicine : Type :………………. Name :……………… Dosage:…………… Diet : DM kcal Low

protein gram /day

Low salt I II III Dietary advices : Recommendation for Physical Activity (exercise) : Others :

PLAN

Attachment 4

7

FOLLOW UP

INFORM CONCENT (lembar persetujuan)

Saya yang bertanda tangan dibawa ini menyatakan SETUJU/TIDAK SETUJU (coret yang

tidak diperlukan) menjadi responden penelitian “Risiko Obesitas terhadap Kejadian Diabetes

Mellitus Tipe 2. Kami juga SETUJU/TIDAK SETUJU (coret yang tidak diperlukan) untuk

dilakukan pemeriksaan fisik dan pemeriksaan laboratorium yang perlu dilakukan dalam

kegiatan penelitian ini.

Demikian, pernyataan ini kami tanda tangani dalam keadaan sadar dan tanpa tekanan dari pihak

manapun.

Depok, Tanggal : N o Identitas Responden (nomor kuesioner)

Tanda tangan persetujuan Responden : Nama

Tanda tangan Petugas : Nama

PENJELASAN INFORM CONSENT (lembar persetujuan)

Berdasarkan hasil pemilihan secara acak, Ibu/Bapak/Saudara terpilih sebagai salah satu responden survey Penyakit Tidak Menular (PTM) di Kota Depok Jawa Barat”. Kami ucapkan terimakasih atas kesediaan Ibu/ Bapak berpartisipasi dalam kegiatan pemeriksaan kesehatan yang dilakukan oleh Badan Litbang Kesehatan Departemen Kesehatan RI dan Dinas Kesehatan Kota Depok. .Kegiatan ini dilakukan mengingat kejadian PTM di Indonesia, dewasa ini cenderung mengalami peningkatan. Informasi dari kegiatan ini sangat diperlukan Dinas Kesehatan Kota Depok, dalam merencanakan program pencegahan dan penanggulangan PTM di masyarakat. Dengan demikian kesehatan masyarakat setempat dapat selalu terlindungi dan penderita yang ada dapat terlayani kondisi kesehatannya dengan lebih baik. Bagi Bapak/Ibu kegiatan ini bermanfaat untuk mengetahui ada tidaknya PTM dan faktor risikonya. Dengan demikian Bapak /Ibu dapat melakukan tindak lanjut secara lebih dini.

Kami mengharap kesediaan Ibu/ Bapak menjawab beberapa pertanyaan yang akan diajukan oleh petugas kami. Materi pertanyaan adalah mengenai data identitas, riwayat sakit, sikap, pengetahuan dan perilaku mengenai kesehatan, pola makanan, merokok dan kegiatan jasmani. Selain itu, kami juga akan melakukan pengukuran tekanan darah, berat badan, tinggi badan, lingkar perut, dan lingkar pinggul, dan pemeriksaan laboratorium (gula darah dan kolesterol darah). Untuk keperluan pemeriksaan laboratorium, kami akan mengambil 3 cc darah dari pembuluh darah vena Ibu/ Bapak, dengan jarum streril yang sudah disiapkan 1 jarum untuk 1 orang. Pengambilan darah ini hanya akan menyebabkan sedikit rasa sakit, tetapi sama sekali tidak berbahaya bagi tubuh. Setelah pengambilan darah, luka tempat darah diambil akan ditutup dengan kapas sampai darah tidak keluar dan kemudian ditutup dengan kapas alkohol/plester. Pengambilan darah ini akan berlangsung sekitar 5 menit. Setelah pemeriksaan darah yang pertama Bapak/Ibu akan diberi minuman yang manis (larutan glukosa), dan selang waktu 2 jam akan dilakukan pengambilan darah yang kedua. Apabila terjadi gangguan kesehatan yang disebabkan tindakan pengambilan darah, dokter yang bertugas dan dokter Kepala Puskesmas Abadijaya (dr Auliadi) sebagai penanggung jawab medis, akan mengatasi gangguan tersebut hingga kesehatan Bapak/Ibu pulih kembali dengan tanpa dipungut biaya apapun.

Sambil menunggu waktu pengambilan darah kedua Bapak/Ibu /saudara dapat berkonsultasi tentang masalah kesehatan khususnya tentang Penyakit Tidak Menular. Setelah pengambilan darah kedua Bapak/Ibu akan mendapatkan konsumsi. Kami akan memberitahukan hasil pemeriksaan laboratorium (gula darah dan kolesterol) Ibu/ Bapak setelah 1 minggu ( 7 hari) dilakukannya pemeriksaan. Hasil pemeriksaan dapat Bapak/Ibu/saudara ambil/terima melalui Koordinator Posbindu/Ketua PKK/Ketua RW. Kasus yang kami temukan dari kegiatan ini, akan diberi saran tindak lanjut dan pengobatan yang diperlukan, melalui Puskesmas setempat.

Data wawancara, pengukuran fisik, dan pemeriksaan laboratorium pribadi Ibu/ Bapak/saudara akan kami jaga kerahasiaannya. Apabila Ibu/Bapak berkeberatan untuk mengikuti kegiatan/dilakukan tindakan Ibu/Bapak dapat menolak ikut menjadi peserta dengan mencoret tanda setuju pada lembar persetujuan.

Attachment 7 No : Depok Mei 2006

Kepada Yth :

Bapak/Ibu/Sdr :

Di RT RW Kelurahan Abadijaya Kecamatan Sukmajaya Depok

Dengan Hormat,

Bersama ini disampaikan bahwa dalam rangka pencegahan dan pengendalian Penyakit Tidak Menular (PTM) yaitu Jantung koroner, Diabetes Melitus, Hipertensi dll di masyarakat, Dinas Kesehatan Kota Depok bekerja sama dengan Badan Litbang Depkes RI dan WHO melakukan kegiatan monitoring Faktor Risiko PTM di Kelurahan Abadijaya. Secara acak Bapak/Ibu/Sdr telah terpilih menjadi peserta kegiatan ini, untuk itu kami mengundang Bapak/Ibu/Sdr untuk melakukan pemeriksaan kesehatan. Terhadap Bapak/Ibu/Sdr akan dilakukan pemeriksaan tekanan darah, pengukuran fisk, wawancara kesehatan, dan pemeriksaan laboratorium (glukosa darah puasa dan 2 jam pp, dan kolesterol darah total). Untuk keperluan pemeriksaan laboratorium, Bapak/Ibu/Sdr diminta berpuasa (selama berpuasa boleh minum air putih tawar) mulai jam 10 malam (22.00 WIB) sampai waktu pengambilan darah pertama. Pelaksanaan kegiatan memerlukan waktu pemeriksaan minimal 2 jam dan seluruh pemeriksaan tidak dipungut biaya. Pemeriksaan akan dilakukan pada :

Hari /Tanggal : Sabtu / Minggu 2006

Jam : WIB

Tempat : Surat undangan ini harus dibawa pada saat pemeriksaan untuk pendaftaran ulang dan diminta kembali untuk keperluan pengambilan hasil. Hasil pemeriksaan kesehatan akan disampaikan 7 (tujuh) hari kemudian melalui Ketua RW/RT atau Puskesmas. Atas perhatiannya kami ucapkan terima kasih.

Ketua Pelaksana

Monitoring Faktor Risiko PTM Di Kota Depok

DR Ekowati Rahajeng, SKM MKes NIP. 14 01 25 224

Kepala Puskesmas Kelurahan Abadijaya

Kecamatan Sukmajaya Kota Depok

Dr. Auliadi NIP.

Tembusan Kepada YTH: 1. Lurah Abadijaya 2. Ketua RT 3. Ketua RW

Attachment 8

‘Posbindu PTM’

The define of ‘Posbindu PTM’, which is developed specifically for NCD

monitoring and counselling program in community.

a. Terminology

1) Integrated Health Post for Non Communicable Diseases (‘Posbindu PTM’)

A manifestation of community participation to support promotion and

preventive programs of early detection for common risk factors of major NCD (such

as overweight, hypercholesterolemia, hypertension, hyperglycemia, unhealthy diet,

and smoking). Programs in the Integrated Health Post for NCD include risk factors

monitoring activities, and increasing knowledge among the society regarding NCD

risk factors through counselling and education or interactive dialogue.

2) Major NCD Risk Factors Monitoring Activity

Strategy to reduce the occurrence of NCD in community can be more

effective when the risk factors have been identified earlier. Monitoring the risk

factors of NCD among the healthy people is an early detection measure which is

very substantial for NCD prevention

Activities in monitoring the major NCD risk factors are monitoring the Body

Mass Index (BMI), blood pressure, blood glucose, blood cholesterol, in routine

periodic. Routine means that health examination should be considered as a routine

activity even though they don’t feel ill. Periodic means the health examinations is

held in certain periodic time as recommended by the health workers.

3) Counselling of NCD Risk Factors

Controlling NCD risk factors implies to maintain and/or bring the risk factors

to normal condition by counselling activity. The aim of the counselling program for

healthy individual is to maintain the normal condition. The counselling consist

information about healthy diet, stop smoking, physical activity, and stress

management. Meanwhile for ones who already have suffered non communicable

diseases, the aim of counselling is to prevent further chronic complication diseases,

1

such as kidney failure, coronary heart diseases, neuropathy, or other chronic non

communicable diseases.

b. Goal of Integrated Health Post for Non Communicable Diseases (“Posbindu

PTM”)

The main goal of implementation of Integrated Health Post for NCD

(‘Posbindu PTM’) is to make the community has more accessible and affordable

health care in recognising NCD risk factors in early stage in a way that can be

medically liable. This activity gives beneficial for individual who had risk factors of

non communicable diseases to response immediately in controlling the risk factors

effectively.

Accessible or easy to carry out, this activity is conducted in simple and

integrated way in the neighbourhood area or certain workplace. It can be said that it

is affordable because integrated health care is more economical rather than single

one. Moreover, the activity is managed by the community who also make agreement

for the cost of service which is affordable for the community. The activity is

medically liable because it is supervised by the selected health workers who had

been trained by the local health office.

c. Activities of Integrated Health Post for Non Communicable Diseases

(“Posbindu PTM”)

The activities are from the community (well trained health volunteer) for the

community, which are facilitated legally by the local government office (village

office), and technically supervised by local health office and public health centre,

and other supporting organisations. Management and funding for the activities of this

integrated health post is co-ordinated according to community agreement (‘Rembug

Warga’) and give accounted to the community.

Basically, the implementation of Integrated Health Post for NCD (‘Posbindu

PTM’) is similar to previous integrated health post, but it has different population

target. Population target for Health Post for NCD (‘Posbindu PTM’) is all individual

age ≥ 25 years old. Coverage area for each ‘Posbindu PTM’ is population in 1

administrative block (RW) in maximum and 1 neighbourhood block (RT) in

2

minimum. However, the implementation is not limited in the residential area, but it

can be initiated by other health related organisations such as Healthy Hearth Club,

Elderly group, or in other setting such as workplaces.

Five main activities in ‘Posbindu PTM’ are:

1) Anthropometric measurement (weight and height) for Body Mass Index

examination

2) Blood pressure measurement

3) Blood glucose and cholesterol measurement.

4) Health counselling and education (diet, stop smoking, stress, physical

activity, other health aspect)

5) Physical activities or exercise

Schedule for each activity is arranged by the community according to their

agreement with considering clinical recommendation for the health examination. The

recommendations for the activities schedule are:

1) For activity 1 and 2: once per month or in the minimum of once in 3

months.

2) For activity 3: once per year for individual without any NCD risk factors

and once in 3 months for individual with any of NCD risk factors.

3) For activity 4: Every time when the other activities are done.

3

Recommendation of time schedule for health examination can be seen on the

table bellow:

Matrix 1. Recommended Time schedule for health examination

Risk Factors Has not suffered NCD Has suffered NCD

Fasting blood glucose 1x /year 1x / 3 months

PP blood glucose 1x /year 1x / 3 months

Blood glucose (without

fasting)

1x /year 1x / month

Total blood cholesterol 1x /year 1x / month

Blood pressure 1x / 3 month 1x / month

Body Mass Index 1x / 3 month 1x / month

During the health examination both examiner and patient should understand

the risk factors. Because, this makes the patient become more aware and makes the

health workers gives appropriate counselling or education as required. In this case,

each patient should have an individual monitoring card, which is called NCD Risk

Factors Monitoring Card or ‘KMR-PTM’ (see annex 4). Some supplies that are

required for reporting and recording are:

1. Participant’s record book, to record participant identity, includes number, name,

age, sex, address, etc (see attachment 2).

2. Recording and reporting monitoring forms for NCD risk factors.

(see attachment 3).

3. Progress monitoring form (see attachment 4).

4. The final goal of the activities in Integrated Health Post for NCD (‘Posbindu

PTM’) is to control NCD risk factors. NCD risk factors control not always

requires pharmacology therapy. In the early stage NCD risk factors can be

controlled by health counselling and education regarding adequate diet, physical

activities, and better life style such as stop smoking, stop drinking alcohol, better

stress management, etc.

4

Matrix 2. Criteria for NCD Risk Factors Control Program

Risk Factors Good Moderate Bad

Fasting blood glucose 80-109 110-125 ≥126

PP blood glucose 80-144 145-179 ≥180

Blood glucose (non fasting) 80-144 145-199 ≥200

Total blood cholesterol < 150 150-199 ≥200

Blood pressure <130/80 130-139/80-90 ≥ 140/90

Body Mass Index 18,5-22,9 23-24 >25

Waist-Hip ratio P<0,95;W<0,85 P<0,95;W<0,85 P>0,95;W>0,85

d. Growth and Development Indicators for Integrated Health Post for NCD

Improving ‘Posbindu PTM’ is one of the integrated measures concerning

NCD risk factor that using previous program and increasing it function to be more

complete and comprehensive. Some indicators that are used to assess the level of

development of ‘Posbindu PTM’ are:

1) Activities implementation :

This is presenting the frequency of NCD risk factor monitoring activities and

integrated health counselling/education within a year.

2) Coverage of Obesity Monitoring :

Obesity is measured by Body Mass Index (BMI) calculation, which is comparing the

height and weight. The formula to calculate BMI is :

weight in Kg

(height in meter)2 .

Coverage of obesity monitoring is proportion of individuals who have measured

their weight and height in routine time at ‘Posbindu PTM’ among the total

population target in the working area of ‘Posbindu PTM’.

5

3) Coverage of Blood Pressure Monitoring:

This refers to proportion of individuals who have measured their blood pressure in

routine time at ‘Posbindu PTM’ among the total population target in the working

area of ‘Posbindu PTM’.

4) Coverage of Blood Glucose Monitoring:

It is a proportion of individuals who have examined their blood glucose once in a

year at ‘Posbindu PTM’ among the total population target in the working area.

5) Coverage of Blood Cholesterol Monitoring:

It is a proportion of individuals who have examined their blood cholesterol once in a

year at ‘Posbindu PTM’ among the total population target in the working area.

6) NCD Education:

It is the frequency of education of NCD and its risk factors, which is performed at

the ‘Posbindu PTM’ in a year.

7) Counselling:

Availability of counselling activity at of ‘Posbindu PTM’ , and type/variation of counselling that have been conducted.

8. Coverage of Physical Activity/Exercise (once per week):

Physical activity is not only assessed by number of group exercise that has been done

in the community, but also activity such as clean-up the neighbourhood environment

areas.

9) Coverage of Participant:

This is a proportion of community member who participate in ‘Posbindu PTM’

among the total population target in the working area of ‘Posbindu PTM’ according

to certain age group.

10) Activities personnel:

This is a proportion of volunteers or community members who are working for the

implementation of ‘Posbindu PTM’

6

11) Health safety insurance:

Financial resources for the activities of ‘Posbindu PTM’ can be acquired from

several resources. At the beginning the funding can be supported or simulated from

the local government. It is expected that the community is able to afford

independently, in any form of financial management such as ‘JPKM’ (community

health safety network), health insurance, or monthly payment. This indicator was

selected to learn the capability and independence of community in health funding,

which is based on the calculation of budget proportion from the community compare

to the total budget spent for the implementation of ‘Posbindu PTM’ .

12) Independent participant :

This refers to proportion of participants who are regularly pay the compulsory

payment out of the amount of target in working area of ‘Posbindu PTM’ .

13) Partnership:

It is a frequency of collaboration with other related institutions, such as private

sectors, industries, professionals, etc), in implementing ‘Posbindu PTM’ for one year

period.

7

NCD Risk Factor Monitoring Card

(KMR-PTM)

I D number :

Name :

Age/Date of Birth :

Sex :

3Address : Rt __ RW __ Telephone : ____________________

Village _______________ Sub district ______________

Depok Jawa Barat

dd/mm/yy BMI WHR Blood Pressure

Blood Glucose

Blood Cholesterol

Counselling Recommen dation

8

PosBindu PTM Participant Record Book

“Name of PosBindu” Village :_________________ Sub-district : _________________ Depok West Java

Address Identity

Number

Name Age & year of birth

Sex

Rt RW

Phone dd/mm/yy of membership

Number of Population Target : 1. Age 25 – 35 years old : ___ persons (Man __ Women __ ) 2. Age 35 – 44 years old : ___ persons (Man __ Women __ ) 3. Age 45 – 54 years old : ___ persons (Man __ Women __ ) 4. Age ≥ 55 years old : ___ persons (Man __ Women __ )

9

Recording – Reporting Form for Controlling NCD Risk Factors

“Name of PosBindu PTM” Village :_________________ Sub-district : _________________ Depok West Java

dd/mm/yyyy :

Identity

Number

Age Sex BMI WHR Blood Pressure

Blood Glucose

Blood Cholesterol

Counseling and

Suggestions

Number of Population Target : 1. Age 25 – 35 years old : ___ persons (Man __ Women __ ) 2. Age 35 – 44 years old : ___ persons (Man __ Women __ ) 3. Age 45 – 54 years old : ___ persons (Man __ Women __ ) 4. Age ≥ 55 years old : ___ persons (Man __ Women __ )

10

11

Progress Monitoring Form of “Posbindu PTM” by Public Health Center “Name of PosBindu PTM”

Village :_________________ Sub-district : _________________ Depok West Java dd/mm/yyyy :

No Activities Indicator Monitoring unit Achievement

1 Activities implementation Times per year

2 Obesity monitoring coverage % target

3 Blood pressure monitoring coverage % target

4 Blood glucose monitoring coverage % target

5 Blood cholesterol monitoring coverage % target

6 NCD education Times per year

7 Counseling Activities and material

8 Coverage of Physical activities / exercise once a week

% target

9 Participant coverage : Age > 55 year old Age 5 – 55 year old Age 35 – 44 year old Age 25 – 34 year old

% target

10 Pelaksana Kegiatan % population

11 Pembiayaan kesehatan % population

12 Peserta mandiri % target Monitoring Personnel, (Name & Signature)

46

Indicators of Achiement Level of Integrated Health Post for NCD (‘Posbindu PTM’)

No Indicator ‘Pratama’

‘Madya’

‘Purnama’ ‘Mandiri’

1 Activities implementation 1 – 2 times per year 3 – 4 times per year 5 – 6 times per year > 6 times per year

2 Obesity monitoring coverage ≤ 25 % of target > 25 % - 40 % of target > 40 % - 50 % of target > 50 % of target

3 Blood pressure monitoring coverage ≤ 25 % of target > 25 % - 40 % of target > 40 % - 50 % of target > 50 % of target

4 Blood glucose monitoring coverage ≤ 25 % of target > 25 % - 40 % of target > 40 % - 50 % of target > 50 % of target

5 Blood cholesterol monitoring coverage ≤ 25 % of target > 25 % - 40 % of target > 40 % - 50 % of target > 50 % of target

6 NCD education ≤ 3 times per year 3-4 times per year 4-6 times per year > 6 times per year

7 Counselling none Available for diet only Diet and Stop smoking Diet, stop smoking, and others

8 Exercise coverage/ Physical Activity once in a week

≤ 25 % of target > 25 % - 40 % of target > 40 % - 50% of target > 50 % of target

9 Participant Coverage : Age > =55 y old Age 45 – 54 y old Age 35 – 44 y old Age 25 – 34 y old

≤ 25 % of target ≤ 25 % of target ≤ 25 % of target ≤ 10 % of target

25– 40 % of target 25– 40 % of target 25– 40 % of target 11 - 25 % of target

>40%-50 % of target >40%-50 % of target >40%-50 % of target >25%-40 % of target

> 50 % of target > 50% of target > 50 % of target > 40 % of target

10 Activities personnel 50 % is community 75 % is community 90 % is community 100% is community

11 Health safety insurance ≤ 25 % of target > 25 % - 40 % of target > 40 % - 50 % of target > 50 % of target

12 Independent participant <50 % of member 50 % - 60 % of member 61 % - 75 % of member > 75 % of member

13 Partnership none < 2 times 3 – 4 times > 4 times

14 All Indicator ≤ 25 % of indicator > 25 % - 40 % of indicator > 40 % - 50 % of indicator > 50 % of indicator

47

Attachment 6

Questionnaire ACTIVITY EVALUATION OF “POSBINDU PTM”

ID number : RW: Village : Sub District : (administrative unit)

A. General Identification of ‘Posbindu’/ Organization / Club 1.a Name of ‘Posbindu’/ Organization / Club :

1.b Address : .............................................. Telephone : .........................................

1.c Major activities of the ‘Posbindu’/ Organization / Club prior to conducting “Posbindu PTM”

a. Sport/exercise b. Housewife gathering c. Religious activity d. Family Welfare Education e. Integrated health post for under five children f. Integrated health post for elderly g. Other, specify....................

1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No

1.d Have this organization/ club already implemented “Posbindu PTM” activity? 1. Yes we have 2. No we haven’t not

2.a Name of Coordinator/ Organization leader/Club leader :

2.b Coordinator status/ position in his/her residential neighborhood : 1. Position in RT (neighborhood block) /RW(administrative unit)/Village

office 2. Public figure 3. Community activist 4. no position 5. others, specify ...............

2.c Education background of Coordinator/leader : 1. Incomplete high school or lower 2. High school 3. Higher than high school

2.d What kind of courses/training that have been taken by Coordinator/Leader ? (any kind of courses/training, including non- health or not NCD) .................................................................................. .................................................................................. ..................................................................................

2.e What is the main occupation of Coordinator/Leader : 1. Unemployee/no full time job 2. Working as ( specify ..........) 2. Retired from government employee (specify ..................) 3. Retired from private company (specify ...................) 4. Retired from military (specify ................. ) 5. Small business (sales) 6. Big business 7. Self employee/family company 8. Other, specify ........................................

1

Attachment 6

2.f Economy status of Coordinator/leader : 1. Below average income in the surrounding residential area 2. Equal to average income in the surrounding residential area 3. Above average income in the surrounding residential area

3.a Name of health educator/health volunteer of NCD prevention activity/other volunteer:

1. ....................................

2. .....................................

3. ......................................

4.......................................

5.....................................

3.b Health educator/health volunteer of NCD prevention activity/other volunteer status/ position in his/her residential neighborhood :

1. Position in RT (neighborhood block) /RW(administrative unit)/Village office

2. Public figure 3. Community activist 4. no position 5. others, specify ...............

1 2 3 4 5

3.c Education background of health educator/health volunteer of NCD prevention activity/other volunteer:

1. Incomplete high school or lower 2. High school 3. Higher than high school

1 2 3 4 5

3.d What kind of courses/training that have been taken by health educator/health volunteer of NCD prevention activity/other volunteer ? (any kind of courses/training, including non- health or not NCD) .................................................................................. .................................................................................. .................................................................................. ................................................................................... ..................................................................................

3.e What is the main occupation of health educator/health volunteer of NCD prevention activity/other volunteer 1. Unemployee/no full time job 2. Working as ( specify ..........) 2. Retired from government employee (specify ..................) 3. Retired from private company (specify ...................) 4. Retired from military (specify ................. ) 5. Small business (sales) 6. Big business 7. Self employee/family company 8. Other, specify………………….

1 2 3 4 5

2

Attachment 6

3.f Education background of health educator/health volunteer of NCD prevention activity/other volunteer:

1. Incomplete high school or lower 2. High school 3. Higher than high school

1 2 3 4 5

B. Progress of “Posbindu PTM” (For those who have implemented “Posbindu PTM”)

1. During year 2005, how many times have you conducted the “Posbindu PTM” activity? ............time

1.a Have the activities conducted in routine? 1. Yes, every month (go to 1.b) 2. Yes but every month 3. No, it is not routine

1.b What are the constraints of unable to run the activities in routine time?

a. The community doesn’t agree to have routine activity b. The personnel/health volunteer unable to conduct routine activity c. The facility is not available for routine activity d. Financial problem e. Time arrangement difficulty f. Others, specify ...........................................................

1.c How do you usually determine the activity schedule ?

1. Determined by coordinator 2. Determined by PHC 3. Determined by community agreement 4. Others, specify ...................

2.a How much are the percentage of BMI and WHR monitoring coverage?

2.b Is there any problem or constraint that make the community unable to monitor their body weight? 1. Yes there is a problem 2. No, there is no problem

2.c If there is a problem/constraint, what is the main problem/constraint?

a. Limited number of human resources b. Limited quality of human resources c. Limited facility d. Limited budget e. Community member afraid to know their body weight f. Other, specify............................................

2.d What are the supporting aspects (if available) in regard of monitoring the body weight?

1. yes 2. no

a. Adequate human resources b. Adequate facility c. Free of charge services

3

Attachment 6

d. Community willingness to pay e. Community awareness on body weight monitoring benefits f. Other, specify ....................................

3.a How much the percentage of blood pressure monitoring coverage?

3.b Is there any constrain/problem in blood pressure monitoring activity?

1. Yes there is a problem 2. No, there is no problem

3.c If there is a problem/constraint, what is the main problem/constraint?

a. Limited number of human resources b. Limited quality of human resources c. Limited facility d. Limited budget e. Community member afraid to know their body weight f. Other, specify............................................

3.d What are the supporting aspects (if available) in regard of blood pressure monitoring?

1. yes 2. no

a. Adequate human resources b. Adequate facility c. Free of charge services d. Community willingness to pay e. Community awareness on body weight monitoring benefits f. Other, specify ....................................

4.a How much the percentage of blood glucose monitoring coverage?

4.b Is there any constrain/problem in blood glucose monitoring activity? 1. Yes there is a problem 2. No, there is no problem

4.c If there is a problem/constraint, what is the main problem/constraint?

a. Limited number of human resources b. Limited quality of human resources c. Limited facility d. Limited budget e. Community member afraid to know their body weight f. Other, specify............................................

4.d What are the supporting aspects (if available) in regard of blood glucose monitoring?

1. yes 2. no

a. Adequate human resources b. Adequate facility c. Free of charge services d. Community willingness to pay e. Community awareness on body weight monitoring benefits

4

Attachment 6

f. Other, specify ....................................

5.a How much the percentage of blood cholesterol monitoring coverage?

5.b Is there any constrain/problem in blood cholesterol monitoring activity? 1. Yes there is a problem 2. No, there is no problem

5.c If there is a problem/constraint, what is the main problem/constraint?

a. Limited number of human resources b. Limited quality of human resources c. Limited facility d. Limited budget e. Community member afraid to know their body weight f. Other, specify............................................

5.d What are the supporting aspects (if available) in regard of blood cholesterol monitoring?

1. yes 2. no

a. Adequate human resources b. Adequate facility c. Free of charge services d. Community willingness to pay e. Community awareness on body weight monitoring benefits f. Other, specify ....................................

6.a During year 2005 how much time have you conducted counseling activity for NCD prevention ? ........... time

6.b What are the problems/constraints found in conducting counseling activity for NCD prevention ?

1. Yes 2. no

a. Lack of time or opportunity b. Lack of self confident c. Lack of capability d. Lack of facility e. Other, specify .........................

6.c What is the supporting aspect found in the counseling activity?

1. Yes 2. No

a. Community interest on NCD issues b. Skill on giving counseling c. Adequate time availability d. Adequate facility e. Other, specify.........................

7.a Did counseling always conducted in every “Posbindu PTM” activity? 1. Yes 2. No

7.b What were the risk factor issues that had been raised in counseling activity?

1. Yes 2. No

a. Diet

5

Attachment 6

b. Smoking c. Stress d. Weight management e. Sport/exercise f. Other, specify.................................................

7.c What is the main constrain/problem found in counseling activity?

1. Yes 2. No a. Lack of community trust b. Lack of opportunity c. Lack of self confident among the health volunteer d. Lack of knowledge or capability e. Lack of facility f. Other, specify .........................

Supervisor

(.........................................)

6

Attachment 10

Courses Topics for Health Volunteer and Health Workers

Topic of material in brief regarding clinical course or training of NCD controlling

strategy and community development in health service are as follow :

a. For health worker in Public Health Centre

1) Strategy of Controlling Risk Factors of NCD in Depok

2) Classifications, Diagnosis, Prevention, and Initial Treatment of Coronary Heart

Diseases

3) Classifications, Diagnosis, Prevention, and Initial Treatment of Hypertension

4) Electrocardiogram examination and assessment

5) Classifications, Diagnosis, Prevention, and Initial Treatment of Diabetes Mellitus

6) Management Diabetes Mellitus and Its Complication

7) Diagnosis, Prevention, and Management of Obesity

8) Diet for NCD, and calorie calculation

9) Strategy of Stop Smoking

10) Stop smoking technique and coping for smoking cessation

11) The benefit of Exercise and Physical Activity in controlling major NCD

12) Strategy of motivation for Exercise

13) Training of community participation on developing ‘Integrated Health Post

(Posbindu) of NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD’ for health

workers

14) Ministry of Health Fundamental Policy on Community Health Care

15) The role of ‘Integrated Health Post (Posbindu) of NCD’ and ‘ Integrated Health

Care’ (Yandu) of NCD to reduce risk factors NCD

16) Management strategy of developing ‘Integrated Health Post (Posbindu) of NCD’

and ‘ Integrated Health Care’ (Yandu) of NCD

17) Developing Partnership and Networking on ‘Integrated Health Post (Posbindu) of

NCD’ and ‘Integrated Health Care’ (Yandu) of NCD at municipality stage

18) Health Promotion in Work places (Centre of Occupational Health)

19) Role of businessman on NCD management and risk factor to the labour (Centre of

Occupational Health)

20) Major NCD problems in Worker at Depok city

21) Occupational Health Care on controlling NCD to the labour

b. For potential health cadre in community

1) Implementation of ‘Integrated Health Post (Posbindu) of NCD’ and ‘Integrated

Health Care’ (Yandu) of NCD’

2) Roles of Health Volunteer in Development and Sustainability of ‘Integrated Health

Post (Posbindu) of NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD’

3) Management Strategy of ‘Integrated Health Post (Posbindu) of NCD’ and

‘Integrated Health Care’ (Yandu) of NCD’

4) Developing Partnership and Networking on ‘Integrated Health Post (Posbindu) of

NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD’ at village stage

5) Coronary Heart Diseases and its prevention

6) Hypertension and its prevention

7) Diabetes Mellitus and its prevention

8) Obesity and its prevention

9) Diet for NCD, and calorie calculation

10) Stop smoking technique and coping for smoking cessation

11) The benefit of Exercise and Physical Activity in controlling major NCD