L/O/KESMAS no.1 Juli '06

TABLE OF CONTENT

Pizza and Hamburger Consumption to Overweight among Adolescents in Jambi City......................... 53-59 Ummi Kalsum, Sahridayanti Nainggolan, Nawi Ng

Work-Related Skin Diseases among Workers in the Sewing Section at PT. X Shoe Company in West Java.............................................................................................................................................60-64Hendra, Eva Nirwana, Marzuki Isahak

Adolescents' Attitude toward HIV/AIDS Prevention in Yogyakarta..................................................... 65-69Meysa Tiranda, Nanik Setiyawati, Anita Rahmawati

Health Promotion toward Knowledge and Intention for Early Detection of Cervical Cancer in Commercial Sex Workers................................................................................................................... 70-74Desi Rusmiati, Tiurlan Yunetty Silitonga, Warendi

Risk Factors Associated with Low Birth Weight.................................................................................... 75-80 Mohammad Zen Rahfiludin, Yudhy Dharmawan

Role Stress, Personality Type, Burnout, and Performance of Midwives towards Postnatal Care Program Achievement in Surabaya City..................................................................................................81-86Elita Halimsetiono, Thinni Nurul Rochmah, Dewi Retno Suminar

Family Perception Towards Health Role in Filariasis Countermeasures Using the Health Belief Model Approach in Aceh Besar District................................................................................................. 87-91Said Devi Elvin, Mutia Yusuf, Wirda Hayati, Teuku Alamsyah

Impact of Budget Increase on Primary Health Care Performance in the Era of National Health Insurance: Case Study in Buleleng District............................................................................................. 92-98Kadek Suranugraha, Ni Made Sri Nopiyani, Pande Putu Januraga

Utilization of Styrofoam as Soundproofing Material with Auditory Frequency Range........................... 99-104Sjahrul Meizar Nasri, Iting Shofwati

Accredited (Second Grade, SINTA 2) by Ministry of Research, Technology and Higher Educationof the Republic of Indonesia, the Decree No.30/E/KPT/2018 dated on October 24, 2018,

valid year 2017 - 2021

KesmasNational Public Health Journal

Volume 13, Issue 2, November 2018 p-ISSN 1907-7505e-ISSN 2460-0601

KesmasNational Public Health Journal

Volume 13, Issue 2, November 2018 p-ISSN 1907-7505e-ISSN 2460-0601

Kesmas: National Public Health Journal is a journal that contains both research articles and invited review articles in the field of public health and published quarterly

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AbstractJunk food is unhealthy and poor in nutrient quality, and may result in weight gain, obesity, and coronary heart disease, if consumed regularly. The prevalenceof overweight in adolescents is 5-10% higher in urban areas. Adolescents undergo lifestyle changes, including in food consumption behavior. This studyaimed to determine relation between junk food consumption patterns and overweight in adolescents. This study was conducted based on a cross-sectionaldesign. A total of 137 high school students in Jambi City were involved in this study. Patterns of junk food consumption were assessed using food frequencyquestionnaires that examined the eating habits of study subjects. The variables were sex, maternal education, parents’s occupation, and family’s socio-eco-nomic level. Analysis was conducted using the chi-square test and multiple logistic regression. Nutritional status was measured using body mass index-for-age with WHO Antro software. The results of this study indicated a 23.4% prevalence of overweight in adolescents. After controlling for maternal education,father’s occupation, instant noodle eating habits, and tea, coffee and cookies consumption, final model showed that consumption of pizza and hamburgersamong adolescents was the dominant determinant for overweight (OR=3.55). Consumption of pizza and hamburger was related to overweight among ado-lescents in Jambi City.Keywords: Adolescent, junk food, nutritional status, overweight

AbstrakMakanan cepat saji merupakan makanan yang tidak sehat dan buruk, yang dapat menyebabkan penambahan berat badan/obesitas, dan penyakit jantungkoroner jika dikonsumsi secara teratur. Prevalensi kegemukan pada remaja meningkat 5-10%, lebih tinggi di daerah perkotaan. Remaja menjalani perubahangaya hidup, termasuk dalam perilaku konsumsi makanan. Penelitian ini bertujuan mengetahui hubungan pola makanan cepat saji dengan kegemukan padaremaja. Penelitian dilakukan berdasarkan desain potong lintang. Sebanyak 137 siswa sekolah menengah atas di Kota Jambi dilibatkan dalam penelitian ini.Pola konsumsi makanan cepat saji dikaji menggunakan kuesioner frekuensi makanan terhadap kebiasaan makan. Variabel meliputi jenis kelamin, pendidikanibu, pekerjaan orang tua, dan tingkat sosial ekonomi keluarga. Analisis menggunakan kai kuadrat dan regresi logistik ganda. Status gizi diukur menggunakanindeks massa tubuh menurut usia dengan perangkat lunak WHO Antro. Hasil penelitian menunjukkan prevalensi kegemukan sebesar 23,4%. Setelahdikontrol oleh pendidikan ibu, pekerjaan ayah, kebiasaan makan mie instan dan konsumsi teh, kopi, cappuccino, dan kue. Model terakhir menunjukkanbahwa konsumsi pizza dan hamburger pada remaja merupakan faktor dominan kegemukan (OR = 3,55). Konsumsi pizza dan hamburger berhubungan dengan kegemukan pada remaja di Kota Jambi.Kata kunci: Remaja, makanan cepat saji, status gizi, gemuk

Pizza and Hamburger Consumption to Overweightamong Adolescents in Jambi City

Konsumsi Pizza dan Hamburger terhadap Kegemukan pada Remaja di KotaJambi

Ummi Kalsum*, Sahridayanti Nainggolan**, Nawi Ng***

Correspondence: Ummi Kalsum, Public Health Studies Program, Public HealthFaculty, Universitas Jambi, Raya Jambi-Muara Bulian Street Km. 15 MendaloDarat Jambi, Phone: +62741-582965, E-mail: [email protected] Received: August 29th 2017Revised: March 26th 2018Accepted: September 26th 2018

*Public Health Studies Program, Faculty of Public Health, Universitas Jambi, Jambi, Indonesia, **Jambi HealthOffice, Jambi, Indonesia, ***Department of Public Health and Clinical Medicine UMEA University, Sweden

Kalsum et al. Kesmas: National Public Health Journal. 2018; 13 (2): 53-59DOI:10.21109/kesmas.v13i2.1694

Kesmas: National Public Health Journal

Copyright @ 2018, Kesmas: National Public Health Journal, p-ISSN: 1907-7505, e-ISSN: 2460-0601, Accreditation Number: 30/E/KPT/2018, http://journal.fkm.ui.ac.id/kesmas

How to Cite: Kalsum U, Nainggolan S, Ng N. Pizza and hamburger con-sumption to overweight among adolescents in Jambi City. Kesmas: NationalPublic Health Journal. 2018; 13 (2): 53-59. (doi:10.21109/kesmas.v13i2.1694)

IntroductionAdolescence is a transition period from childhood to

adulthood. The teenage phase is between 13 and 18 yearsold. Adolescents are vulnerable, particularly during thesecond phase of rapid growth called the adolescent“growth spurt”, they need plenty of nutrients for theirgrowth.1 Alongside the physical growth in adolescents,they also experience social and psychological growth.This growth exposes adolescents to a variety of lifestylesand behaviors, including food consumption influencedby environment, family and media campaigns. Such ad-vertising may highlight new low-nutrient food products,foods that supposedly maintain a slim body outline, orWestern foods such as pizza and hamburgers.

According to data from the 2007 National BasicHealth Research, consumption of unhealthy and poorquality junk food in the population aged 10 years was at65.2%.2 Long term consumption of junk food may resultin conditions such as obesity. The prevalence of obesityin adolescents aged 13-15 years in Jambi Province was6.0%. In youths between 16 and 18 years old, prevalenceof obesity rose from about 1.4% in 2010 to 7.3% in2014.3,4 Several studies observed a relationship betweenthe consumption of junk food and the nutritional statusof adolescents, particularly the incidence of overweight.The increase in prevalence of overweight among adoles-cents, particularly in urban areas, has led to a doubleburden of nutritional problems in Jambi, and inIndonesia as a whole. Excess nutrients can result in obe-sity, which occurs in children, youths and adults. Junkfood causes obesity because it creates an imbalance be-tween the amount of energy obtained and the amount ofenergy consumed by the body's need for growth and de-velopment, activity and immunity.5 Common complica-tions from being overweight or obese include non-com-municable diseases such as heart disease, hypertension,and diabetes mellitus.

The aim of this study was to determine relation be-tween the consumption of junk food such as pizza andhamburgers, and overweight in adolescents. Other riskfactors were to be studied as well.

MethodThis study utilized a cross-sectional design with pri-

mary data collected from grade 10 high school studentsin Jambi City, Jambi Province. Data were collected inOctober of 2015. The study population included all 679students at the Jambi 5 State Senior High School in JambiCity. A total of 149 participants were randomly selectedfrom 18 classes of grade 10 students that met the inclu-sion criteria, were aged < 18 years, and willing to parti -cipate in the study. Grade 10 students were selected be-cause they were on average younger than 18 years of age.All subjects in this study obtained permission from the

school to participate in this study. Students with an un-derweight nutritional status (-3 SD to <-2 SD) were ex-cluded, as this study aimed to compare overweight andobese participants to those of a normal nutritional status.As a result, a total of 137 subjects participated and com-pleted this study.

The sample size calculated by hypothesis tests for apopulation proportion (two-sided) was carried out by thesample size determination software, Lemeshow andLwanga.6 It used a= 5% and b= 20%. The dependentvariable was being overweight, which was measured us-ing body mass index-for-age (BMI/A). Calculation ofBMI/A was performed using the WHO Anthro software.The criteria for BMI/A (5-18 years old) was based on theIndonesian Ministry of Health (2011).7 To evaluate nu-tritional status, subjects were grouped into normal (-2 to1 standard deviation of the Z curve), and overweight(overweight + obese) (>1 SD of the Z curve).Underweight subjects (-3 to -2 SD of the Z curve) wereexcluded and not analyzed.

The main independent variable was consumption pat-terns of junk food including pizza and hamburgers, in-stant noodles, popcorns, chips and French fries, cake andsugary foods, soft drinks, as well as tea, coffee, cappuc-cino, cookies, and cakes.

Data were collected using a food frequency question-naire (FFQ) with structured questionnaires which used aLikert scale with outcomes such as “never”, “rarely”,“sometimes”, “often” and “always” to assess junk foodconsumption habits. The five Likert scale outcomes werere-coded into two categories. Outcomes 1-3, i.e. “neverto sometimes” were re-coded into a single outcome of“rarely” (1), and outcomes 4-6, i.e. “often and always”were re-coded into “often” (2).

Nutritional status was measured directly using a di -gital scale (weighing scale) to the nearest 0.1 kg. Heightwas measured using a portable height instrument madeof super aluminum, with a tool accuracy of 0.1 cm. Itwas previously used for measurement by the 2013National Basic Health Research study. Measurementswere conducted by a team of four trained enumerators,and monitored by the researchers from this study team.

As the research questionnaire was designed to be self-administered, all other variables were filled directly intothe research questionnaire. Analysis, including univariateanalysis, bivariate analysis using the chi-square test, andmultiple logistic regression analysis at the 95% confi-dence level was conducted using a statistical software.Modelling with consideration of screening candidateswas entered into the model using p value 0.25, with theconfounding test using the formula ((crude-adjusted/ad-justed*100%) > 10 %).

As a total of ten variables were analyzed in this study,the variables with a p value 0.25 were pizza and ham-

54

Kesmas: National Public Health Journal, 2018; 13 (2): 53-59

Kalsum et al, Pizza and Hamburger Consumption to Overweight among Adolescents

burger consumption, consumption of instant noodles,soft drinks, cakes and sweets, popcorn, chips and Frenchfries, tea, coffee, cappuccino and cookies.

ResultsTable 1 shows that 23.4% of the adolescents in this

study were overweight. The study participants had ahigher percentage of females, subjects with highly edu-cated parents, unemployed mothers, fathers with un-steady occupation, and families in the middle to high so-cioeconomic range.

Figure 1 shows that “often” consumption of pizza andhamburgers, instant noodles and soft drinks in adoles-cents was 15%. However, “often” consumption of pop-corn, chips and fries and cake and sweets, and of tea,coffee, cappuccino and cookies was relatively high at>30%.

Table 2 shows that adolescents who consumed pizzaand hamburgers “often” had a greater risk of being over-weight than those who “rarely” consumed (OR = 3.17;95% CI = 1.13-8.89; p value = 0.035). Adolescents witha father who held a steady job had a greater risk of beingoverweight than those with a father who did not hold a

steady job (OR = 2.5; 95% CI = 1.11-5.65; p value =0.040). Consuming popcorn, chips and fries “often”,having a highly educated mother, having an employedmother, and having a family in the middle to high socioe-conomic level, all increased the risk of becoming over-weight in adolescents of overweight in adolescents (OR= 1.14; 3.58; 1.37 and 2.21, respectively). However,these increases were not proven to be statistically signif-icant. Subjects with overweight and normal nutritionalstatus were similarly distributed to “often” and “rarely”consuming instant noodles, soft drinks, tea, coffee, cap-puccino and cookies, cake, and sweet foods. There wasno statistical difference in overweight incidence acrossboth sexes.

A final model based on multivariate logistic regres-sion analysis is shown in Table 3. After controlling forconsumption of instant noodles, tea, coffee, cappuccinoand cookies, mother’s education level, and father’s occu-pation, the model revealed that adolescents who con-sumed hamburgers and pizza “often” had a greater riskof being overweight (OR = 3.54) than those consumedthem “rarely”. Maternal education, father’s occupation,consuming instant noodles, tea, coffee, cappuccino and

55

Table 1. Prevalence of Overweight and Distribution of Sociodemographic Characteristics

Variable Criteria %

Nutritional status Overweight 23.4 Normal 76.6Sex Female 52.6 Male 47.4Father's education* High 88.1 Low 11.9Maternal education** High 83.3 Low 16.7Mother’s occupational status Employed 38.0 Unemployed 62.0Father's occupation Steady 45.3 Not 54.7Socioeconomic level Middle to high 94.2 Low 5.8

Notes:n = 137 for all variable except *n=135 and **n=132

Figure 1. Junk Food Consumption Pattern in Adolescents, Jambi City

pastries were confounding factors for the incidence ofoverweight in adolescents in this model.

The most dominant predictor for becoming over-weight in adolescents aged 14-17 years was consumingpizza and hamburgers. More highly educated adolescentshad a 20% risk of being overweight, and those with em-ployed fathers had a 10% risk of being overweight. Thismodel was satisfactory because it was able to predict ado-lescent overweight incidence by 79.5%.

DiscussionAs a group, adolescents are susceptible to malnutri-

tion because they are in a second phase of growth spurt,just before adulthood. Adolescents who live in urban ar-eas are greatly influenced by their external environmentincluding friends, family, and hedonistic lifestyle.8,9 Thecharacteristics of urban adolescents are relatively differ-

ent from rural adolescents. Middle to high socioeconom-ic class, highly educated parents, and working motherstend to influence the lifestyle and food consumption pat-terns of adolescents.10,11

The growth of the fast food industry has been acce -lerated by aggressive advertisement of low-nutrient foodproducts, particularly visible to adolescents in urban ar-eas. This increases the consumption of junk food amongadolescents.10,11

This study intended to prove the hypothesis that con-suming junk food “often” may increase the risk of ado-lescents becoming overweight. After controlling for ma-ternal academic level, father’s occupation, consuming in-stant noodles “often”, and consuming tea, coffee, cap-puccino and cookies, this study found that consumingpizza and hamburgers “often” was the dominant predic-tor for being overweight in adolescents. This is similar to

56

Table 2. Bivariate Analysis for Factors Related to Overweight in Adolescents

Nutritional Status Variable Criteria Overweight Normal POR 95% CI p Value n % n %

Pizza and Hamburger Often 8 44.4 10 55.6 3.17 1.13-8.89 0.04* Rarely 24 79.8 95 20.2

Instant Noodle Often 1 7.1 13 92.9 0.23 0.03-1.82 0.19 Rarely 31 25.2 92 74.8

Pop Corn, Chips, French Fries Often 16 24.6 49 75.4 1.14 0.52-2.52 0.9 Rarely 16 22.2 56 77.8

Soft Drink Often 3 18.8 13 81.3 0.73 0.19-2.75 0.76 Rarely 29 24 92 76

Tea, Coffee, Cappuccino and Cookies Often 10 16.1 52 83.9 0.46 0.20-1.07 0.11 Rarely 22 29.3 53 70.7

Cake and Sweet Snacks Often 9 19.6 37 80.4 0.72 0.30-1.71 0.6 Rarely 23 25.3 68 74.7

Sex Female 14 19.4 58 80.6 0.63 0.28-1.39 0.35 Male 18 27.7 47 72.3

Maternal Education Level High 29 26.4 81 73.6 3.58 0.79-16.27 0.14 Low 2 9.1 20 90.9

Mother's Occupational Status Employed 14 26.9 38 73.1 1.37 0.61-3.06 0.57 Unemployed 18 21.2 67 78.8

Father's Job Steady 20 32.3 42 67.7 2.5 1.11-5.65 0.04* Not steady 12 16 63 84

Socio-economic Middle to high 31 24 98 76 2.21 0.26-18.70 0.68 Low 1 12.5 7 87.5

Notes:*p value < 0.05

Table 3. The Final Model of Overweight and Junk Food Consumption Frequency, and Confounders

Variable B Adjusted OR (95% CI) p Value

Pizza and hamburger habit: often/rarely (n=137) 1.27 3.54 (1.08-11.68) 0.037Instant noodle habit: often/rarely (n=137) -1.59 0.21 (0.02-1.83) 0.156Tea, coffee, cappuccino and cookies: often/rarely (n=137) -0.81 0.45 (0.18-4.77) 0.079Maternal education level: high/low (n=132) 0.78 2.17 (0.44-10.73) 0.341Father's occupation: steady/not (n=137) 0.68 1.97 (0.81-4.77) 0.135Constant -1.96 0.14 0.011

Overall percentage = 79.5% (p value of omnibus test = 0.010)


results obtained from previous studies that found thatobesity is influenced by the energy intake from junk foodconsumption (OR = 1.58, 95% CI= 1.08-2.32 and p va -lue = 0.01).10 Also in line with a study by Badjebar, stu-dents who consume junk food ‘often’ at least three timesa week are 3.28 times more likely to be overweight thanthose who consume “rarely”. This result was statisticallysignificant.12 Damapolii et al showed that the occurrenceof obesity was related to consumption of junk food.13 Astrong association between the consumption of junk foodand obesity was reported among adults in Michigan.Regular consumers of junk food were 60% to 80% morelikely to be obese higher compared to those who con-sumed junk food less than once per week.14

However, this study finding was not consistent withresults from the study in Yogyakarta, which found thatthe frequency of junk food consumption was not relatedto a child’s nutritional status (p > 0.05).15 This differenceis likely because the participants of the Yogyakarta studywere elementary school children. The percentage of chil-dren who consumed junk food “often” in the Yogyakartastudy was only 4.6%, 63% of the children consumedjunk food at a “rare” frequency, and 32% never con-sumed junk food. Due to limited financial power, pri-mary school children only bought or consumed junk foodwhen facilitated by their parents. In a study by Graceand Indasari,16 excessive consumption of carbohydrateswas associated with the incidence of obesity among highschool students in Makassar (p value = 0.000). However,frequency of junk food consumption was not related toobesity (p value = 0.686).

Adolescents in Indonesia are currently experiencing alifestyle change. Today, Western junk food such as friedchicken, French fries, pizza, doughnuts, burgers, hotdogs and ice cream are preferred and desirable. Mostjunk food are nutritionally imbalanced with high calories,fat, sugar and sodium levels but low fiber, vitamin A,ascorbic acid, calcium and folate levels. Excessive con-sumption of such foods causes nutritional problems suchas overweight and obesity.12

Burgers and pizzas are main components of theWestern diet. Consumption of pizza and burgers inIndonesia began in the 1990’s. Furthermore, the proli -feration of fast food restaurants with menus includinghamburgers and pizza has increased their popularity.Previously, pizza and hamburgers could only be enjoyedby the upper and middle class. However, due to socioe-conomic progress, hamburgers and pizza are now moreaccessible and affordable (IDR 2,500-4,000), makingthem available to people in the middle and lower socioe-conomic class.17

The hamburgers currently in the market are com-posed of 13% cholesterol and carbohydrate, and 30%fat and saturated fat. Compared to hamburgers, pizzas

are quite nutritious, containing minerals, fiber, vitaminsB1, B2, B3 and vitamin A. Eating two slices of pizza, willprovide most major nutrients and up to 410 calories(20.5% of the daily requirement); 126 calories of fat(6.3%); 14 grams total fat (22%); 40 mg cholesterol(13%); and 1,178 mg sodium (49%). Consumption ofpizza satisfies of a person's daily saturated fat require-ments. However, saturated fats are linked to degenera-tive diseases e.g. heart disease.15

Previously, pizza was considered a healthy food be-cause it was made with an ideal composition of flour,tomato, olive oil and mozzarella. However, because ofthe use of many commercially affordable processed prod-ucts, pizza now contains too much fat, calories, sodiumbut is low in nutrition value. As a result, pizza is nowcategorized as junk food.15 This study showed that con-suming pizza and hamburgers “often” was the dominantpredictor for being overweight among adolescents inJambi City.

In a study by Bowman,18 consuming large portions offoods, foods with high energy density, high fat content,high sugar and salt content, high glycemic index and lowin fiber increased energy intake, and spurred a positiveenergy balance. This increased the risk of obesity.Children and adolescents who consume junk food havehigher levels of total calories, total fat, saturated fat, totalcarbohydrates, sugar but lower levels of fiber than chil-dren and adolescents who do not consume junk food.18

The high energy density of fat promotes increased en-ergy intake. Total fat is associated with accumulation ofadipose tissue. Junk food contains high levels of starchand sugar, and has a high glycemic index value.Therefore, it can stimulate energy intake.18 When thebody consumes a high glycemic index food, the source ofenergy used comes from glycogen (carbohydrate de-posits), so that fat is accumulated unused. If this is re-peated continuously, fat deposits will accumulate, be-come abnormal and cause overweight and obesity.19

Some Western junk foods also contain several nutri-ents such as fat, protein, vitamins and minerals in mo -derate to high quantities. However, most of Western junkfoods have a bad impact because they contain largeamounts of saturated fat, cholesterol, sodium and high-calorie salt e.g. hamburgers and pizza. About 40-60% ofcalories from Western junk food are fat. Ingredients suchas cheese, mayonnaise, creams and the use of deep-fryingmethods increase the high fat content of these foods.18

Some types of foods contain higher than the recom-mended levels of sodium. Likewise, soft drinks have highsugar content, which contributes significantly to thenumber of calories consumed. Furthermore, the fibercontent in junk food is way below the recommended lev-els.20 Junk food consumption begins to show a signifi-cant association with the incidence of obesity when it ex-

57


ceeds one-third of total daily caloric intake.17

Junk food also affects the body's energy level. Junkfood does not contain many of the nutrients that the bodyneeds. The high level of sugar in junk food causes meta-bolic dysfunction. The pancreas secretes high amounts ofinsulin to prevent dangerous spikes in blood sugar levelsbecause fast food and junk food do not contain enoughamounts of protein and carbohydrates. Junk food con-tributes to poor performance and obesity. The more over-weight an individual is, the higher the risk for chronicdiseases such as diabetes, heart disease, and arthritis.20

A study by Mahdiah et al,20 showed that urban juniorhigh school adolescents consumed more types of junkfood, because fast food restaurants or counters in the cityprovided more varied menus than restaurants in rural ar-eas.21 There is an increase in the number of overweightchildren and adolescents because children and adoles-cents consume Western junk food, which contains moreenergy and less fiber.13,22

There are several limitations in this study e.g. the fre-quency of consuming junk food was only evaluated qual-itatively (using a Likert scale with criteria ranging from“never” to “always consume”). However, the criteriarange was defined to the respondents before they filledthe questionnaire. Further studies need to utilize betterstudy methods, add variables in accordance with the sub-stance of the study, increase the number of samples, andutilize better measurements to identify junk food con-sumption patterns among adolescents or other vulnera-ble groups.

ConclusionThis study concludes that after controlling for mater-

nal education levels, paternal occupation, consumptioninstant noodles, tea and coffee, cappuccino so cookies,consuming pizza and hamburgers “often” is the domi-nant risk factor for being overweight among adolescents.Consuming junk food “often” is mostly influenced by thehigh level of maternal education. Working mothers, onaverage, have less time to prepare and serve healthyfoods at home. This influences the consumption patternof the adolescent towards the consumption of low-nutri-ent junk food.

It is necessary to provide education, communicationand information to parents, especially mothers on select-ing healthy foods and providing a balanced diet for ado-lescents, to decrease the incidence of overweight or obe-sity. Creative and innovative communication and educa-tion programs on food consumption patterns and thedangers of junk food on adolescent health should be en-couraged and implemented.

References 1. Adriani M, Wirjatmadi B. The role of nutrition in the life cycle. Jakarta:

Group of Kencana Prenada Media. 2012

2. Kementerian Kesehatan Republik Indonesia. Riset kesehatan dasar

2007: laporan nasional 2007. Jakarta: Kementerian Kesehatan Republik

Indonesia; 2008. p.205.


2010. Jakarta: Kementerian Kesehatan Republik Indonesia; 2010. p.60.


2013. Jakarta: Kementerian Kesehatan Republik Indonesia; 2013.

p.222.

5. Sartika RAD. Faktor risiko obesitas pada anak 5-15 tahun di Indonesia.

Makara Kesehatan. 2011; 15(1): 37-43.

6. Lemeshow, S, Hosmer DW, Klar J, Lwanga SK, World Health

Organization. Adequacy of sample size in health studies. England: John

Wiley and Sons;1997.

7. Menteri Kesehatan Republik Indonesia. Keputusan menteri kesehatan

Republik Indonesia nomor: 1995/Menkes/SK/XII/2010 tentang stan-

dar antropometri penilaian status gizi anak. Jakarta: Kementerian

Kesehatan Republik Indonesia; 2010. p.36-40.

8. Cuzzocrea F, Larcan R, Lanzarone C. Gender differences, personality

and eating behaviors in non-clinical adolescent. Eating and Weight

Disorders. 2013; 17(4): e282.

9. Newmark-Sztainer D, Story M, Perry CL, Cassey MA. Factors influenc-

ing food choices of adolescent. Journal of the American Dietetic

Association. 1999; 99(8): 929-937.

10. Nurwanti E, Hadi H, Julia M. Paparan iklan junk food dan pola kon-

sumsi junk food sebagai faktor risiko terjadinya obesitas pada anak

sekolah dasar kota dan desa di Daerah Istimewa Yogyakarta. Journal of

Nutrition and Dietetics Indonesia (Indonesian Journal of Nutrition and

Dietetics). 2016;1(2): 59-70.

11. Story M, Neumark-Sztainer D, French S. Individual and environmental

influences on adolescent eating behaviors. Journal of the American

Dietetic Association. 2002; 102(3): S40-S51.

12. Badjeber F, Kapantouw, NH, Punuh M. Konsumsi fast food sebagai fak-

tor risiko terjadinya gizi lebih pada siswa SD Negeri II Manado. Kesmas:

Jurnal Kesehatan Masyarakat Universitas Sam Ratulangi. 2012; (1): 11-

14.

13. Damapolii W, Mayulu N, Masi G. Hubungan konsumsi fastfood dengan

kejadian obesitas pada anak SD di Kota Manado. Jurnal Keperawatan.

2013; 1(1): 1-7.

14. Anderson B, Lyon Callo S, Fussman C, Imes G, Raffety AP. Fast food

consumption and obesity among Michigan adults. Preventing Chronic

Diseases. 2011; 8(4): A71.

15. Kushardianti T, Sudargo T. R. Hubungan antara keputusan memilih

restoran fast food dan frekuensi konsumsi fast food terhadap status gizi

anak sekolah dasar [Skripsi]. Yogyakarta: Universitas Gadjah Mada;

2014.

16. Anugrah AA, Indriasari R, Yustini. Hubungan konsumsi fast food den-

gan kejadian overweight pada remaja di SMA Katolik Cendrawasih

Makassar [Skripsi]. Makassar: Universitas Hasanuddin; 2014.

17. Banowati L, Nugraheni N, Puhita N. Risiko konsumsi western fast food

dan kebiasaan tidak makan pagi terhadap obesitas remaja studi di

SMAN 1 Cirebon. Media Medika Indonesiana. 2011;45(2): 118-24.

18. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS.

Effects of fast-food consumption on energy intake and diet quality

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among children in a national household survey. Pediatrics. 2004;

113(1): 112-8.

19. Apriadji WH. Healthy fast food, fast food healthy dishes, favorites of

children and the whole family. Jakarta: Gramedia Pustaka Utama; 2007.

20. Mahdiah. Prevalensi obesitas dan hubungan konsumsi fast food dengan

kejadian obesitas pada remaja SLTP kota dan desa di Daerah Istimewa

Yogyakarta. Jurnal Gizi Klinik Indonesia. 2004; 1(2): 69-77.

21. Putra RO. Junk food berkontribusi terhadap kinerja buruk dan obesitas.

2013. Available from: http://sumsel.tribunnews.com/m/index.php/

2013/02/27/junk-foodberkontribusi-terhadap-kinerja-buruk-dan-obesi-

tas.

22. Daradkeh G, Muhannadi A, Chandra P, Al Hajr M. Fast food vs healthy

food intake and overweight/obesity prevalence among adolescents in

The State of Qatar. Journal of Obesity Treatment and Weight

Management. 2018; 1(1): 1-4.

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Correspondence: Hendra, Department of Occupational Health and Safety,Faculty of Public Health Universitas Indonesia, Building D 1st Floor KampusBaru UI Depok 16424, Phone: +6221-78849033, E-mail: [email protected]: August 29th 2017Revised: March 22nd 2018Accepted: September 14th 2018

Hendra et al. Kesmas: National Public Health Journal. 2018; 13 (2): 60-64DOI:10.21109/kesmas.v13i2.1705

AbstractOccupational skin diseases are the most common work-related diseases in many countries. Shoe industry workers are potential to be affected by work-relatedskin diseases (WRSDs). This study aimed to analyze the risk factors associated with WRSDs among workers in the sewing section at a shoe company inWest Java. A total of 477 workers were examined and interviewed using the modified Nordic Occupational Skin Questionnaire-2002/LONG from May 2016 toJuly 2016. Chi-square test and logistic regression were used to analyze the risk factors related to WRSDs. The results showed that 57.7% of the workers suf-fered from WRSDs. Most of the workers (71.7%) did not wear gloves while working; however, they washed their hands adequately at work (67.1%). Multivariateanalysis indicated that a term of work, allergy records, organic dust exposure and duration of exposure per day, handwashing habits, and use of gloves whileworking were significant to WRSDs. Having allergy records and not wearing gloves were the two dominant factors associated with WRSDs (odds ratio: 6.743and 6.224, respectively). Understanding the importance of using chemical protective gloves while working and washing hands with running water are essentialfor the proper implementation of protective measures to ensure worker's safety and health.Keywords: Allergies, gloves, sewing, shoe company, work-related diseases

AbstrakPenyakit kulit akibat kerja merupakan penyakit terkait kerja yang paling umum di banyak negara. Pekerja industri sepatu berpotensi terkena penyakit kulitterkait kerja (PKTK). Penelitian ini bertujuan menganalisis faktor risiko yang berhubungan dengan PKTK pada pekerja bagian jahit di sebuah perusahaansepatu di Jawa Barat. Sebanyak 477 pekerja diteliti dan diwawancarai dengan menggunakan Nordic Occupational Skin Questionnaire-2002/LONG yang di-modifikasi, dari bulan Mei 2016 sampai Juli 2016. Uji kai kuadrat dan regresi logistik digunakan untuk menganalisis faktor risiko yang terkait dengan PKTK.Hasil menunjukkan bahwa 57,7% pekerja mengalami PKTK. Sebagian besar pekerja (71.7%) tidak memakai sarung tangan saat bekerja; namun mempunyaikebiasaan cuci tangan saat bekerja (67.1%). Analisis multivariat menunjukkan bahwa masa kerja, riwayat alergi, pajanan debu organik, dan lamanya pajananper hari, kebiasaan mencuci tangan, dan tidak memakai sarung tangan saat bekerja signifikan terhadap PKTK. Memiliki riwayat alergi dan tidak memakaisarung tangan merupakan dua faktor dominan yang berhubungan dengan PKTK (masing-masing OR: 6,743 dan 6,224). Memahami perlunya memakaisarung tangan pelindung bahan kimia saat bekerja dan mencuci tangan dengan air mengalir sangat penting untuk implementasi tindakan perlindungan yangtepat guna memastikan keselamatan dan kesehatan pekerja.Kata kunci: Alergi, sarung tangan, jahit, perusahaan sepatu, penyakit terkait kerja

Work-Related Skin Diseases among Workers in theSewing Section at PT. X Shoe Company in West Java

Penyakit Kulit Terkait Kerja pada Pekerja Bagian Penjahitan PerusahaanSepatu PT. X di Jawa Barat

Hendra*, Eva Nirwana**, Marzuki Isahak***

*Occupational Health and Safety Department, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia,**PT. Prima Yasa Medika, Sukabumi, Indonesia, ***Department of Social and Preventive Medicine, Faculty ofMedicine, University of Malaya, Malaysia

How to Cite: Hendra, Nirwana E, Isahak M. Work-related skin diseasesamong workers in the sewing section at PT. X shoe company in West Java.Kesmas: National Public Health Journal. 2018; 13 (2): 60-64.(doi:10.21109/kesmas. v13i2.1705)

Hendra et al, Work-Related Skin Diseases among Workers in the Sewing Section

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IntroductionThe term work-related skin diseases (WRSDs) is de-

fined as any disorder of the skin caused or made worseby work activity or workplace conditions. However, theskin problems directly caused by work was called occu-pational skin diseases (OSDs). The wider definition ofskin problems in the workplace is called WRSDs.1 Themost common WRSD is contact dermatitis.2

WRSDs account for approximately 50% of occupa-tional diseases and are responsible for an estimated 25%of all lost workdays. These dermatoses are often underre-ported because their association with the workplace isnot recognized.3 In Germany, 23,596 out of the 71,263reported occupational diseases in 2010 were classified asWRSDs.4 OSDs are also found in 75% of patients inVictoria, and 45% were diagnosed as WRSDs.5 The an-nual incidence of WRSDs is reported to be between 5.7and 101 cases per 100,000 workers.6 As per anotherstudy in Norway, about 5 million people and 2.65 millionemployees had a skin disease in 2014.7 Industrial der-matitis in Singapore resulted in absence from work in21% of the employees with a median of 3 days away fromwork.6 Skin disease and asthma are the most commonoccupational diseases in the member states of theEuropean Union and result in long absence from work.8The prevalence of WRSDs in the shoe industries inIndonesia is 29%.9 An epidemiological study with 389cases of WRSDs found that 97% of them are contactdermatitis, of which 63% are irritant contact dermatitisand the rest is allergic contact dermatitis.10

The shoe industry is one of the manufacturing indus-tries that involve a high-risk process. Every day, workersare exposed to hazardous materials that are capable ofcausing skin diseases. However, OSDs have rarely beenreported in shoe manufacturing workers.11 A study con-ducted in 1992 on 1,194 workers from five shoe manu-facturing companies in Italy showed a prevalence of14.6% for occupational contact dermatitis, 6% for hy-perkeratosis of the fingertips, and 3.2% for pruritus sinemateria. Workers in the shoe manufacturing industry areexposed to an extensive range of potential occupationalhazards (physical or chemical) on a daily basis. Duringthe process of shoe production, there is a high possibilityof occupational exposure to a broad spectrum of aller-gens present in adhesives, preservatives, acrylic resins,leather, rubber, dyes, and several types of glue (neoprene,epoxy resin, and rubber glues). Adhesives and solventsused in the production process may also be potential irri-tants.11

PT. X is a shoe manufacturer with 10,836 workers infive departments, including preparation, preparing/uppersole, assembling, finishing, and packing. Based on thecompany clinic's records, from January 2015 toDecember 2015, the sewing process, which is a subsec-

tion of the preparing/upper sole department, had thehighest complaints of skin diseases (57.65%). The typesof skin diseases present in the workers of the sewingprocess included contact dermatitis (52%), urticaria(21%), and pruritus (17%). The workers from thesewing department did not deal directly with chemicals;however, they have the highest prevalence of skin diseasecomplaints. Several factors other than exposure to haz-ardous materials can cause skin disease; if not managedproperly, these will affect a worker's health and produc-tivity. Specific research studies are needed to determinethe risk factors associated with WRSDs and to identifythe dominant WRSDs risk factors among workers in thesewing department at PT. X.

The aim of this study was to determine risk factors ofWRSDs among workers in the sewing section at PT. X in2016. The analyzed risk factors included a term of work,allergy records, organic dust exposure and duration ofexposure per day, handwashing habit, and the practice ofwearing gloves during work.

MethodA cross-sectional survey method was used to assess

the prevalence of WRSDs and its risk factors at a shoefactory located in Sukabumi District, West JavaProvince, Indonesia. This shoe factory had 10,836 work-ers with many complaints of skin problems in the sewingprocess work. The randomly selected 477 subjects wereincluded in this study conducted from May 2016 to July2016.

The dependent variable was WRSDs experienced bythe workers. The independent variables were a term ofwork, allergy records, organic dust exposure and dura-tion of exposure per day, handwashing habit, and thepractice of wearing gloves during work.

Data were collected using the modified NordicOccupational Skin Questionnaire-2002/LONG.12 Thesurvey is divided into four parts. Part A includes the cha -racteristics of workers such as the name, age, sex, worklocation, and department, while Part B is related to thejob, with questions about the work, duration of exposureto hazardous material, and additional workload otherthan their main job. Part C is related to individual factorsand control programs, with questions about the habits ofthe respondents inside and outside the workplace, prac-tices related to personal hygiene such as washing handsand wearing gloves while working, and allergy records,and Part D is related to physical examination and anam-nesis as well as medical records and reports of clinic visitsfrom January 2015 to December 2015.

Data were processed using a computer-assisted statis-tical program to calculate the frequency distribution andproportions of all independent and dependent variables.The subsequent bivariate analyzes were conducted using

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the chi-square test to assess the relation of the dependentvariable with every independent variable. Finally, multi-variate logistic regression analysis was used to identifythe dominant variable associated with WRSDs.

ResultsThis study included 141 (29.6%) male and 336

(70.4%) female workers in the sewing section. Most ofthe subjects were operators (n = 396; 83%) and then fol-lowed by leaders (9.7%) and supervisors (7.3%). In ad-dition, 244 (51.2%) workers performed the sewing ac-tivity, while the others did the gluing. The detailed fre-quency distribution of all study variables is shown inTable 1.

As shown in Table 1, 275 (57.7%) workers in thesewing process had WRSDs. There were more partici-pants with a term of work of 3 years (n = 288, 60.4%)than those with a term of >3 years (n = 189, 39.6%).Most workers (87%) in the sewing section had no allergyrecords. Based on the work process involved in sewing,321 (67.3%) workers were being exposed to organicdust. Exposure to organic dust occurred at the time ofcontact with the shoe material during the sewing process.A total of 250 (52.4%) workers were exposed to organicdust for 5–7 hours per working day. Table 1 also showsthat 320 (67.1%) workers had a habit of washing theirhands during working hours. However, only 135(28.3%) workers used gloves while working.

Table 2 shows the distribution of study participantsaccording to the presence of WRSDs. Bivariate analysisshowed that a term of work, records of allergies, organicdust exposure, duration of exposure per day, handwash-ing habits, and the practice of wearing gloves while work-ing were significantly correlated with WRSDs (p value <0.005, odds ratio [OR]= 0.422–5.762). The finding thatworkers with a term of work of 3 years had a greater risk

of WRSDs than those with a term of work of >3 yearswas noteworthy. Based on the OR from the chi-squaretest, a longer term of work became a protection factor toWRSDs.

Based on the final model results shown in Table 3,variables with a p value = 0.05 such as the term of work,allergy records, organic dust exposure, duration of expo-sure per day, handwashing habits, and the practice ofwearing gloves while working were significantly associ-ated with WRSDs among workers in the sewing section.The results of logistic regression analysis showed that outof all the independent variables, an allergy record wasthe most important risk factor for WRSDs (OR= 6.743,95% confidence interval [CI]= 2.947–15.428) followedby the practice of not wearing gloves while working(OR= 6.224, 95% CI= 3.735–10.371). Logistic regres-sion analysis also showed that the term of work of >3years was a protective factor against the occurrence ofWRSDs (OR= 0.334).

Table 1. Frequency Distribution of the Study Variables

Variables Category N %

Work-related skin diseases Yes 275 57.7 No 202 42.3Term of work >3 years 189 39.6 3 years 288 60.4

Allergy records Yes 62 13.0 No 415 87.0Organic dust exposure Yes 321 67.3 No 156 32.7Duration of exposure per day 5–7 h 250 52.4 <5 h 227 47.6Handwashing habit No 157 32.9 Yes 320 67.1Wearing gloves while working No 342 71.7 Yes 135 28.3

Notes: n= The Number of Samples

Table 2. Bivariate Analysis of Factors Associated with WRSDs among Workers in the Sewing Section

WRSDs (n = 275) Non-WRSDs (n = 202) Total Variable Category p Value Unadjusted OR 95% CI n % n % n % Term of work (years) >3 85 30.9 104 51.5 189 39.6 <0.001 0.422 (0.289–0.614) <3 190 69.1 98 48.5 288 60.4

Allergy Records Yes 47 17.1 15 7.4 62 13.0 0.003 2.570 (1.393–4.742) No 228 82.9 187 92.6 415 87.0Organic dust exposure Yes 209 76.0 112 55.4 321 67.3 <0.001 2.545 (1.720–3.765) No 66 24.0 90 44.6 156 32.7 Duration of exposure per day (h) 5–7 169 61.5 81 40.1 250 52.4 <0.001 2.382 (1.642–3.454) <5 106 38.5 121 59.9 227 47.6 Handwashing habit No 114 41.5 43 21.3 157 32.9 <0.001 2.618 (1.731–3.959) Yes 161 58.5 159 78.7 320 67.1 Wearing gloves while working No 237 86.2 105 52.0 342 71.7 <0.001 5.762 (3.711–8.945) Yes 38 13.8 97 48.0 135 28.3 Notes:WRSDs = Work-Related Skin Diseases, OR = Odds Ratio, CI = Confidence Interval, n = The Number of Samples

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DiscussionThe results of this study showed the prevalence of

WRSDs at 57.7%. A study on garment workers inBangladesh also found a high proportion of garmentworkers experiencing skin rash and skin itchiness(73%).13 Workers with a term of work of 3 years tendto be at a greater risk than those with a term of work of>3 years because new workers are more likely to com-plain than experienced ones and the worker with a termof work of >3 years became resistant to symptoms ofWRSDs. A study on textile workers in Jepara, CentralJava, also showed a correlation between a longer term ofwork and dermatitis (p value = 0.038). One factor sus-pected to be the cause of WRSDs in workers with ashorter term of work is the susceptibility of the skin to ir-ritants or infection.14-15

Moreover, workers with a term of work of >3 yearssometimes stop complaining about the damage to theirskin. A previous study has mentioned that workers witha term of work of 2 years have a 3.5 times higher risk ofcontact dermatitis than those with a term of >2 years.14

Another cause of WRSDs is poor awareness of the work-ers about the importance of wearing gloves while work-ing and washing hands during work hours. A study ofworkshop workers in Surakarta showed that workershave an 18.8 times higher risk of WRSDs when hand-washing habits are poor.16

In this study, WRDSs occurred because of an inflam-mation that developed while in contact with shoe mate-rials and organic dust produced during the work process.Inflammatory processes begin when agents (alkalis,acids, and solvents) come into contact with the skin andcause lesions in the corneal layer. This condition can leadto increased permeability, allowing the passage of ha -zardous substances, subsequently leading to the produc-tion of the inflammatory cytokines and keratinocytes.This also stimulates other cells, causing an inflammatoryreaction (cellular immunity) that occurs in three phasesthat are: induction or immunization or sensitization, elic-itation or development, and resolution (the end of the in-

flammatory reaction).17

The results showed that allergy records is a major fac-tor contributing to WRSDs in the workers in the sewingsection at PT. X. This result is the same with the studyconducted by Chen et al,18 in clothing manufacturingworkers in Beijing, China. The study found a significantrisk of contact dermatitis among workers with allergicrhinitis (OR= 2.3, 95% CI= 1.12–4.55).18 Wearinggloves during work is a factor that contributes consider-ably to WRSDs among sewing workers at PT. X. Severalworkers in the sewing section at PT. X were not equippedwith gloves during work. For workers who wore gloves,sometimes, the gloves did not comply with the requiredstandard, and some workers used a glove on only onehand. The findings of this study are in line with those ofa study on automotive workers in the industrial area ofCibitung where the habit of wearing personal protectiveequipment, including hats and work packs in addition togloves, was significantly associated with the incidence ofcontact dermatitis.19 These findings are similar to thoseobtained in this study using multivariate modeling inwhich the use of gloves was found to be the most domi-nant risk factor of WRSDs (OR= 5.370).

Another factor with a high OR is the habit of hand-washing. A study on motorcycle repair workers foundthat workers with poor handwashing habits had an 18.8times higher risk of developing contact dermatitis thanthose with good handwashing habits (OR= 18.791, 95%CI= 4.897–72.104).16 Studies on fishermen in Rembangalso found a statistically meaningful relation between per-sonal hygiene and the incidence of contact dermatitis.Personal hygiene, in this study, refers to the habit ofwashing hands with soap and running water.20 The datapertaining to the condition of the handwashing stationsat PT. X were unavailable. PT. X has provided handwash-ing stations in the five toilets, but soap was occasionallyunavailable. The limited number of washing stations act-ed as an obstacle for the 500 workers in implementingthe habit of washing hands to reduce the incidence ofskin diseases.

Table 3. Multivariate Final Model of Factors Associated with Work-Related Skin Diseases among Workers in the Sewing Section

Variables B coefficient SE p Value Adjusted OR (95% CI)

Term of work -1.097 0.237 <0.001 0.334 (0.210–0.531)Allergy Records 1.908 0.422 <0.001 6.743 (2.947–15.428)Organic dust exposure 0.889 0.256 0.001 2.433 (1.474–4.017)Duration of exposure per day 0.760 0.235 0.001 2.138 (1.348–3.391)Handwashing habit 1.381 0.256 <0.001 3.980 (2.411–6.570)Wearing gloves while working 1.828 0.261 <0.001 6.224 (3.735–10.371)Constant − 9.171 Notes:SE = Standard Error, OR = Odds Ratio, CI = Confidence Interval

Hendra et al, Work-Related Skin Diseases among Workers in the Sewing Section

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This study has certain limitations with respect to datacollection. The respondents themselves filled the ques-tionnaires; this could have triggered communication anddiscussion among the respondents about the questions,resulting in inaccurate and biased responses. In addition,permission from the company's management to observethe working conditions in the sewing section was not ob-tained; therefore, the exposure was based on self-report-ing.

ConclusionAlmost 57.7% of the workers in the sewing section

experience WRSDs. Based on multivariate analysis, therisk factors significantly associated with the WRSDsamong workers in the sewing section are the shorter termof work, having allergy records, organic dust exposure,longer duration of exposure per working day, poor hand-washing habit, and not wearing gloves while working.

Therefore, to decrease the incidence of WRSDs inworkers, especially among workers in the sewing section,PT. X should provide standard gloves to the workers andencourage their use during work, counsel and supervisethe workers, and provide adequate and accessible hand-washing facilities at the workplace.

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Tiranda et al. Kesmas: National Public Health Journal. 2018; 13 (2): 65-69DOI:10.21109/kesmas.v13i2.1672

How to Cite: Tiranda M, Setiyawati N, Rahmawati A. Adolescents' attitudetoward HIV/AIDS prevention in Yogyakarta. Kesmas: National Public HealthJournal. 2018; 13 (2): 65-69. (doi:10.21109/kesmas. v13i2.1672)

Adolescents' Attitude toward HIV/AIDS Prevention inYogyakarta

Sikap Remaja terhadap Pencegahan HIV/AIDS di Yogyakarta

Meysa Tiranda, Nanik Setiyawati, Anita Rahmawati

Midwifery Department Yogyakarta Health Polytechnic of Ministry of Health, Yogyakarta, Indonesia

Correspondence: Nanik Setiyawati, Midwifery Department Yogyakarta HealthPolytechnic of Ministry of Health, Phone: +62274-374331 , E-mail: [email protected]: August 18th 2017Revised: February 14th 2018Accepted: February 20th 2018

AbstractAcquired immunodeficiency syndrome (AIDS) is the second leading cause of death in adolescent groups in the world. In Indonesia, the rate of human immun-odeficiency virus (HIV)-infected adolescents increases annually. Yogyakarta, well-known as the education city, has the highest number of HIV/AIDS cases inthe productive age group of 20–29 years old, which means that they have been already infected with HIV since teen age. This study aimed to determine in-fluential factors that affect adolescents' attitude toward HIV/AIDS prevention. The study was an analytic survey research with a cross-sectional design.Stratified random sampling was applied to select a sample size of 128 respondents of class XI at Muhammadiyah 3 Yogyakarta Senior High School in 2017.Data were taken by using questionnaires that had been tested for validity and reliability. Data were analyzed by chi-square test and logistic regression. Theresults revealed that most of the respondents received information on HIV/AIDS from media (47.7%), have a good knowledge level (82%), and support theprevention of HIV/AIDS (96.9%). The source of information and knowledge level had a statistically significant relation with adolescents' attitude towardHIV/AIDS prevention. Knowledge level is the most influential factor to adolescents' attitude toward HIV/AIDS prevention (p value = 0.006, PR = 1.199; 95%confidence interval = 1052–1367).Keywords: Adolescent, attitude, HIV/AIDS prevention, knowledge

AbstrakAIDS merupakan penyebab kematian kedua pada kelompok remaja di dunia. Di Indonesia kelompok remaja yang terinfeksi HIV selalu meningkat setiaptahunnya. Di Yogyakarta, yang dikenal sebagai kota pendidikan, memiliki kasus HIV/AIDS terbanyak pada usia produktif yaitu kelompok usia 20-29 tahun,yang dapat diartikan bahwa saat usia belasan telah terinfeksi virus HIV. Penelitian ini bertujuan mengetahui faktor yang memengaruhi sikap remaja terhadappencegahan HIV/AIDS. Penelitian ini merupakan penelitian survei analitik dengan desain potong lintang. Pengambilan sampel dengan stratified random sam-pling dan didapatkan 128 responden kelas XI SMA Muhammadiyah 3 Yogyakarta tahun 2017. Pengambilan data menggunakan kuesioner yang telah diuji va-liditas dan reliabilitas. Data dianalisis dengan uji kai kuadrat dan regresi logistik. Hasil menunjukkan sebagian besar responden menerima informasi mengenaiHIV/AIDS dari media (47,7%) tingkat pengetahuan dalam kategori baik (82%) dan sikap responden yang mendukung pencegahan HIV/AIDS (96,9%). Sumberinformasi dan tingkat pengetahuan memiliki hubungan yang signifikan secara statistik dengan sikap remaja terhadap pencegahan HIV/AIDS. Tingkat penge-tahuan merupakan faktor yang paling berpengaruh terhadap sikap remaja terhadap pencegahan HIV/AIDS dengan nilai p = 0,006, PR = 1,199; CI 95%=1,052-1,367.Kata kunci: Remaja, sikap, pencegahan HIV/AIDS, pengetahuan

66


IntroductionThe Joint United Nations Programme on Human

Immunodeficiency Virus (HIV) and AcquiredImmunodeficiency Syndrome (AIDS; UNAIDS) said thatthe world is committed to end AIDS epidemic by 2030.To achieve this target, the transmission prevention ef-forts should be strengthened. According to UNAIDS, anestimated 36.7 million people are living with HIV by theend of 2015.1

According to the United Nations Children's Fund(UNICEF), adolescents are dying of AIDS at an alarmingrate. Globally, AIDS is the second leading cause of deathin adolescents aged 10–19 years. The rate of AIDS mor-tality in adolescents aged 15–19 years has more than dou-bled since 2000, with an average of 29 new infectionsevery hour.2

The Directorate General of Disease Control andEnvironmental Health of the Ministry of Health statedthat in Indonesia, there are 17,784 HIV and 3,267 AIDScases reported by mid-2016. The age group of 25–49years has been dominant, with 12,357 cases of HIV in-fection until June 2016. Also, the number of AIDS casesin school children or students is 61.3

According to the Quarter I report of the AIDSCommission of the Special Region of Yogyakarta in2016, Yogyakarta ranks the first in the region with 759cases of HIV/AIDS. Based on the report, the productiveage group of 20–29 years has the highest percentage at30.98%. On the other hand, new infections are foundevery year in the age group of 15–19 years from 2012 toMarch 2016.4

Adolescence is a period of instability. At this time,adolescents are looking for an identity and likely con-verging to a peer group or peers, so there is an enormousenvironmental influence to their attitudes and perspec-tives on something during this time.5

Yogyakarta City has the highest percentage ofHIV/AIDS cases, among other cities and districts in theprovince, in the age group of 15–19 years at 0.15%.Muhammadiyah 3 Yogyakarta Senior High School is oneof the high schools in the city that holds annual activitiesin cooperation with the Indonesian Planned ParenthoodAssociation of the Special Region of Yogyakarta to im-plement reproductive health education includingHIV/AIDS for the students.

Therefore, this study aimed to determine the influen-tial factors to the attitude of adolescents towardHIV/AIDS prevention. The results of this study are ex-pected to elevate the knowledge of the factors that influ-ence adolescents' attitude toward HIV/AIDS prevention.

MethodThis study used analytic survey research with a cross-

sectional design. The independent variables were sex,

residence, subject major, the source of information, andknowledge level. The dependent variable was the attitudetoward HIV/AIDS prevention. This study was conductedon April 2017 at Muhammadiyah 3 Yogyakarta SeniorHigh School.

The study populations comprised 259 students ofclass XI at Muhammadiyah 3 Yogyakarta Senior HighSchool consisting of four natural science classes andthree social science classes. The minimum sample sizerequired was 119 and was obtained using a stratified ran-dom sampling technique. In this study, 128 respondentscame from two natural science classes and two social sci-ence classes.

ResultsThe study was conducted at Muhammadiyah 3

Yogyakarta Senior High School on April 2017 with a to-tal sample of 128 respondents. Table 1 shows that mostof the respondents are women (52.3%), living in an ur-ban area (96.9%), majoring in natural science (53.1%),and receiving information on HIV/AIDS from non-media(52.3%). The knowledge level of most respondents iscategorized as good at 82.1%, and 96.9% has shown tohave a supportive attitude toward HIV/AIDS prevention.

In this study, there were many factors that theoreti-cally formed attitudes, but not all of them shaped the at-titudes of adolescents toward the prevention ofHIV/AIDS. In Table 2, several variables are not relatedto the attitude of adolescents, including sex with morenumber of female respondents at 98.5%, and not statis-tically related with the attitude toward HIV/AIDS pre-vention (p value = 0.347). Majority of the respondentswere living in an urban area (96.8%), which was not sta-tistically associated with adolescents' attitude towardHIV/AIDS prevention (p value = 1.000). Another vari-able not statistically related was natural science major (pvalue = 1.000).

The results of the multivariate analysis in Table 3 in-dicated that knowledge level was the most influential

Table 1. Univariate Analysis

Variable Characteristic Frequency %

Sex Male 61 47.7 Female 67 52.3Residence Urban 124 96.9 Rural 4 3.1 Major Natural sciences 68 53.1 Social sciences 60 46.9Source of information Media 61 47.7 Non-media 67 52.3 Knowledge level Good 105 82.1 Adequate 19 14.8 Poor 4 3.1Attitude Support 124 96.9 Not support 4 3.1

Tiranda et al, Adolescents' Attitude toward HIV/AIDS Prevention

67

variable to the attitude toward HIV/AIDS prevention (pvalue = 0.006; PR = 1.199). This means that adolescentswith knowledge in good and adequate levels or are rea-sonably likely to support attitudes toward HIV/AIDSprevention were 1.199 times higher than the adolescentswith a poor knowledge level.

DiscussionThis study focused on the influential factors to ado-

lescents' attitude toward HIV/AIDS prevention.According to the Theory of Planned Behavior by Ajzen,6there are several factors that could affect the confidenceof how one behaves toward something. This study tookdemographic or social factors including sex, residencearea, the education major, information sources, andknowledge level in consideration. The results showedthat most respondents (96.9%) were supportive towardthe prevention of HIV/AIDS.

A study by Sohn and Park,7 on high school studentsin Seoul, South Korea, revealed that more girls (53.3%)were using condoms as prevention of HIV/AIDS thanboys (35.3%). Another study by Majelantle et al,8 foundno significant relation of sex, age, and residence areawith knowledge of HIV/AIDS prevention among adoles-cents in Botswana. A study by Rahnama,9 on public uni-versity students in Malaysia mentioned that there is norelation of age, sex, education level, maternal status, andresidence place with the attitude toward HIV/AIDS.

This study is also in line with the study byRahmawan,10 that stated that no statistically significantdifference was found on the grade level between naturalscience and social science classes about their interest inhealth education (p value = 0.214). The characteristicsof the natural science students differ with that of the so-cial science students on their way of thinking. The naturalscience students have a scientific way of thinking, andthey have reasoning patterns based on certain targets,which deve loped from a regular and careful habit of sci-entific thinking based on mathematical logic and statis-tics. On the other hand, the way of thinking of the socialscience class students is more natural, and their reasoningpattern is based on daily habits from the social influenceof their surrounding.10 This is in line with the results ofthis study showing that the natural science student's atti-tude to support HIV/AIDS prevention has a greater per-centage than the social science students.

This study is not in line with the study conducted byRina et al,11 that revealed that there is no relation be-tween exposure to information on premarital sex andadolescents' attitude toward premarital sex (p value =1.000).

Uddin et al,12 mentioned that for adolescents inBangladesh, media have an important role in spreadinghealth information. Overall, the study indicated that halfof the adolescents have a sufficient knowledge level andmost of them have a neutral attitude toward HIV/AIDS.

Table 2. Bivariate Analysis

Attitude Variable Category Support Not support Total p Value F % F % F % Sex Male 58 95.1 3 4.9 61 100 0.347 Female 66 98.5 1 1.5 67 100 Residence Urban 120 96.8 4 3.2 124 100 1.000 Rural 4 100 0 0 4 100 Major Natural Sciences 66 97.1 2 2.9 68 100 1.000 Social Sciences 58 96.7 2 3.3 60 100 Source of information Media 57 93.4 4 6.6 61 100 0.049 Non-media 67 100 0 0 67 100 Knowledge level Good 105 100 0 0 105 100 0.000 Adequate 17 89.5 2 10.5 19 100 Poor 2 50 2 50 4 100

Table 3. Multivariate Analysis 95% CI for Exp (B)Variable B SE Wald df p Value Exp (B) Lower Upper

Knowledge level 0.18 0.07 7.42 1 0.006 1.20 1.05 1.37

Notes:SE, Standard Error; df=degree of freedom; Sig=significance level; CI=confidence interval.

68

The respondents were predominantly at a good andadequate level of knowledge with a supportive attitudetoward HIV/AIDS prevention. This is consistent with thestatement by Handayani,13 that knowledge will supportgood adolescents' attitude on HIV/AIDS. Rasumawatistated that knowledge and behavior on the prevention ofHIV/AIDS have a positive relation.

A further study by Thanavah,14 found that high schoolstudents with sufficient and high knowledge ofHIV/AIDS have a positive attitude to people living withHIV/AIDS (odds ratio = 4.3; 95% confidence interval[CI] = 2.1–9.0; p value < 0.001).14 The results of themultivariate analysis in this study indicated that know -ledge level is the most influential variable to adolescents'attitude toward HIV/AIDS prevention (p value = 0.006;PR = 1.199; 95% CI = 1.052–1.367). This means thatthe adolescents with a high or adequate level of knowl-edge were likely to have a supportive attitude towardHIV/AIDS prevention by 1.199 times greater than theadolescents with a low level of knowledge.

According to the study by Nubed and Akoachere,15 inCameroon, although it is not statistically significant,knowledge raises the willingness of respondents to be-have in safe sex. In addition, respondents with adequateand high levels of knowledge would have more positiveattitudes toward HIV/AIDS.

Christiane et al,16 in a study on adolescents inLibreville, stated that the right knowledge of HIV willsupport young people in making decisions for their be-havior in preventing the transmission HIV. A study byGhojavand et al,17 on adolescents in Isfahan City, Iran,stated that there is a direct relation between adolescents'knowledge of HIV/AIDS and supportive attitude towardHIV/AIDS prevention. Adolescents' knowledge is impor-tant, and the attention of the government and school pro-grams are also necessary.

Verma et al,18 said that the source of knowledge ofHIV/AIDS among adolescents was mostly from electro -nic media and then followed by printed media. Most ofthe adolescents also agreed to the introduction ofHIV/AIDS as a topic in the curriculum. Education pro-grams on HIV/AIDS should be held in the classrooms,and teachers should be trained to educate students aboutthe infection and the ways to prevent HIV/AIDS effec-tively. A study by Etrawati et al,19 also stated that repro-ductive health education for high school students is need-ed to increase their knowledge of reproductive health anddecrease risky sexual behaviors.

ConclusionThe level of students' knowledge of HIV/AIDS is

mostly good, and the students' attitudes largely supportthe prevention of HIV/AIDS. There is no statistically sig-nificant relation of sex, residence area, and education ma-

jors with adolescents' attitude toward HIV/AIDS preven-tion. Sources of information and knowledge level are sta-tistically related to adolescents' attitude towardHIV/AIDS prevention. The knowledge level is the mostinfluential factor to the adolescents' attitude towardHIV/AIDS prevention.

RecommendationSchools that already have health education programs

are expected to maintain and improve existing activities,as well as form a discussion forum, so that informationof HIV/AIDS will be more easily accepted by students.Furthermore, researchers should not only examine atti-tudes that cannot be observed directly, but also investi-gate one's own behavior in preventing HIV/AIDS. In ad-dition, the media can be used as a study instrument.

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AbstractCervical cancer is one of the cancer types that become a haunting danger for many women in the world. In Indonesia, the prevalence rate reached 0.8% oran estimated 98,692 patients. Its prevalence increased to 10% in the commercial sex worker group. This study aimed to explain the effect of health promotionon knowledge and intention for early detection of cervical cancer using the inspection of visual acetate method in the commercial sex workers. This study wasquantitative with a quasi-experimental type, one group of pretest and posttest design. The population sample included the commercial sex workers at GentengSubvillage, Patimban Village, Pusakanegara Subdistrict, Subang District and was determined by using an accidental sampling technique with 35 respondents.Data analysis used McNemar's test. The results showed that there was an increase in knowledge after the health promotion activity and a significant changein intention to perform early detection of cervical cancer. From the statistical test, a p value of 0.000 was obtained for each variable. In conclusion, health pro-motion has a significant effect on the improvement in the knowledge and intention of the respondents. Keywords: Cervical cancer, health promotion, inspection of visual acetate

AbstrakSalah satu jenis kanker yang menjadi hal yang menakutkan bagi perempuan di dunia adalah kanker serviks. Di Indonesia, jumlahnya mencapai 0,8% ataudiperkirakan sebanyak 98.692 penderita. Prevalensinya meningkat sampai 10% pada kelompok pekerja seks komersial (PSK). Penelitian ini bertujuan men-jelaskan pengaruh promosi kesehatan terhadap pengetahuan dan niat untuk melakukan deteksi dini kanker serviks dengan metode inspeksi visual asetat(IVA) pada PSK. Penelitian ini merupakan penelitian kuantitatif dengan jenis kuasi eksperimen dengan rancangan one group pretest and posttest design.Sampel populasinya PSK di Dusun Genteng, Desa Patimban, Kecamatan Pusakanegara, Kabupaten Subang ditentukan dengan menggunakan teknik acci-dental sampling dengan sampel sebanyak 35 responden. Analisis data menggunakan uji Mc Nemar. Hasil menunjukkan bahwa terdapat peningkatan penge-tahuan setelah kegiatan promosi kesehatan serta perubahan niat untuk melakukan deteksi dini kanker serviks yang signifikan. Dari uji statistik, didapatkannilai p 0,000 untuk masing-masing variabel. Dapat disimpulkan bahwa promosi kesehatan berpengaruh signifikan terhadap peningkatan pengetahuan danniat responden.Kata kunci: Kanker serviks, promosi kesehatan, inspeksi visual asetat

Health Promotion toward Knowledge and Intention forEarly Detection of Cervical Cancer in Commercial SexWorkers

Promosi Kesehatan terhadap Pengetahuan dan Niat untuk Deteksi DiniKanker Serviks pada Pekerja Seks Komersial

Desi Rusmiati*, Tiurlan Yunetty Silitonga**, Warendi*

Correspondence: Desi Rusmiati, Public Health Studies Program, Mitra RIAHusada School of Health Sciences, Karya Bhakti Street No. 3 Cibubur,Indonesia, Phone:-, e-mail: [email protected]: December 06th 2017Revised: January 26th 2018Accepted: April 17th 2018

*Undergraduate Public Health Studies Program, Mitra RIA Husada School of Health Sciences, Jakarta,Indonesia, **Diploma III in Midwifery Mitra RIA Husada School of Health Sciences, Jakarta, Indonesia

Rusmiati et al. Kesmas: National Public Health Journal. 2018; 13 (2): 70-74DOI:10.21109/kesmas.v13i2.1919


How to Cite: Rusmiati D, Silitonga TY, Warendi. Effect of health promotionon knowledge and intention for early detection of cervical cancer in com-mercial sex workers. Kesmas: National Public Health Journal. 2018; 13 (2):70-74 (doi:10.21109/kesmas.v13i2.1919)

Rusmiati et al, Health Promotion toward Knowledge and Intention for Early Detection of Cervical Cancer in Commercial Sex Workers

71

IntroductionCervical cancer is considered the fifth most common

cancer in women worldwide.1 According to the GLOBO-CAN data from the International Agency for Researchon Cancer, in 2012, there were 14.1 million new cancercases and 8.2 million cancer deaths worldwide. Cervicalcancer is a frightening specter for women in the world.2Similarly in Indonesia, an estimated 40,000 cases of cer-vical cancer are found every year. According to patholo-gy-based cancer data in 13 laboratory pathology centers,cervical cancer is a cancer type that has the largest num-ber of patients in Indonesia at approximately 36%.1

All women are at risk to develop cervical cancer, butsome evidence suggests a strong relation between a sex-ual relationship and the risk of cervical cancer. For in-stance, women who engaged in a sexual relationship atan early age (<18 years) and women with many sexualpartners have a higher risk of cervical cancer.1

Commercial sex workers are a group susceptible to cer-vical cancer because they usually have many sexual part-ners, increasing their risk to as much as 10–14.2 times.3

In general, cervical cancer patients who come to seektreatment are already at the final stage, and then it is of-ten too late to do the treatment, although determiningthe presence and absence of cervical cells can be donethrough early detection. One of the ways is the inspectionof visual acetate (IVA) method, which is fairly cheap andeasy to do and is very effective in detecting the presenceof cervical cancer. A study showed that IVA has a sensi-tivity of 90.9%, specificity of 99.8%, positive predictivevalue of 83.3%, and negative estimation value of 99.9%compared with cytology. This suggests that the IVA ex-amination has a similar ability to cytologic examinationin detecting cervical pre-cancer lesions.4

A limited access to accurate information is believedto be one of the causes of high cervical cancer cases inIndonesia. Another cause is due to less awareness to per-form early detection. That is why most of the cases arefound at the final stage and can cause death.

In West Java, there are about 8,000 cases of cervicalcancer each year, in which the highest number of patientscomes from the northern coast (pantura).5 This can beunderstood because pantura is a popular place that prac-tices prostitution. From the preliminary study conducted,one of the known prostitution areas is Genteng,Patimban Village, Pusakanegara Subdistrict, SubangDistrict. Therefore, the study was conduct in the regionand intervention was applied through a health promotionactivity expectedly to improve the knowledge and inten-tion of the commercial sex workers to perform early de-tection of cervical cancer with the IVA method.

The aim of the study was to explain the effect ofhealth promotion on increasing the knowledge and in-tention to perform early detection using the IVA method

in commercial sex workers.

MethodThis study was a quasi-experimental study type with

an analytical descriptive of one group pretest and posttestdesign. The measurement was done before and after theintervention. Knowledge and intention to do early detec-tion were measured using questionnaires. The interven-tion used for this study was a health promotion activitythrough a lecture, video playback, booklet, and poster.The population sample included 35 commercial sexworkers at Genteng Subvillage, Patimban Village,Pusakanegara Subdistrict, Subang District that werecounted using a formula of two means. Data were col-lected using questionnaires, and univariate analysis wasdone to determine the knowledge and intention of thecommercial sex workers on early detection of cervicalcancer using the IVA method, both before and after thepromotion efforts. Bivariate analysis was initially plannedusing the t-dependent test, but the data collected werenot normally distributed to explain the effect of the pro-motion effort to increase the knowledge, attitude, andintention of the commercial sex workers on early detec-tion of cervical cancer using the IVA method. This studyused the McNemar test instead.

ResultsTable 1 shows that prior to a health promotion activ-

ity, most respondents had poor knowledge of cervicalcancer detection using the IVA method (82.9%) andmore than half had no intention to perform cervical can-cer detection using the IVA method (54.3%). Table 2shows that after a health promotion activity, most re-spondents had good knowledge of cervical cancer detec-tion using the IVA method (68.6%), and almost all re-spondents had an intention to perform early detection ofcervical cancer using the IVA method.

In Table 3, there is a significant change in the knowl-edge of respondents by 63%, from 6% before to 69%after the health promotion activity. Based on the resultsof the statistical test, a p-value of 0.000 was obtained,which means that the health promotion activity imple-mented had a significant effect on knowledge. Table 4shows a significant change in the intention of respon-dents by 48%. Before the efforts of health promotionwere made, only 46% of the respondents intended totake early detection of cervical cancer through the IVAmethod, but the rate increased to 94% after the healthpromotion activity. From the results of the statistical test,a p value of 0.000 was obtained, which means that thehealth promotion activity conducted had a significant ef-fect on the intention.

In Table 5, the results of the multivariate analysis in-dicated two variables affecting intention on early detec-

72

tion of cervical cancer using the IVA method, namely, at-titude (p value = 0.009) and education level (p value =0.046). The dominant variable was the attitude with anOR value = 10.9 after being controlled by a variable ofeducation le vel.

DiscussionThe results of the study showed that most respon-

dents had poor knowledge of cervical cancer before thehealth promotion activity, which is caused by many fac-tors, such as limited access to health information. This is

evident on the respondents’ answer when asked if theyhave ever heard of cervical cancer. Almost all of the res -pondents had a negative response. The respondents alsosaid there were no healthcare providers who visit, social-ize, and provide counseling on cervical cancer.

The low education level of the respondents, most ofthem were elementary school graduates, affected the lowintention in reading concerning health issues. This alsohas an impact on their low knowledge level. A study men-tioned that formal education relates significantly to one'slevel of knowledge.6-8 Similarly, in theory, it can be ex-plained that knowledge is the result of human sensing orof knowing something is done by someone to the objectthrough the senses he or she has, among them are theeyes and ears. Influential factors to knowledge includeeducation, information media, socio-cultural and eco-nomic backgrounds, environment, experience, and age.9

After performing health promotion including a lec-ture, video playback, and leaflet and poster distribution,the analysis results in this study showed that the level of


Table 1. Frequency Distribution of Knowledge and Intention Before the Intervention

Variable Category Number (n) Percentage (%)

Knowledge of cervical cancer and early detection of cervical cancer using the IVA method Poor 29 82.9 Good 6 17.1Intention in early detection of cervical cancer using the IVA method No intention 19 54.3 With intention 16 45.7

Table 3. Influence of Health Promotion on Knowledge

Knowledge After Health Promotion Variable Category Total p Value Poor Good

Knowledge before health promotion Poor 11 18 29 (83%) 0.000 Good 0 6 6 (17%) Total 11 (31%) 24 (69%) 35 (100%)

Table 2. Frequency Distribution of Knowledge and Intention After the Intervention

Variable Category Number (n) Percentage (%)

Knowledge of cervical cancer and early detection of cervical cancer using the IVA method Poor 11 31.4 Good 24 68.6Intention in early detection of cervical cancer using the IVA method No intention 2 5.7 With intention 33 94.3

Table 4. Effect of Health Promotion on Intention

Intention After Health Promotion Variable Category Total p Value No Intention With Intention

Intention before health promotion No Intention 2 17 19 (54%) 0.000 With Intention 0 16 16(46%) Total 35 (100%) 2 (6%) 33 (94%)

Table 5. The Results of Multivariate Analysis

95% CI for Exp (B)Variable B Wald p Value OR Lower Upper

Attitude 2.4 6.8 0.009 10.9 1.80 66.5Level of education 1.9 3.9 0.046 6.5 1.03 41.3

Notes:OR = Odds Ratio, CI = Confidence Interval

73

knowledge of the respondents improved. The number ofrespondents with poor knowledge decreased from 29 to11 after the health promotion. Meanwhile, the numberof respondents with good knowledge increased from 6 to24 after the health promotion. The statistical test also in-dicated that the health promotion activity had a signifi-cant impact on improving the respondents’ knowledgeof cervical cancer and early detection using the IVAmethod.

Better knowledge is gained through the sense of sight(eyes) as well as through direct and other people's expe-riences.9 Thus, it can be understood that the health pro-motion activity, both as individuals and as groups, in-cludes various ways such as counseling, demonstrating,and providing printed media, which allow for the transferof knowledge that can impact people to increase orchange their knowledge level toward the better.Therefore, health promotion activity is very effective inproviding and improving the knowledge of health.10-11

Thus, one of the ways to prevent cervical cancer is to el-evate the knowledge of reproductive health, especiallyon cervical cancer and its detection method, which canbe done through health promotion activities.12

Most respondents did not have the intention to takeearly detection of cervical cancer using the IVA method,but after the health promotion activity, almost all ex-pressed their intention. The number of respondents withno intention to do early detection of cervical cancer de-creased from 19 to 2 after the health promotion. On theother hand, the number of respondents with the intentionto do so increased from 16 to 33 after the health promo-tion. The statistical test showed a significant effect of thehealth promotion activity on the respondents’ intention.The results of this study indicated the existence of con-formity with some previous studies.13-14

Health promotion activities aimed at predisposingfactors are in the form of providing information due tolack of knowledge, information, description, and aware-ness-raising notification. The purpose of this health pro-motion activity can provide or increase someone’s know -ledge, in this case, it is the knowledge of cervical cancerand early detection efforts through the IVA method.Knowledge is a very important domain for the formationof someone’s actions.9

After the health promotion activity, almost all of therespondents had the intention to take early detection ofcervical cancer with the IVA method. The change in in-tention was affected by the improvement of the respon-dents’ knowledge after the health promotion activity.15

The improved knowledge will raise the respondents’awareness of the importance of early detection of cervicalcancer. Furthermore, they belong to the group who areat risk of cervical cancer. Other than affecting the inten-tion, good knowledge will also affect the respondents’

behavior to do early detection of cervical cancer.16 Thismeans that the respondents’ awareness grows because ofthe improvement in knowledge, and this will also growtheir intention to take early detection of cervical cancerin the end. Good knowledge will shape a good attitude,and a good attitude will grow intention to do good things.

The IVA is a cheap, easy to do, and very effectivemethod to detect the presence of cervical cancer.4However, so far, the coverage of IVA is still low at5.15%.17 Several factors influence a person to do earlydetection of cervical cancer, but the awareness is themost important, especially among the commercial sexworker group who are highly susceptible. Therefore, it isimportant for the government and especially healthworkers to raise awareness of early detection of cervicalcancer to high-risk communities such as commercial sexworkers. From the results of this study, after the healthpromotion, the knowledge of the commercial sex work-ers improved and then the intention followed. Therefore,increasing the knowledge of the commercial sex workersfirst will improve their scope of the IVA. Once they havean intention to do early detection of cervical cancer, itshould be followed up by local health workers using theIVA. It is also much better if it is performed in the local-ization of the commercial sex workers as they tend to beafraid to go to healthcare facilities.

ConclusionBefore the health promotion activity, 8 out of the 10

respondents have less knowledge, and almost all ex-pressed no intention to perform early detection of cervic -al cancer using the IVA method. However, after thehealth promotion activity, more than half of the respon-dents show better knowledge, and almost all expresstheir intention to do early detection of cervical cancerusing the IVA method. Increasing the commercial sexworkers' knowledge and intention first will improve theirscope of early detection of cervical cancer using the IVAmethod.

RecommendationTo increase the knowledge that has an impact on the

change in intention, a health promotion activity can bedone at a time. But to change the attitude, the health pro-motion activity needs to be performed repeatedly. It re-quires a repeated and sustainable health promotion ac-tivity.

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Correspondence: Mohammad Zen Rahfiludin, Faculty of Public HealthDiponegoro University, Prof. Sudharto Street, Semarang, Indonesia, Phone:+6224-7460044, E-mail: [email protected]: September 11th 2017Revised: November 29th 2017Accepted: January 04th 2018


Rahfiludin et al. Kesmas: National Public Health Journal. 2018; 13 (2): 75-80DOI:10.21109/kesmas.v13i2.1719

Risk Factors Associated with Low Birth Weight

Faktor-faktor Risiko Bayi dengan Berat Badan Lahir Rendah

Mohammad Zen Rahfiludin*, Yudhy Dharmawan**

*Public Health Nutrition Department, Faculty of Public Health Diponegoro University, Semarang, Indonesia,**Biostatistics & Population Studies Department, Faculty of Public Health, Diponegoro University, Semarang,Indonesia

How to Cite: Rahfiludin MZ, Dharmawan Y. Risk factors associated withlow birth weight. Kesmas: National Public Health Journal. 2018; 13(2): 75-80 (doi:10.21109/kesmas. v13i2.1719)

AbstractNeonatal deaths are associated with preterm birth complications. The aim of this study was to analyze risk factors associated with LBW. This was a cross-sectional study held in Bulu Primary Health Care, Temanggung, Central Java, Indonesia. The sample size required for this study was 69 based on the Slovinformula. Data were collected using questionnaires and semi-quantitative Food Frequency Questionnaire forms. Data on infant birth weight was taken frommidwives’ delivery cohort records. Mid upper arm circumference (MUAC), hemoglobin level, blood pressure, maternal age, parity, nutritional intake, andserum transferrin receptor data were taken from the infant’s mother using a MUAC tape, automatic blood pressure monitor and blood laboratory analysis byProdia. Data analysis procedures were carried out with quantitative methods. Descriptive statistics were analyzed as means and standard deviations.Inferential statistics used the chi-square test for bivariate analysis and binary logistic regression for multivariate analysis. The results of this study showed thatmean infant birth weight was 2917.68 ± 374.673 kg. Inferential analysis showed that MUAC and pregnancy at a risky age were significant risk factors asso-ciated with LBW, while serum transferrin receptor levels, anemia, parity, energy and protein consumption levels, and systolic and diastolic blood pressurewere nonsignificant risk factors. The probability of LBW in pregnant women with LILA under 23.5 cm and pregnancy at a risky age was 68.9%.Keywords: Low birth weight, risk factors, Central Java

AbstrakKematian neonatal terkait dengan komplikasi kelahiran prematur. Penelitian ini bertujuan menganalisis faktor risiko bayi dengan berat badan lahir rendah(BBLR). Penelitian ini merupakan penelitian potong lintang dan dilakukan di Puskesmas Bulu, Temanggung, Jawa Tengah, Indonesia. Sampel penelitian ber-jumlah 69 sampel berdasarkan rumus perhitungan sampel Slovin. Data dikumpulkan dengan menggunakan kuesioner dan formulir semi kuantitatif FoodFrequency Questionnaire. Data berat lahir bayi diambil dari rekaman kohort persalinan bidan. Lingkar lengan atas (LILA), kadar hemoglobin, tekanan darah,usia ibu, paritas, asupan gizi dan data reseptor transferrin serum diambil dari ibu bayi menggunakan pita LILA, Monitor Tekanan Darah Otomatis dan analisislaboratorium darah oleh Prodia. Prosedur analisis data dilakukan dengan metode kuantitatif. Statistik deskriptif dianalisis dengan mean dan standar deviasi.Statistik inferensial menggunakan uji kai kuadrat untuk analisis bivariat dan regresi logistik biner untuk analisis multivariat. Hasil penelitian menunjukkanbahwa berat lahir bayi rata-rata 2917,68 ± 374.673 kg. Analisis inferensial menunjukkan LILA dan usia kehamilan berisiko secara signifikan sebagai faktor ri-siko yang menyebabkan BBLR, sedangkan reseptor serum transferin, anemia, paritas, tingkat konsumsi energi dan protein, tekanan darah sistolik dandiastolik bukanlah faktor risiko yang signifikan. Kemungkinan ibu hamil BBLR dengan LILA di bawah 23,5 cm dan kehamilan pada usia berisiko sebesar 68,9%.Kata kunci: Berat bayi lahir rendah, faktor risiko, Jawa Tengah

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IntroductionChild mortality is a core indicator of child health and

well-being. The proposed Sustainable DevelopmentGoals target for child mortality represents a renewedcommitment to the world’s children under 5 years of allage, with all countries aiming to reduce neonatal morta-lity to 12 deaths per 1000 live births or lower and under-5 mortality to 25 deaths per 1000 live births or lower.The worldwide neonatal mortality rate in 2015 was 19deaths per 1000 live births.1 This number shows that theworldwide neonatal mortality rate is still high. Amongthe top 10 countries that contribute 67% of neonataldeaths in the world, Indonesia contributes 2%.2

Neonatal deaths are caused by intrapartum complica-tions and severe infections, and the leading cause ofdeath in all regions of the world is preterm birth compli-cations.3 Preterm birth is also related to low birth weight(LBW). LBW is defined as a weight at birth of less than2500 gram. Not only is LBW a major predictor of prena-tal mortality and morbidity, but recent studies havefound that low birth weight also increases the risk of non-communicable diseases, such as diabetes and cardiova-scular disease, later in life.4 There are multiple causes ofLBW, including low income, maternal age under 20 yearsor over 35 years, heavy physical work, low maternaleducation, maternal complications (placenta previa,pregnancy-induced hypertension, premature rupture ofmembranes), anemia, malaria, inadequate antenatal care,and maternal nutritional factors.5-6

National Basic Health Research in 2013 showed thatLBW occurs in Indonesia at a rate of 10.2%. In CentralJava, the rate of LBW was 9.7%.7 In Temanggung, spe-cifically in the working area of Bulu Primary Health Care,the incidence of LBW in 2013, 2014, and 2015 was6.94%, 7.09%, and 7.88%, respectively.8

The aim of this study was to analyze risk factors ofLBW, including mid upper arm circumference (MUAC),hemoglobin levels, blood pressure, maternal age, parity,nutritional intake, and serum transferrin receptor levels.There have been many studies on risk factors associatedwith LBW, but only a few studies have examined the re-lation between the serum transferrin receptor and LBW.The transferrin receptor is the best indicator of iron de-ficiency in pregnant woman. The serum level of this re-ceptor can be measured easily by conventional techni-ques and presents a large distinction between iron defici-ency anemia and chronic anemia disease.9

MethodThis was a cross-sectional study held in Bulu Primary

Health Care, Temanggung, Central Java, Indonesia. Thestudy population consisted of 114 pregnant women inthe second and the third trimesters. The required samplesize for this study was 69 samples based on the Slovin

formula.10 A random sampling technique was applied.MUAC, maternal age, serum transferrin receptor, hemo-globin, parity, and systolic and diastolic blood pressuredata were collected using a questionnaire, while energyand protein consumption data were collected using semi-quantitative food frequency questionnaire forms. MUACwas measured using a MUAC Tape accurate to 1 mm.Blood samples were taken for measurement of hemoglo-bin and serum transferrin receptor levels according tostandard protocols in the Prodia Laboratory. Hemoglobinwas measured using cyanmethemoglobin, and serumtransferrin receptor was measured using the QuantikineIV D, human sTfR Immunoassay, R&D systems,Minneapolis, MN, USA.11-12 Anemia is defined as a he-moglobin level of less than 11 gram/dl or a transferrinreceptor level of more than 21 nmol/l. Data on the in-fant’s birth weight was taken from the midwives in BuluPrimary Health Care, by copying the infant's weight re-corded by the midwives in a baby cohort. The data werecollected a week after delivery. Data analysis procedureswere carried out with quantitative methods. Descriptivestatistics were analyzed by mean and standard deviation.Categorical data were analyzed by cross tabulation.Inferential statistics used the chi-square test for bivariateanalysis and binary logistic regression for multivariateanalysis. A significant correlation between independentand dependent variables was shown at p value = 0.05.Ethical clearance was obtained from the Commission ofEthics of Medical and Public Health Research, Faculty ofPublic Health, Diponegoro University (approval no.252/EC/FKM/2016).

ResultsThe mean (SD) birth weight was 2917.68 (374.673)

kg, and the mean age of the pregnant women was 26.71(5.806) years; furthermore, the mean and standard devi-ation of each variable are presented in Table 1. The re-sults of this study, shown in Table 2, indicated that MU-AC and pregnancy at a risky age were significant risk fac-tors causing LBW, while serum transferrin receptor, ane-mia, parity, energy and protein consumption levels, andsystolic and diastolic blood pressure were nonsignificantrisk factors.

Multivariate analysis with multiple logistic regressionshowed a significance of 0.905 for the Hosmer andLemeshow Test, indicating an acceptable goodness of fitto the model tested. A Nagelkerke R Square of 0.328 sho-wed that risky age and MUAC variable models are riskfactors for LBW at 32.8%. The values of B and the expo-nential B, along with their significance, can be seen inTable 3.

The odds ratio for maternal age was 3.7 and that ofMUAC was 15.38 for the incidence of LBW. Based onthe table above, Exp(B) can be used to construct a logistic

Rahfiludin et al, Risk Factors Associated with Low Birth Weight

77

regression equation to determine the probability of oc-currence of LBW if pregnancy occurred at a risky ageand MUAC was <23.5 cm, as follows Equation 1.

Based on this model, if there was a mother with arisky age at pregnancy (<19 or >35 years old) and shehad MUAC less than 23.5 cm, the probability of LBWwas 68.2%.

DiscussionAnemia is the most common nutritional deficiency in

the world. The World Health Organization has estimatedthat the prevalence of anemia is 51% in developingcountries.13 In Southeast Asia, anemia during pregnancyhas a 48.2% prevalence, equal to 18.1 million cases. InIndonesia, the prevalence of anemia during pregnancy is50.9%.14 In this study, anemia in pregnant women wasnonsignificant as a risk factor for having a LBW infant.Anemia in pregnant mothers associated with adverse out-comes may be related to other maternal complications,such as hemoglobinopathy, malnutrition, chronic infec-tion, and inadequate access to prenatal care, and anemiaitself may be a marker of these underlying conditions. Astudy by Xiong, et al.15 also showed that anemia was notstatistically significantly associated with infant LBW.

MUAC is another anthropometric measure used toevaluate adult nutritional status that has been found tobe particularly effective in determining malnutrition inadults in developing countries.16 This study used an MU-AC measure threshold of 23.5 for pregnancy outcome,infant morbidity, and mortality.17 The results showedthat a MUAC of less than 23.5 cm increased the risk ofLBW by a factor of 19. Women with MUAC less than23.5 cm had more LBW infants than those with MUACof 23 cm and more. A study by Assefa,18 also showed astatistically significant association between LBW andMUAC less than 23 cm.

Serum transferrin receptor was a nonsignificant as arisk factor in LBW. Transferrin is the main iron transportprotein found in the blood and plays a role in maintainingcellular iron homeostasis through regulation of cellular

Table 2. Prevalence Risk of Maternal Factors (n = 69)

95% CI Variable PR p Value Lower Upper Anemia 1.333 0.275 6.457 0.72Mid upper arm circumference 19.333* 3.172 117.853 0.0001*Serum transferrin receptor 2.857 0.322 25.350 0.327Maternal age at pregnancy 5.893* 1.806 31.698 0.025*Parity 0.798 0.140 4.545 0.799Level of energy consumption 0.684 0.076 6.323 0.745Systolic blood pressure 0.216 0.025 1.903 0.135Diastolic blood pressure 0.571 0.063 5.153 0.614

Notes: PR = Prevalence Risk, CI = Confidence Interval, Significant < 0.05

Table 1. Infant Birth Weight According to Selected Maternal Factors

Birth Weight Variable Category Mean SD Low Normal Anemia Anemia (<11 gr/dl) 4 (11.4%) 31 (88.6%) 10.90 1.02 Normal ( 11 gr/dl) 3 (8.8%) 31 (91.2%) Mid upper arm circumference Chronic Energy Deficiency (< 23.5 cm) 4 ( 50%) 4 (50%) 26.84 2.98 Normal ( 23.5cm) 3 (4.9%) 58 (54.8%) Serum transferrin receptor Iron Deficiency ( 21 nmol/l) 6 (12.5%) 42 (87.5%) 24.80 7.29 Normal (<21 nmol/l) 1 (4.8%) 20 (95.2%) Maternal age at pregnancy Risky Age (<19 years or >35 years) 3 (30%) 7 (70%) 26.71 5.80 Normal Age (19-35 years) 4 (6.8%) 55 (89.9%) Parity Multipara ( 2 live births) 5 (9.6%) 47 (90.4%) 2.14 0.93 Primipara ( 1 live birth) 2 (11.8%) 15 (88.2%) Level of energy consumption Less (<80%) 1 (7.7%) 12 (92.3%) 96.09 12.66 Normal ( 80%) 6 (10.7%) 50 (89.3%) Level of protein consumption Less (<80%) 2 (7.4%) 25 (92.6%) 90.34 26.77 Normal ( 80%) 5 (11.9%) 37 (88.1%) Systolic blood pressure Prehypertension (>120 mmHg) 1 (3.6%) 27 (96.4%) 114.51 12.66 Normal ( 120 mmHg) 6 (14.6%) 35 (85.4%) Diastolic blood pressure Prehypertension (>80 mmHg) 1 (6.7%) 14 (93.3%) 72.68 10.30 Normal ( 80 mmHg) 6 (11.1%) 48 (88.9%)

Notes:SD = Standard Deviation

Table 3. Variables in the Equation

Variable B S.E. Wald df p Value Exp(B)

Maternal Age at Pregnancy 1.312 1.010 1.687 1 0.194 3.713MUAC 2.732 .955 8.176 1 0.004 15.358Constant -3.212 .662 23.531 1 0.000 0.040

Equation 1. Probability of LBW

78


iron intake. Serum transferrin receptor is largely derivedfrom developing red blood cells. Assessment of serumtransferrin receptor levels has been used to distinguishiron deficiency anemia from anemia of chronic diseasebecause the receptors are generally unaffected by con-current infection or inflammation.19 The results of thepresent study showed that the serum transferrin receptorwas not significant as risk factor in LBW. Although manystudies found an association between iron deficiency andpregnancy outcomes.20–22 A previous study byKhambalia et al,23 did not detect a significant associationbetween iron deficiency and preterm birth. the inconsi-stencies may have been caused by study population dif-ferences and confounders.

Maternal age affects fertility. Fertility starts to decre-ase at the age of 20 years and decreases rapidly after theage of 35 years. Getting pregnant at a young age is also arisk factor, as the endometrium has not yet matured,whereas the endometrium is less fertile after the age of35 years. This will increase the likelihood of having con-genital syndrome and affecting maternal and child healthduring pregnancy.24 A previous study indicated that mo -thers at the younger and older ends of the childbearingage range are at increased risk for LBW. This study sho-wed that maternal age increase the risk of LBW by a fac-tor of 5. A study by Fraser,25 found that adolescent mot-hers aged 13 to 17 years had a significantly higher risk (pvalue < 0.001) than mothers aged 20 to 24 years of deli-vering an infant with LBW (relative risk, 1.7; 95% CI,1.5 to 2.0). Kartasurya,26 also found that pregnancy at arisky age (<20 or >35 years) was also a risk factor asso-ciated with LBW (<20 or >35 years; OR = 1.95 with CI= 1.16–3.36) in Batang District, Central Java Province.

Based on the result, parity was nonsignificant as a riskfactor in LBW. Parity and maternal age have been shownto increase the risk of adverse neonatal outcomes, suchas intrauterine growth restriction, prematurity, and mor-tality.22, 27, 28 Nulliparity may confer risk through com-plications during childbirth, such as obstructed labor,whereas high parity has been linked to an increased riskof hypertension, placenta previa, and uterine rupture.29

A meta-analysis by Shah,30 concludes that multiparity,although it is associated with reduced birth weight, isnot associated with LBW or preterm birth, in which mul-tiparity is often confounded by socioeconomic status.Higher complications in terms of birth outcome associa-ted with multiparity are valid for communities with poorsocioeconomic status, low levels of education, and ina-dequate access to health care.

In this study, energy consumption was found to benonsignificant as a risk factor in LBW. It should be thatdeficient energy consumption or weight during pregnan-cy can cause impaired fetal growth and increase the riskof LBW in newborns.31 Furthermore, LBW infants have

serious health problems, such as cerebral palsy, mentalretardation, and even cardiovascular disease, when theybecome adults.32 In study by Karima,33 pre-pregnancyweight, weight gain during pregnancy, maternal age, andbirth order were factors affecting birth weight signifi-cantly, with pre-pregnancy weight as the dominant factor(OR = 6.643, CI: 2.3–18.8). Therefore, it is important topay more attention to undernourished women who areplanning a pregnancy.33 Pre-pregnancy weight and ma-ternal weight gain in the first, second, and third tri-mesters have a moderate power relation and positive pat-tern.34

Protein is important for fetal development becauseone of its roles is to form fetal cells and tissues. Proteinconsumption is increased during pregnancy to preventprotein deficiency and malnutrition.35 In this study, thelevel of protein consumption was nonsignificant as riskfactor in LBW. Even though a previous study byRamakrishnan,36 stated that poor nutrition is one of fac-tors associated with LBW babies, this inconsistency maybe due to the limitation of sample size in this study (n =69) with only seven infants with LBW.

The maternal cardiovascular system undergoes pro-gressive adaptations throughout pregnancy, includingdecreased vascular resistance, increased blood volume,and other metabolic changes. Systolic blood pressure(SBP) and diastolic blood pressure (DBP) decreased fromthe first to second trimester and then increased up to thepostpartum period.37 The causes of LBW are multifacto-rial, and one such factor is blood pressure. This studyshowed that SBP and DBP were nonsignificant as riskfactors in LBW infants. A study by Walker et al,38 indi-cated an association between blood pressure and infantswith LBW. This inconsistency may be due to the inclu-sion of subjects with pre-hypertension, whose blood pres-sures were not very high (<120 mmHg for SBP and <80mmHg for DBP).

LBW is one of the risk factors for perinatal death.LBW has a PAR value of 14.90. This means that if thefocus of the intervention program is on decreasing theperinatal mortality rate by decreasing the prevalence ofLBW infants, there will be a 15% reduction in the risk ofperinatal death out of all live births in the population.39

Interventions for pregnancy at a risky age and motherswith MUAC less than 23.5 cm are indispensable for re-ducing LBW occurrence, as confirmed in a study byKartasurya.26

ConclusionIt can be concluded that MUAC and age are risk fac-

tors associated with LBW in newborns, with a probabilityof 68.2%. It is suggested that public education on theimportance of nutrition during pregnancy be increasedto increase MUAC and avoid pregnancy under the age of

79

19 years or above the age of 35 years to reduce the inci-dence of infants with LBW.

AcknowledgmentThe authors would like to thank the Directorate of

Research and Community Services and the Ministry ofResearch, Technology and Higher Education of theRepublic of Indonesia, as well as the Research Instituteof Diponegoro University that facilitated and funded thisstudy.

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Correspondence: Elita Halimsetiono, Faculty of Medicine, Surabaya University,Raya Kalirungkut Street Surabaya, Phone: +6231-2981353, E-mail: [email protected] Received: October 31th 2016Revised: January 24th 2018Accepted: August 3th 2018


Halimsetiono et al. Kesmas: National Public Health Journal. 2018; 13 (2): 81-86DOI:10.21109/kesmas.v13i2.1223

AbstractThe coverage of postnatal care program in Surabaya City had declined since 2011–2013 and could not reach the target. This analytic observational studyused a cross-sectional design and was conducted during April–May 2015 to analyze the effect of role stress, personality type, and burnout on midwives’ per-formance towards postnatal care program achievement in Surabaya City. A total sample of 45 midwives was collected from eight primary health care centersin Surabaya City with basic emergency obstetric and neonatal care services. Accidental sampling was used for sample selection. This study indicated thatmost of the midwives were aged 20–30 years and had an diploma level of education in midwifery. Majority of them were married and were predominantly con-tract workers with <5 and 5 to <10 years workers experiences. Most of the midwives did not have role stress and had agreeableness personality type.However, majority of them had mild burnout and showed medium performance level. There was no influence of demographic characteristics, role stress, andpersonality type on burnout, whereas the performance was affected by role stress and personality type. The midwives’ performance was more influenced bypersonality type than by role stress.Keywords: Burnout, performance, personality type, role stress

AbstrakCakupan program pelayanan nifas di Kota Surabaya menurun sejak tahun 2011-2013 dan tidak dapat mencapai target. Penelitian analitik dengan pendekatanobservasional dan desain potong lintang ini dilakukan pada bulan April - Mei 2015 untuk menganalisis pengaruh tekanan peran, tipe kepribadian, dankejenuhan kerja terhadap kinerja bidan dalam pencapaian program pelayanan nifas di kota Surabaya. Total sampel sebanyak 45 bidan diperoleh dari delapanpusat kesehatan masyarakat di Kota Surabaya dengan layanan kebidanan dan neonatal darurat dasar. Accidental sampling digunakan dalam pemilihansampel. Hasil penelitian ini menunjukkan sebagian besar bidan berusia 20–30 tahun dengan pendidikan diploma kebidanan. Mayoritas bidan telah menikahdengan status kepegawaian didominasi oleh tenaga kontrak dan memiliki masa kerja <5 tahun dan 5 sampai 10 tahun. Sebagian besar bidan tidak mengalamitekanan peran dan memiliki tipe kepribadian agreeableness (patuh). Sebagian besar bidan mengalami kejenuhan kerja ringan dan menghasilkan kinerjatingkat menengah. Hasil penelitian ini juga menunjukkan kejenuhan kerja tidak dipengaruhi oleh karakteristik demografis, tekanan peran, dan tipe kepribadian,sedangkan kinerja dipengaruhi oleh tekanan peran dan tipe kepribadian. Kinerja bidan lebih dipengaruhi oleh tipe kepribadian daripada tekanan peran. Kata kunci: Kejenuhan kerja, kinerja, tekanan peran, tipe kepribadian

Role Stress, Personality Type, Burnout, and Performanceof Midwives towards Postnatal Care ProgramAchievement in Surabaya City

Tekanan Peran, Tipe Kepribadian, Kejenuhan Kerja, dan Kinerja Bidandalam Pencapaian Program Pelayanan Nifas di Kota Surabaya

Elita Halimsetiono*, Thinni Nurul Rochmah**, Dewi Retno Suminar***

*Department of Public Health, Faculty of Medicine, Surabaya University, Surabaya, Indonesia, **Department ofHealth Policy and Administration, Faculty of Public Health, Airlangga University, Surabaya, Indonesia,***Department of Educational and Developmental Psychology, Faculty of Psychology, Airlangga University,Surabaya, Indonesia


How to Cite: Halimsetiono E, Rochmah TN, Suminar DR. Role stress, per-sonality types, burnout, and performance of midwives in the achievement ofpostnatal care program in Surabaya. Kesmas: National Public HealthJournal. 2018; 13 (2): 81-86. (doi:10.21109/kesmas.v13i2.1223)

82


IntroductionOne of health problems in Indonesia is high maternal

mortality rate (MMR). Data from Surabaya Health Officecollected during 2011–2013 indicate that MMR was stillquite high in Surabaya City, and the city also had thesecond highest rate of maternal deaths in East Java. Datafrom the Surabaya Mother and Child Health LocalMonitoring collected during 2011–2013 also revealed adecline in the coverage of the postnatal care program,with an average decrease of 2.92% every year and beingunable to reach the target. Average achievement was of92.99% of the target 95%.1 More than half of allmaternal deaths occurred within 24 hours after birth pri-marily due to heavy blood loss. In several countries, atleast one-quarter of all maternal deaths are caused due tohemorrhage; the proportion ranges from <10% to almost60%. Although a woman may survive after sufferingfrom postnatal hemorrhage, she would suffer from severeblood loss (severe anemia) and experience the problems.2To decrease maternal mortality, midwife personnel asone of the health care workers becomes an importanthuman resource because of their ability to provideservices in accordance with established standards. Dueto their numerous roles, midwives may potentially sufferfrom role stress that can result in the emergence ofburnout. Furthermore, their personality type alsodetermine the onset of burnout, which can affect theirperformance in postnatal care.

According to the Ministry of Health Republic ofIndonesia, the midwives’ performance in postnatal careinvolves checking the blood pressure, pulse, respiration,temperature, fundus uteri (uterine involution), lochia andother vaginal discharges, and the breast andrecommending exclusive breastfeeding for 6 months, vi-tamin A supplements 200,000 IU twice, and postnatalfamily planning services.3 Regarding burnout, accordingto Maslach and Pines in Yusuf,4 it is an emotional fatiguesyndrome, characterized by depersonalization anddecreased sense of self-efficacy, experienced byindividuals who work and always keep in touch withothers. Burnout is an important issue in an organizationas it can result in decreased performance. Sopiah,5argued that role stress is a condition where a person hasdifficulties in understanding his/her duties; thus, the roleshe/she played would become too heavy or he/she wouldplay a variety of roles in the organization where he/sheworks. Role stress can decrease the level of individualperformance in an organization. Hence, it can affect thequality of work production, which would not be inaccordance with the expectations of the organizationitself. Lestari,6 emphasized the beneficial effects ofpersonality assessments to both individuals andorganizations, as such assessments could identifyindividuals with motivation and match them with the

right job. When the personality type of an employee issuited to their jobs, it would result in high satisfaction tothe employee. He or she would therefore will be loyaland contribute maximally to the organization.

This study was conducted to analyze the effect of rolestress, personality types, and burnout on the performanceof midwives in the achievement of postnatal care pro-gram in Surabaya.

MethodsThis analytic observational study using cross-sectional

design was conducted during April–May 2015. The studypopulation consisted of 45 midwives from eight primaryhealth cares in Surabaya City having basic emergency ob-stetric and neonatal care services. Accidental samplingwas used for sample selection. The following hypothesistesting formula for proportions was used to determinethe minimum sample size of the midwives.7

The formula was used to calculate the sample size inthis study because this study analyzed the differences orcomparisons between the study groups (the group whoseperformance was affected by burnout and the groupwhose performance was not affected by burnout).

The values of p1 and p2 were obtained based on thestudy by Maharani and Triyoga,8 on the effect of burnoutand performance of nurses on the delivery of nursingcare.

Maharani and Triyoga,8 demonstrated that there weretwo groups of burnout (mild burnout and no burnout).The values of p1 and p2 in the present study were ob-tained from the percentage between the group with goodperformance and mild burnout and the group with mildburnout (p1 = 31/45 × 100% = 69%) and from the per-centage between the group with good performance andno burnout and the group with no burnout (p2 = 8/8 ×100% = 100%).

Data collection was carried out using questionnairefor it’s validity and reliability and also using observationsto check midwives’examination on two or three firstpostnatal visits (KF-1). The observations of midwives’performance were conducted on KF-1 because postnatalmaternal mortality primarily occurred within the first 24hours after delivery. Data processing was done throughdata editing, data scoring, data coding, and data cleaning.Data were analyzed descriptively and analytically to de-termine the influence of independent variables on de-pendent variables simultaneously. The data were then as-sessed using multiple linear regression analysis. In theanalysis of influence, independent variables such aseducation level, marital status, role stress, andpersonality types were converted into dummy variables,and then each dummy variable was compared with thevariable of their reference group.

The role stress variable was assessed through the as-

Halimsetiono et al, Role Stress, Personality Type, Burnout, and Performance of Midwives towards Postnatal Care Program Achievement

83

sessment of its subvariables such as role conflict, role am-biguity, and role overload. Role conflict was assessed us-ing the role conflict scale, which was an eight-item scaleadapted from Rizzo et al.9 Role ambiguity was assessedusing the role ambiguity scale, a six-item scale adaptedfrom Rizzo et al.9 Role overload was assessed using therole overload scale, which was a three-item scale adaptedfrom Beehr et al.10 Respondents indicated their level ofagreement on each statement by applying a four-point re-sponse scale (1 = strongly disagree, 2 = disagree, 3 =agree, and 4 = strongly agree).

The personality type variable was assessed using BigFive Inventory (BFI), a 44-item scale adapted from Johnand Srivastava.11 The indicators of personality typeswere neuroticism (8 items), extraversion (8 items), open-ness to experience (10 items), agreeableness (9 items),and conscientiousness (9 items). Respondents indicatedtheir level of agreement on each statement by applying afour-point response scale (1 = strongly disagree, 2 = dis-agree, 3 = agree, and 4 = strongly agree).

The burnout variable was assessed using MaslachBurnout Inventory, which was a 22-item scale adaptedfrom Maslach and Jackson.12 The indicators of burnoutwere emotional exhaustion (9 items), depersonalization(5 items), and personal accomplishment (8 items).Respondents indicated their level of burnout frequencyon each statement by applying a four-point response scale(0 = never, 1 = rarely, 2 = often, and 3 = always).

The midwives’ postnatal care performance variablewas assessed using a questionnaire with six indicatorsthat were appropriate with the postpartum health careprogram based on the manual book of Surabaya Motherand Child Health Local Monitoring.3 To determine mid-wives’ postnatal care performance, 45 midwives wereobserved while they were performing postnatal care ontwo or three KF-1, and they were then assessed by fillingout a six-indicator questionnaire with a two-point re-sponse scale (0 = if the item of postnatal care was not

performed and 1 = if the item of postnatal care wasperformed).

ResultsMajority of midwives were 20–30 years and primarily

diploma in midwifery. These midwives (86.7%) weremarried, and >50% of them (62.2%) were contractworkers with working experiences <5 years and 5 to <10years. More than half (62.2%) did not have role stress,whereas only 6.7% of them had severe role stress. Mostmajority of them have agreeableness personality type, andonly 8.9% have conscientiousness personality type.Almost all midwives had mild burnout, whereas only6.7% of them did not have this experience. Most of them(55.6%) showed medium-level performance, and the re-maining showed good and bad performance of the samemeasure (22.2%) (Table 1).

As shown in the Table 2, the personality type variable(conscientiousness type with p value = 0.010, b= 0.356)and role stress (severe role stress with p value = 0.014,b = −0.340) had significant effect on midwives’ postnatalcare performance. This implies that midwives with theconscientiousness personality type (accuracy) showed ahigher performance level than midwives with theopenness to experience personality type (openness toexperience) and the agreeableness personality type (deal).This also implies that the greater the role stressexperienced by the midwives, the lower the performancethey produced. Conscientiousness personality type isfound to have a more significant effect on midwives’

Table 1. Frequency Distribution of Midwives’ Postnatal Care Performance

Performance Frequency Percentage

Bad Performance 10 22.2Medium Performance 25 55.6Good Performance 10 22.2

Total 45 100.0

Mean = 3.29 and Standard Deviation = 0.94

Table 2. The Effect of Demographic Characteristics, Role Stress, Personality Type, and Burnout on Midwives’ Postnatal Care Performance

95% Confidence Interval for BVariable (Subvariable) B Beta p Value Lower Bound Upper Bound

Agreeableness 0.201 0.176 Conscientiousness 1.168 0.356 0.010 0.289 2.047Openness to Experience reference group Mild Role Stress 0.067 0.627 Moderate Role Stress 0.012 0.931 Severe Role Stress –1.270 –0.340 0.014 –2.273 –0.267No Role Stress reference group Burnout –0.007 0.956 Age –0.099 0.500 D4 Midwifery 0.112 0.406 Married –0.087 0.523

Notes:p < 0.05 significant, multiple linear regression analysis, B = regression coefficient

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postnatal care performance than severe role stress. Thedemographic characteristics and burnout variables hadno significant influence on midwives’ postnatal careperformance (Table 2).

DiscussionThis study demonstrated a difference in the

performance of midwives who experienced mild,moderate, and severe role stress, indicating that thegreater the role stress experienced by the midwives, thelower the performance they produced. Kahn et al. inAhmad and Taylor,13 introduced the role theory inorganizational behaviour. They stated that anorganization’s environment can affect individual’sexpectation in terms of their role behavior. Theexpectation includes norms or pressure to act in a certainmanner. Individuals receive the messages, interpret, andrespond in a variety of ways. Role stress is divided into:role conflict, role ambiguity, and role overload types.Based on field observations, this role stress is generallydue to conditions in the field, that is, the unmet numberof personnel in primary health cares in accordance withthe required fields, so that midwives carry out their dutiesand responsibilities that do not match with theircompetencies.

Kinicki and Kreitner in Tewal and Tewal,14 statedthat when individuals feel conflicting demands from thesurrounding people, then they are said to experience roleconflict. Role conflict is experienced by individuals wheninternal values, ethics, or their standards collide withother demands. Robbins in Rozikin,15 defined roleconflict as “a situation in which an individual (person) isfaced with the expectations of different roles.” Hence, aconflict arises when individuals in certain roles areconfused by demands or necessity to do somethingdifferent from what they need, or when that is not a partof their work field. According to Fanani et al.,16 role con-flict can cause discomfort in working and may reduce themotivation to work because it has a negative impact onan individual’s behavior, such as the onset of worktension, turnover, and job dissatisfaction that candegrade the overall performance. In this study, roleconflict was also found in almost all the midwives, whichaffected them in performing their duties. The study con-ducted by Agustina,17 Widyastuti, and Sumiati,18

showed that role conflict can affect performance, whereinthe greater the role conflict experienced by theindividuals, the lower the performance they produced.

According to Ahmad and Taylor,13 role ambiguity isa concept that describes the availability of informationrelating to the roles. The role holders must know whetherthese expectations are appropriate and in accordancewith the activities and responsibilities of their positions.In addition, people must understand whether the

activities have been able to fulfill the responsibilities of aposition and how the activities are carried out. Roleambiguity is due to unclear job descriptions, incompleteorders from work leaders, and lack of experience. Tangand Chang,19 stated that a high role ambiguity mayreduce one’s confidence on his/her ability to workeffectively. Midwives who experience role ambiguity tendto be inefficient and unfocused in working, thus causingdeprivation of their performance. Agustina,17 demon-strated that role ambiguity can affect performance,wherein the greater the role ambiguity experienced bythe individuals, the lower the performance theyproduced.

According to Suyanto,20 workload can be calculatedbased on three aspects, physical, mental, and timeutilization. The physical aspect includes workload basedon human physical criteria. The mental aspect is acomputation of workload by considering the mentalaspect (psychological). The time utilization aspectconsiders more in using time to work. The amount ofadditional jobs to be done by midwives can interfere theirjob performance. High task demands in working have thenegative effect of the emergence of burnout amongmidwives, which can lead to a drop in performance andquality of services delivered. This condition has also beenconfirmed by the study by Agustina,17 which found thatrole excess or workload can affect the performance,wherein the higher the role excess or the workloadexperienced by the individuals, the lower theperformance they produced.

The present study showed that midwives with theconscientiousness personality type (accuracy) producedbetter postnatal care performance than midwives withthe agreeableness personality type (deal) and theopenness to experience personality type (openness toexperience). Conscientiousness personality type(accuracy) is one dimension of the big five personalitiesthat are consistently associated with performance andsuccess of work. Individuals with this personality typeare characterized as hard workers, highly self-disciplined,reliable, organized, meticulous and detailed, and likely tobe industrious; thus, it would have an impact onimproving the performance. A person with thispersonality type has a strong motivation to achievesuccess and has a task-oriented behavior.21,22

Individuals with the agreeableness personality type(agreement) may work together in a team and betrustworthy, caring, kind, helpful, unselfish, andforgiving and do not like to quarrel with others. Thestudy by Barrick et al. in Rustiarini,23 showed that thispersonality has a strong effect on a person’s performance.However, the tendency of the individuals with thispersonality type to create a conducive workingenvironment, avoid conflicts with colleagues, and reduce

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the chances of conflict at the workplace can in fact causethese conditions that are not favorable for them as it canreduce the enthusiasm in competing for success andachieving higher performance than the achievements ofother colleagues. Therefore, the creation of theseconditions will indirectly reduce the spirit of work andperformance of the individuals.23

Individuals with the openness to experiencepersonality type are characterized as imaginative,ingenious, loving variety, curious, creative, innovative,free-thinkers, and artistic. McAdams and Pals inRustiarini,23 described that persons with this personalitytype have high intellect and thus possess innovation andingenuity in solving problems. However, the study con-ducted by Rustiarini,23 demonstrated that individualswith this personality type when carrying out the standardtype of assignments, which are less varied and evenperformed on the clients repeatedly for each year, canmake them feel less challenged while carrying out theirassignments. This is because they are not able to use theircreativity and intellect to solve new problems. Inaddition, the less variety as well as the repetitive routineform of any given assignments can make them to getbored quickly, which would then have an impact indeclining the performance they produced.

Midwives with mild burnout produced lower per-formance on postnatal care than midwives with noburnout because mild burnout was often found on mid-wives with moderate and severe role stress. Midwiveswith openness to experience and agreeableness personal-ity types had lower performance than midwives with norole stress and midwives with conscientiousness person-ality type. In this study, it was observed that burnout oc-curred among the midwives only in the early stages,which is entirely possibly due to the limited populationsize of the midwives studied, resulting in limitations toevaluate the midwives who experienced moderate andsevere burnout.

ConclusionMost of the midwives were 20–30 years with

education level is dominated by diploma in midwifery,married, and >50% of them are contract workers withworking experiences of <5 and 5 to <10 years. More thanhalf did not experience role stress, whereas only 6.7% ofthem have severe role stress. Most of the midwives tendto have an agreeableness personality type, whereas asmall proportion tend to have a conscientiousnesspersonality type. Almost all midwives have mild burnout,whereas only 6.7% of them do not experience burnout.Most of them show medium-level performance, whereasthe remaining showed good and bad performance of thesame measure. The performance of midwives is affectedby role stress (severe role stress with p value = 0.014, b

= −0.340) and personality types (conscientiousness typewith p value = 0.010, b= 0.356). The performance ofmidwives is found to be more affected by the conscien -tiousness personality type than by severe role stress.

RecommendationPrimary health cares should recruit new employees

who will fit into the required fields to avoid inadequatehuman resources, which could have an impact onadministering tasks to midwives that do not match withtheir competencies. Midwives who get new tasks that arenot suitable to their competencies should be trained first,so that they can understand better about their duties andresponsibilities in carrying out the new tasks, thus avoid-ing role ambiguity. Primary health cares should conducta personality test on the process of recruitment andselection of midwives and prioritize those midwives whoare hard workers, highly self-disciplined, reliable,organized, meticulous and detailed, and likely to beindustrious (midwives with the tendency of conscien -tiousness personality type). Subsequent researchers whowould conduct studies on the same topic can developmore complex variables that have not been examined inthis study, such as social support, job satisfaction, andorganizational commitment. Further more, a largerpopulation size can be considered.

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Correspondence: Said Devi Elvin, Nursing Department Aceh Health Polytechnicof Ministry of Health, Tgk. Mohd. Daud Beureueh Street No. 110 Lampriet,Banda Aceh, Aceh, Phone: +62651-21252, E-mail: [email protected]: May 8th 2018Revised: September 19th 2018Accepted: October 5th 2018

Elvin et al. Kesmas: National Public Health Journal. 2018; 13 (2): 87-91DOI:10.21109/kesmas.v13i2.2241

How to Cite: Elvin SD, Yusuf M, Hayati W, Alamsyah T. Family perceptionof health role in filariasis countermeasures using the health belief model ap-proach in Aceh Besar District. Kesmas: National Public Health Journal.2018; 13 (2): 87-91. (doi:10.21109/kesmas.v13i2.2241)

AbstractAceh Besar District is a filariasis endemic area. This endemic state is strongly influenced by people’s perception of filariasis countermeasures. This studyaimed to determine relation between family perceptions towards health role in filariasis countermeasures using the Health Belief Model. An analytical surveywas applied with a cross-sectional study approach. The study population was families at three villages that are Lambaro Bileu, Lambaet, and Cot Preh of KutaBaro Primary Health Care. This represents 1,113 families with a sample of 92 families that were selected using a proportionate stratified random sam- plingtechnique. The study instrument was a questionnaire and data were analyzed in a univariate, bivariate, and multivariate. This study showed that the families’perceived susceptibility to filariasis disease and the families’ perception of the benefits from filariasis preventive actions are influenced the health role infilariasis countermeasures (p value = 0.012 and 0.0001). However, the families’ perception of the seriousness of filariasis disease and the families’ perceptionof barriers in filariasis preventive action did not influence the health role in filariasis countermeasures (p value = 0.259 and 0.230). The families’ perceivedbenefits of preventive action were the dominant factor related to the families’ health role in filariasis countermeasures (OR = 12.863; 95% CI = 2.566–93.537) after adjusting with perceived susceptibility to diseases (OR = 8.316; 95% CI = 1.769–26.949). Keywords: Family’s health role, filariasis, Health Belief Model, perception

AbstrakKabupaten Aceh Besar merupakan daerah endemis filariasis di Aceh. Hal ini sangat dipengaruhi oleh persepsi masyarakat tentang penanggulangan filariasisdengan menggunakan Health Believe Model. Penelitian ini bertujuan mengetahui pengaruh persepsi keluarga terhadap tugas kesehatan dalam penanggulanganfilariasis. Desain penelitian yang digunakan adalah survei analitik dengan pendekatan potong lintang. Populasi penelitian adalah keluarga di tiga desa dalamwilayah kerja Puskesmas Kuta Baro, yaitu Lambaro Bileu, Lambaet dan Cot Preh yang berjumlah 1.113 keluarga dengan jumlah sampel 92 keluarga yang dipilihdengan teknik proportionate stratified random sampling. Instrumen penelitian menggunakan kuesioner dan dianalisis dengan statistik univariat, bivariat, dan mul-tivariat. Hasil penelitian menunjukkan bahwa persepsi keluarga tentang kerentanan penyakit filariasis dan persepsi keluarga tentang manfaat tindakan penang-gulangan filariasis memberikan pengaruh terhadap tugas kesehatan (nilai p = 0,012 dan 0,0001). Sedangkan persepsi keluarga tentang keseriusan penyakit fi-lariasis dan persepsi keluarga tentang hambatan tidak memberikan pengaruh terhadap tugas kesehatan dalam penanggulangan filariasis (nilai p= 0,259 dan0,230). Persepsi keluarga tentang manfaat dari tindakan pencegahan merupakan faktor paling dominan yang mempengaruhi tugas kesehatan keluarga (OR =12.863; 95% CI = 2.566–93.537) setelah dikontrol oleh persepsi keluarga terhadap kerentanan penyakit filariasis (OR = 8.316; 95% CI = 1.769–26.949).Kata kunci: Peran kesehatan keluarga, filariasis, Health Belief Model, persepsi

Family Perception Towards Health Role in FilariasisCountermeasures Using the Health Belief ModelApproach in Aceh Besar District

Persepsi Keluarga terhadap Tugas Kesehatan dalam PenanggulanganFilariasis dengan Pendekatan Health Belief Model di Kabupaten AcehBesar

Said Devi Elvin, Mutia Yusuf, Wirda Hayati, Teuku Alamsyah

Nursing Department, Aceh Health Polytechnic of Ministry of Health, Aceh, Indonesia

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IntroductionFilariasis is a parasitic chronic infectious disease

caused by filarial worms. Filariasis is transmitted throughmosquito bites containing filarial worms in its body. Inthe human body, the worm grows into an adult wormand settles in the lymph tissue, causing swelling in thelegs, limbs, breasts, arms, and genital organs.1

The number of filariasis patients in Indonesia is in-creasing every year. In 2016, the provinces of East NusaTenggara (2,864), Aceh (2,732), West Papua (1,244),Papua (1,184), and West Java (955) had the highest casesof chronic filariasis. The Aceh Province ranks the secondin the number of filariasis patients after East NusaTenggara.1

Aceh Besar District is one of the districts in the AcehProvince recorded as a filariasis-endemic district. In2015, they were 49 cases of filariasis in Aceh BesarDistrict. The subdistrict with the highest number of filar-iasis case was Kuta Baro Subdistrict with 17 cases.2

Filariasis elimination program becomes a priority inAceh Besar District and the main agenda is to performMass Drug Distribution activities to break the chain offilariasis transmission in all the filariasis-endemic subdis-tricts. The Aceh Besar District Government through theHealth Office provides filariasis drugs for the people in2016.2 In 2015, only 75% of the population wanted totake filariasis drugs, and in the district, the coverage wasmore than 65%, but this coverage was not evenly dis-tributed, and several subdistricts had low coverage.3

To achieve the elimination of filariasis, people needto understand the dimensions of the problems and influ-ential risk factors associated with filariasis. Therefore,people’s active participation in filariasis countermeasuresis very important.4

Taken together, the main factors in filariasis counter-measures are people’s behavior in protecting themselvesand taking filariasis drugs. The complete eradication offilariasis becomes challenging when people’s behavior to-ward maintaining the environment hygiene is poor andthe level of filariasis drug compliance is low. One of themodels associated with the people’s perception of filari-asis countermeasures is the Health Belief Model (HBM),which was first developed in the 1950s by the social psy-chologists Hochbaum, Rosenstock, and Kegels from theUnited States of America. HBM produces a set of per-ception patterns that give rise to possible behaviors ofcountermeasures.5

According to Hayden,6 the application of HBM in astudy on people’s behavior in filariasis countermeasurescan predict the likelihood of taking the recommendedpreventive health actions based on the results of the as-sessment of the people’s perceived susceptibility to di -seases, perceived seriousness of diseases, perceived ben-efits of preventive action, and perceived barriers to pre-

ventive action.There is a great paucity in regards to research on the

families’ perception of health role in filariasis counter-measures in Aceh Besar District. Therefore, the aim ofthis study was to determine the relation of the families’perception of health role in filariasis countermeasures inthe working areas of Kuta Baro Primary Health Care,Aceh Besar District using the HBM approach.

MethodThis study used an analytical survey with a cross-sec-

tional approach. The study population involved familiesfrom three villages in the working areas of Kuta BaroPrimary Health Care, namely Lambaro Bileu, Lambaet,and Cot Preh. A total of 92 families were selected usinga proportionate stratified random sampling technique.Data collection was conducted from January 22 toFebruary 20, 2018. The independent variable in thisstudy was families’ perception based on HBM construct,which are the perceived susceptibility to diseases, per-ceived seriousness of diseases, perceived benefits ofpreventive actions and perceived barriers to preventiveactions. The dependent variable was the family’s healthrole in filariasis countermeasures in filariasis countermea-sures are people’s behavior in protecting themselves andtaking filariasis drugs. A questionnaire was administered,and its results were analyzed by univariate, bivariate, andmultivariate statistics. The results are presented in tables.The study was reviewed and approved by the EthicsCommittee of the Faculty of Nursing, University of SyiahKuala Banda Aceh (Number 160551622).

ResultsAccording to results as shown in Table 1, the variable

of families’ perceived susceptibility to diseases was pre -sent in 55 families with good health perception, and 48(87.3%) families played a good health role in filariasiscountermeasures. Further, 37 families had poor healthperception, and 14 (37.8%) families had a good healthrole in filariasis countermeasures. The results of the chi-square test indicated that there was a relation betweenthe family’s perceived susceptibility to diseases and thehealth role in filariasis countermeasures (p value =

Table 1. Relation between Families’ Perceived Health and the Health Role in Filariasis Countermeasures

Health Role Variable Category p Value Good Poor

Susceptibility Good 48 (87.3%) 7 (12.7%) 0.000 Poor 14 (37.8%) 23 (62.2%) Seriousness Good 46 (76.7%) 14 (23.35) 0.012 Poor 16 (50.0%) 16 (50.0%) Benefit Good 50 (86.2%) 8 (13.8%) 0.000 Poor 12 (35.3%) 22 (64.7%) Barrier Good 47 (83.9%) 9 (16.1%) 0.000 Poor 15 (41.7%) 21 (58.3%)

Elvin et al, Family Perception Towards Health Role in Filariasis Countermeasures Using the Health Belief Model Approach

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0.000). Results also showed that 60 families had a good per-

ception of the seriousness of the diseases, and 46(76.7%) families played a good health role in filariasiscountermeasures. Further, 32 heads of families had apoorly perceived seriousness of the diseases, and 16(50.0%) families had a good health role in filariasis coun-termeasures. The results of the chi-square test showedthat there was a relationship between the families’ per-ceived seriousness of diseases and the health role in filar-iasis countermeasures (p value = 0.012).

Results revealed that the family’s perceived benefitsof preventive actions had 58 families with good percep-tion, 50 (86.2%) families played a good health role in fi-lariasis countermeasures. Further, 34 families had poorperception, and 22 (64.7%) families played a good healthrole in filariasis countermeasures. Based on the results ofthe chi-square test, there was a relation between the fam-ily’s perceived benefits of preventive actions and thehealth role in filariasis countermeasures (p value =0.001).

The study also shows that 56 families had well-per-ceived barriers to preventive actions, 47 (83.9%) familiesplayed a good health role in filariasis countermeasures.Further, 36 families had poorly perceived barriers to pre-ventive actions, 21 (58.3%) families played a good healthrole in filariasis countermeasures. Based on the results ofthe chi-square test, there was a relation between the fam-ily’s perceived barriers to preventive actions and thehealth role in filariasis countermeasures (p value = 0.001).

Based on the results of the logistic regression analysismethod (Table 2), the families’ perceived susceptibilityto diseases (p value = 0.012) and the families’ perceivedbenefits of preventive action (p value = 0.001) were sig-nificant to predictors of families’ health role in filariasiscountermeasures. The families’ perceived benefits of pre-ventive action were the dominant factor related to thefamilies’ health role in filariasis countermeasures (OR =12.863; 95% CI = 2.566–93.537) after adjusting withperceived susceptibility to diseases (OR = 8.316; 95%CI = 1.769–26.949).

DiscussionBased on the results of this study, it can be concluded

that most families felt susceptible to or at risk of filariasisdisease, thus they followed a health role to prevent fila -riasis. This is as stated by Hochbaum, Rosenstock, andKegels that mentioned perceived susceptibility includesan estimation of susceptibility to diseases and is one ofthe stronger perceptions in promoting healthy behavioradopted by people. The greater the perceived risk, thegreater the possibility to get involved in a decreasing riskbehavior.7

When persons believe that they are at risk of diseases,they will do something to prevent the disease to happen.Otherwise, when a person believes that they are not atrisk or less likely to suffer from a disease, they tend toperform unhealthy behaviors.8 For example, adults ge -nerally do not consider themselves at risk of filariasis,therefore, they do not make the maximum efforts to pre-vent mosquito breeding such as eradicating man-mademosquito nests from garbage cans, used tires, or otherwater storage containers.9

Based on the explanation above, it can be concludedthat the health role in the forms of filariasis countermea-sure practices through mosquito bite preventive actions,vector control through home hygiene maintenance, andparticipation at filariasis mass treatment would be per-formed by families if they felt susceptible to or at risk ofmosquito bites and suffering from filariasis. The findingsof this study can be an example for the Kuta Baro PrimaryHealth Care, Aceh Besar District, for preparing filariasis-related health promotion programs in the community.

Perceived seriousness/severity of diseases refers to anindividual belief about the seriousness and severity of adisease.10 According to results, most of the families inKuta Baro Primary Health Care, Aceh Besar District hadnot considered filariasis as a serious/severe disease. Thiswill affect the families understanding of the filariasis con-sequences and not perceive filariasis as a serious healththreat which needs an immediate response.

Perceived seriousness or severity of diseases includeshow a person sees any bad consequences of any serioushealth issue. Severity is considered as the person’s beliefabout the importance or the magnitude of a health threat.Perceived seriousness is often based on medical or insightinformation. It also may come from a belief of someonewho has experienced the pain of illness previously and itimpacts on his/her life.11

One factor of poor families’ perceived seriousness/severity of diseases is the lack of medical and insightinformation on bad consequences of filariasis. Onemistake families make is the assumption that filariasissymptoms are common and not serious symptoms, hencethe family tends to take self-treatment. However, if thefamily knows the examination results of the symptoms,which may indicate positive filariasis, then the perceptionof the family will change and they will start taking any

Table 2. Summary of Logistic Regression Analysis for Family’s Perception as the Predictors

95% CIFamily’s Perceived OR p Value Lower Upper

Susceptibility 8.316 0.012 1.769 26.949Seriousness 0.340 0.259 0.052 2.210Benefit 12.863 0.000 2.566 93.537Barrier 2.256 0.230 0.597 8.522Constant 0.057 0.001

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filariasis symptoms seriously. As Carpenter12 points out,the understanding of perceived seriousness/severity ofdiseases can be illustrated with the example that mostpeople consider fever a common symptom of illness.However, if a person has a fever and the examinationresult causes him/her to be hospitalized, then his/herperception of fever will change into a serious illness.12

To increase families’ perceived seriousness/severityof diseases, the health workers at Kuta Baro PrimaryHealthcare, Aceh Besar Subdistrict must improve thefamilies’ knowledge of filariasis dangers andconsequences.

This study found a relation between the families per-ceived benefits of preventive action to the health role infilariasis countermeasures. The results of this studypointed that most families perceived that filariasis coun-termeasure actions such as avoiding mosquito bites, con-trolling vectors through home hygiene maintenance, andparticipation at filariasis mass treatment provide benefitsand preventive actions to family members from filariasisdisease. This result was closely associated with the goodfamilies’ perceived susceptibility to diseases.

A similar statement is also expressed by Jones,Christina Jane, Helen Smith, and Carrie Llewellyn,13 thatmention the actions taken by a person for disease coun-termeasures (or treatment) depends on the considerationand evaluation from the perceived susceptibility to dis-eases and the perceived benefits of preventive actions.Therefore, the person would accept the recommendedhealth actions if considered beneficial. A person tends toadopt healthy behaviors if they believe that healthy be-havior will decrease their risk (susceptibility) of diseases.The perceived benefit plays an important role in adoptingthe behavior for secondary countermeasures like screen-ing.13

Based on the explanation above, the steps needed tobe taken by the health workers, especially at Kuta BaroPrimary Health Care, Aceh Besar District is to facilitateand actively motivate families to avoid mosquito bites,vector control through home hygiene maintenance, andparticipation at filariasis mass treatment. These are im-portant actions, and if completed families would perceivethe good benefits of filariasis countermeasure actionsthey have taken.

Results also indicated that there was a relation be-tween the families’ perceived barriers to preventive ac-tion and the health role in filariasis countermeasures. Thefamilies perceived that there was no barrier to filariasiscountermeasures action, thus the families perceived bar-riers to preventive action was a related variable in carry-ing out the health role for filariasis prevention.

The similar statement is also expressed by Amarillowhere perceived barriers are the individual self-evalua-tion on barriers to adopting new behaviors. Of all HBM

constructions, the most important barrier is determiningthe change of a person’s behavior. The family’s perceivedseriousness of diseases did not significantly influence tothe health role in filariasis countermeasures. However,the families’ perceived seriousness/severity of diseasescan influence the families’ perceived barriers in filariasiscountermeasures.14 Jones and Barlett,7 also stated thatto improve people’s behavior in filariasis countermea-sures, the real threat of seriousness/severity of filariasisdisease would motivate the people to take countermea-sure actions by avoiding mosquito bites, controlling vec-tor through home hygiene maintenance, and participatingin filariasis mass treatment. Any barriers felt by people inmosquito nest eradication, it can be overcome if peoplehave a high perception of the seriousness/severity of fi-lariasis disease.

The results of the logistic regression showed that thefamily’s perceived susceptibility to diseases (p value =0.012) and the family’s perceived benefits of preventiveaction (p value= 0.001) were the significant predictors offamilies’ health role in filariasis countermeasures. Thisresult aligns with Hayden,6 that previously described thatthe actions taken by a person to prevent (or cure) thedisease depends on the evaluation and consideration ofthe perceived susceptibility to diseases and the perceivedbenefits of any preventive action. A person will accept ahealth action if beneficial to them. A person tends toadopt health behaviors that decrease their risk of diseaseexposure. Perception of the perceived benefit had an im-portant role in adopting secondary preventive behaviors.6

Results of the logistic regression analysis showedpredictors for both perceived susceptibility to diseasesand perceived benefits of preventive action. The mostdominant factor related to the family’s health role in fi-lariasis countermeasures was the perceived benefits ofpreventive action (OR = 12.863; 95% CI = 2.566–93.537) after adjusting for perceived susceptibility to dis-eases (OR = 8.316; 95% CI = 1.769–26.949). Jones andBartlett,7 had similar findings and suggestions. The con-struct of perceived benefits is a person’s opinion of thevalue or usefulness of a new behavior to decrease the riskof developing a disease. People tend to adopt healthierbehaviors when they believe the new behavior will de-crease their likelihood of developing a disease.7

ConclusionThe families’ perceived susceptibility to diseases and

the families’ perceived benefits of preventive action aresignificant predictors of the families’ health role in filari-asis countermeasures. The families’ perceived benefits ofpreventive action are the dominant factor related to fam-ilies’ health role in filariasis countermeasures such as pro-tecting themselves and taking drugs after adjusting forperceived susceptibility to diseases.


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Acknowledgment The researchers would like to thank the Aceh Health

Polytechnic for their financial support. We also wouldlike to express our gratitude to the Kuta Baro PrimaryHealth Care in Aceh Besar District, and all respondentswho have participated in this study.

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kesehatan Indonesia 2016. Jakarta: Pusat Data dan Infomasi

Kementerian Kesehatan Republik Indonesia; 2017.

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tahun 2015. Aceh Besar: Dinas Kesehatan Aceh Besar; 2016.

3. Pemerintah Kabupaten Aceh Besar [homepage on the Internet].

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Kesehatan Republik Indonesia tentang penanggulangan filariasis.

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5. Glanz K, Rimer BK, Viswanath K. Health behavior and health educa-

tion: Theory, research, and practice [Monograph on the Internet]. San

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from: https://sph.unc.edu.

6. Hayden J. Introduction to health behavior theory [Monograph on the

Internet]. USA: Jones & Bartletts Publishers LLC; 2009 [cited 2017

May 20]. Available from: www.jblearning.com.

7. Jones, Bartlett. The health belief model [monograph on the Internet].

Burlington, Massachusetts, United States: Jones and Bartlett Publishers;

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8. Donev D, Mirchevska L, Velkovski Z, Kosevska E, Stojanovska V,

Gligorov I, et al. Health promotion and health education [monograph

on the Internet]. Skopje: University Ss Cyril and Methodius Faculty of

Medicine in Skopje; 2014 [cited 2017 May 20]. Available from:

https://www.researchgate.net/ publication/ 260986858.

9. Green EC, Elaine M. Health belief model. The wiley blackwell encyclo-

pedia of health, Illness, behavior, and society [homepage on the

Internet]. Hoboken, New Jersey, USA: John Wiley & Sons, Ltd; 2014:

766-769. [updated 2014 February 21; cited 2017 May 20]. Available

from: https://onlinelibrary.wiley.com/doi/full/10.1002.

10. Skinner CS, Jasmin T, Victoria LC. The health belief model. Health be-

havior: theory, research, and practice. 5th ed. San Francisco (US):

Jossey-Bass; 2015.

11. Hou, Su-I. Health education: Theoretical concepts, effective strategies,

and core competencies. Health Promotion Practice [serial on the

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12. Carpenter, Christopher J. A meta-analysis of the effectiveness of health

belief model variables in predicting behavior. Health

Communication [serial on the Internet] Dec. 9, 2010 [cited 2017 May

20]. Available from: https://www.tandfonline.com.

13. Jones CJ, Smith H, Llewellyn C. Evaluating the effectiveness of health

belief model interventions in improving adherence: a systematic review

[serial on the Internet]. Health Psychology Review. 2010; 8(3): 253-269

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14. Amarillo MLE, Belizario VY, Sadiang-abay JT, Sison SAM, Dayag AMS.

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Elvin et al, Family Perception Towards Health Role in Filariasis Countermeasures Using the Health Belief Model Approach

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Correspondence: Ni Made Sri Nopiyani, Faculty of Medicine, UdayanaUniversity, PSIKM Building, PB Sudirman Street, Denpasar, Phone: +62361-222510, Email [email protected]: November 19th 2017Revised: April 18th 2018Accepted: May 14th 2018

AbstractSince 2014, there has been an increase in funds for primary health care (PHC) coming from the National Health Insurance program capitation funds and theHealth Operational Assistance Fund. This study aimed to explore the effect of this budget increase on the health care services at PHC. The case study useda qualitative approach and interviews from 19 PHC health workers with the highest and lowest budget. Data were analyzed using thematic analysis and sup-ported by quantitative data. The positive impact of the increasing PHC budget was felt by PHC staff due to the addition of operational equipment andincentives provided. Nevertheless, there was also a negative impact such as feeling overwhelmed due to an increase in the quantity of PHC activities and ad-ditional administrative affairs. It also triggered a negative interaction between staff due to the number of incentives received. The regulation on the use ofbudget empowers PHC to better arrange the schedule of activities and manage human resources. However, these regulations are considered restrictive andthe administrative flow of funds is too long that hinder the optimal use of the budget. Keywords: Budget increase, Health Operational Assistance Fund, National Health Insurance, performance, primary health care

AbstrakSejak tahun 2014 peningkatan anggaran terjadi di pusat kesehatan masyarakat (puskesmas)yang bersumber dari dana kapitasi Jaminan Kesehatan Nasionaldan program Bantuan Operasional Kesehatan. Penelitian ini bertujuan menggali dampak peningkatan anggaran pada komponen sistem layanan dipuskesmas. Penelitian studi kasus menggunakan pendekatan kualitatif dan wawancara mendalam 19 orang tenaga kesehatan puskesmas dengan jumlahanggaran tertinggi dan terendah. Data kualitatif dianalisis dengan analisis tematik serta didukung dengan data kuantitatif. Dampak positif peningkatananggaran puskesmas dirasakan oleh petugas karena adanya penambahan peralatan operasional dan insentif yang disediakan. Namun, dampak negatif jugadialami oleh petugas seperti perasaan kewalahan karena adanya peningkatan jumlah kegiatan serta penambahan urusan administrasi. Hal tersebut jugamemicu interaksi negatif antar petugas karena besaran jasa pelayanan yang diterima. Regulasi pemanfaatan anggaran mendorong puskesmas untuk men-gatur jadwal kegiatan dan sumber daya manusia dengan lebih baik. Meskipun demikian, regulasi pemanfaatan anggaran dinilai sangat ketat dan alur peman-faatan dana juga dinilai terlalu panjang sehingga menghambat pemanfaatan anggaran secara optimal. Kata kunci: Peningkatan anggaran, Bantuan Operasional Kesehatan, Jaminan Kesehatan Nasional, kinerja, puskesmas

Impact of Budget Increase on Primary Health CarePerformance in the Era of National Health Insurance:Case Study in Buleleng District

Dampak Peningkatan Anggaran terhadap Kinerja Puskesmas di EraJaminan Kesehatan Nasional: Studi Kasus di Kabupaten Buleleng

Kadek Suranugraha*, Ni Made Sri Nopiyani**, Pande Putu Januraga**

*Buleleng District Health Office, Bali, Indonesia, **Department of Public Health and Preventive Medicine, Facultyof Medicine, Udayana University, Bali, Indonesia

How to Cite: Suranugraha K, Nopiyani NMS, Januraga PP. Impact of budg-et increase on primary health care performance in the era of national healthinsurance. Kesmas: National Public Health Journal. 2018; 13 (2): 92-98.(doi:10.21109/kesmas.v13i2.1875)

Suranugraha et al. Kesmas: National Public Health Journal. 2018; 13 (2): 92-98DOI:10.21109/kesmas.v13i2.1875

Suranugraha et al, Impact of Budget Increase and Primary Health Care Performance in the Era of National Health Insurance

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IntroductionThe Government of Indonesia has made various ef-

forts to improve the budget of health programs and serv-ices.1 In 2004, the Law No. 40 initiated the reform of thehealth financing system in the National Health Insurance(NHI). The government began to pay attention to the pre-ventive program aspects by providing the HealthOperational Assistance Fund for primary health care(PHC) since 2010.2 The government re-issued aPresidential Regulation (Law No. 12) on 2013 for HealthInsurance, followed by the Regulation of Health MinisterNo. 71 of 2013 for NHI Health Services that regulatesthe granting of PHC funds. Since 2014, these regulationshave resulted in a noticeable increase in the bud get ofPHC throughout Indonesia, including in BulelengDistrict.

Health financing is an important component of thehealth system and influences other factors.3 Changes inhealth financing can have an impact on human resources,types of service provided, fund allocation, the technologyused, health information, and institutional leadership.3-8

However, there is evidence that while grant incentivesfor financing health care providers can increase the fi-nancial benefits of service providers and improve healthcare activities, these do not necessarily contribute to theimprovement of health status in the community.9

Studying the impact of the increased budget on PHC'sperformance in the NHI era has never been done before.Such a study is necessary in order to provide importantinput for policymakers and ensure the improvement ofhealth system outcomes.10 This study aimed to examinethe changes and impacts on PHC’s performance inBuleleng District.

MethodThis was a case study with data collected on May

2017. PHC selection was determined by the budget level.The PHC with the highest budget was Buleleng I PrimaryHealth Care and the PHC with the lowest budget wasSeririt III Primary Health Care. Qualitative data were col-lected through semi-structured interviews using interviewguidelines, and quantitative data were collected from thebudget and performance reports of selected PHC. The in-terviewed participants included the head of PHC, headof the administrative sub-division, Public Health ProgramManager, Individual Health Program manager, pharma-ceutical service manager, and laboratory service managerat each PHC. From Buleleng I Primary Health Care 9participants were interviewed and 10 were interviewedfrom Seririt III Primary Health Care.

Changes and impacts of PHC budget improvementswere analyzed using thematic analysis methods based onthe Quality of Care framework by Campbell. The analy-sis was performed on the structure and process compo-

nents of health services. The component structure con-sisted of building and environment aspects of PHC,health equipment, medications, human resources, man-agement and leadership, funding, information system,and process component consisting of health service andmanagement implementation. The information obtainedwas coded, then grouped into a code list to make betterdefine by theme. Validation strategies used were a tri -angulation of data, including the combination of datadrawn from the different interviewed participant, andmethodological triangulation using interviews and sec-ondary data review.

This study was reviewed and approved by the MedicalEthics Committee of Udayana University/ Sanglah PublicHospital with Number 1256/UN.14.2/KEP/2017 onMay 18th, 2017.

ResultsBuleleng I Primary Health Care and Seririt III Primary

Health Care are located in urban areas and carry outhealth services mandated by the government. However,Buleleng I Primary Health Care has a range of work areaof 1,202 km2 that is larger than Seririt III Primary HealthCare with a working area of 754 km2. Buleleng I PrimaryHealth Care also has a larger population, 66,164 peoplecompared to Seririt III Primary Health Care with a popu -lation of 13,121 people. The increase in funds led to anincrease of Buleleng I Primary Health Care’s budget fromIDR 1,894,829,000 in 2014 to IDR 3,750,456,000 in2016, while Seririt III Primary Health Care’s budget in-creased from IDR 381,528,500 in 2014 to IDR993,391,281 in 2016.

The existing budget was used to finance the imple-mentation of Public Health Programs, improve the struc-ture component, operational equipment, and human re-sources.

Analysis of secondary data revealed that the perform-ance of both PHCs in terms of coverage of Individual andPublic Health Program, and management was improved.Coverage of the Individual Health Program in both PHCsalso increased after the increased budget. The coverageof Public Health Programs in both PHCs especially inmaternal and child health services, family planning,

Figure 1. The Total Budget of Buleleng I Primary Health Care and Seririt IIIPrimary Health Care in 2014–2016

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health education, integrated health care, integratedhealth care for non-communicable diseases, promotionof exclusive breastfeeding, and monitoring of vitamin Aadministration was also increased. Furthermore, im-provements in management aspects were observed inboth PHCs after the increase of fund.

Ultimately, an improvement on the health servicesand management leveled up the performance score ofBuleleng I Primary Health Care and Seririt III PrimaryHealth Care. Classification of PHC performance was pre-sented in Table 1.

Based on the budget report of Buleleng DistrictHealth Office in 2014 to 2016, the existence of capitationfunds tends to be utilized for the procurement of admin-istrative equipment whose addition has improved staffperformance in carrying out administrative activities.

“So helpful…really makes our work easier, we usedto have only 1 computer to work with, now we have moreso it's easier to work” (UKM1_PB)

The positive impact was also felt by the PHC staff dueto the provision of cash incentives based on the numberof activities performed, as well as in the form of trans-portation allowance. As clarified in one statement from arespondent.

“We have always been enthusiastic about our work,but now we feel more appreciated, our contributions are

better acknowledged…” (UKM7_PS)Unfortunately, others problems have arisen, particu-

larly regarding human resources. Higher budgets indi-rectly lead to an increase in the number of activities car-ried out, thereby requiring more people to perform thoseactivities. On the other hand, the number of staff avail-able did not align with the program’s needs, which madestaff feel overwhelmed. Buleleng I Primary Health Careofficials revealed that if the staff was forced to carry outactivities in accordance with the existing budget, theywould have difficulty being accountable.

“If we are asked to do more nothing will get doneproperly because there simply aren’t enough of us…”(UKM2_PB)

Adequate administrative requirements and inade-quate staff's accountability has resulted in some staff feel-ing the strain of the additional workload.

“That's a matter of the administration; sometimes wedon’t really understand how to make the accountabilityfiles.” (KTU_PB)

Some program managers also revealed that the PHC’sbudget increase has not been utilized in accordance withthe needs of the health program. The budget for pro-grams should be equitable across the board; however,this is not always the case, as one respondent explained.

“There is a very small budget for child health because

Table 1. The Performance Level of Buleleng I Primary Health Care and Seririt III Primary Health Care in 2012–2016

Health Services Coverage Management Coverage PHC ClassificationYear Buleleng I Seririt III Buleleng I Seririt III Buleleng I Seririt III 2012 87.1 83.6 6 6 Level 3 (poor) Level 2 (fair)2013 88.0 85.5 6 6 Level 3 (poor) Level 2 (fair)2014 88.8 81.7 6.6 6.6 Level 2 (fair) Level 2 (fair)2015 86.8 86.3 7.7 7.7 Level 2 (fair) Level 2 (fair)2016 91 91 8.9 8.9 Level 1 (good) Level 1 (good)

Table 2. Summary of the In-depth Interview Results

Variable Result

Buildings Improvement of the condition of PHC buildings and environment due to increased budgetSupporting facilities Improvement of the quantity and quality of supporting facilities due to increased budgetHuman resources Improvement on the provision of financial incentives for staff due to increased budget Improvement on staff performance due to a better PHC supporting facilities and environment

Increase in staff’s motivation due to improvement on incentive provision Increasing staff’s workload due to additional service activities and administrative tasks Decreased interaction among staff due to differences in the number of activities performed and the number of incentives received Payment mechanism led to a change in work ethic. Some staff tend to work only on the basis of rewards givenLeadership Changes in the internal policy of PHC to adapt to the regulation of NHI capitation fund and Health Operational Assistance Fund Financing Long and complicated process for using NHI capitation fund and Health Operational Assistance Fund Inability to utilize the budget optimally and according to PHC needs due to strict regulations Obstacles in the preparation of financial accountability reports due to lack of staff’ knowledge and experienceInformation system The increased budget did not affect the health information system Health service delivery The increased budget did not bring equitable effect across all the PHC programs. It mainly benefited essential Public Health (public and individual Programhealth programs) Increased quantity and quality of Public Health Program activities Reactivation of some development activities in the Public Health Program Increased quantity of individual health serviceManagement More intensive monitoring and supervision on the utilization of NHI and Health Operational Assistance Fund Regulation on the utilization of funds forces the PHC to better plan activities and more intensively manage human resources


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it has been redirected to maternal health. You can seethe difference in the quality and scope of activities in theearly childhood health class, compared to the maternalhealth class…” (UKM2_PS)

PHC leaders should be more open to discussing theseproblems. Another staff was not aware of what a budgetconstraint entails.

“The thing is that not everyone fully understandswhat is going on, where the money is going and whatfor…” (KPS_PS)

“The funds are all divided according to the differentprograms in different PHC sections…” (UKM4_PS)

This gap ultimately leads to new problems, such asthe changes in the interaction between health workerstriggered by the difference in the number of activities be-tween officers. The difference in the number of activitiesaffects the number of incentives received by the officers,which decrease the interaction among the staff, as ex-pressed by some program managers.

“In the past, those outside our direct managementline didn’t have a lot to do, we only speak with themwhen needed something, but now that we have a com-petitive compensation program, people don’t want to getinvolved unless they are compensated…” (UKM2_PS)

These conditions indicate a change in the staff workethic. The officer tends to only conduct activities forwhich they get paid, thus prioritizing work on the basisof rewards given. The differences in the size of compen-sation foster a feeling of dissatisfaction among the PHCstaff. Some informants considered that the basis for theprovision of services was not in accordance with the con-ditions at PHC. The assignment of managers of healthprograms at Buleleng I Primary Health Care and SeriritIII Primary Health Care I was based on the criteria ofhealthcare worker suitability with the health program forwhich they will be responsible. At these two PHC, therewas no degree of responsibility differentiating betweenthe sizes of the programmer's responsibilities from thelevel of education, thus the level of education does notguarantee that the staff performs more tasks than thosewith lower levels of education. It can be assume that ed-ucational level did not have a significant effect on theworkload of staff.

“For example, an undergraduate level officer is re-sponsible for program development and has not a lot ofpaperwork to carry out, but those with a lower technicalschool degree are responsible for immunization whichhas more reporting, VCT services, and other activities…” (UKM6_PS)

The increased PHC’s budget has resulted in an in-creased number of Public Health Program activities,quality improvement of Individual Health Program, andPHC management quality improvement. The HealthOperational Assistance Fund program report on both

PHCs indicates that there is an increased frequency ofimplementation of 14 types of health activities. The di-rector of Seririt III Primary Health Care also revealedthat they had reactivated some development activities,such as sport health activities, nutrition, and traditionaltreatment activities.

“Because some activities have been reintroduced andwe have funds to carry this out we really need to carrythem out effectively…”(UKM4_PB)

In addition, the increase in budgetary revenues alsohas an impact on the addition of new activities such ashigh risk pregnant women's home visits, postpartumhome visits, exclusive breastfeeding, family and carecoaching, a new type of laboratory examination, new im-munization services that now include JapaneseEncephalitis vaccination and the existence of a chronicdisease management program.

On the Individual Health Program side, both PHCsexperienced an increase in the number of outpatient visitssince 2014, as indicated by reports from the HealthServices Profile of Buleleng District Health Office from2012 until 2016. This indicates an increase in the quan-tity of Individual Health Program activities inside thePHC building. There was also an increase in demand forblood samples. This is reiterated by laboratory serviceworkers.

“There is an increase in patient’s seeking testing,sometimes up to 150 per month…” (PL_PB)

On the other hand, the PHC budget increase also hasa positive effect on management aspects. All activities fi-nanced by the Health Operational Assistance Fund mustbe contained in the PHC’s activity implementation plandocumentation. This is done to avoid administrative er-rors and compliance with applicable rules, hence the staffis able to carry out activities without having to worryabout the division of tasks and implementation times thatmight clash with other activities.

Besides, the utilization of NHI capitation and HealthOperational Assistance Fund also faces several obstacles,such as strict regulation that enable the optimal use ofbudget according to the PHC needs. The director ofSeririt III Primary Health Care revealed that they did notneed the extra funds for the procurement of consum-ables, as their consumables stock supplies exceed a one-year requirement, but every year a proportion of NHIcapitation budget has been set for consumables procure-ment, and cannot be used for other purposes.

“For example, if only the regulation could be moreflexible we could divide the funds for 60% staff wagesand 40% operational costs, so it would be helpful if wecould re-allocate those unused funds for something moreurgent….” (KPS_PS)

Health program managers also felt the barriers to theuse of funds because of such regulations. Because there


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are regulations on budget utilization for certain healthprograms, the existing budget cannot be used for somehealth programs at PHC.

“The increase has helped us to better carry out activ-ities…there are now available funds… …but if these ac-tivities are not stipulated within the guidelines we can’t”(UKM6_PS)

This has resulted in the incomplete distribution ofavailable funds for the PHC, as expressed by the directorof administration.

“No…if there are funds leftover we cannot usethese…there is some leftover…” (KTU_PS)

Officials also felt that the administrative flow of budg-et utilization was too time-consuming which complicatesthe process.

“There are funds from NHI…so things should be eas-ier, but for example, we can’t simply make whatever pur-chases we like, we have to place a request to the DistrictHealth Office, and then getting signatures which is time-consuming” (UKP_PB)

Health providers attempted to increase budget ab-sorption by maximizing the possibility of channelingfunds in each health program.

“We always try to make sure that funds are used…and offer them across all the management programs….to help meet targets” (UKP_PB)

DiscussionThis study suggests that improvement of the budget

from the NHI and Health Operational Assistance Fundat both PHCs had positive and negative consequences.Financial improvement support enabled PHC to improvethe procurement of supporting facilities, such as com-puters and medical equipment. This made the adminis-trative works easier and supported the implementationof computerized health information system. Integratedhealth information with the computerized system hasbetter accuracy, saves time, and is more efficient.11

Moreover, budget improvement leads to more resourcesavailable to support operational PHC activities and pro-vide incentives for PHC staff. It could be concluded thatthe budget improvement brought a direct positive impactin improving the quantity and quality of health manage-ment and health care at PHC. The regulatory aspect ofNHI also had a positive impact on health care quality.The Regulation of Health Ministry HK.02.02/MENKES/514/2015 on Clinical Practice Guidelines for Physiciansat First Level Medical Service Facilities elucidates thatthere are 179 diseases that should be treated by primaryhealthcare services. The PHC has an obligation to handlea number of diagnoses and/or follow through with thereferral process so that the quality of the services is pro-vided according to the patient's needs. Regulation onclinical practices guideline for physicians in primary

health care services is effective in improving the qualityof individual health care and reducing non-specialist re-ferrals.

On the other side, improvement in the financial as-pect, healthcare equipment, and technology should bebalanced with human resources optimization. Based onthe Health Minister’s Regulation Number 75 of the Year2014 concerning Primary Health Care, both PHCs inthis study have not met the minimum quantity standardof human resources. Lack of human resources at PHCcould impede healthcare provision and budget utiliza-tion.

A limited number of human resources at PHC causeda burden among the staff to conduct health care servicesand related administrative tasks. Improvement of thebudget was accompanied by an increase in administrativetasks to report the use of NHI capitation fund and HealthOperational Assistance Fund. Buleleng District HealthOffice and PHC have not undertaken workload analysisof their staff; therefore, job allocation was not equitableamong staff. Disproportionate workload distributionleaves some staff with higher workload pressure thanothers.

This study reveals that the improvement of budget re-ceived by PHC has led to the improved implementationof Individual Health Program and Public HealthProgram, particularly the essential Public HealthProgram. The finding is in line with the result of a studyby Nurmansyah & Kilic,12 that showed the improved rev-enue from capitation fund of NHI has improved healthpromotion activities of PHC in South Tangerang City.However, in line with the findings of other studies, im-provement of budget does not necessarily result in an in-crease in financial support for all PHC programs.Availability of more funding does not guarantee the eq-uitable improvement of resources across all the PHC pro-grams. Some programs benefited more than others.Therefore, equity is an important aspect to ensure thatall PHC programs receive an adequate allocation fromthe improved budget.13 Furthermore, disproportionateshares of the budget among programs affected the num-ber of activities undertaken by the staff. The number ofactivities conducted by the staff will determine the num-ber of their service incentives. Therefore, inequitablebudget allocation indirectly leads to the different amountof service incentives and triggers jealousy among PHCstaff.

Different amount of service incentives could negative-ly influence the staff’s satisfaction. Review of current reg-ulation about the calculation of service incentives is per-ceived important by PHC staff since it is considered lessfair and inappropriate with the current working situationon PHC. Similar findings from the previous study con-ducted in Karangasem District suggested that staff of


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PHC in this District perceived that the scores given foreach type of health workers was inappropriate and coulddiminish interaction among staff.14

Financial incentives may affect healthcare perform-ance at PHC, but it could also be potentially harmful tothe working environment.4 Incentives providing mecha-nisms should be undertaken cautiously as there is limitedevidence to support the use of financial incentives forimproving the quality of PHC services over the longerterm.15,16 Performance-based financial incentives couldchange the staff’s work ethic. PHC staff prefer to takepaid activities and avoid activities with no incentives.This practice resulted in a shifting of the organizationculture.17,18

A complex effect of budget improvement on humanresources has a significant implication for health care, ashuman resource is one of the main aspects of health careand it could influence other health care components.3,19

If the negative impacts of improved budget on human re-sources are not seriously overcome, it could lead to a de-crease in staff quality of work, working satisfaction, badcommunication, and consequently lead to poor health-care provision for the community.

PHCs in Buleleng District could have different re-sults if compared to other PHCs. Therefore, the resultsof this study can be used as a theoretical reference onthe intervention in a similar context or situation. Studyreplication in other locations could produce differentresults, and considering the design of this study is a casestudy, it is premature to make any conclusive deduc-tions.

ConclusionIncreasing PHC's revenue in the NHI era coincides

with improved performance in both program and man-agement coverage, but there are still some problems andbarriers that have a negative impact. Human resourcesare affected by the increase in PHC’s budget. Consideringthat human resources are an integral aspect of the healthsystem, the relevant actors need to make efforts to mini-mize the negative impact and inhibiting factors in orderto have an optimum and profitable increase in the budgetfor the implementation of health care services at PHC inIndonesia.

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International Journal for Quality in Health Care. 2008; 20(5): 308–13.



Utilization of Styrofoam as Soundproofing Material withAuditory Frequency Range

Pemanfaatan Styrofoam sebagai Bahan Peredam Bising dengan RentangFrekuensi Pendengaran

Sjahrul Meizar Nasri*, Iting Shofwati**

*Occupational Health and Safety Department, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia,**Occupational Health and Safety Department, Faculty of Health Sciences, Universitas Islam Negeri SyarifHidayatullah, Jakarta, Indonesia


AbstractThe utilization of bricks made of styrofoam is expectedly able to be a soundproof for noise control and as a preventive action to reduce the steadily increasingprevalence of hearing loss. This study aimed to assess the use of sound absorption material in which styrofoam was utilized to reduce the noise exposure.In this study, fine aggregates (sand and styrofoam) were made with a mixture of cement with a composition of 1:4 and 1:6, also the addition of polystyrenewaste with a percentage of 0%, 20%, 40%, 60%, and 80%. Determination of acoustical property of the mixture was done by testing the sound absorptioncoefficient (α) using Four Microphones Impedance Tube (ISO 140-3). The results showed that the highest value of absorption coefficient was at a fre-quency of 800 Hz with an additional 80% styrofoam for the composition of 1:4 at 0.4100 dB and at a frequency of 800 Hz with an additional 40% styrofoamfor the composition of 1:6 at 0.5870 dB. Keywords: Noise, sound absorption coefficient, sound transmission loss, styrofoam

AbstrakPemanfaatan batako yang terbuat dari styrofoam diharapkan dapat menjadi peredam bising guna pengendalian bising dan sebagai langkah pencegahanuntuk mengurangi prevalensi penurunan pendengaran yang terus meningkat. Penelitian ini bertujuan mengkaji penggunaan bahan penyerap suaradimana styrofoam dimanfaatkan untuk mengurangi paparan kebisingan. Pada penelitian ini, agregat halus (pasir dan styrofoam) dibuat dengan cam-puran semen dengan komposisi 1:4 dan 1:6, serta penambahan limbah polistirena dengan persentase 0%, 20%, 40%, 60%, dan 80%. Penentuan ke-mampuan akustik dari campuran dilakukan dengan menguji koefisien penyerap suara menggunakan Empat Mikrofon Tabung Impedansi (ISO 140-3).Hasil menunjukkan nilai tertinggi koefisien penyerap suara berada pada frekuensi 800 Hz dengan penambahan styrofoam 80% untuk komposisi 1:4sebesar 0.4100 dB dan pada frekuensi 800 Hz dengan penambahan styrofoam 40% untuk komposisi 1:6 sebesar 0.5870 dB.Kata kunci: Bising, koefisien penyerap suara, kehilangan transmisi suara, styrofoam

Narsi et al. Kesmas: National Public Health Journal. 2018; 13 (2): 99-104DOI:10.21109/kesmas.v13i2.2633

How to Cite: Nasri SM, Shofwati I. Utilization of styrofoam as soundproofingmaterial with auditory frequency range. Kesmas: National Public HealthJournal. 2018; 13 (2): 99-104. (doi: 10.21109/kesmas.v13i2.2633)

Correspondence: Sjahrul Meizar Nasri, Faculty of Public Health UniversitasIndonesia, Building D 1st Floor Kampus Baru UI Depok 16424, Phone: +6221-78849033, E-mail: [email protected]: September 6th 2018Revised: October 26th 2018Accepted: October 31th 2018

100

IntroductionAn ‘unwanted’ sound at certain amplitude that could

cause discomfort and disturb is called noise.1 In low- andmiddle- income countries, 80% of over 275 million peo-ple around the world suffer from noise-induced hearingloss (NIHL).2 Although NIHL is irreversible but HearingLoss Prevention Program (HLPP) can be implemented toprevent the damage. Employing engineering and admin-istrative control are the innovation of the hearing conser-vation program for the exposure level that closes to 85dBA which is benefited to decrease the number ofNIHL.3 A method commonly implemented in many in-dustries is employing personal protective equipment(PPE) program only, such as providing the earmuff andearplug, in which the use of the PPE depends on theworkers’ behavior and habit. The PPE program only pre-vents the noise exposure indirectly, however, this pro-gram needs to be strictly supervised.4

One of the engineering controls that can be consid-ered to reduce the noise exposure is by using a sound-proofing material (noise absorbent) which will reducethe level of noise received by the workers. Some previousstudies are already conducted to develop any material ca-pable of absorbing the noise by using many kinds of nat-ural fiber wastes, such as cotton, jute fiber, palm fiber ,rice husk, rice straw, coconut husk, sawdust, rice huskpowder, tea fiber leaf waste, wheat straw, glass-wool androckwool.5-14 However, the utilization of these fibers,particularly the glass-wool and rockwool, has health andsafety impacts, such as damaging the lungs and eyes.14

Then the utilization of the fibers has disadvantages sincethe natural fibers easily absorb the water and are alsoflammable.15 In the previous study, styrofoam was addedon a brick production and the study found that styrofoamcreated some air cavities within the transition zone ofstyrofoam and cement-sand.16 The more styrofoam beingadded, the more water will be absorbed by the cavities.16

This previous study also found that styrofoam is hydro-phobic and has smooth surface which makes styrofoamsuitable to be mixed with cement and sand as the aggre-gate. Based on these findings, it is hypothesized that sty-rofoam might be used as alternative material in brick pro-duction and reduce the noise since the air cavity createdby the styrofoam in the brick material potentially absorbsthe noise. In addition, the previous study presented thatby employing styrofoam as a sound-absorbing materialwith a core thickness of around 30 mm and 40 mm, theabsorption coefficient of 0.628 and 0.574 at 500 Hz fre-quency.17 In other words, the ability in absorbing thenoise was shown by using the styrofoam as the sound-ab-sorbing material.17

The utilization of styrofoam can be increased by con-ducting a further study to produce “light brick”. The abi -lity of brick as a soundproof is expected to be used for

noise control, also as the preventive action of hearingloss. Hence, the aim of this study was to obtain the ap-propriate material capable of reducing the noise exposureby finding the best composition of the mixture in whichthe styrofoam was added.

MethodThis study used experimental method and primary da-

ta. Data analysis was by implementing ASTM E-1050-98procedure to measure the sound absorption coefficient.18

Variable measured in this study was the ability of styro-foam in a mixture to reduce noise exposure based on dif-ferent composition of styrofoam in the mixture. Sound-absorbing material was developed from cement, fine ag-gregate, and water and the ratio of cement to fine aggre-gate were 1:4, 1:6, and 1:8 as a composite. The treatedstyrofoam wastes added to the composite were 0%, 20%,40%, 60% and 80% of the total volume of the composite(cement and fine aggregates). The styrofoam waste hasbeen cleaned before being added to the composite to en-sure that it was free of dirt and grease which could affectthe composite’s quality. In addition, the styrofoam wastewas also sieved to ensure that the composite met the re-quirements for fine aggregate referring to SNI-03-6821-2002.1 There are three specimens on each mixture, andas a result, the total sample in this study was 45 samples.The specimens’ diameter was 10 cm. The detailed com-position of each specimen is shown in the Table 1.

The sound absorption coefficient test was conductedin Acoustical Laboratory of Physics, Department Facultyof Mathematics & Natural Sciences Universitas SebelasMaret Surakarta by using ASTM E-1050-98 procedure.The absorption coefficient (a) test was conducted at 250Hz, 400 Hz, 500 Hz, 800 Hz, 1000 Hz, 1250 Hz, and1600 Hz. The frequencies were obtained from the testresults using Impedance Tube Method.

After the styrofoam was cleaned and ready, the mix-


Table 1. The Composition of Cement and Fine Aggregate with Various Additional Percentage of Styrofoam Waste

Cement Fine Aggregate Ratio Additional % of Styrofoam Waste From the Total Sample code Volume of Cement and Fine Aggregate Cement Fine Aggregate

4-0 1 4 04-2 1 4 204-4 1 4 404-6 1 4 604-8 1 4 806-0 1 6 06-2 1 6 206-4 1 6 406-6 1 6 606-8 1 6 808-0 1 8 08-2 1 8 208-4 1 8 408-6 1 8 608-8 1 8 80

Nasri et al, Utilization of Styrofoam as Soundproofing Material with Auditory Frequency Range

101

ing process began and included the cement, sand, andstyrofoam itself. The three mixture compositions werecement : fine aggregate with ratio 1:4, 1:6, and 1:8 witha percentage of 0%, 20%, 40%, 60% and 80% styro-foam (value FAS = 0.645). This specimen fabricationrefers to the requirement of acoustic testing at low fre-quency up to 1600 Hz. Then the absorption coefficient(a) was determined. Absorption coefficient (a) is the ra-tio of absorbed sound energy by the material towards to-tal sound energy that hit the material itself. It has a rangeof 0 to 1. Material with a= 0 shows that material has thecapability/potential to absorb 0 or reflection, and materi-al with a= 1 shows that the material itself has the capa-bility/potential of proper absorption, i.e. 100%.19

Since there were three replications on each mixture,the absorption coefficient (a) value was obtained by cal-culating the mean of each mixture’s absorption coeffi-cient. Then the equal variances across group of sampleswas determined by using Lavene test. This test is used toverify the assumption that the samples have equal vari-ances. The ethical clearance of this study was obtainedfrom the Ethics Committee of Faculty of Public Health,Universitas Indonesia (No.33/H2.F10/PPM.00.02/2014).

ResultsTwo parameters were taken to examine the acoustic

capability or potential of styrofoam waste material, i.e.,the sound absorption coefficient (a) and sound transmis-sion loss (TL). The measurement of absorption coeffi-cient (a) was performed at 125, 250, 500, 1000, 2000,and 4000 Hz frequencies. This test was carried out usingan Impedance Tube.

Based on the table above, in composition of 1:4 be-tween cement and fine aggregate, the maximum absorp-tion coefficient (a) value was shown in sample code 4-8.In the other words, the maximum capability to absorb thenoise was at which the styrofoam was added by 80% tothe fine aggregate among the 1:4 composition. The maxi-mum ability to absorb the noise was in the frequency at800 Hz and the absorption coefficient (a) value was0.4100 (Table 2).

On the other hand, in 1:6 compositions between ce-ment and fine aggregate, the maximum value was present-ed in sample code 6-4. It means that the maximum abilityto absorb the noise was at which 40% styrofoam wasadded to the fine aggregate. The maximum ability to ab-sorb the noise among the 1:6 composition was in the fre-quency at 800 Hz and the absorption coefficient (a) value

Table 2. Absorption Ability of Styrofoam Waste Material on Mixed Composition of 1:4 and 1:6 Based on Variation of Styrofoam Addition

Sound Absorption Coefficient aSample Code

250Hz 400Hz 500Hz 800Hz 1kHz 1.25kHz 1.6kHz

4-0 0.0466 0.0288 0.3640 0.0838 0.0516 0.0644 0.07774-2 0.0140 0.0770 0.1540 0.2740 0.0825 0.0661 0.09924-4 0.0280 0.0865 0.1610 0.2580 0.0944 0.0953 0.16304-6 0.0179 0.0903 0.1650 0.2680 0.1070 0.1730 0.11704-8 0.0217 0.0781 0.1250 0.4100* 0.2050 0.1625 0.1366-0 0.0355 0.1550 0.3130 0.2490 0.1040 0.1050 0.19506-2 0.0580 0.2170 0.3260 0.2760 0.1710 0.1080 0.16406-4 0.0392 0.1130 0.1650 0.5870* 0.2230 0.1700 0.19406-6 0.0792 0.2720 0.4630 0.2590 0.1580 0.2050 0.27606-8 0.0689 0.2200 0.2740 0.2550 0.1850 0.1600 0.20308-0 0.0799 0.2729 0.4139 0.1421 0.1013 0.1325 0.22728-2 0.0587 0.2188 0.4558 0.3539 0.1399 0.1231 0.17668-4 0.0858 0.3502 0.5138 0.1991 0.1286 0.1625 0.26438-6 0.091 0.288 0.5169* 0.318 0.1795 0.1553 0.23988-8 0.1292 0.2681 0.3524 0.217 0.1497 0.1677 0.2324

Notes:*The maximum absorption coefficient (α) value

Table 3. Lavene Test Results

Source Type III Df Mean Square F p Value Partial Eta Sum of Squares Squared

Corrected Model 2.730a 14 0.195 3.814 0.001 0.640Intercept 119.643 1 119.643 2340.746 0.000 0.987Prosen_Sty 0.462 4 0.115 2.258 0.086 0.231Composition 1.469 2 0.734 14.367 0.000 0.489Prosen_Sty*Komposisi 0.799 8 0.100 1.955 0.088 0.343Error 1.533 30 0.051 Total 123.906 45 Corrected Total 4.263 44

102

tions, so that the sound or noise is able to enterthrough.28 Besides, styrofoam also has a high elasticmodulus.29 The results of this study are in accordancewith the prior studies, such as study by Sinarep, et al,30

finding that styrofoam with the thickness of 30 mm and40 mm could reduce the noise and the absorption coef-ficient value were 0.512 and 0.719. The absorption co-efficient measurement showed that the development ofnoise absorbent can be conducted by utilizing styro-foam. The ratio of sound absorbed by the material pertotal sound energy which stroke the material itself is thedefinition of absorption coefficient. In addition, absorp-tion coefficient calculates how much sound is absorbedby the material and the transmission of sound throughit.31

Sound absorption ability of a material is divided intosix classes, if value of a< 0.1, the material was not in-cluded as sound-absorbing material.8,32 According to theresults of this study, on the material without an additionalstyrofoam and with additional 20%, 40%, and 80%styrofoam at 1:4 composition presented that the abilityof this composition in absorbing the noise could be cate-gorized into classification D (a between 0.30 - 0.55). Onthe other hand, the addition of 60% styrofoam was cate-gorized into classification C (a between 0.60 - 0.75).Moreover, on the material without additional styrofoamand with additional 20%, 60%, and 80% Styrofoam at1:6 composition could be classified into classification D(a between 0.30 - 0.55), while the additional 40% styro-foam at 1:6 composition was categorized into classifica-tion C (a between 0.60 - 0.75). Then in 1:8 composition,either in the additional 20%, 60%, or 80% styrofoam,most of the absorption coefficient results were catego-rized into classification D.

Based on the findings of this study and other priorstudies, the results commonly presented that fiber couldbe used as a noise absorbent. Therefore, fibers can bedeveloped as simple materials for implementing the en-gineering control and reducing the level of noise expo-sure. According to a study, exposure to noise modifiesthe function of human body systems and organs and canbe a significant factor to stress and a high bloodpressure.33 The other study also mentioned that noisecan cause stress, annoyance, and sleep disturbance.34

Hence, the development of noise absorbent also affectsthe improvement of public health quality. Conductingthe interventions and educating the workers by the in-dustries, insurance companies and the suppliers, provid-ing the workers compensation are suggested to alsoadopt engineering control to reduce the noise expo-sure.20 A further study is recommended to determinethe ability of styrofoam as a noise barrier. A study alsosuggested that vegetation can be useful to perceived thenoise barrier performance.35

was 0.5870. Furthermore, in 1:8 composition between cement and

fine aggregate, the maximum value was presented in sam-ple code 8-6. It means that the maximum ability to absorbthe noise was at which 60% styrofoam was added to thefine aggregate. The maximum ability to absorb the noiseamong the 1:8 composition was in the frequency at 500Hz and the absorption coefficient (a) value was 0.5169.

The test results (Table 3) indicated that the composi-tions of styrofoam (1:4, 1:6, or 1:8) were significantly cor-related with the ability of styrofoam to absorb the noise (pvalue < 0.05). In other words, the Lavene test showedthat the greater the composition of Styrofoam in the fineaggregate, the better it is to absorb the noise.

DiscussionAccording to the results, which is in line with the re-

sults of previous studies, styrofoam material can be usedas noise absorbent as proven by the findings showing thatthe mixed compositions of styrofoam with 1: 4, 1: 6, and1: 8 had the potential to reduce noise. Another study de-clared that mixed composition of cement with fine aggre-gates (rice husk and sand) with 10% and 100% noise ab-sorbent get the result of 0.42 – 0.05.17 The absorptioncoefficient value of composition mixture of 10% cement,80% sand, and 10% rice husk was 0.42, in which thisvalue was the highest one.20 A prior study also showedthat the natural fibres, such as the rice straw and kenaffiber, were able to wave the noise effectively. These fibers’mass and diameters had a big effect on sound absorptioncoefficient.21

The previous study on noise absorbents using coconutcoir showed the average value of absorption coefficientswith a composition of 20% coconut coir, 20% recycledrubber, and 25% polyurethane was 0.50.22 While anoth-er study showed that the highest absorption coefficient inthe utilization of coconut coir was 0.83 on 3784 Hz fre-quency with a 10 mm thickness of coconut coir.23 Basedon these studies, it could be concluded that sound-ab-sorbing materials could be made by utilizing fibers. Thereare some advantages in using natural fibers instead of sty-rofoam since the natural fibers are recyclable, biodegrad-able, also less in health hazards.24 However, the naturalfibers commonly only have higher sound absortion coef-ficients at higher frequency range.25 In addition, all nat-ural fibers usually absorb the moisture, especially duringthe condition with high humidity.26 In general, the natu-ral fibers are already hydrophilic in nature and tend toabsorb the water even from the air.27

The results of this study presented that the composi-tion of fine aggregate and styrofoam gained the highestabsorption coefficient of 0.5870 on 800 Hz frequency in1:6 composition. Styrofoam is one of the porous absorb-ing materials that contain cavities, channels or intersec-


103

Conclusion In this study, the results indicate that noise absorbent

material can be developed by utilizing styrofoam. Thepotential use of styrofoam as ‘light brick’ to reduce thenoise is also suggested by the findings. Since styrofoamis cheaper and lighter than other synthetic materials, itsutilization as noise absorbent performs a good potential.

Acknowledgment This study is funded by PUPT BOPTN Grant. Hence,

the researchers would like to express gratitude for thefunder’s support.

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L/O/KESMAS no.1 Juli '06