Bundle of Academics AMSA-UI 2018/2019 by AMSA-UI

bundle of acads amsa-ui 2018/2019

nrpc 2019

national research proposal competition

bundle of acads amsa-ui 2018/2019

nrpc 2019

Research project proposal

bundle of acads amsa-ui 2018/2019

HUBUNGAN PENDEKATAN KELUARGA TERHADAP KEPATUHAN KONSUMSI OBAT ANTIHIPERTENSI Proposal Riset Nasional AMSA-Indonesia

Ugiadam Farhan Firmansyah

1706982941

Yehezkiel Alexander Eduard George

1706982954

Gita Fajri Gustya

1706982595

AMSA-Universitas Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia (AMSA-Indonesia) 2018

Lembar Pengesahan Proposal penelitian kami yang berjudul â&#x20AC;&#x153;Hubungan Pendekatan Keluarga terhadap Kepatuhan Konsumsi Obat Antihipertensiâ&#x20AC;? telah kami setujui untuk diajukan pada National Research Proposal Competition AMSA-Indonesia. Proposal penelitian ini disusun oleh: Penulis 1 Nama : Ugiadam Farhan Firmansyah NPM : 1706982941 Penulis 2 Nama : Yehezkiel Alexander Eduard George NPM : 1706982954 Penulis 3 Nama : Gita Fajri Gustya NPM : 1706982595 AMSA-Universitas Indonesia Representative AMSA-Universitas Indonesia

Ketua Tim Peneliti

Bintang Wirawan Manurung

Ugiadam Farhan Firmansyah

NPM 1606826722

NPM 1706982941

Dosen Pembimbing

Dr. dr. Aria Kekalih, M.T.I NIP 198104172008121003

Halaman Pernyataan Orisinalitas Saya yang bertanda tangan di bawah ini: Ketua Tim Peneliti Nama : Ugiadam Farhan Firmansyah NPM : 1706982941 Menyatakan dengan sebenar-benarnya bahwa proposal penelitian berjudul â&#x20AC;&#x153;Hubungan Pendekatan Keluarga terhadap Kepatuhan Konsumsi Obat Antihipertensiâ&#x20AC;? yang saya ajukan untuk National Research Proposal Competition AMSA-Indonesia merupakan hasil karya tim peneliti sendiri tanpa ada jiplakan dari proposal penelitian lain dan belum pernah dipublikasikan di manapun. Sumber maupun referensi yang kami gunakan merupakan sumber yang sah dan dapat dipertanggungjawabkan. Apabila pernyataan yang saya sebutkan di atas tidak benar, saya bersedia dituntut sesuai dengan peraturan perundang-undangan yang berlaku. Jakarta, 11 Oktober 2018 Ketua Tim Peneliti

Ugiadam Farhan Firmansyah NPM 1706982941

Kata Pengantar Puji syukur kami panjatkan kepada Tuhan Yang Maha Esa karena atas berkat dan rahmatnya, kami dapat menyelesaikan proposal penelitian dengan judul â&#x20AC;&#x153;Hubungan Pendekatan Keluarga terhadap Kepatuhan Konsumsi Obat Antihipertensiâ&#x20AC;?. Tak lupa kami berterima kasih kepada Dr. dr. Aria Kekalih, M.T.I sebagai dosen pembimbing kami dalam menyusun proposal ini. Proposal ini dibuat dengan tujuan mengikuti lomba pada National Research Proposal Competition AMSA-Indonesia. Selain itu, kami juga berharap proposal ini dapat menambah wawasan dan pengetahuan kami mengenai pendekatan keluarga, obat-obat antihipertensi, kepatuhan pengobatan, dan hubungan antar pendekatan keluarga dan kepatuhan konsumsi obat antihipertensi. Setelah membaca proposal penelitian ini, kami berharap seluruh pihak terkait dapat memahami dan mengaplikasikan proposal ini dalam bentuk penelitian. Selanjutnya, kami turut berharap hasil penelitian yang akan dilaksanakan kemudian hari dapat dimanfaatkan sebaikbaiknya demi meningkatkan taraf hidup dan tingkat kesehatan masyarakat Indonesia. Apabila terdapat kesalahan kata, kami memohon maaf. Selain itu, kami memohon kritik dan saran yang membangun demi pelaksanaan penelitian di masa depan. Jakarta, 11 Oktober 2018

Penyusun

iii

Daftar Isi Lembar Pengesahan .................................................................................................................... i Halaman Pernyataan Orisinalitas ...............................................................................................ii Kata Pengantar ......................................................................................................................... iii Daftar Isi ................................................................................................................................... iv Bab I: Pendahuluan .................................................................................................................... 1 A.

Latar Belakang ............................................................................................................ 1

Rumusan Masalah dan Pertanyaan Penelitian ............................................................. 1

Tujuan Penelitian......................................................................................................... 2

Manfaat Penelitian....................................................................................................... 2

Bab II: Tinjauan Pustaka ............................................................................................................ 4 A.

Tinjauan Pustaka ......................................................................................................... 4

Kerangka Konsep ........................................................................................................ 9

Bab III: Metode Penelitian ....................................................................................................... 10 A.

Ruang Lingkup Penelitian ......................................................................................... 10

Desain Penelitian ....................................................................................................... 10

Identifikasi Variabel .................................................................................................. 10

Definisi Operasional Variabel ................................................................................... 10

Populasi dan Subjek Penelitian ................................................................................. 11

Kriteria Inklusi dan Eksklusi .................................................................................... 12

Teknik Pengambilan Sampel ..................................................................................... 12

Instrumen Penelitian.................................................................................................. 13

Cara Pengumpulan Data ........................................................................................... 13

Rencana Analisis ....................................................................................................... 13

Daftar Pustaka .......................................................................................................................... 15 Lampiran .................................................................................................................................. 16

Bab I: Pendahuluan A. Latar Belakang Pada tahun 2016, Kementerian Kesehatan Republik Indonesia menerbitkan â&#x20AC;&#x153;Pedoman Umum Program Indonesia Sehat dengan Pendekatan Keluargaâ&#x20AC;?. Program ini dicanangkan berdasarkan Agenda ke-5 Nawa Cita, yakni meningkatkan kualitas hidup manusia Indonesia. Dalam hal ini, terdapat 12 indikator utama penanda kesehatan sebuah keluarga. Salah satu indikator yang menarik perhatian peneliti adalah penderita hipertensi (tekanan darah tinggi) melakukan pengobatan secara teratur.1 Berdasarkan data Riset Kesehatan Dasar (Riskesdas) 2013, kejadian hipertensi di Indonesia mengalami penurunan dari 31,7% tahun 2007 menjadi 25,8% tahun 2013.2 Hal ini dapat terjadi karena perbedaan alat pengukur tekanan darah atau memang masyarakat yang sudah mulai berobat. Pada tahun 2014, prevalensi hipertensi di Jawa Barat mencapai 13.612.359 jiwa atau 29,4% dari jumlah penduduk.3 Namun, berdasarkan wawancara dengan penderita hipertensi yang telah menjalani pengobatan terjadi peningkatan prevalensi hipertensi dari 7,6% tahun 2007 menjadi 9,5% tahun 2013.2 Lebih lanjut, Pusdatin menjelaskan bahwa pengontrolan hipertensi belum adekuat meskipun tersedia banyak obat-obat yang efektif.3 Oleh karena itu, peneliti tertarik untuk mengetahui bagaimana hubungan pendekatan keluarga terhadap pengontrolan tekanan darah penderita hipertensi. Rixiang Xu, dkk pada tahun 2018 telah melakukan penelitian mengenai intervensi yang dapat dilakukan untuk meningkatkan kepatuhan pengobatan pada penderita hipertensi di Cina. Kesimpulan penelitian tersebut adalah intervensi berupa pemantauan pribadi tekanan darah, pengaturan peringatan, dan durasi intervensi dapat meningkatkan kepatuhan pengobatan dan mengurangi tekanan darah penderita hipertensi.4 Dengan demikian, peneliti berniat melaksanakan penelitian guna mengetahui pendekatan keluarga yang optimal terhadap kepatuhan konsumsi obat antihipertensi. B. Rumusan Masalah dan Pertanyaan Penelitian Rumusan Masalah Prevalensi penderita hipertensi yang diobati meningkat karena pengobatan hipertensi tersebut tidak terkontrol. Tentu, hal tersebut berkaitan dengan kepatuhan pengobatan yang masih menjadi masalah. Bersamaan dengan itu, sekarang pemerintah sedang menggalakkan 1

â&#x20AC;&#x153;Program Indonesia Sehat dengan Pendekatan Keluargaâ&#x20AC;?. Hal ini merupakan salah satu upaya untuk mengurangi prevalensi hipertensi dari penderita yang telah menjalani pengobatan. Oleh karena itu, perlu diketahui hubungan pendekatan keluarga dalam meningkatkan kepatuhan konsumsi obat antihipertensi. Pertanyaan Penelitian 1. Apa saja pendekatan keluarga terkait kepatuhan konsumsi obat antihipertensi yang dapat diterapkan sehari-hari? 2. Bagaimana hubungan pendekatan keluarga terhadap kepatuhan konsumsi obat antihipertensi? 3. Apakah jenis pendekatan keluarga yang optimal dalam menunjang kepatuhan konsumsi obat antihipertensi? C. Tujuan Penelitian Tujuan Umum Mengetahui hubungan pendekatan keluarga terhadap kepatuhan konsumsi obat antihipertensi di Indonesia Tujuan Khusus 1. Mengetahui tingkat kepatuhan konsumsi obat antihipertensi subjek penelitian 2. Mengetahui bentuk pendekatan keluarga yang dapat dilakukan dalam menunjang kepatuhan konsumsi obat antihipertensi 3. Mengetahui hubungan pendekatan keluarga terhadap kepatuhan pengobatan 4. Mengetahui hubungan faktor-faktor lain (aktivitas fisik, tingkat pendidikan, dan riwayat keluarga yang menderita hipertensi) dengan kepatuhan pengobatan 5. Mengetahui faktor-faktor yang berhubungan dengan kepatuhan konsumsi obat antihipertensi D. Manfaat Penelitian Bidang Pendidikan dan Pengajaran 1. Menambah pengetahuan mengenai pendekatan keluarga terkait kesehatan 2. Memperkaya ilmu terkait penyakit tekanan darah tinggi (hipertensi) 3. Meningkatkan pengetahuan terkait obat antihipertensi 2

Bidang Penelitian dan Pengembangan 1. Mengetahui hubungan pendekatan keluarga terhadap kepatuhan pengobatan Bidang Pengabdian kepada Masyarakat 1. Menerapkan pendekatan keluarga yang optimal dalam menunjang kepatuhan konsumsi obat antihipertensi

Bab II: Tinjauan Pustaka A. Tinjauan Pustaka 1. Pendekatan Keluarga 1.1 Konsep Pendekatan Keluarga Pendekatan keluarga adalah suatu cara Pusat Kesehatan Masyarakat (Puskesmas) guna meningkatkan jangkauan sasaran dan akses pelayanan kesehatan dengan mendatangi keluarga. Menurut Frisedman tahun 1998, fungsi keluarga antara lain fungsi afektif, sosialisasi, reproduksi, ekonomi, dan perawatan atau pemeliharaan kesehatan. Dengan adanya keluarga, setiap anggota keluarga memiliki tugas tertentu untuk menjaga kesehatan agar produktivitasnya tetap tinggi. Tugas-tugas tersebut antara lain sebagai berikut. Mengetahui gangguan perkembangan kesehatan. Mengambil tindak kesehatan yang tepat. Memberikan perawatan. Menciptakan suasana rumah yang sehat. Mempertahankan hubungan timbal balik dengan fasilitas kesehatan.1 Selanjutnya, pendekatan keluarga dapat dinilai menggunakan Kuesioner Pendekatan Keluarga (Perceived Social Support ScaleFamily).5,6 1.2 Pelaksanaan Pendekatan Keluarga Pelaksanaan pendekatan keluarga memerlukan adanya instrumen, forum komunikasi, dan keterlibatan masyarakat. Di tingkat keluarga, diperlukan instrumen berupa Profil Kesehatan Keluarga (Prokesga) dan Paket Informasi Keluarga (Pinkesga). Berkaitan kontak dengan keluarga, diperlukan forum komunikasi seperti kunjungan rumah keluarga, diskusi kelompok terarah, kesempatan konseling, dan forum masyarakat. Keterlibatan masyarakat dapat diupayakan melalui kader kesehatan dan pengurus organisasi masyarakat.1 Pada penelitian yang dilakukan oleh Mengendai, dkk., diketahui bahwa salah satu faktor yang memengaruhi kepatuhan pengobatan adalah dukungan keluarga. Dukungan keluarga yang dimaksud adalah dalam bentuk sikap, tindakan, dan perlakuan yang dilakukan keluarga terhadap penderita penyakit.7 2. Hipertensi 2.1 Definisi Hipertensi Hipertensi atau tekanan darah tinggi didefinisikan sebagai peningkatan tekanan darah sistolik menjadi lebih dari 140 mmHg dan tekanan darah diastolik menjadi lebih dari 90 4

mmHg dengan pengukuran sebanyak dua kali dengan interval lima menit dalam keadaan cukup istirahat dan tenang. Peningkatan tekanan darah secara persisten merupakan risiko terjadinya penyakit jantung koroner, gagal ginjal, stroke, dan lain-lain.3

2.2 Klasifikasi Hipertensi The American Heart Association and Joint National Committee (JNC) mengklasifikasikan hipertensi menjadi sebagai berikut. Prehipertensi, yakni TD sistolik/diastolik 120-139/8189 mmHg. Hipertensi tingkat 1, yakni TD sistolik/diastolik 140-159/90-99 mm Hg. Hipertensi tingkat 2, yakni TD sistolik/diastolik â&#x2030;Ľ160/â&#x2030;Ľ100 mmHg.3,8 Berdasarkan bentuk, hipertensi dapat dibedakan menjadi hipertensi sistolik, diastolik, dan campuran (sistolik-diastolik).3,8 Berdasarkan penyebabnya, hipertensi terbagi menjadi hipertensi primer dan sekunder. Hipertensi primer atau esensial adalah hipertensi yang penyebabnya tidak diketahui (idiopatik). Sedangkan hipertensi sekunder adalah hipertensi yang penyebabnya diketahui, contohnya penyakit ginjal, kelainan hormonal, atau penggunaan obat tertentu.3 Hipertensi juga dapat dikategorikan menjadi hipertensi jas putih (white coat hypertension) dan hipertensi bertopeng (masked hypertension). Hipertensi jas putih adalah peningkatan tekanan darah ketika diukur di fasilitas kesehatan, tetapi normal ketika diukur di rumah. Hal ini bisa terjadi karena pasien stres atau gugup ketika diperiksa. Sedangkan, hipertensi bertopeng adalah peningkatan tekanan darah ketika diukur di rumah, tetapi normal ketika diukur di fasilitas kesehatan.8 Oleh karena itu, banyak penderita hipertensi yang tidak terdeteksi.

3. Obat Antihipertensi Berdasarkan mekanisme kerja, obat antihipertensi dapat dibedakan menjadi sebagai berikut. Diuretik menurunkan tekanan darah dengan menghabiskan natrium dalam tubuh dan mengurangi volume darah. Diuretik terbagi menjadi 3 golongan, yakni thiazida, loop diuretics, dan diuretik penghematan K+. Agen simpatoplegik atau simpatolitik menurunkan tekanan darah dengan mengurangi resistensi pembuluh darah tepi, menghambat fungsi jantung, dan meningkatkan genangan vena dalam kapasitansi. Agen ini dibedakan menjadi bloker beta adrenergik, bloker alfa adrenergik, bloker campuran adrenergik, agen aksi 5

sentral, dan bloker neuron adrenergik. Vasodilator langsung bekerja dengan cara merelaksasikan otot polos pembuluh darah. Terdapat 2 vasodilator, yakni untuk arteri saja dan untuk arteri dan vena.9,10 Agen yang menghalangi reseptor angiotensin mengurangi resistansi pembuluh darah tepi dan volume darah.9 Bloker kanal kalsium menyebabkan relaksasi otot polos arteriol dan mengurangi resistensi pembuluh darah tepi. Selanjutnya, Inhibitor ACE (Angiotensin-Converting Enzyme) bekerja dengan cara menekan kenaikan konsentrasi hormon aldosteron sehingga tubuh mengekskresikan lebih banyak Na+ dan akhirnya menurunkan tekanan darah.10

4. Kepatuhan Pengobatan (Medication Adherence) 4.1 Definisi Kepatuhan Pengobatan Kepatuhan pengobatan didefinisikan sebagai tingkat perilaku seseorang yang berhubungan dengan rekomendasi yang telah disetujui oleh penyedia layanan kesehatan. WHO menyebutkan bahwa meningkatkan efektivitas intervensi kepatuhan pengobatan dapat memberikan dampak yang jauh lebih besar terhadap kesehatan populasi daripada kemajuan tatalaksana medis spesifik lainnya.11 Sampai sekarang, pengukuran kepatuhan pengobatan dan intervensi guna meningkatkan kepatuhan pengobatan masih langka dalam praktik klinis dan obat. Sekitar 50â&#x20AC;&#x201D;60% pasien yang menderita penyakit kronik sering kali menerima berbagai obat sehingga menyebabkan tingginya risiko untuk tidak patuh terhadap konsumsi obat tersebut. Padahal, kepatuhan pengobatan sangat penting untuk meningkatkan hasil kesehatan dan mencapai tujuan klinis.4,11 4.2 Pendekatan Kepatuhan Pengobatan Dalam mengetahui perilaku konsumsi obat terdapat beberapa pendekatan yang bisa dilakukan. Metode yang paling tepat adalah pengamatan terapi secara langsung, metode biologis, dan pengukuran kadar obat dalam darah atau urin. Terdapat pula beberapa metode lain di antaranya laporan klinis, hitung pil, angka pengisian kembali resep, monitor pengobatan elektronik, buku harian pasien, dan laporan pribadi pasien.4 4.3 Faktor-faktor yang Memengaruhi Kepatuhan Pengobatan Berikut ini merupakan beberapa faktor yang memengaruhi kepatuhan pengobatan. Pertama, perubahan gaya hidup termasuk pola makan dan aktivitas fisik.12 Kedua, motif alamiah termasuk tantangan lingkungan hidup, kecocokan pasien terhadap jenis obat, pola 6

minum obat, dan rekomendasi keluarga.13 Terdapat pula faktor-faktor yang memengaruhi kepatuhan seseorang dalam berobat ke pusat pelayanan kesehatan antara lain tingkat pendidikan, peran petugas kesehatan, serta motivasi dan edukasi yang diberikan petugas kesehatan, baik dokter, perawat, dan apoteker.7 Hal tersebut menjadi perbedaan antara faktor-faktor yang memengaruhi kepatuhan pengobatan dan faktor-faktor yang memengaruhi kepatuhan berobat ke pusat pelayanan kesehatan. 4.4 Penghalang Kepatuhan Pengobatan Penghalang kepatuhan pengobatan juga dapat menjadi faktor yang menurunkan kepatuhan pengobatan seseorang. Penghalang ini dapat berasal dari pasien, sistem pelayanan kesehatan, karakteristik terapi pengobatan, dan peran tim profesional pelayanan kesehatan. Penghalang dari pasien antara lain kurangnya manajemen diri dan pengetahuan terhadap penyakit dan obat, merasa takut terhadap obat, menyembunyikan informasi obat yang diresepkan, menggantikan obat yang diresepkan menjadi obat yang diatur sendiri, dan sebagainya. Penghalang dari sistem pelayanan kesehatan berupa perjanjian yang singkat dengan dokter, akses buruk, daftar obat yang tidak terbarukan, dan buruknya sistem teknologi informasi dan komunikasi. Penghalang dari terapi pengobatan, yakni pengobatan yang kompleks, polifarmasi, durasi konsumsi obat (sementara atau permanen), dan efek merugikan. Penghalang peran tim profesional pelayanan kesehatan mencakup tantangan meninjau informasi pengobatan secara penuh, peran dokter yang terlalu otoriter, dan keahlian yang tidak memuaskan dalam mengajarkan manajemen diri kepada pasien.14 4.5 Penilaian Kepatuhan Pengobatan Kuesionar Kepatuhan Pengobatan atau Medication Adherence Questionnaire (MAQ) yang dicetuskan oleh Morisky, dkk merupakan skala terbaik dan telah digunakan secara luas untuk penelitian mengenai kepatuhan pengobatan. MAQ memiliki beberapa keuntungan, yakni mengidentifikasi rintangan untuk ketidakpatuhan, cara terpendek, paling mudah untuk menilai, dan sangat mudah diadaptasi untuk berbagai kelompok pengobatan. Kuesioner ini dapat digunakan untuk menilai kepatuhan pengobatan secara umum.4 5. Aktivitas Fisik 5.1 Penilaian Aktivitas Fisik Aktivitas fisik dapat dinilai melalui beberapa jenis instrumen, salah satunya adalah SelfReport Physical Activity Questionnaires (SRPAQ). Salah satu kuesioner jenis ini adalah 7

International Physical Activity Questionnaire (IPAQ). IPAQ short form 7 days (IPAQS7S) merupakan salah satu kuesioner singkat yang mendemonstrasikan tes dan tes ulang dengan konsistensi yang sangat baik.15 Dihasilkan sebuah bentuk pengukuran aktivitas fisik yang dapat diterima dan digunakan dalam berbagai latar dan bahasa yang berbeda.16 Kategori aktivitas fisik dibagi menjadi rendah (skor < 600), sedang (skor 600â&#x20AC;&#x201D;1499), dan tinggi (skor â&#x2030;Ľ 1500) dalam satuan MET-menit/minggu (Metabolic Equivalent of Task).17

B. Kerangka Konsep Kerangka Teori Hipertensi Berdasarkan Penyebab

Tingkat Hipertensi 1. 2. 3.

Prehipertensi Hipertensi Tingkat 1 Hipertensi Tingkat 2

1. 2.

Hipertensi Primer Hipertensi Sekunder

Penyebab Hipertensi 1. 2. 3. 4.

Jenis Obat Antihipertensi 1. 2. 3. 4. 5. 6.

Diuretik Agen Simpatoplegik Vasodilator Langsung Penghalang Reseptor Angiotensin Bloker Kanal Kalsium Inhibitor ACE

Idiopatik Kelainan Hormon Penggunaan Obat Abnormalitas Metabolisme

Tugas Terkait Kesehatan

Keluarga

Faktor-faktor yang Memengaruhi Kepatuhan Pengobatan 1. 2. 3. 4.

Pasien Terapi Pengobatan Tim Profesional Kesehatan Sistem Pelayanan Kesehatan

Pendekatan Keluarga

Kepatuhan Pengobatan

Kerangka Konsep

Pelaksanaan Pendekatan Keluarga

Instrumen berupa Profil Kesehatan Keluarga (Prokesga) dan Paket Informasi Keluarga (Pinkesga) Forum komunikasi berupa kunjungan rumah keluarga, diskusi kelompok terarah, konseling, dan forum masyarakat Keterlibatan kesehatan melalui kader kesehatan dan organisasi masyarakat

Tugas Keluarga terkait Kesehatan

Pendekatan Keluarga

1. Pejamu • • • • • • • •

Usia Jenis Kelamin Aktivitas Fisik Tingkat Pendidikan Riwayat Keluarga yang Menderita Hipertensi Jenis Obat Antihipertensi yang Dikonsumsi Efek Samping Obat Konplikasi Obat

2. 3. 4. 5.

Mengetahui gangguan perkembangan kesehatan Mengambil tindakan kesehatan yang tepat Memberikan perawatan Menciptakan suasana rumah yang sehat Mempertahankan hubungan timbal balik dengan fasilitas kesehatan

Kepatuhan Konsumsi Obat Antihipertensi

Bab III: Metode Penelitian A. Ruang Lingkup Penelitian Penelitian akan dilaksanakan di berbagai pusat kesehatan masyarakat di Indonesia Penelitian dilakukan pada November 2018 sampai Mei 2019 Penelitian berkaitan dengan ilmu jantung dan pembuluh darah, ilmu kedokteran komunitas, dan ilmu kesehatan masyarakat B. Desain Penelitian Jenis penelitian yang dilakukan adalah penelitian observasional dengan menggunakan desain analisis potong lintang atau cross-sectional analytic C. Identifikasi Variabel Variabel bebas pada penelitian ini adalah pendekatan keluarga Variabel terikat pada penelitian ini adalah kepatuhan konsumsi obat antihipertensi Variabel perancu pada penelitian ini adalah jenis obat antihipertensi yang digunakan, usia, jenis kelamin, aktivitas fisik, tingkat pendidikan, dan riwayat keluarga yang menderita hipertensi dari subjek penelitian D. Definisi Operasional Variabel No.

Variabel

Definisi

Alat Ukur

Cara Ukur

Hasil Ukur

Jenis Data

Kepatuhan

Tingkat perilaku

Kuesioner

Pengisian

0 = Tinggi (skor 0)

Kategorik

Pengobatan

seseorang terkait

kuesioner

1 = Sedang (skor 1 atau

rekomendasi

tertulis

pengobatan

2 = Rendah (skor > 2)

yang

telah

disetujui

oleh

penyedia layanan kesehatan 2.

Pendekatan

Cara

Keluarga

yang

Kuesioner

Pengisian

0 = Tinggi (skor > 15)

dilakukan

kuesioner

1 = Rendah (skor < 16)

keluarga dalam

tertulis

Kategorik

memengaruhi anggotanya

Jenis

Obat

Antihipertensi

Golongan yang

obat

Kuesioner

berguna

untuk

Pengisian

0 = Diuretik

kuesioner

1 = Agen simpatoplegik

tertulis

Kategorik Vasodilator

menurunkan

langsung

tekanan

3 = Penghalang reseptor

darah

tinggi

angiotensin 4

Bloker

kanal

kalsium 5 = Inhibitor ACE 4.

Usia

dalam

satuan dihitung

Kuesioner

Pengisian

0 = Dewasa (26â&#x20AC;&#x201D;59

tahun

kuesioner

tahun)

sejak

tertulis

1 = Lansia (> 59 tahun)

Pengisian

0 = Perempuan

kuesioner

1 = Laki-laki

Kategorik

subjek lahir 5.

Jenis Kelamin

Status

kelamin

subjek

sesuai

Kuesioner

kartu identitas 6.

Aktivitas

yang

Fisik

memerlukan energi

dan

gerakan

otot

dalam

Kategorik

tertulis Kuesioner

Pengisian

0 = Tinggi (skor â&#x2030;Ľ 1500

kuesioner

MET-menit/minggu)

tertulis

1 = Sedang (600 â&#x2030;¤ skor <

durasi

1500

Kategorik

MET-

menit/minggu)

waktu tertentu

2 = Rendah (skor < 600 MET-menit/minggu)

Tingkat

Jenjang

Pendidikan

Kuesioner

Pengisian

0 = Tinggi (SLTA dan

pendidikan

kuesioner

PT)

berdasarkan

tertulis

1 = Rendah (tak sekolah,

tingkat

Kategorik

SD, dan SLTP)

perkembangan peserta didik 8.

Riwayat

Kejadian

Keluarga

Kuesioner

Pengisian

0 = Ada

hipertensi yang

kuesioner

1 = Tidak ada

yang

pernah

tertulis

Menderita

pada

Hipertensi

keluarga

terjadi

Kategorik

anggota

E. Populasi dan Subjek Penelitian Populasi penelitian adalah penderita hipertensi yang disarankan meminum obat antihipertensi di Indonesia

Sampel penelitian adalah penderita hipertensi yang disarankan meminum obat antihipertensi di lokasi penelitian Subjek penelitian adalah penderita hipertensi berusia lebih dari 25 tahun yang dianjurkan meminum obat antihipertensi di Indonesia F. Kriteria Inklusi dan Eksklusi Kriteria Inklusi •

Penderita hipertensi

•

Sedang menjalani pengobatan meminum obat antihipertensi

•

Berdomisili di Indonesia

•

Berusia lebih dari 25 tahun

Kriteria Eksklusi •

Tidak memiliki keluarga

•

Hidup sendiri

•

Baru meminum obat selama 1 bulan

G. Teknik Pengambilan Sampel Teknik pengambilan sampel penelitian ini menggunakan stratified random sampling, yakni peneliti mengambil sampel secara acak dan mengelompokkannya sesuai rentang usia Jumlah sampel minimal menggunakan penyederhanaan rumus Lameshow: n=

4pq d'

n = jumlah sampel minimal Zα = tingkat kepercayaan 95% = 1.96 (Zα)2 = (1.96)2 ≈ 4 p = proporsi yang patuh meminum obat q = 1-p = proporsi yang tidak patuh meminum obat d = batas kesalahan ditetapkan = 10% Berdasarkan jurnal Wai Yin Lam dan Paula Fresco, sekitar 50% pasien tidak patuh terhadap pengobatan. Maka dengan data tersebut dan estimasi batas kesalahan sebesar 10%, peneliti dapat menentukan jumlah sampel minimal sebagai berikut. n=

4 x 0.5 x 0.5 (0.1)' n = 100

Sehingga didapatkan bahwa jumlah sampel minimal penelitian ini adalah 100 orang 12

H. Instrumen Penelitian Instrumen penelitian ini berupa kuesioner kepatuhan pengobatan, kuesioner pendekatan keluarga, dan kuesioner aktivitas fisik. I. Cara Pengumpulan Data Jenis data yang didapatkan adalah data kategorik Pengumpulan data dilakukan melalui wawancara dengan subjek penelitian lalu hasil wawancara tersebut diisi pada kuesioner ataupun subjek penelitian langsung mengisi kuesioner disertai pendampingan pengisian kuesioner akan menghabiskan waktu sekitar 10 menit. Tidak ada risiko atau ketidaknyamanan ketika pengambilan sampel. Subjek penelitian berhak menolak untuk mengisi kuesioner apabila tidak berkenan Secara ringkas alur penelitian ini adalah pengumpulan data menggunakan kuesioner, pengolahan data secara analisis, dan penafsiran hasil pengolahan data J. Rencana Analisis Uji statistik menggunakan Chi Square (Ď&#x2021;2) Uji ini digunakan karena variabel-variabel yang diuji (variabel independen dan dependen) merupakan variabel dengan data kategorik Dummy Tabel Hasil Uji Statistik Odd

Kepatuhan Pengobatan Variabel

Tinggi

Pendekatan

Tinggi

Keluarga

Rendah

Sedang

Rendah

Nilai P

Ratio

Diuretik

Jenis Obat

Agen

Antihipertensi

simpatoplegik Vasodilator langsung

Penghalang reseptor angiotensin Bloker kanal kalsium

Inhibitor ACE Usia

Dewasa Lansia

Jenis Kelamin

Perempuan Laki-laki Tinggi

Aktivitas Fisik

Sedang Rendah

Tingkat Pendidikan Riwayat

Tinggi Rendah Ada

Keluarga yang Menderita Hipertensi

Tidak ada

Daftar Pustaka 1.

Kemenkes RI. Program Indonesia sehat dengan pendekatan keluarga. Kemenkes RI. 2016.

Badan Penelitian dan Pengembangan Kesehatan. Riset Kesehatan Dasar (RISKESDAS) 2013. Lap Nas 2013. 2013.

Kemenkes RI. Pusdatin hipertensi. Infodatin. 2014.

Xu R, Xie X, Li S, Chen X, Wang S, Hu C, et al. Interventions to improve medication adherence among Chinese patients with hypertension: a systematic review and metaanalysis of randomized controlled trails. Int J Pharm Pract. 2018 Apr 25.

Procidano M. Measures of perceived social support from friends and from family : three validation studies. Am J Community Psychol. 2014.

Toepfer SM. Family social support and family intrusiveness in young adult women. Fam Sci Assoc. 2010;15(2).

Mengendai Y, Rompas S, Hamel SR. Faktor-Faktor yang berhubungan dengan kepatuhan berobat pada pasien hipertensi di puskesmas ranotana weru. e-journal Keperawatan. 2017;5.

Materson BJ. Diagnostic evaluation: classification of hypertension. J Am Soc Hypertens. 2014 Sep 1;8(9):680–1.

Katzung BG, Trevor AJ. Basic & clinical pharmacology. 13th ed. San Francisco: McGraw-Hill Education; 2015.

10.

Brunton LL, Lazo JS, Parker KL. Goodman and Gilman’s the pharmacological basis of therapeutics. 11th ed. Brunton LL, editor. Vol. 59, The Yale journal of biology and medicine. New York: McGraw-Hill Education; 2006.

11.

Lam WY, Fresco P. Medication adherence measures: an overview. Biomed Res Int. 2015:217047.

12.

Fletcher BR, Hartmann-Boyce J, Hinton L, McManus RJ. The effect of self-monitoring of blood pressure on medication adherence and lifestyle factors: a systematic review and meta-analysis. Am J Hypertens. 2015 Oct 1;28(10):1209–21.

13.

Najimi A, Mostafavi F, Sharifirad G, Golshiri P. Barriers to medication adherence in patients with hypertension: a qualitative study. J Educ Health Promot. 2018;7(1):24.

14.

Kvarnström K, Airaksinen M, Liira H. Barriers and facilitators to medication adherence: a qualitative study with general practitioners. BMJ Open. 2018 Jan 23;8(1).

15.

Silsbury Z, Goldsmith R, Rushton A. Systematic review of the measurement properties of self-report physical activity questionnaires in healthy adult populations. BMJ Open. 2015 Sep 15;5(9).

16.

Short last 7 days self-administered format. Assessment. 2002;71(August):2000–2.

17.

Forde C. Scoring the International Physical Activity Questionnaire (IPAQ). Dublin: Trinity College Dubbin.

18.

Kemenkes RI. Buku Monitoring dan Evaluasi PIS-PK. Vol. 1, Kemenkes RI. 2017.

19.

Culig J, Leppee M. From Morisky to Hill-bone; self-reports scales for measuring adherence to medication. Coll Antropol. 2014;38(1):55–62.

Lampiran Berikut ini terlampir lembar informed consent, kuesioner monitoring dan evaluasi pelaksanaan kunjungan keluarga dan intervensi awal tingkat puskesmas, kuesioner kepatuhan pengobatan, kuesioner persepsi subjek terhadap pendekatan keluarga, kuesioner aktivitas fisik, budget penelitian, timeline penelitian, dan daftar riwayat hidup pengusul proposal.

Informed Consent Selamat Pagi/Siang/Sore/Malam, Perkenalkan kami Ugiadam Farhan Firmansyah, Yehezkiel Alexander Eduard George, dan Gita Fajri Gustya. Kami adalah mahasiswa Fakultas Kedokteran Universitas Indonesia. Kami bermaksud untuk melaksanakan penelitian dengan judul â&#x20AC;&#x153;Hubungan Pendekatan Keluarga terhadap Kepatuhan Konsumsi Obat Antihipertensi. Penelitian ini dilakukan dalam rangka National Research Proposal Competition yang diadakan oleh AMSA-Indonesia. Saya berharap Bapak/Ibu/Saudara bersedia untuk menjadi responden pada penelitian ini dengan mengisi beberapa kuesioner yang berkaitan dengan penelitian ini. Kami berharap kuesioner ini dapat diisi dengan sebenar-benarnya. Nantinya, data yang diberikan pada penelitian ini akan dijamin kerahasiaannya. Setelah membaca pernyataan di atas, kami berharap Bapak/Ibu/Saudara mengisi nama dan tanda tangan dibawah ini. Saya setuju untuk bersedia dalam penelitian ini. Nama

Jenis Kelamin

: Laki-laki/Perempuan

Usia

Alamat

Nomor Telepon/HP

Tingkat Pendidikan

: Tak Sekolah/SD/SLTP/SLTA/PT

Jenis Obat Antihipertensi

Aturan Pakai dan Dosis Obat

) Diuretik

(

) Agen simpatoplegik

(

) Vasodilator langsung

(

) Penghalang reseptor angiotensin

(

) Bloker kanal kalsium

(

) Inhibitor ACE

Efek Samping dan Komplikasi Obat : Riwayat Keluarga yang Menderita Hipertensi : Ada/Tidak ada Tanda tangan

Terima kasih atas kesediaan Bapak/Ibu/Saudara untuk menjadi responden dalam penelitian ini. *Silakan coret yang tidak perlu 17

Kuesioner Monitoring dan Evaluasi Pelaksanaan Kunjungan Keluarga dan Intervensi Awal Tingkat Puskesmas18 Petunjuk pengisian: 1. Mohon diisi dengan tanda centang ( ) pada kotak yang tersedia 2. Mohon diisi dengan tulisan yang jelas untuk pertanyaan uraian I. Bagian 1 (Diisi oleh Responden) a.

Apakah Puskesmas telah melaksanakan kunjungan keluarga Program Indonesia Sehat dengan Pendekatan Keluarga pada Anda? (

) 1. Sudah

(

) 2. Belum

Bila sudah, pihak yang mengunjungi Anda berasal dari profesi ____________________ sebanyak _____ kali kunjungan Bila belum, jelaskan apa kendalanya?

1. Belum ada sosialisasi dari Dinas Kesehatan Kabupaten/Kota/Provinsi

(

)

2. Lainnya, sebutkan......................................

(

)

Apa jenis pendekatan keluarga yang dilaksanakan oleh Petugas Puskesmas? (

) 1. Konseling Keluarga

(

) 2. Konseling Pribadi

Apakah petugas Puskesmas saat melakukan kunjungan keluarga memberikan informasi kesehatan kepada keluarga? (

) 1. Ya

(

) 2. Tidak

Apakah pembina Keluarga Sehat membawa alat pengukur tekanan darah dan stetoskop saat kunjungan keluarga? (

) 1. Ya

(

) 2. Tidak

Jika ada hasil pengukuran yang menunjukkan tekanan darah yang meningkat, Apa yang dilakukan pembina KS? (

) 1. Intervensi lanjut di Puskesmas

(

) 2. Rujuk ke Rumah Sakit

(

) 3. Intervensi Lanjut ke Upaya Kesehatan Bersumberdaya Manusia (UKBM)

Alasan merujuk ke rumah sakit: 1. Keterbatasan fasilitas

(

)

2. Keterbatasan kompetensi

(

)

3. Keterbatasan obat-obatan

(

)

4. Lainnya, sebutkan..................................... (

) 18

II. Bagian 2 (Diisi oleh Petugas Puskesmas) a. Apakah Puskesmas telah membentuk tim pembina keluarga? (

) 1. Sudah

(

) 2. Belum

b. Apakah seluruh staf Puskesmas memahami konsep PIS-PK? (

) 1. Sudah

(

) 2. Belum

Jika ya, berapa persentase yang sudah memahami: 1. <25%

(

)

2. 25â&#x20AC;&#x201C;50%

(

)

3. 50â&#x20AC;&#x201C;75%

(

)

4. 75â&#x20AC;&#x201C;100%

(

)

c. Instrumen apa yang digunakan melaksanakan kunjungan keluarga Program Indonesia Sehat dengan Pendekatan Keluarga? (

) 1. Form Prokesga

(

) 2. Aplikasi KS

Bila menggunakan formulir Prokesga (Profil Kesehatan Keluarga), sumber biaya cetak bersumber dari: (boleh lebih dari satu) (

) 1. APBN

(

) 2. APBD I/II

(

) 3, Puskemas

(

) 4. Lain-lain

Bila menggunakan aplikasi Keluarga Sehat apakah ada kendala dalam menggunakannya (

) 1. Ada

(

) 2. Tidak ada

Bila menggunakan aplikasi lainnya apakah ada kendala dalam menggunakannya? (

) 1. Ada

(

) 2. Tidak ada

Bila ada, jelaskan kendala yang ditemukan dan usulan solusi? 1. Kesulitan/tidak bisa menggunakan aplikasi (

)

2. Tidak ada jaringan internet

(

)

3. Lainnya

(

)

d. Apakah di Puskesmas telah tersedia Pinkesga (Paket Informasi Kesehatan Keluarga)? (

) 1. Tersedia

(

) 2. Tidak tersedia

e. Dalam bentuk apa Pinkesga yang tersedia tersebut? (

) 1. Soft Copy

(

) 2. Bentuk fisik (leaflet/brosur/lainnya)

f. Apakah di Puskesmas tersedia alat-alat kesehatan yang dapat mendukung PIS-PK? (

) 1. Tersedia

(

) 2. Tidak tersedia

g. Apakah tenaga Puskesmas dapat menggunakan alat pengukur tekanan darah tersebut serta melakukan pembacaan hasil pengukuran? (

) 1. Ya

(

) 2. Tidak

Kuesioner Kepatuhan Pengobatan (Medication Adherence Questionnaire)19 Anda terindikasi bahwa Anda sedang mengonsumsi obat untuk (identifikasi mengenai kesehatan, seperti â&#x20AC;?tekanan darah tinggiâ&#x20AC;?). Para individu telah mengidentifikasi beberapa isu berkenaan perilaku konsumsi obat mereka dan kita tertarik tentang pengalaman Anda. Tidak ada jawaban yang benar atau salah. Silakan jawab setiap pertanyaan berdasarkan pengalaman pribadi Anda dengan pengobatan (terkait kesehatan). Pewawancara mungkin mengindentifikasi diri berkenaan kesulitan yang mereka mungkin alami tentang perilaku konsumsi obat. (Silakan pilih jawaban yang sesuai) Jawaban

Skor

Responden Ya=1 Tidak=0 1. Apakah Anda terkadang lupa untuk meminum obat? 2. Orang-orang terkadang tidak minum obat untuk berbagai alasan lain daripada lupa. Selama dua minggu terakhir, apakah ada hari ketika Anda tidak meminum obat?

3. Apakah Anda pernah berhenti meminum obat tanpa memberitahu dokter Anda karena Anda merasa lebih buruk ketika meminum obat tersebut? 4. Ketika Anda berpegian atau meninggalkan rumah, apakah Anda terkadang lupa untuk membawa obat Anda? 5. Apakah Anda meminum obat Anda kemarin? 6. Ketika Anda merasa gejala yang dirasakan sudah membaik, apakah Anda terkadang berhenti untuk minum obat?

7. Meminum obat setiap hari merupakan sebuah ketidaknyamanan bagi beberapa orang. Apakah Anda pernah merasa terganggu mengikuti rencana pengobatan Anda? 8. Seberapa sering Anda merasa sulit untuk mengingat dalam hal minum obat? (Silakan lingkari angka yang sesuai) Tidak pernah/jarang................................................ 0 Sesekali....................................................................1 Terkadang................................................................ 1 Biasanya.................................................................. 1 Selalu....................................................................... 1 Penilaian Kuesioner Skor > 2 = Kepatuhan rendah Skor 1 atau 2 = Kepatuhan sedang Skor 0 = Kepatuhan tinggi

Kuesioner Persepsi Subjek terhadap Pendekatan Keluarga (Perceived Social Support Scale-Family)5 Petunjuk: Pernyataan di bawah ini merujuk pada perasaan dan pengalaman yang dialami kebanyakan orang pada satu waktu maupun waktu lainnya pada hubungan mereka dengan keluarganya. Untuk setiap pernyataan, terdapat tiga pilihan jawaban: Ya, Tidak, dan Tidak Tahu. Lingkari jawaban yang menurut Anda sesuai. No Pertanyaan 1

Jawaban

Keluarga saya memberi dukungan moral yang Ya=0 Tidak=1 Tidak Tahu=2 saya butuhkan

Saya mengetahui dengan baik bagaimana dan apa Ya=0 Tidak=1 Tidak Tahu=2 yang bisa saya dapatkan dari keluarga saya

Kebanyakan orang lain lebih dekat dengan Ya=0 Tidak=1 Tidak Tahu=2 keluarganya dibanding saya dengan keluarga saya

Ketika saya menceritakan rahasia kepada anggota Ya=0 Tidak=1 Tidak Tahu=2 keluarga yang menurut saya paling dekat dengan saya, saya merasa ia tidak nyaman

Keluarga saya senang mendengarkan apa yang Ya=0 Tidak=1 Tidak Tahu=2 sedang saya pikirkan

Anggota keluarga memiliki banyak minat yang Ya=0 Tidak=1 Tidak Tahu=2 sama dengan saya

Beberapa anggota keluarga mendatangi saya Ya=0 Tidak=1 Tidak Tahu=2 ketika memiliki masalah atau butuh nasihat

Saya bergantung pada keluarga saya untuk Ya=0 Tidak=1 Tidak Tahu=2 dukungan emosional

Terdapat seorang anggota keluarga di keluarga Ya=0 Tidak=1 Tidak Tahu=2 saya yang dapat saya datangi apabila saya merasa sedih, tanpa merasa malu pada akhirnya

Saya dan keluarga saya sangat terbuka mengenai Ya=0 Tidak=1 Tidak Tahu=2 bagaimana kita berpikir mengenai suatu hal

Keluarga saya peka terhadap kebutuhan pribadi Ya=0 Tidak=1 Tidak Tahu=2 saya 22

Anggota keluarga saya mendatangi saya ketika Ya=0 Tidak=1 Tidak Tahu=2 membutuhkan dukungan emosional

Anggota keluarga saya sangat baik dalam Ya=0 Tidak=1 Tidak Tahu=2 membantu saya menyelesaikan masalah

Saya

cenderung

memiliki

hubungan

yang Ya=0 Tidak=1 Tidak Tahu=2

mendalam dengan beberapa anggota keluarga saya 15

Anggota keluarga saya mengetahui dengan baik Ya=0 Tidak=1 Tidak Tahu=2 bagaimana dan apa yang bisa saya dapatkan dari keluarga saya

Ketika saya menceritakan rahasia kepada anggota Ya=0 Tidak=1 Tidak Tahu=2 keluarga saya, saya merasa tidak nyaman

Anggota keluarga saya mencari saya apabila Ya=0 Tidak=1 Tidak Tahu=2 merasa butuh ditemani

Saya berpikir bahwa keluarga saya merasa bahwa Ya=0 Tidak=1 Tidak Tahu=2 saya

baik

dalam

membantu

mereka

menyelesaikan masalah 19

Saya tidak memiliki hubungan dengan anggota Ya=0 Tidak=1 Tidak Tahu=2 keluarga saya yang sedekat hubungan orang lain terhadap keluarganya

Saya berharap memiliki keluarga yang berbeda Ya=0 Tidak=1 Tidak Tahu=2 dari sekarang

Penilaian Kuesioner Pendekatan keluarga tinggi apabila poin dari kuesioner bernilai >15, pendekatan keluarga rendah apabila poin dari kuesioner bernilai <16. Pada nomor selain nomor 3, 4, 16, 19, 20, jawaban “Ya” bernilai +1, jawaban “Tidak” dan “Tidak Tahu” bernilai 0. Pada nomor 3, 4, 16, 19, dan 20, jawaban “Tidak” bernilai +1, jawaban “Ya” dan “Tidak Tahu” bernilai 0.

Kuesioner Aktivitas Fisik (International Physical Activity Questionnaire)16 Pertanyaan di bawah ini adalah pertanyaan seputar aktivitas fisik yang Anda lakukan selama 7 hari terakhir. Jawablah setiap pertanyaan di bawah ini meskipun Anda merasa bahwa Anda bukanlah orang yang aktif. Pikirkan tentang aktivitas fisik yang Anda lakukan di tempat kerja, di rumah dan halaman, untuk bergerak dari satu tempat ke tempat lain, dan pada waktu luang untuk rekreasi atau berolahraga. Ingat kembali semua aktivitas fisik berat yang telah Anda lakukan selama 7 hari terakhir. Aktivitas fisik berat adalah aktivitas yang memerlukan kerja keras dan menyebabkan Anda bernafas jauh lebih cepat daripada biasanya. Pikirkan aktivitas fisik yang telah Anda lakukan selama sekurang-kurangnya 10 menit pada suatu waktu. 1. Selama 7 hari terakhir, berapa hari kah Anda melakukan aktivitas fisik berat seperti mengangkat beban berat, menggali, senam aerobik, atau bersepeda cepat? _______ hari per minggu Tidak ada aktivitas fisik berat, harap lanjutkan ke pertanyaan nomor 3 2. Berapa lama waktu yang biasa Anda gunakan untuk melakukan aktivitas fisik berat tersebut? _______ jam per hari _______ menit per hari (

) Tidak tahu/tidak pasti

Ingat kembali semua aktivitas fisik moderat (sedang) yang telah Anda lakukan selama 7 hari terakhir. Aktivitas fisik moderat adalah aktivitas yang memerlukan kerja fisik sedang dan menyebabkan Anda bernafas agak lebih cepat daripada biasanya. Pikirkan aktivitas fisik yang telah Anda lakukan selama sekurang- kurangnya 10 menit pada suatu waktu. 3. Selama 7 hari terakhir, berapa hari kah Anda melakukan aktivitas fisik moderat seperti mengangkat beban ringan, bersepeda santai, atau bermain tenis berpasangan? Ini tidak termasuk berjalan kaki. _______ hari per minggu Tidak ada aktivitas fisik moderat, harap lanjutkan ke pertanyaan nomor 5

4. Berapa lama waktu yang biasa Anda gunakan untuk melakukan aktivitas fisik moderat tersebut? _______ jam per hari _______ menit per hari (

) Tidak tahu/tidak pasti

Ingat kembali tentang waktu yang Anda gunakan untuk berjalan kaki dalam 7 hari terakhir, termasuk berjalan kaki di tempat kerja, di rumah, berjalan kaki dari satu tempat ke tempat lain, dan berjalan kaki semata-mata untuk rekreasi, olahraga, atau mengisi waktu luang. 5. Selama 7 hari terakhir, berapa hari kah Anda telah berjalan kaki selama sekurang-kurangnya 10 menit? _______ hari per minggu Tidak ada aktivitas berjalan kaki, harap lanjutkan ke pertanyaan nomor 7 6. Berapa lama waktu yang biasa Anda gunakan untuk berjalan kaki dalam satu hari? _______ jam per hari _______ menit per hari (

) Tidak tahu/tidak pasti

Pertanyaan terakhir adalah mengenai waktu yang Anda gunakan untuk duduk dalam sehari selama 7 hari terakhir. Termasuk waktu yang digunakan duduk di tempat kerja, di rumah, saat belajar, dan selama waktu luang. Waktu ini juga termasuk waktu yang digunakan duduk di kursi, duduk saat mengunjungi teman-teman, membaca, atau berbaring sambil menonton televisi. 7. Selama 7 hari terakhir, berapa banyak waktu yang Anda gunakan untuk duduk dalam satu hari? _______ jam per hari _______ menit per hari (

) Tidak tahu/tidak pasti

Penilaian Kuesioner Nilai aktivitas fisik tinggi berarti tingkat aktivitas fisik yang dilakukan setara dengan kurang lebih satu jam aktivitas per harinya atau lebih dengan intensitas aktivitas fisik minimal sedang. Skor tinggi dipenuhi apabila: - Aktivitas fisik berat minimal 3 hari dengan total paling tidak 1500 MET menit per minggu atau - Kombinasi dari berjalan, aktivitas fisik sedang atau berat dengan total paling tidak 3000 MET menit per minggu Nilai aktivitas fisik sedang berarti tingkat aktivitas fisik yang dilakukan setara dengan kurang lebih setengah jam aktivitas fisik sedang. Skor sedang dipenuhi apabila: - Aktivitas fisik berat selama 3 hari atau lebih dan/atau berjalan paling tidak 30 menit per hari atau - Aktivitas fisik sedang selama 5 hari atau lebih dan/atau berjalan paling tidak 30 menit per hari atau - Kombinasi dari berjalan, aktivitas fisik sedang atau berat selama 5 hari atau lebih paling tidak 600 MET menit per minggu Nilai aktivitas fisik rendah berarti tingkat aktivitas fisik yang dilakukan tidak memenuhi kriteria aktivitas fisik sedang maupun berat. Keterangan: aktivitas kurang dari 10 menit tidak dihitung Cara Menghitung - Konversi seluruh durasi aktivitas fisik menjadi satuan menit - Aktivitas fisik lebih dari 3 jam dipotong, sehingga maksimal durasi aktivitas fisik setiap minggunya adalah 21 jam (3 jam x 7 hari) - Untuk MET menit per minggu, kalikan durasi menit sesuai dengan nilai MET sebagai berikut. Berjalan = 3,3; aktivitas fisik sedang = 4; aktivitas fisik berat = 8 - Nilai MET menit dapat dijumlahkan pada setiap kategori untuk mendapat total MET menit per minggu 26

Budget Penelitian Pengeluaran Penelitian Uraian

Vol

Satuan volume

Harga satuan

Subtotal

Total

Cetak Informed Consent

dan

100

paket

Rp5,000.00

Rp500,000.00

100

unit

Rp5,000.00

Rp500,000.00

Kuesioner Souvenir Responden

Total Pengeluaran Penelitian

Rp1,000,000.00

Timeline Penelitian No

Kegiatan

September 2018

Oktober 2018

Timeline November Desember Januari Februari 2018 2018 2019 2019

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1 Penyusunan Proposal Konsultasi dengan Dosen 2 Pembimbing 3 Proposal Final 4 Pengumpulan data 5 Pengolahan Data 6 Penafsiran Data

PENGARUH AIR JAHE (ZINGIBER OFFICINALE) DAN AIR CENGKEH (SYZYGIUM AROMATICUM) TERHADAP POST-TRAUMATIC STRESS DISORDER

Diajukan untuk mengikuti lomba Proposal Riset Nasional AMSA-Indonesia

Disusun oleh: VALENTINO RYU YUDIANTO 1706029754 SEAN ALEXANDER LEE TZIEN YI 1706030011 KEVIN WIJAYA 1706030062 AMSA-UNIVERSITAS INDONESIA

ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION-INDONESIA 2018

LEMBAR PENGESAHAN

Judul Karya Tulis: PENGARUH AIR JAHE (ZINGIBER OFFICINALE) DAN AIR CENGKEH (SYZYGIUM AROMATICUM) TERHADAP POST-TRAUMATIC STRESS DISORDER

Disusun untuk mengikuti lomba Proposal Riset Nasional AMSA-Indonesia

Oleh: Ketua Tim Peneliti

Representative AMSA-UI

(Valentino Ryu Yudianto)

Dosen Pembimbing

(Bintang Wirawan)

Wakil Dekan Bidang Kemahasiswaan

(Dr. Drs. Kusmardi M.S.)

(Dr. dr. Dwiana Ocviyanti, SpOG(K))

HALAMAN PERNYATAAN ORISINALITAS

Proposal ini merupakan hasil karya yang murni dibuat oleh tim penyusun. Semua sumber, kutipan, dan rujukan telah kami nyatakan dengan benar.

Depok, 12 Oktober 2018

Tim peneliti,

- tanda tangan - tanda tangan (Valentino Ryu Y.)

(Sean Alexander L. T. Y.)

(Kevin Wijaya)

iii

KATA PENGANTAR Puji syukur kami panjatkan kepada Tuhan Yang Maha Esa karena atas rahmat-Nya. kami dapat menyelesaikan penyusunan proposal penelitian yang berjudul â&#x20AC;&#x153;Pengaruh Air Jahe (Zingiber officinale) dan Air Cengkeh (Syzygium aromaticum) terhadap Post-Traumatic Stress Disorderâ&#x20AC;? ini. Proposal ini pada faktanya tidak mungkin akan selesai tanpa bantuan dari berbagai pihak. Adanya dukungan dari keluarga, teman, sahabat, sarana dan prasarana fakultas, serta tentunya bimbingan dari Dr. Drs. Kusmardi M.S yang membantu kelancaran penyusunan proposal penelitian ini sehingga dapat selesai tepat waktu. Maka dari itu, kami mengucapkan terima kasih yang sebesar-besarnya kepada semua pihak yang telah memberikan kami bantuan, baik dalam bentuk waktu, materi, ruang, ataupun tenaga. Harapan kami atas proposal penelitian ini adalah dapat dilaksanakan dengan baik dan dapat menjadi karya yang bermanfaat bagi orang lain, terutama mereka yang mengidap Post-Traumatic Stress Disorder. Di samping itu, kami juga berharap agar proposal ini mampu mendapatkan pendanaan yang sesuai sehingga penelitian ini dapat berjalan dengan lancar. Besar harapan kami agar hasil penelitian ini dapat dijadikan acuan bagi penelitian-penelitian di masa mendatang yang sekiranya membutuhkan data hasil penelitian ini. Akhir kata, kami memohon maaf apabila terdapat kekurangan dalam penyusunan proposal ini. Oleh sebab itu, kami menerima kritik dan saran yang sekiranya hendak disampaikan demi terwujudnya penelitian yang lebih baik. Depok, 12 Oktober 2018

Tim Penyusun

DAFTAR ISI LEMBAR PENGESAHAN ...................................................................................ii HALAMAN PERNYATAAN ORISINALITAS ............................................... iii KATA PENGANTAR........................................................................................... iv DAFTAR ISI .......................................................................................................... v 1. PENDAHULUAN ............................................................................................ 1 1.1. Latar Belakang ............................................................................................ 1 1.2. Identifikasi Masalah.................................................................................... 3 1.3. Pertanyaan Penelitian.................................................................................. 3 1.4. Hipotesis ..................................................................................................... 3 1.5. Tujuan Penelitian ........................................................................................ 3 1.6. Manfaat Penelitian ...................................................................................... 4 2. TINJAUAN PUSTAKA ................................................................................... 5 2.1. PTSD ........................................................................................................... 5 2.2. Pengaruh Jahe terhadap PTSD .................................................................... 8 2.3. Pengaruh Cengkeh terhadap PTSD ............................................................. 9 2.4. Kerangka Teori ......................................................................................... 11 2.5. Kerangka Konsep ...................................................................................... 12 3. METODE PENELITIAN .............................................................................. 13 3.1. Desain Penelitian ...................................................................................... 13 3.2. Populasi dan Sampel ................................................................................. 13 3.3. Besar Sampel ............................................................................................ 14 3.4. Variabel Penelitian .................................................................................... 14 3.5. Teknik Pengumpulan Data ........................................................................ 14 3.6. Prosedur Kerja .......................................................................................... 15 3.7. Definisi Operasional ................................................................................. 16 3.8. Analisis Statistik ....................................................................................... 17 3.9. Etika Penelitian ......................................................................................... 17 3.10. Jadwal Penelitian .................................................................................... 18 3.11. Rencana Anggaran .................................................................................. 18 DAFTAR PUSTAKA ........................................................................................... 19

BAB I PENDAHULUAN 1.1 Latar Belakang Post-Traumatic Stress Disorder (PTSD) merupakan sebuah gangguan yang diidap orang-orang yang memiliki pengalaman traumatis terkait kejadian yang menakutkan, mengejutkan, atau berbahaya.1 Pengalaman traumatis ini mencakup pengalaman yang dialami langsung dan pengalaman yang disaksikan. Tidak semua orang yang mengalami Post-Traumatic Stress (PTS) mengidap PTSD. Hanya mereka yang menimbulkan gejala atau symptom tertentu akibat PTS tersebut yang dapat dicap mengidap PTSD.1,2 Pada tahun 2005, World Health Organization menyatakan jumlah penderita PTSD mencapai 3.230.000 orang, dengan persentase 0,2% dari seluruh angka orang sakit di dunia. Distirbusi PTSD sebanyak 28,5% terdapat di Pasifik Barat; 27,4% di Asia Tenggara; 14,2%di Eropa; 12,6% di Amerika; 9,3% di Afrika dan 8,0% di Mediterania Timur. Sementara itu, di Indonesia sendiri, belum ada data yang secara menyeluruh mengukur prevalensi pasien pengidap PTSD. Berdasarkan penelitian yang dilakukan oleh Universitas Pendidikan Indonesia pada tahun 2016, dengan subjek anak dan remaja dengan rentang usia 8 sampai 17 tahun, 171 dari 859 anak memenuhi kriteria PTSD berdasarkan instrument Downs Posttraumatic Stress Scale. Sementara itu, berdasarkan Survei Kesehatan Rumah Tangga pada tahun 2005, 140 dari 1000 penduduk Indonesia mengalami gangguan kejiwaan, dimana 23%nya adalah PTSD.2,3.4 PTSD yang merupakan gangguan psikis di Indonesia seringkali dianggap sepele dalam stigma masyarakat. Banyak yang menganggap bahwa gangguan psikis tidak akan menimbulkan dampak buruk yang cukup besar dan para pengidap gangguan dapat sembuh dengan sendirinya. Masyarakat juga seringkali menganggap bahwa para pengidap gangguan psikis hanya melebih-lebihkan penyakitnya dan tidak jarang dituduh berbohong. Hal ini dapat disebabkan oleh kurangnya pengetahuan masyarakat Indonesia mengenai gangguan mental sehingga mereka yang mengalaminya seringkali tidak mendapatkan pengobatan yang serius dan sesuai.

Hal ini terbukti dengan banyaknya orang yang belum mengetahui apa itu PTSD dan bagaimana PTSD bekerja dalam kesehatan mental korban. Sampai saat ini, Indonesia juga belum mengaplikasikan instrumen penilaian PTSD yang sah, sehingga

asesmen

mengenai

data

prevalensi

pengidap

PTSD

belum

diselenggarakan seara maksimal. Jika hal ini terus dibiarkan, mereka yang mengidap PTSD tidak akan terurus dengan benar dan dapat mengarah pada dampak yang sangat serius, seperti bunuh diri.4,5 Di lain sisi, beberapa orang yang mengetahui apa itu PTSD memiliki sudut pandang bahwa pengobatan PTSD membutuhkan biaya yang cukup besar dan merepotkan. Oleh karena sudut pandang inilah, kami memutuskan untuk melakukan penelitian ini. Kami ingin menelaah apakah konsumsi air jahe dan air cengkeh dapat memberikan dampak positif bagi pengidap PTSD dan membandingkan efek yang ditimbulkan bagi kondisi pengidap PTSD dari keduanya. Selama ini, jahe dan cengkeh telah terbukti menjadi salah satu bahan pangan yang kaya akan antioksidan. Salah satu antioksidan jahe yang paling dikenal adalah gingerol. Gingerol dapat menjaga kerja fisiologis tubuh dari serangan radikal bebas. Begitu pula halnya dengan Euginol, salah satu antioksidan cengkeh yang cukup tersohor. Perlindungan antioksidatif ini berpotensi mempengaruhi patofisiologi PTSD. Air jahe dan air cengkeh juga memberikan banyak dampak lain bagi tubuh, seperti rasa hangat yang kemudian menimbulkan rasa rileks dan mengurangi depresi. Aroma rempah-rempah juga dipercaya dapat menstimulasi pengeluaran neurotransmitter dopamin serta serotonin dalam persinyalan yang berperan dalam memberikan rasa kebahagiaan dan mengurangi rasa stres. Kebanyakan Cengkeh dan jahe merupakan bahan yang mudah didapatkan di Indonesia dengan harga yang relatif terjangkau. Pembuatan air jahe dan air cengkeh juga tentunya bukan sesuatu yang merepotkan, mengingat bahan tersebut hanya perlu diseduh dengan air panas. Apabila penelitian ini menunjukkan suatu pengaruh positif yang signifikan, konsumsi air jahe dan air jahe dapat diaplikasikan dalam pengobatan pasien pengidap PTSD. Dengan demikian, masyarakatpun dapat mengganti stigma yang menyatakan bahwa pengobatan PTSD merupakan hal

yahng merepotkan dan menaruh perhatian lebih terhadap pasien pengidap PTSD.611

1.2 Identifikasi Masalah Pengobatan terhadap PTSD di Indonesia masih belum mendapatkan perhatian khusus. Salah satu faktor yang menyebabkan hal tersebut adalah karena PTSD masih dianggap remeh oleh berbagai kalangan masyarakat. Mereka menganggap bahwa gangguan psikis tidak akan memengaruhi kehidupan seseorang dan mereka yang mengalaminya akan sembuh dengan sendirinya seiring dengan berjalannya waktu. Faktor lainnya adalah karena adanya stigma yang menganggap bahwa medikasi seperti psikoterapi terhadap para pengidap gangguan mental, termasuk PTSD, akan memakan banyak waktu dan biaya. Oleh karena itu, peneliti ingin menunjukkan pengobatan alternatif dengan menggunakan bahan yang murah dan mudah didapat seperti cengkeh dan jahe. 1.3 Rumusan Masalah Berdasarkan identifikasi masalah yang telah dipaparkan di atas, pertanyaan yang dapat dirumuskan adalah â&#x20AC;&#x153;Bagaimana pengaruh air cengkeh dan air jahe terhadap PTSD?â&#x20AC;? 1.4 Hipotesis Air cengkeh dan air jahe memiliki potensi untuk mengurangi severity gejala Post-Traumatic Stress Disease. 1.5 Tujuan 1.5.1

Tujuan Umum Mengetahui manfaat pemberian air cengkeh dan air jahe terhadap PTSD

1.5.2

Tujuan Khusus 1. Mengetahui mekanisme kimiawi yang terjadi dalam tubuh pengidap PTSD setelah dan sebelum pemberian air cengkeh terhadap PTSD 2. Mengetahui mekanisme kimiawi yang terjadi dalam tubuh pengidap PTSD setelah dan sebelum pemberian air jahe terhadap PTSD

3. Mengetahui gejala yang terlihat setelah dan sebelum pemberian air cengkeh terhadap PTSD 4. Mengetahui gejala yang terlihat setelah dan sebelum pemberian air jahe terhadap PTSD 1.6 Manfaat 1.6.1 Manfaat Aplikatif Meningkatkan pemahaman masyarakat akan efektivitas air jahe serta air cengkeh bagi perkembangan kesembuhan pasien pengidap PTSD sehingga dapat diaplikasikan pada pengidap PTSD 1.6.2 Manfaat Keilmuan Menjadi acuan untuk kajian lebih lanjut mengenai substansi dalam cengkeh dan jahe yang berperan penting dalam fungsi fisiologis manusia 1.6.3 Manfaat Penelitian Menjadi dasar rujukan bagi penelitian lainnya yang berhubungan dengan dampak cengkeh dan jahe terhadap penderita PTSD.

BAB II TINJAUAN PUSTAKA 2.1. Post-Traumatic Stress Disease 2.1.1. Definisi Post-Traumatic Stress Disease PTSD merupakan sebuah gangguan kesehatan mental yang diidap oleh orang-orang yang pernah mengalami atau menyaksikan sebuah kejadian yang berbahaya atau menakutkan seperti kekerasan seksual, bencana alam, peperangan, kecelakaan, dan sebagainya. Rasa takut yang dialami orang-orang tersebut setelah kejadian traumatik merupakan sebuah hal yang normal. Rasa takut akan memicu tubuh untuk melakukan respons â&#x20AC;&#x153;fight or flightâ&#x20AC;? yang berguna untuk mempertahankan diri. Hampir semua orang akan mengalami serangkaian reaksi atau respons lanjutan setelah kejadian traumatik dan sebagian besar dari mereka akan secara progresif merasa lebih baik dan pada akhirnya kembali ke keadaan normal. Reaksi yang berlangsung terus-menerus tersebut dapat berujung pada PTSD. Mereka yang mengidap PTSD aakan merasa takut atau stres bahkan ketika mereka tidak sedang dalam bahaya.1,12,13 PTSD memiliki klasifikasi yang didasarkan pada severity gejala yang ditimbulkan. Salah satu sistem klasifikasi PTSD adalah Clinican Administrated PTSD Scale (CAPS). Sistem CAPS berupa pertanyaan-pertanyaan terkait durasi gejala, kesulitan subjektif, dampak gejala terhadap kehidupan sosial dan pekerjaan, validitas respons secara keseluruhan, severity PTSD secara keseluruhan, serta spesifikasi pada perilaku disosiatif.14,15

Table 2.1. Clinican Administrated PTSD Scale (CAPS) 2.1.2. Faktor Risiko PTSD Faktor risiko dari PTSD terbagi menjadi dua jenis, yakni faktor eksternal dan faktor internal. Faktor eksternal dapat terjadi karena adanya kerjadian traumatik 5

seperti peperangan, bencana alam, kekerasan, dan kecelakaan.16 Trauma yang dialami oleh seseorang harus memiliki pengaruh yang besar dan kuat terhadap kondisi psikososial korban agar dapat berkembang menjadi PTSD. Di samping itu, jenis kelamin juga berperan sebagai faktor kerentanan seseorang untuk mengidap PTSD. Data menunjukkan bahwa wanita lebih banyak mengalami kejadian traumatik yang memiliki pengaruh yang kuat, seperti kekerasan atau pemerkosaan.17,18 Sementara itu, faktor internal terjadinya PTSD adalah faktor genetik. PTSD memiliki korelasi yang erat dengan sistem saraf pusat. Mutasi yang mempengaruhi sistem kerja otak dapat menyebabkan munculnya PTSD ini.19 Alkohol atau obatobatan tertentu mampu memnyebabkan mutasi hingga 40%.20 Di samping itu, Sebuah penelitian menunjukkan bahwa orang dengan ukuran hippocampus yang kecil lebih berpotensi untuk mengidap PTSD dibandingkan mereka yang memiliki hippocampus yang normal.19 2.1.3. Gejala PTSD Gejala yang timbul pada pengidap PTSD biasanya muncul sekitar tiga bulan setelah kejadian traumatik. Namun, gejala tersebut juga dapat muncul setelah bertahun-tahun. Gejala yang ditimbulkan harus muncul minimal selama satu bulan dan memiliki pengaruh yanag cukup besar dalam hubungan atau pekerjaan korban agar bisa dikatakan sebagai PTSD. Gejala PTSD dalam satu bulan mencakup satu gejala mengalami kembali kejadian traumatik, seperti kilas balik, mimpi buruk, atau pemikiran yang menakutkan; satu gejala penghindaran, seperti menghindar dari tempat yang berkaitan dengan kejadian atau menghindari kenangan dan perasaan yang berkaitan dengan kejadian; dua gejala reaktivitas, seperti mudah tersinggung, merasa tegang, sulit tidur, atau marah secara belebihan; serta dua gejala kognisi dan suasana hati, seperti kesulitan mengingat fitur utama kejadian traumatik, pikiran negatif terhadap diri sendiri dan dunia, perasaan bersalah, atau kehilangan minat dalam aktivitas yang digemarinya.1,19 Pada anak-anak usia lima tahun ke atas dan remaja, reaksi yang ditimbulkan terhadap kejadian traumatik biasanya terjadi lebih ekstrem dibandingkan pada orang dewasa. Gejala yang muncul juga dapat berbeda dari gejala yang ditimbulkan

oleh orang dewasa, walaupun sebagian besar serupa. Perilaku dekstruktif, kasar, dan tidak sopan dapat berkembang. Perasaan membalas dendam juga mungkin tumbuh dalam diri mereka. Sementara itu, pada balita, gejala PTSD meliputi memeragakan kejadian mengerikan ketika bermain, cenderung terus menempel pada orang tua, lupa cara berbicara, atau mengompol setelah diajarkan buang air di toilet.1 2.1.4. Patofisiologi PTSD Mekanisme kimiawi dalam fisiologi tubuh pengidap PTSD mencakup intervensi pada berbagai sistem fungsional tubuh. Kerja sistem yang membedakan pengidap PTSD dengan orang normal salah satunya adalah sistem noradrenergik. Adrenoreseptor, sebuah reseptor yang termasuk dalam kelas G protein-coupled receptor (GPCR), menstimulasi aktivitas sistem saraf pusat dan respons otonom simpatik dengan memproyeksikannya pada korteks prefrontal dan sistem limbik, seperti amigdala dan hipotalamus, sehingga berperan dalam respons yang berhubungan dengan rasa takut dan stres.21,22,23 Para pengidap PTSD diketahui mengalami disregulasi pada sistem ini yang berdampak pada kondisi psikiatrik seperti depresi berat atau gangguan kecemasan.21 Selain itu, pengidap PTSD juga diketahui mengalami penurunan kemampuan kerja Noradrenaline Transporter (NET). NET merupakan sebuah transporter neurotransmitter yang banyak terletak di locus coeruleus. NET berperan dalam penyimpanan noradrenalin presinaptik dan meregulasi penyimpanan dopamin.24 Disregulasi pada NET dapat menyebabkan gangguan mood dan stress.24,24 Komponen fisiologis lain yang mengalami gangguan pada pengidap PTSD adalah reseptor serotonergik (5-HT). 5-HT merupakan anggota kelas GPCR yang terbagi menjadi tujuh kelas, yaitu 5-HT1 sampai 5-HT7. Kelas yang paling berpengaruh dalam PTSD adalah 5-HT1 dengan subkelas 5-HT1A dan 5-HT1B. Proses persinyalan yang melibatkan 5-HT diketahui memiliki kaitan dengan regulasi rasa takut dan terancam di amigdala. Agonis 5-HT secara selektif juga diketahui dapat menginduksi kecemasan dan menimbulkan kilas balik yang terasosiasi dengan kejadian traumatik. 5-HT1A dapat menstimulasi pelepasan trophic-factor S-100Î˛ yang berperan dalam perkembangan sistem serotonergik.

Abnormalitas neuropatologik yang muncul di sistem limbik dan paralimbik seringkali diasosiasikan dengan gangguan pada reseptor 5-HT1A ini. Sementara itu, reseptor 5-HT1B berperan dalam mengatur jalur berbagai neurotransmitter seperti GABA, noradrenalin, asetilkolin, dopamin, dan glutamate. Reseptor 5-HT1B memegang peranan dalam aktivitas lokomotor, perilaku apetitif (seksual, makan), tidur, dan agresi. Para pengidap PTSD diketahui mengalami penurunan kemampuan mengikat atau perubahan konformasi pada reseptor ini. 26-28 Beberapa bukti lain juga menunjukkan bahwa reseptor kanaboid (CB1 dan CB2) memiliki peranan penting dalam PTSD.29 CB1 dapat ditemukan sepanjang sistem limbik dalam jumlah sedang sampai banyak. CB1 diketahui berfungsi untuk memodulasi kecemasan, stres, memori, mood, maupun rasa takut.29,30 Disrupsi genetik atau farmakologis yang mengganggu persinyalan CB1 dapat menimbulkan rasa cemas dan tidak terkontrolnya memori aversif.30 Gangguan persinyalan pada aksis Hipotalamus â&#x20AC;&#x201C; Pituitari â&#x20AC;&#x201C; Adrenalin juga dapat menimbulkan gejala PTSD. Salah satu zat yang menjalani rangkaian proses melalui aksis ini adalah corticotropin-releasing factor (CRF). Jumlah CRF yang tinggi pada saat kejadian traumatik dipercaya dapat memperkuat memori traumatik serta rasa cemas. Gangguan pada reseptor CRF-1 menunjukkan berkurangnya respons stres dan perilaku cemas, sementara gangguan pada reseptor CRF-2 menunjukkan meningkatnya kecemasan dan hipersensitivitas terhadap stres.29.30 2.2. Pengaruh Jahe terhadap PTSD 2.2.1. Komposisi dan Nutrisi Jahe Kandungan zat terbanyak dalam jahe adalah air. Dari enam gram jahe, sekitar 4.73 gramnya adalah air. Makronutrien yang terdapat paling banyak pada jahe adalah karbohidrat sebanyak 1.07 gram. Jahe jujga kaya akan berbagai mikronutrien, seperti vitamin C, kolin, folat, kalsium, magnesium, potassium, dan fosfor. Selain itu, komponen fenolik pun banyak terdapat di jahe, seperti ginerol, shogaol, paradol, zerumbon, dan komponen phenolic volatile oils.6

2.2.2. Pengaruh Jahe terhadap Fungsi Fisiologis Tubuh Manusia Jahe memiliki banyak khasiat bagi tubuh. Shogaol dan Zingeron memiliki peran penting dalam mengurangi stres oksidatif karena sifatnya sebagai antioksidan. Sementara itu, ginerol, shogaol, dan substansi lainnya yang memiliki kemiripan struktur juga berperan dalam antiinflamasi. Substansi-substansi tersebut dipercaya dapat menginhibisi kerja leukotrien dan prostaglandin serta menghambat sintesis sitoken pro-inflamasi sehingga menyebabkan terhambatnya respons inflamasi. Dalam efek antikanker, substansi yang berperan adalah ginerol, shogaol, paradol, dan zerumbon yang mampu menghambat proliferasi sel karsinoma dengan menggangu jalur transduksi sinyal sel. Efek positif konsumsi jahe lainnya adalah jahe secara signifikan dapat mengurangi kadar gula darah, kolesterol serum total, trigliserida, HDL dan LDL yang menumpuk dalam darah. Regulasi kadar gula darah dan kolesterol dari konsumsi jahe menyebabkan lancarnya aliran darah menuju otak, sehinga membuat manusia merasa lebih santai dan stres berkurang. Jahe juga dipercaya berperan dalam peningkatan pelepasan serotonin dan dopamin serta menjaga kedua reseptor neurotransmitter tersebut dengan cara menangkal kerusakan oksidatif melalui komponen antioksidannya. Rasa hangat dan aroma yang dihasilkan oleh jahe pun telah terbukti berpengaruh dalam mengurangi rasa stres.6-8 2.3. Pengaruh Cengkeh terhadap PTSD 2.3.1. Komposisi dan Nutrisi Cengkeh Nutrisi yang terkandung dalam seratus gram cengkeh meliputi 65 gram karbohidrat, enam gram protein, 13 gram lemak total, 33 gram serat, serta mineralmineralnya antara lain kalsium, magnesium, fosfor, potassium, sodium, dan zat besi.6,9 Vitamin yang banyak ditemukan di cengkeh adalah vitamin C, thiamin, vitamin A, vitamin D, vitamin E, dan vitamin K, riboflavin, folat, vitamin B6, dan vitamin B12.6,10 Beberapa komponen bioaktif yang terkandung dalam cengkeh meliputi flavonoid, ethanol, hexane, thymol, eugenol, metil klorida, serta komponen polifenol lainnya yang berperan sebagai antioksidan, antimikroba, maupun antiinfllamasi.6,9,10

2.3.2. Pengaruh Cengkeh terhadap Fungsi Fisiologis Tubuh Manusia Cengkeh merupakan bahan rempah yang paling banyak mengandung senyawa polifenol.11 Jenis yang paling banyak ditemukan adalah asam galat, phenolic volatile oils (eugenol, asetil eugenol), flavonol glukosida, serta tanin. Senyawa ini berperan sebagai antioksidan dengan berperan sebagai reduktor, donator atom hidrogen, serta memangsa singlet oksigen.32 Contohnya adalah eugenol yang memiliki konjugasi rantai karbon dengan cincin aromatik dapat mendonasikan atom hidrogen dan menstabilisasi fenoksil radikal melalui resonansi. Di samping itu, eugenol juga berperan sebagai antibakteri. Eugenol dapat membuat spora dan misel lisis melalui deformasi ataupun disrupsi pada makromolekul membran bakteri.34,35 Pada virus, euginiin, salah satu substansi cengkeh lainnya, memiliki peranan dalam menghambat sintesis DNA virus melalui inhibisi sintesis DNA polymerase. Hal ini membuktikan bahwa cengkeh bersifat antivirus. Cengkeh juga dipercaya dapat berperan sebagai penahan sakit. Aktivasi kanal kalsium dan klorida pada ganglion diperkirakan menjadi faktor adanya sifat analgesik cengkeh ini.36,37

2.4. Kerangka Teori

Jenis Kelam

Faktor Genetik

Penurunan severity gejala

Internal Pemberian Air Jahe dan Air Cengkeh

PTSD

Eksternal

Peperangan

Kenaikan severity gejala Kecelakaan

Bencana Alam

Perubahan Gejala

Kecelakaan

2.5. Kerangka Konsep Variabel Terikat

Variabel Bebas • •

•

Air Jahe Air Cengkeh

Variabel Perancu • •

Usia Jenis Kelamin

Perubahan gejala PTSD

BAB III METODE PENELITIAN 3.1. Desain Penelitian Desain penelitian yang diambil dalam penelitian ini adalah Randomized Control Trial atau RCT. Alasan peneliti memilih desain ini adalah karena dirasa paling baik untuk melihat pengaruh intervensi yang diberikan pada sampel dan kemungkinan adanya bias dari pengambilan data juga minimal. 3.2. Populasi dan Subjek Penelitian 3.2.1. Populasi Populasi dalam penelitian ini adalah pasien pengidap PTSD di Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo (RSCM). 3.2.2. Subjek Sampel adalah bagian dari populasi yang memenuhi kriteria inklusi. Sampel akan diambil dengan menggunakan metode Simple Random Sampling (SRS). Pasien pengidap PTSD di RSCM diambil sebagai sampel karena RSCM merupakan salah satu rumah sakit dengan jumlah pasien pengidap PTSD yang cukup banyak. Selain itu, RSCM juga dipilih karena lokasinya yang mudah diakses dari domisili peneliti. 3.2.2.1.Kriteria Inklusi Pasien pengidap PTSD di RSCM dengan usia di atas 13 tahun yang telah setuju untuk dijadikan responden dalam penelitian ini dan untuk diberikan intervensi 3.2.2.2. Kriteria Eksklusi Pasien pengidap PTSD di luar RSCM atau pasien pengidap PTSD yang memiliki alergi atau hipersentivitas terhadap jahe maupun cengkeh dan pasien PTSD yang masih berusia di bawah 13 tahun.

3.3. Besar Sampel Besar sampel minimum yang digunakan untuk penelitian ini dihitung dengan rumus sebagai berikut: [$â&#x2C6;? 2PQ + $+ ,- .- + ,/ ./ ]/ != (,- â&#x2C6;&#x2019; ,/ )/ N = Jumlah subjek penelitian $â&#x2C6;? = Tingkat Kemaknaan (ditetapkan) $+ = Power (ditetapkan) ,- = Proporsi pengidap PTSD (pustaka) ,/ = Proporsi efek air cengkeh dan jahe terhadap PTSD (clinical judgement) [1,96 2(0,4995)(0,5005) + 0,895 (0,199) 0,801) + (0,8)(0,2 ]/ != (0,4995 â&#x2C6;&#x2019; 0,8000)/ ! = 39,63 = 40 (dibulatkan) 3.4. Variabel Penelitian 3.4.1. Variabel Dependen Variabel dependen dalam penelitian ini adalah perubahan gejala yang dialami oleh pengidap PTSD 3.4.2. Variabel Independen Variabel independen dalam penelitian ini adalah konsumsi air jahe dan air cengkeh pada pengidap PTSD 3.4.3. Variabel Perancu Variabel Perancu dalam penelitian ini adalah usia dan jenis kelamin subjek 3.5. Teknik Pengumpulan Data 3.5.1. Sumber dan Jenis Data Sumber data dalam penelitian ini merupakan data primer yang didapatkan melalui pendataan gejala-gejala yang muncul setelah

diberikan

variabel

independen

sesuai

dengan

Clinician-

Administered PTSD Scale 3.5.2. Cara Pengumpulan Data Pengumpulan data akan dilakukan melalui pertemuan dengan responden. Peneliti kemudian akan menanyakan pasien perubahan gejala yang terjadi setelah pemberian air jahe dan air cengkeh dan mendatanya. 3.5.3. Persiapan Pengumpulan Data 1. Menyiapkan Clinician-Administered PTSD Scale 2. Mengurus perizinan kepada pihak RSCM untuk melakukan penelitian dalam rangka mencari responden untuk penelitian ini 3. Mempersiapkan kuesioner etik penelitian 3.5.4. Prosedur Pengumpulan Data Pengumpulan data berupa tanya jawab yang antara peneliti dan responden. 3.6. Prosedur Kerja Sebelum mengumpulkan data dari sampel penelitian, yaitu penderita PostTraumatic Stress Disease di Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo, peneliti akan memberikan surat pengantar terlebih dahulu kepada responden. Setelah itu, responden yang bersedia untuk dijadikan sampel akan diberikan lembar persetujuan untuk mengonfirmasi bahwa mereka setuju untuk berpartisipasi dalam penelitian ini. Sampel akan dibagi menjadi dua kelompok, yaitu kelompok yang diberikan air jahe dan kelompok yang diberikan air cengkeh. Data akan diambil seminggu setelah responden diberikan intervensi, yakni konsumsi air jahe atau air cengkeh. Sebelumnya, peneliti akan menemui responden terlebih dahulu untuk memberikan air jahe dan air cengkeh serta memastikan bahwa responden telah mengonsumsinya. Apabila responden sekiranya tidak dapat atau tidak bersedia untuk ditemui, maka air jahe atau air cengkeh dapat dibuat sendiri oleh responden dengan takaran serta cara pembuatan yang sama seperti yang dibuat oleh peneliti. Untuk kelompok yang diberikan air jahe, pembuatan air jahe akan

dilakukan dengan cara sebagai berikut. Pertama, mempersiapkan bahan, yakni 5 ruas jahe (2 cm) yang telah diparut dan 500 ml air. Selanjutnya, rebus jahe selama 5 menit dengan suhu 60-70 derajat celsius. Air tidak boleh direbus hingga mendidih karena kandungan senyawa aktif pada jahe dapat rusak pada suhu yang terlalu tinggi. Setelah 5 menit, air rebusan didiamkan selama 3 menit agar air rebusan tidak terlalu panas. Setelah didiamkan selama 3 menit, air jahe dapat dikonsumsi. Air jahe dikonsumsi sehari sekali setelah sarapan. Untuk kelompok yang diberikan air cengkeh, pembuatan air cengkeh dapat dilakukan dengan cara sebagai berikut. Pertama, menyiapkan bahan yakni 1 sdt cengkeh dan 500 ml air. Selanjutnya, air direbus dengan cengkeh selema 5 menit pada suhu 60-70 derajat celsius. Setelah 5 menit, air rebusan didiamkan selama 3 menit sampai suhunya menurun. Setelah itu, air cengkeh dapat dikonsumsi oleh responden. Air cengkeh dikonsumsi sehari sekali setelah sarapan. Setiap harinya, peneliti akan memantau gejala yang muncul pada responden dan mendatanya. Peneliti akan menanyakan apakah gejala-gejala yang terdaftar pada CAPS muncul pada responden dan menilai tingkat severity-nya sesuai dengan skala yang telah ditetapkan. Proses ini akan dilakukan selama dua minggu hingga akhirnya data akan diproses serta dianalisis. 3.7. Definisi Operasional Variabel

Definisi

Cara Ukur

Operasional

Pedoman

Hasil Ukur

Pengukuran

Ukur

Perubahan

Perbedaan

Memantau

Clinician-

Gejala

gejala yang

tingkat

Administered ada

muncul antara

keparahan

PTSD Scale

Skor 1: Mild /

setelah dan

atau severity

(CAPS)

Subthreshold

sebelum

rating gejala

Skor 2:

diberikan air

PTSD yang

Moderate /

jahe dan air

muncul

Threshold

cengkeh

Skala

Skor 0: Tidak

Ordinal

Skor 3: Severe / markedly elevated Skor 4: Extreme / incapacitating Konsumsi

Konsumsi air

Memberikan

Air Jahe

yang direbus

air jahe

dengan jahe

kepada

selama dua

pasien sekali

minggu

sehari

Konsumsi

Konsumsi air

Memberikan

Air

yang direbus

air cengkeh

Cengkeh

dengan

kepada

cengkeh

pasien sekali

selama dua

sehari

Nominal

minggu 3.8. Analisis Statistik Pengolahan dan analisis data akan dilakukan dengan tes Pearson hi-square melalui SPSS for Windows. Hipotesis nol (H0) akan ditolak dengan p-Value < Îą (0,05), dengan interval kepercayaan sebesar 95%. Besar kekuatan uji klinis yang diharapkan adalah 80% 3.9. Etika Penelitian Pelaksanaan penelitian ini didasarkan pada etika penelitian. Bentuk etika penelitian yang utama adalah melindungi serta menghormati hak pasien untuk mengikuti maupun berhenti menjadi bagian dari penelitian dan menjaga segala kerahasiaan identitas subjek penelitian dengan tidak menyebutkan nama pasien pada hasil dan analisis data. Instrumen penelitian jahe dan cengkeh diberikan secukupnya dengan tidak berlebihan maupun kekurangan. Penelitian ini hanya dilakukan jika pasien telah setuju untuk menandatangani perjanjian setelah diberikan informed consent.

3.10.

Jadwal Penelitian

Kegiatan

Mei

Juni

Juli

Agustus

September Oktober

Revisi Proposal Penelitian Pembuatan Instrumen Pengumpulan Data Pengolahan Data Pembahasan Penulisan Laporan

3.11. No 1

Rencana Anggaran Kebutuhan

Jumlah

Harga per Satuan

Total

Biaya Cetak proposal dan

Rp15,000

Rp45,000

90 x 14

Rp5,000

Rp6,300,000

laporan penelitian 2

Persiapan Instrumen

Transportasi

Rp50,000

Biaya Administrasi Lain

Rp100,000

Rp10,000

Biaya Publikasi

Rp9,000,000

Total

Rp15,405,000

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11. Pérez-Jiménez J, Neveu V, Vos F, Scalbert A. Identification of the 100 richest dietary sources of polyphenols: an application of the PhenolExplorer database. Eur J Clin Nutr. 2010 Nov; 64(3):112-20. 12. Post traumatic stress disorder [Internet]. Nebraska: Nebraska Department of Veterans’ Affairs; 2017 [cited 2018 May 2]. Available from: http://www.ptsd.ne.gov/what-is-ptsd.html 13. Understanding PTSD and PTSD treatment. Washington DC: U.S. Department of Veterans Affairs. 2017 Sep 15 14. Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) [Internet]. National Center for PTSD; 2013 [cited 2018 May 19]. Available from: https://www.ptsd.va.gov/professional/assessment/adultint/caps.asp 15. Pupo MC, Jorge MR, Schoedl AF, et al. The accuracy of the ClinicianAdministered PTSD Scale (CAPS) to identify PTSD cases in victims of urban violence. Psychiatry Res. 2011 Jan 30; 185(1-2): 157-60. 16. Geracioti TD, Baker DG, Ekhator NN, et all. CSF norepinephrine concentrations in posttraumatic stress disorder. Am J Psychiatry. 2001; 158 (8): 1227–30. 17. Sten TA. Massachusetts general hospital comprehensive clinical psychiatry. London: Elsevier; 2016. 380–90. 18. Kessler RC, Aguilar GS, Alonso J, et al. Trauma and ptsd in the who world mental health surveys. European Journal of Psychotraumatology. 2017 Oct 27; 23(2):665-69. 19. Davydow DS, Gifford JM, Desai SV, et al. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. General Hospital Psychiatry. 2008 Sep; 30(5): 421–34. 20. Skelton K, Ressler KJ, Norrholm SD, et al. PTSD and gene variants: new pathways and new thinking. Neuropharmacology. 2012; 62(2): 628–37.

21. Morilak DA, Barrera G, Echevarria DJ, Garcia AS, Hernandez A, Ma S, Petre CO. Role of brain norepinephrine in the behavioral response to stress. Prog Neuropsychopharmacol Biol Psychiatry. 2005 Dec; 29(8):1214-24. 22. O'Donnell T, Hegadoren KM, Coupland NC. Noradrenergic mechanisms in the pathophysiology of post-traumatic stress disorder. Neuropsychobiology. 2004; 50(4):273-83 23. Shin LM, Rauch SL, Pitman RK. Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Ann N Y Acad Sci. 2006 Jul; 1071():6779 24. Torres GE, Gainetdinov RR, Caron MG. Plasma membrane monoamine transporters: structure, regulation and function.Nat Rev Neurosci. 2003 Jan; 4(1):13-25. 25. Miner LH, Jedema HP, Moore FW, Blakely RD, Grace AA, Sesack SR. Chronic stress increases the plasmalemmal distribution of the norepinephrine transporter and the coexpression of tyrosine hydroxylase in norepinephrine axons in the prefrontal cortex. J Neurosci. 2006 Feb 1; 26(5):1571-8. 26. Azmitia EC, Whitaker-Azmitia PM. Awakening the sleeping giant: anatomy and plasticity of the brain serotonergic system. J Clin Psychiatry. 1991 Dec; 52 Suppl():4-16 27. Pietrzak RH, Henry S, Southwick SM, Krystal JH, Neumeister A. Linking in vivo brain serotonin type 1B receptor density to phenotypic heterogeneity of posttraumatic stress symptomatology.Mol Psychiatry. 2013 Apr; 18(4):399-401. 28. Sari Y. Serotonin1B receptors: from protein to physiological function and behavior.Neurosci Biobehav Rev. 2004 Oct; 28(6):565-82. 29. Marsicano G, Wotjak CT, Azad SC, Bisogno T, Rammes G, Cascio MG, et al. The endogenous cannabinoid system controls extinction of aversive memories. Nature. 2002 Aug 1; 418(6897):530-4.

30. Chhatwal JP, Davis M, Maguschak KA, Ressler KJ. Enhancing cannabinoid neurotransmission augments the extinction of conditioned fear. Neuropsychopharmacology. 2005 Mar; 30(3):516-24. 31. Adamec R, Fougere D, Risbrough V. CRF receptor blockade prevents initiation and consolidation of stress effects on affect in the predator stress model of PTSD. Int J Neuropsychopharmacol. 2010 Jul; 13(6):747-57 32. Shan B, Cai YZ, Sun M, Corke H. Antioxidant capacity of 26 spice extracts and characterization of their phenolic constituents. J Agric Food Chem. 2005 Oct 5; 53(20):7749-59. 33. Gülçin İ. Antioxidant activity of eugenol: a structure-activity relationship study. J Med Food. 2011 Sep; 14(9):975-85. 34. Devi KP, Nisha SA, Sakthivel R, Pandian SK. Eugenol (an essential oil of clove) acts as an antibacterial agent against Salmonella typhi by disrupting the cellular membrane. J Ethnopharmacol. 2010 Jul 6; 130(1):107-15. 35. Li HY, Lee BK, Kim JS, Jung SJ, Oh SB. Eugenol Inhibits ATP-induced P2X Currents in Trigeminal Ganglion Neurons. Korean J Physiol Pharmacol. 2008 Dec; 12(6):315-21. 36. Healthcare T. PDR for herbal medicines. 4th ed. Montvale: Thomson Healthcare; 2004. 37. Kurokawa M, Hozumi T, Basnet P, Nakano M, Kadota S, Namba T, et al. Purification and characterization of eugeniin as an anti-herpesvirus compound from Geum japonicum and Syzygium aromaticum. J Pharmacol Exp Ther. 1998 Feb; 284(2):728-35.

Hubungan antara Waktu Admisi terhadap Resiko Mortalitas pada Pasien Sindrom Koroner Akut di Indonesia: Sebuah Studi Multisenter Proposal Riset Nasional AMSA-Indonesia

Kresanti Dewi Ngadimin, 1606896552, AMSA-UI Lowilius Wiyono, 1606880062, AMSA-UI Jeremy Rafael Tandaju, 1606880075, AMSA-UI Metta Dewi, 1606900316, AMSA-UI Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia (AMSA-Indonesia) 2018

Lembar Pengesahan 1. Judul Proposal: Hubungan antara Waktu Admisi terhadap Resiko Mortalitas pada Pasien Sindrom Koroner Akut di Indonesia: Sebuah Studi Multisenter 1. Nama Penulis: Kresanti Dewi Ngadimin (1606896552) Lowilius Wiyono (1606880062) Jeremy Rafael (1606880075) Metta Dewi (1606900316) 2. Institusi: Fakultas Kedokteran Universitas Indonesia Depok, 15 Oktober 2018 Mengetahui dan Menyetujui: Ketua Tim Peneliti

Representative AMSA-UI

Kresanti Dewi Ngadimin

Bintang Wirawan

Dosen pembimbing

Wakil Dekan Bidang Kemahasiswaan Dwiana Ocviyanti

dr. Dian Zamroni, SpJP(K)

Dr. dr. Dwiana Ocviyanti, SpOG(K)

Halaman Pernyataan Orisinalitas National Research Proposal Competition " Non-Communicable Disease " 2. Judul Proposal: Hubungan antara Waktu Admisi terhadap Resiko Mortalitas pada Pasien Sindrom Koroner Akut di Indonesia: Sebuah Studi Multisenter 3. Nama Penulis: Kresanti Dewi Ngadimin (1606896552) Lowilius Wiyono (1606880062) Jeremy Rafael (1606880075) Metta Dewi (1606900316) 4. Institusi: Fakultas Kedokteran Universitas Indonesia 5. Alamat Institusi: Jl. Salemba Raya No. 4 Kami yang bertanda tangan di bawah ini menyatakan bahwa memang benar karya dengan judul di atas tersebut merupakan karya orisinal dan belum pernah dipublikasikan dan/atau dilombakan. Demikian pernyataan ini kami buat dengan sebenarnya, dan apabila terbukti terdapat pelanggaran di dalamnya, maka kami siap untuk didiskualifikasi dari kompetisi ini sebagai bentuk pertanggungjawaban kami. Depok, 15 Oktober 2018

Kresanti Dewi Ngadimin

KATA PENGANTAR Salam sejahtera, Puji syukur kami panjatkan kepada Tuhan Yang Maha Esa atas berkat dan rahmat yang diberikan oleh-Nya sehingga kami dapat menyelesaikan penulisan karya tulis yang berjudul â&#x20AC;&#x153;Hubungan antara Waktu Admisi terhadap Resiko Mortalitas pada Pasien Sindrom Koroner Akut di Indonesia: Sebuah Studi Multisenterâ&#x20AC;?. Penulis juga ingin mengucapkan terima kasih yang sebesar-besarnya kepada dr. Dian Zamroni, SpJP(K) selaku dosen pembimbing kami yang senantiasa memberikan bimbingan dan arahan selama penulisan, orangtua penulis yang selalu mendukung segala proses penulisan, serta pihak-pihak lain yang tidak dapat kami sebut satu persatu yang juga turut serta membantu dalam penulisan karya tulis ini. Penulis berharap dengan karya tulis ini, penulis dapat turut serta berkontribusi dalam memberikan kebermanfaatan kepada masyarakat. Penulis juga berharap agar karya tulis ini dapat menjadi kontribusi terhadap perkembangan sektor kesehatan di Indonesia, terkhusus dalam penanganan penyakit jantung dan pembuluh darah (kardiovaskular) yang masih menjadi momok menyeramkan di masyarakat. Penulis harap karya tulis ini juga mampu menjadi inspirasi dan landasan untuk pengembangan berikutnya yang akan sangat bermanfaat bagi dunia kesehatan di Indonesia. Karya tulis ini juga tidak luput dari berbagai kesalahan selama penggarapannya. Maka dari itu, penulis juga mengharapkan bantuan, saran, maupun kritik yang akan sangat bermanfaat bagi perkembangan semua pihak. Akhir kata, semoga karya tulis ini dapat membantu segala pihak dengan harapan mencapai masyarakat Indonesia yang lebih sehat.

Depok, 15 Oktober 2018 Penulis

iii

DAFTAR ISI Lembar Pengesahan ............................................................................................................ i Halaman Pernyataan Orisinalitas ........................................................................................ ii Kata Pengantar…………………………………………………………………………….iii Daftar isi…………………………………………………………………………………...iv 1. Pendahuluan ............................................................................................................ 1 1.1. Latar belakang .................................................................................................. 1 1.2. Rumusan Masalah ……………………………………………………………2 1.3. Identifikasi Masalah…………………………………………………………..2 1.4. Pertanyaan Penelitian…………………………………………………………2 1.5. Hipotesis………………………………………………………………………2 1.6. Tujuan…………………………………………………………………………2 1.7. Manfaat………………………………………………………………………..3 2. Tinjauan Pustaka…………………………………………………………………...4 2.1. Tinjauan Pustaka………………………………………………………………4 2.2. Kerangka Konsep……………………………………………………………...11 3. Metodologi Penelitian…………………………………………………………...…12 3.1. Ruang Lingkup Penelitian……………………………………………………..12 3.2. Desain Penelitian………………………………………………………………12 3.3. Identifikasi Variabel……………………………………………………………12 3.4. Definisi Operasional Variabel……………………….…………………………12 3.5. Populasi dan Subjek Penelitian…………………………………………………12 3.6. Kriteria Inklusi dan Eksklusi………………………………………………...…12 3.7. Teknik Pengambilan Sampel……………………………………………...……13 3.8. Instrumen Penelitian……………………………………………………………13 3.9. Cara Pengumpulan Data………………………………………………………..13 3.10. Alur Penelitian………………………………………………………………..14 3.11. Rancangan Penelitian…………………………………………………………15 4. Penutup……………………………………………………………………………..16

Daftar Pustaka………………………………………………………………………16

Bab I Pendahuluan 1.1.

Latar Belakang Masalah

Penyakit kardiovaskular adalah penyakit yang berkaitan dengan jantung (kardio) dan pembuluh darah (vaskular), yang termasuk diantaranya adalah penyakit jantung koroner, penyakit arteri koroner, dan juga sindrom koroner akut. Penyakit kardiovaskular telah menjadi komoditi terbesar dari non-communicable disease, yang menyebabkan lebih dari sepertiga non-communicable disease di dunia.1 Penyakit kardiovaskular menyebabkan sekitar 7 juta kematian setiap tahunnya dan juga menyebabkan disabilitas hingga mencapai 129 juta disability-adjusted life years (DALY) dalam satu tahun. Meskipun penyakit kardiovaskuler sudah menunjukkan penurunan angka insidensi di negara-negara maju, angka mortalitas dari penyakit kardiovaskular seperti penyakit jantung koroner tetap mengalami peningkatan setiap tahunnya. Keadaan ini semakin berbahaya pada negaranegara berkembang dengan insidensi yang terus meningkat.2 Salah satu penyakit kardiovaskular yang memiliki prevalensi tertinggi adalah sindrom koroner akut. Sindrom koroner akut adalah bagian dari penyakit arteri koroner yang menunjukkan manifestasi klinis atau gejala-gejala khas seperti angina tak stabil, dan gejala lainnya.1 Sindrom koroner akut di Indonesia sudah mencapai angka 1,5% dari seluruh penduduk Indonesia (sekitar 2,6 juta orang) dan terus meningkat.3 Angka prevalensi dan insidensi dari sindrom koroner akut menjadi tanda bahaya sindrom ini pada penduduk Indonesia. Prognosis sindrom koroner akut terkesan baik dengan angka tingkat keselamatan sebesar 94%.4 Terdapat berbagai faktor yang menentukan prognosis penyakit ini, mulai dari faktor risiko, progresi penyakit, dan tentu penanganan penyakit.5 Salah satu faktor penting dalam suksesnya penanganan adalah waktu penanganan. Waktu penanganan penyakit sindrom koroner akut menjadi faktor penting yang harus dicermati secara baik dalam penanganannya.5 Diketahui bahwa lebih dari 40% pasien sindrom koroner akut datang antara 6 jam hingga 96 jam setelah onset dimulai, terutama 1

pada pasien berusia tua dan dengan sakit intermiten yang mengabaikan rasa sakit yang dialami.6 Waktu admisi yang lebih lama diasosiakan dengan prognosis yang memburuk, khususnya karena tindakan reperfusi yang semakin terhambat.7 Hasil riset antara kedua variabel tersebut menunjukkan hasil yang variatif di setiap daerah.6-8 Penelitian ini bertujuan untuk mengamati pengaruh waktu admisi terhadap progresi penyakit di rumah sakit seluruh Indonesia. Penelitian akan dilakukan secara cross-sectional dengan menggunakan kuesioner untuk mengamati progresi penyakit dan waktu admisi dari pasien sindrom koroner akut di berbagai rumah sakit di Indonesia. 1.2.

Identifikasi Masalah dan Pertanyaan Penelitian

1.2.1

Rumusan Masalah

Setelah meninjau latar belakang di atas, dapat dirumuskan suatu masalah, yaitu: 1. Apakah waktu admisi pasien sindrom koroner akut di Indonesia berpengaruh terhadap progresi dan prognosis sindrom koroner akut yang dideritanya? 2. Bagaimana masalah sindrom koroner akut di Indonesia? 3. Bagaimanakah penjelasan hubungan antara waktu admisi dengan progresi penyakit pada sindrom koronner akut?

1.3.

Tujuan Umum dan Tujuan Khusus serta Manfaat Penelitian 1.3.1.

Tujuan Umum

Tujuan umum dari penelitian ini adalah mengetahui pengaruh waktu admisi pasien terhadap progresi serta prognosis penyakit pada sindrom koroner akut di Indonesia. 1.3.2.

Tujuan Khusus

Tujuan khusus dari penelitian ini, yaitu sebagai berikut: 1. Menambah pengetahuan mengenai sindrom koroner akut; 2. Menambah pengetahuan mengenai progresi sindrom koroner akut; 3. Melakukan uji cross-sectional pengaruh waktu admisi pasien terhadap progresi sindrom koroner akut; 2

4. Mengetahui hubungan antara waktu admisi terhadap progresi sindrom koroner akut. 1.4.

Manfaat Penelitian

Dalam penelitian ini, manfaat yang didapatkan, berupa: o Bagi masyarakat 1. Meningkatkan wawasan dan kewaspadaan mengenai sindrom koroner akut; 2. Memberikan data mengenai faktor prognosis sindrom koroner akut di Indonesia. o Bagi peneliti 1. Menjadi salah satu sarana pembelajaran dalam melaksanakan penelitian; 2. Melatih kemampuan berpikir dan analisis terhadap permasalah yang terjadi di masyarakat; 3. Memberikan kontribusi terhadap penyelesaian permasalahan sindrom koroner akut di masyarakat; 4. Melengkapi beberapa penelitian sebelumnya yang membahas hal yang serupa. o Bagi bidang akademis 1. Membantu Indonesia dalam memajukan bidang riset kesehatan 2. Mewujudkan salah satu kewajiban mahasiswa kedokteran, Tri Dharma, yakni penelitian. 3. Membantu mewujudkan hubungan akademis antar mahasiswa kedokteran dari seluruh wilayah Indonesia.

Bab II Tinjauan Pustaka 2.1. Tinjauan Pustaka 2.1.1. Sindrom Koroner Akut Sindrom koroner akut (SKA) merupakan salah satu jenis gawat jantung yang terjadi akibat ruptur, erosi, atau oklusi dari plak aterosklerosis yang dapat bermanifestasi sebagai angina pektoris tidak stabil, infark miokardium akut dengan atau tanpa peningkatan segmen ST. SKA disebabkan oleh penurunan suplai darah ke jaringan jantung. Hal ini disebabkan oleh hambatan thrombus, embolus, obstruksi dinamik seperti spasme atau vasokontruksi, obstruksi mekanik progresif, inflamasi atau infeksi, dan lain sebagainya. Penyebab di atas juga didudukung oleh berbagai faktor risiko, baik yang tidak dapat dicegah (Usia, jenis kelamin, riwayat keluarga) maupun yang dapat dicegah (Dislipidemia, obesitas, riwayat hipertensi, kebiasaan merokok, kebiasaan minum alkohol, riwayat diabetes mellitus, aktivitas fisik rendah).9,10 SKA berkontribusi terhadap >50% dari keseluruhan masalah kardiovaskular yang dilaporkan pada manusia berusia di bawah 75 tahun. Penyakit kardiovaskular menyebabkan 17.900.000 kematian setiap tahunnya dan merupakan penyakit yang berkontribusi terbesar terhadap kematian akibat penyakit non-komunikabel. Melihat statistik di atas, SKA berkontribusi terhadap lebih dari 8.950.000 kematian di dunia setiap tahunnya, di mana sekitar 85% di antaranya terjadi di negara berpenghasilan rendah hingga sedang.9 SKA diawali oleh proses ruptur atau sobek pada plak aterom akibat perubahan komposisi plak dan penipisan lapisan fibrosa yang menutupi plak. Fenomena tersebut akan diikuti dengan proses agregrasi trombosit dan aktivasi jaras koagulasi. Proses tersebut akan menghasilkan white thrombus yang kaya akan trombosit. Trombus tersebut akan menghambat aliran darah pada pembuluh darah koroner secara penuh atau sebagian. Terkadang, thrombus ini dapat berukuran sangat kecil sehingga baru akan menghambat sirkulasi pada pembuluh distal. Pelepasan zat vasoaktif dapat mengikuti fenomena ini sehingga semakin menghambat aliran darah pada pembuluh darah koroner. Peristiwa ini 4

akan menyebabkan jaringan jantung kekurangan oksigen, yang apabila terjadi lebih dari 20 menit akan mengakibatkan nekrosis pada miokardium, disebut sebagai infark miokardium.10-12 SKA akan memunculkan gambaran klinis yang bervariasi tergantung dengan manifestasi yang ditimbulkan. Gambaran klinis tersebut penting untuk diketahui karena untuk gambaran klinis yang berbeda memerlukan penanganan yang berbeda. Berikut adalah gambaran klinis yang dapat dijumpai:10-12 â&#x20AC;˘

Angina tidak stabil

: Keluhan berupa angina pertama atau

lebih hebat dari biasanya. Keluhan berupa nyeri dada yang dapat disertai dengan sesak napas, mual, hingga muntah, terkadang dijumpai diaphoresis. â&#x20AC;˘

Infark miokard tanpa elevasi segmen ST

: Keluhan berupa nyeri dada pada

area substernal, jarang pada epigastrium. Nyeri terasa seperti diremas, diikat, hingga dibakar. Pada NSTEMI, umum dijumpai nyeri tumpul, berat, menekan. Nyeri juga dirasa lebih hebat ketika beristirahat. Selain itu, pada pemeriksaan elektrokardiogram, tidak dijumpai peningkatan pada segmen ST. â&#x20AC;˘

Infark miokard dengan elevasi segmen ST

Nyeri

dada

pada

substernal,

retrosternal, dan prekordial. Nyeri dirasa sakit seperti ditekan dan dibakar. Nyeri yang dirasakan berat, tajam, dan memeras. Nyeri dapat menjalar ke area lengan kiri, leher, rahang bawah, gigi, punggung, perut, dan lengan kanan. Nyeri dapat diperbaiki dengan istirahat atau administrasi nitrat. Diagnosis SKA wajib ditegakkan dengan cepat dan tepat berdasarkan anamnesis, pemeriksaan fisik, dan penunjang. Anamnesis diperlukan untuk mencari tahu apakah ada faktor risiko yang dapat memicu insidensi SKA. Pemeriksaan fisik diperlukan untuk menentukan gejala-gejala kardinal pada SKA seperti nyeri dada tipikal dan rasa tidak nyaman di dada. Pemeriksaan fisik juga dapat melihat ada atau tidaknya faktor-faktor yang dapat memicu SKA seperti hipertensi, anemia, tirotoksikosis, stenosis aorta berat, kardiomiopati hipertropik, dan lain sebagainya. Adanya disfungsi ventrikel kiri merupakan petunjuk prognosis yang buruk. Sedangkan, adanya carotid bruit atau penyakit vaskular 5

perifer menandakan bahwa pasien mungkin menderita SKA bersamaan dengan penyakit jantung koroner. Pemeriksaan elektrokardiografi merupakan pemeriksaan penunjang yang diperlukan untuk menentukan diagnosis SKA. Gambaran yang dapat dijumpai pada angina tidak stabil dan NSTEMI dapat berupa depresi segmen ST, inversi gelombang T, gelombang Q menetap, yang dapat disertai oleh elevasi segmen ST non-persisten. Selain elektrokardiografi, pemeriksaan troponin I/T merupakan standar baku emas dalam diagnosis NSTEMI. Pemeriksaan CKMB dapat digunakan apabila troponin tidak tersedia. Diagnosis tersebut penting dilakukan dalam menentukan pengobatan. Pengobatan dan manajemen yang segera dapat menekan risiko dan prognosis buruk dari SKA.10-12 Berdasarkan diagnosis kerja yang dibuat, dapat dilakukanlah tindakan awal yang diberikan pada pasien dengan diagnosis kerja kemungkinan SKA atau SKA. Terapi awal ini disingkat MONA atau Morfin, Oksigen, Nitrat, dan Aspirin yang tidak harus diberikan semuanya atau secara bersamaan dengan detail sebagai berikut:13 a. Nitrogliserin spray/tablet sublingual diberikan kepada pasien yang masih mengalami nyeri dada pada saat tiba di ruang gawat darurat. Jika nyeri dada tidak hilang dalam satu kali pemberian, maka dapat diulang setiap lima menit sampai maksimal tiga kali pemberian. Apabila pasien masih tidak responsif, maka dapat diberikan nitrogliserin intravena. Apabila nitrogliserin tidak tersedia maka dapat digantikan oleh isosorbid dinitrat. b. Morfin sulfat 1-5 mg intravena dapat diberikan setiap 10-30 menit untuk pasien yang tidak responsif dengan pemberian tiga dosis nitrogliserin sublingual. c. Suplementasi oksigen harus diberi segera bagi pasien yang memiliki saturasi O2 arteri <95% atau mengalami distres respirasi. d. Suplementasi oksigen boleh diberikan pada seluruh pasien SKA dalam 6 jam pertama tanpa mempertimbangka saturasi O2 arteri. e. Aspirin 160-320 mg segera diberikan kepada seluruh pasien yang tidak diketahui intoleransinya terhadap aspirin, terutama aspirin tidak bersalut karena absorpsinya yang sublingual akan menghasilkan efek yang lebih cepat. f. Penghambat reseptor adenosine diphosphate (ADP)

Dosis awal ticagrelor dianjurkan 180 mg, yang dilanjutkan dengan dosis pemeliharaan 2 x 90 mg/hari kecuali pada penderita STEMI yang direncanakan untuk reperfusi menggunakan agen fibrinolitik Atau

ii.

Dosis awal clopidogrel dianjurkan 300 mg yang dilanjutkan dengan dosis pemeliharaan 75 mg/hari. Penggunaan clopidogrel dianjurkan untuk pasien STEMI yang akan direperfusi menggunakan agen fibrinolitik.

2.1.2. Stratifikasi Risiko Stratifikasi risiko dalam pasien sindrom koroner akut diperlukan dalam penanganan serta memprediksi prognosis dari SKA. Terdapat beberapa kriteria yang dapat digunakan untuk stratifikasi risiko ini seperti Thrombolysis In Myocardial Infarction (TIMI), Global Registry of Acute Coronary Events (GRACE), serta Can Rapid risk stratification of Unstable Angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE). Akan tetapi yang lebih umum digunakan di Indonesia adalah TIMI dan GRACE.13 Skor TIMI ditentukan dari 7 variabel yang masing-masing variabelnya bernilai satu poin. Variabel tersebut berupa usia, jumlah factor risiko yang dimiliki, riwayat penggunaan aspirin dalam 7 hari terakhir, peningkatan marka jantung, dll yang dapat dilihat selengkapnya pada tabel 1. Apabila jumlah skor 0-2 maka pasien memiliki risiko rendah untuk kejadian kardiovaskular kedua, yakni <8,3%. Sedangkan jumlah skor 3-4 menandakan risiko menengah dengan <19,9% terjadi kejadian kedua, dan 5-7 untuk risiko tinggi dan risiko kejadian kedua sebesar â&#x2030;¤41%.13

Tabel 1. Kriteria skor TIMI.13

Berbeda dengan TIMI, GRACE Risk Score atau klasifikasi GRACE dapat memprediksi mortalitas pasien saat dirawat di rumah sakit dan dalam 6 bulan setelah keluar dari rumah sakit. Terdapat beberapa variable dalam klasifikasi ini seperti usia, kelas Killip, tekanan darah sistolik, deviasi segmen ST, kadar kreatinin serum, marka jantung, dll yang dapat dilihat pada tabel 2. Variabel-variabel ini memiliki skor yang bervariasi. Untuk memprediksi mortalitas di rumah sakit, pasien dengan skor â&#x2030;¤108 memiliki risiko yang rendah (<1%). Sedangkan pasien dengan skor 109-140 memiliki risiko sedang (1-3%), dan tinggi untuk skor >140 (>3%). Sementara itu, untuk prediksi mortalitas dalam 6 bulan setelah keluar dari rumah sakit, pasien dengan skor â&#x2030;¤88 memiliki risiko yang rendah (<3%), skor 89-118 dan >118 secara berturut-turut memiliki risiko kematian menengah (38%), serta tinggi (>8%).13

Tabel 2. Skor GRACE.13

2.1.3. Waktu admisi dan keterlambatan prehospital Waktu admisi atau waktu sejak pasien merasakan gejala sampai dengan masuk rumah sakit dan diberikan tata laksana merupakan hal yang penting untuk dicermati. Berdasarkan data, terdapat lebih dari setengah pasien dengan sindrom koroner akut yang mengalami kematian sebelum mendapatkan pertolongan. Hal ini dapat terjadi karena lambatnya waktu sejak pasien serangan sampai dengan masuk ke rumah sakit atau keterlambatan prehospital yang merupakan tantangan yang dihadapi oleh negara dari seluruh belahan dunia. Selain itu, pada pasien SKA dapat terjadi iskemi dan dalam waktu yang berkepanjangan dapat berkembang menjadi nekrosis yang akan meluas daerahnya seiring bertambah waktu apabila tidak segera dilakukan reperfusi. Reperfusi terbukti dapat menjaga fungsi otot jantung yang iskemi apabila dilakukan 2-3 jam setelah terjadi serangan, akan tetapi apabila reperfusi dilakukan setelah lebih dari 6 jam fungsi otot jantung yang dikembalikan akan sangat sedikit sekali atau bahkan tidak ada.13,14 Terlambatnya pasien mendapatkan pertolongan atau keterlambatan prehospital dapat berdampak kepada gagalnya tata laksana serta meningkatkan risiko mortalitas pasien. Karena semakin lama pasien mendapatkan pertolongan, maka semakin luas pula daerah yang iskemi serta nekrosis. Selain itu semakin lama dilakukannya tata laksana dan reperfusi, fungsi otot jantung yang dapat dikembalikan pun semakin sedikit atau bahkan tidak ada.13,14 2.1.4. Hubungan antara waktu admisi dan prognosis SKA Studi hubungan antara waktu admisi dan prognosis sindrom koroner akut ini belum banyak diteliti terutama di Indonesia. Akan tetapi, studi yang hampir sama yakni penelitian yang dilakukan oleh Chen et al tentang waktu menunggu untuk mendapatkan pertolongan yang panjang pada pasien NSTEMI,8 serta penelitian efek admisi rumah sakit pada akhir pekan dengan penanganan sindrom koroner akut yang dilakukan oleh Martin et al15 dimana hasil dari penelitian ini adalah tidak ada hubungan yang signifikan antara keterlambatan penanganan SKA dan hasil klinis dari pasien SKA.

2.2. Kerangka Konsep

Bab III Metode Penelitian 3.1. Ruang Lingkup Penelitian Tempat: Center Utama dan juga Center Institusi yang berpartisipasi dalam penelitian Waktu: November 2018-Mei 2019 Disiplin Ilmu Terkait: Kedokteran Kardiovaskular 3.2. Desain Penelitian Desain penelitian ini menggunakan penelitian cross-sectional analitik. Data diambil dari rekam medis pasien dengan sindrom koroner akut pada rumah sakit di Indonesia. Data yang digunakan merupakan data primer. 3.3. Identifikasi Variabel o Variabel bebas (independent variable) : waktu administrasi pasien (di bawah 12 jam dan di atas 12 jam) o Variabel tergantung (dependent variable) : skor GRACE & TIMI o Variabel perancu (confounding variable) : umur, riwayat penyakit jantung 3.4. Definisi Operasional Variabel o Waktu admisi pasien merupakan waktu dari pasien mulai merasakan gejala sampai dengan masuk rumah sakit o Resiko mortalitas sindrom koroner akut (SKA) ditentukan oleh GRACE dan TIMI assessment 3.5. Populasi dan Subjek Penelitian o Populasi target: seluruh pasien dengan SKA di wilayah center institusi di Indonesia. o Sampel penelitian: Populasi target yang memenuhi kriteria inklusi dan diseleksi kriteria eksklusi

3.6. Kriteria Inklusi dan Eksklusi o Kriteria Inklusi: Pasien yang terdiagnosa memiliki ACS oleh dokter, pergi berobat ke rumah sakit dan sudah diberi informed consent 12

o Kriteria eksklusi: Pasien yang ditransfer dari fasilitas kesehatan lain, mengalami ACS karena sebab sekunder, atau menolak dimasukkan kedalam penelitian o Kriteria Dropout: Pasien yang tidak tertangani 3.7. Teknik Pengambilan Sampel Metode pengambilan sampel yang digunakan adalah consecutive sampling. Perhitungan besar sampel untuk penelitian korelasi dapat dilihat pada rumus berikut:

Keterangan: n: Jumlah sampel ZÎą: 1,96 ZÎ˛: 0,84 R: 0,5 Dengan mengasumsikan kesalahan tipe satu 5%, power penelitian 80%. Koefisien minimal yang dianggap bermakna atau R belum diketahui karena belum terdapat kepustakaan yang membahas masalah tersebut. Dengan menganggap waktu admisi memiliki resiko sedang, maka itu digunakan R=0,5. Besar sampel yang digunakan pada penelitian ini adalah 28.98 â&#x2030;&#x2C6;30 sampel. 3.8. Instrumen Penelitian Instrumen yang digunakan merupakan sistem skoring GRACE dan TIMI yang digunakan untuk mengetahui resiko mortalitas pasien yang menderita ACS. 3.9. Cara Pengumpulan Data Jenis data yang digunakan merupakan data kategorik tidak berpasangan. Variabel Data diambil oleh setiap center institusi dari rumah sakit atau PUSKESMAS yang merawat pasien sindrom koroner akut. 1. Subjek (rekam medis) penelitian diseleksi berdasarkan kriteria inklusi dan eksklusi 2. Data rekam medis yang sudah diseleksi, diambil waktu admisi dan rekam medis tersebut dinilai dengan sistem skoring GRACE dan TIMI 3. Data yang diperoleh dikumpulkan dan dianalisis oleh center utama. 13

3.10.

Alur Penelitian

3.11. Rencana Analisis Data akan dianalisis menggunakan SPSS 24.0. Uji hipotesis akan dilakukan dengan metode uji korelasi Pearson jika persebaran data normal dan uji korelasi Spearman jika persebaran data tidak normal.

PENUTUP 1. Daftar Pustaka 1. Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Annals of Translational Medicine. 2016;4(13):256. 2. Vedanthan R, Seligman B, Fuster V. Global perspective on acute coronary syndrome. Circulation Research. 2014;114(12):1959-75. 3. Kementerian Kesehatan Republik Indonesia. Situasi kesehatan jantung. Jakarta: Pusat Data dan Informasi Kementerian Kesehatan Republik Indonesia. 2014. 4. Bounhoure J, Farah B, Fajadet J, Marco J. Prognosis after acute coronary syndrome: lack of difference according to the sex. Bull Acad Natl Med. 2004;188(3):383-97. 5. Chu C, Lin T, Lai W. The management and prognostic factors of acute coronary syndrome: evidence from the Taiwan acute coronary syndrome full spectrum registry. Acta Cardiol Sin. 2017;33(4):329-38. 6. Takada J, Roza L, Ramos R, Avakian S, Ramires J, Mansur A. Hora da admissão na unidade de emergência e mortalidade hospitalar na síndrome coronária aguda. Arquivos Brasileiros de Cardiologia. 2012;98(2):104-10. 7. DeVon H, Hogan N, Ochs A, Shapiro M. Time to Treatment for Acute Coronary Syndromes. The Journal of Cardiovascular Nursing. 2010;25(2):106-14. 8. Chen C, Chiu I, Cheng F, Wu K, Li C. The impact of prolonged waiting time for coronary care unit admission on patients with non ST-elevation acute coronary syndrome. The American Journal of Emergency Medicine. 2017;35(8):1078-1081. 9. World Health Organization. Non-communicable diseases: Key facts and fact sheets [Online]. 2018. Available on: http://www.who.int/news-room/factsheets/detail/noncommunicable-diseases

10. Cervellin G, Rastelli G. The clinics of acute coronary syndrome. Ann Transl Med. 2016; 4(10): 191. 11. Smith JN, Negrelli JM, Manek MB, Hawes EM, Viera AJ. Diagnosis and management of acute coronary syndrome: An evidence-based update. J of the American Board of Fam Med. 2015; 28(2): 283 – 93. 12. Luscher TF. Acute coronary syndromes: Early diagnosis, management, and risk prediction. Eur Heart J. 2017; 38(41): 3037 – 40. 13. Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman tatalaksana sindrom koroner akut. 3e. Jakarta: Centra Communications; 2015. 5 – 72. 14. DeVon HA, Hogan N, Ochs AL, Shapiro M. Time to treatment for acute coronary syndromes: The cost of indecision. J Cardiovasc Nurs. 2010; 25(2): 106 – 14. 15. Martin GP, Kinnaird T, Sperrin M, Anderson R, Gamal A, Jabbar A, et al. Effect of weekend admission on process of care and clinical outcomes for the management of acute coronary syndromes: A retrospective analysis of three UK centres. BMJ Open. 2017; 7(2): 1 – 10.

HUBUNGAN FAKTOR PSIKOSOSIOEKONOMI DENGAN KEJADIAN DEPRESI POSTPARTUM PADA PEREMPUAN DI INDONESIA: SEBUAH STUDI MULTICENTER Diajukan untuk mengikuti lomba Proposal Riset Nasional AMSA-Indonesia

Disusun oleh: JOHAN CAHYADIRGA

1606892743

GILBERT LAZARUS

1706030176

AZIS MUHAMMAD PUTERA

1706982462

AMSA-UNIVERSITAS INDONESIA

ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION-INDONESIA 2018

LEMBAR PENGESAHAN

Judul Karya Tulis: HUBUNGAN FAKTOR PSIKOSOSIOEKONOMI DENGAN KEJADIAN DEPRESI POSTPARTUM PADA PEREMPUAN DI INDONESIA: SEBUAH STUDI MULTICENTER

Disusun untuk mengikuti lomba Proposal Riset Nasional AMSA-Indonesia Oleh: Ketua Tim Peneliti

Representative AMSA-UI

(Johan Cahyadirga)

(Bintang Wirawan)

Dosen Pembimbing

(dr. Dewi Friska, MKK.)

HALAMAN PERNYATAAN ORISINALITAS Proposal ini merupakan hasil karya yang murni dibuat oleh tim penyusun. Semua sumber, kutipan, dan rujukan telah kami nyatakan dengan benar. Depok, 13 Oktober 2018 Tim peneliti,

(Johan Cahyadirga)

(Gilbert Lazarus)

(Azis Muhammad Putera)

KATA PENGANTAR Puji syukur kami panjatkan kepada Tuhan Yang Maha Esa atas berkatnya sehingga kami dapat menyelesaikan proposal penelitian berjudul â&#x20AC;&#x153;Hubungan Faktor Sosioekonomi dengan Terjadinya Depresi Postpartum pada Perempuan di Indonesia: Studi Multicenterâ&#x20AC;?. Kami juga ingin mengungkapkan rasa terima kasih kami kepada seluruh pihak yang berperan dalam pembuatan proposal ini terutama dosen pembimbing yang senantiasa memberikan saran dan masukan kepada kami serta pihak-pihak lainnya yang tidak dapat kami sebutkan satu per satu. Penulis menyadari bahwa proposal ini tidak luput dari kesalahan sehingga penulis terbuka dengan kritik, saran serta masukan. Penulis berharap karya ini dapat bermanfaat bagi masyarakat luas.

Jakarta, 15 Oktober 2018

Penulis

iii

DAFTAR ISI LEMBAR PENGESAHAN ...........................................................................................

HALAMAN PERNYATAAN ORISINALITAS .........................................................

KATA PENGANTAR....................................................................................................

iii

DAFTAR ISI ..................................................................................................................

DAFTAR TABEL ..........................................................................................................

DAFTAR GAMBAR......................................................................................................

vii

DAFTAR LAMPIRAN ..................................................................................................

viii

BAB I: PENDAHULUAN ............................................................................................. 1.1 Latar Belakang ..................................................................................................... 1.2 Rumusan Masalah ................................................................................................ 1.3 Tujuan Penelitian ................................................................................................. 1.3.1. Tujuan Umum ............................................................................................ 1.3.2. Tujuan Khusus ........................................................................................... 1.4 Manfaat Penelitian ............................................................................................... 1.4.1. Ilmu Pengetahuan....................................................................................... 1.4.2. Masyarakat Awam ..................................................................................... 1.4.3. Layanan Kesehatan .................................................................................... 1.4.4. Peneliti .......................................................................................................

1 1 1 2 2 2 2 2 2 2 2

BAB II: TINJAUAN PUSTAKA .................................................................................. 2.1 Postpartum Depression........................................................................................ 2.1.1. Definisi dan Epidemiologi ......................................................................... 2.1.2. Etiologi dan Faktor Risiko ......................................................................... 2.1.3. Patogenesis dan Patofisiologi .................................................................... 2.1.4. Diagnosis.................................................................................................... 2.1.5. Komplikasi dan Prognosis ......................................................................... 2.1.6. Pencegahan dan Tatalaksana...................................................................... 2.2 Determinan Sosial Kesehatan .............................................................................. 2.2.1. Gradien Sosial ............................................................................................ 2.2.2. Stres............................................................................................................ 2.2.3. Kehidupan Usia Dini ............................................................................... 2.2.4. Eksklusi Sosial ........................................................................................... 2.2.5. Pekerjaan .................................................................................................... 2.2.6. Pengangguran dan Status Kepegawaian .................................................... 2.2.7. Dukungan Sosial ........................................................................................ 2.2.8. Adiksi ......................................................................................................... 2.2.9. Pangan ........................................................................................................ 2.2.10. Transportasi.............................................................................................. 2.3. Kerangka Konsep ................................................................................................

3 3 3 3 5 6 6 7 8 8 9 9 9 9 10 10 10 10 11 12

BAB III: METODE PENELITIAN..............................................................................

3.1. Ruang Lingkup Penelitian................................................................................... 3.1.1. Tempat Penelitian ..................................................................................... 3.1.2. Waktu Penelitian ....................................................................................... 3.1.3. Disiplin Ilmu Terkait................................................................................. 3.2. Desain Penelitian ................................................................................................ 3.3. Identifikasi Variabel............................................................................................ 3.3.1. Variabel Terikat ........................................................................................ 3.3.2. Variabel Bebas .......................................................................................... 3.3.3. Variabel Perancu ....................................................................................... 3.4. Definisi Operasional ........................................................................................... 3.4.1. Definisi Operasional Variabel Bebas ........................................................ 3.4.2. Definisi Operasional Variabel Terikat ...................................................... 3.5. Populasi dan Subjek Penelitian ........................................................................... 3.5.1. Populasi Penelitian .................................................................................... 3.5.2. Subjek Penelitian ...................................................................................... 3.6. Kriteria Inklusi dan Eksklusi .............................................................................. 3.6.1. Kriteria Inklusi .......................................................................................... 3.6.2. Kriteria Eksklusi ....................................................................................... 3.7. Teknik Pengambilan Sampel .............................................................................. 3.8. Instrumen Penelitian ........................................................................................... 3.9. Cara Pengambilan Data....................................................................................... 3.10. Rencana Analisis .............................................................................................. 3.11. Etika Penelitian .................................................................................................

13 13 13 13 13 13 13 13 13 14 14 17 17 17 17 17 17 17 18 18 19 19 19

BAB IV: DAFTAR PUSTAKA .....................................................................................

BAB V: LAMPIRAN ..................................................................................................... 5.1. Formulir Kuesioner ............................................................................................. 5.1.1. Karakteristik Responden ............................................................................ 5.1.2. Kuesioner Edinburgh Postnatal Depression Scale .................................... 5.1.3. Kuesioner Determinan Psikososioekonomi ............................................... 5.2. Formulir Persetujuan Mengikuti Penelitian ........................................................ 5.3. Anggaran Penelitian ............................................................................................ 5.4. Timeline Penelitian ............................................................................................. 5.5. Biodata Peneliti ................................................................................................... 5.5.1. Biodata Peneliti 1 ...................................................................................... 5.5.2. Biodata Peneliti 2 ....................................................................................... 5.5.3. Biodata Peneliti 3 .......................................................................................

23 23 23 25 25 27 28 28 29 29 31 33

DAFTAR TABEL Tabel 2.1. Faktor Risiko Depresi Pasca-Melahirkan (PPD)............................................

Tabel 3.1. Definisi Operasional Variabel Bebas .............................................................

Tabel 3.2. Definisi Operasional Variabel Terikat ...........................................................

DAFTAR GAMBAR Bagan 2.1. Kerangka Konsep ..........................................................................................

vii

DAFTAR LAMPIRAN Formulir Kuesioner .......................................................................................................... Karakteristik Responden .......................................................................................... Kuesioner Edinburgh Postnatal Depression Scale .................................................. Kuesioner Determinan Psikososioekonomi .............................................................

23 23 23 25

Formulir Persetujuan Mengikuti Penelitian .....................................................................

Anggaran Penelitian .........................................................................................................

Timeline Penelitina ..........................................................................................................

Biodata Peneliti ................................................................................................................ Biodata Peneliti 1 .................................................................................................... Biodata Peneliti 2 ..................................................................................................... Biodata Peneliti 3 .....................................................................................................

29 29 31 33

viii

BAB I PENDAHULUAN 1.1 Latar Belakang Postpartum depression (PPD) adalah sebuah jenis depresi yang dialami oleh orang tua pasca melahirkan anak mereka.1 PPD tergolong ke dalam kluster gangguan kesehatan mental (i.e. depresi, gangguan kecemasan) yang baru-baru ini diklasifikasikan sebagai bagian dari penyakit tidak menular (NCDs).2 Di Indonesia, pada sebuah studi yang dilakukan oleh Idaiani S3, ditemukan bahwa sebanyak 440 dari 18 937 responden mengalami depresi pasca kelahiran. Secara umum, depresi pasca kelahiran dapat dialami 1 dari 10 ibu setelah melahirkan anak mereka dan manifestasi gejala dari depresi pasca kelahiran adalah rasa sedih terus menerus, kurangnya rasa bahagia, gangguan siklus tidur, gangguan dalam membentuk kelekatan dengan bayi serta munculnya pikiran untuk menyakiti diri sendiri dan bayi.1 PPD dapat ditangani dengan tiga cara yaitu dengan melakukan self-help, terapi psikologis atau antidepresan. Sayangnya, karena gejala yang timbul secara perlahan-lahan banyak ibu yang tidak menyadari depresi pasca kelahiran dan bahkan masih banyak ibu yang menunda mencari bantuan karena rasa malu terhadap diri sendiri dan pandangan orang lain.1 Apabila PPD tidak tertangani secara segera maka PPD dapat menyebabkan penurunan kualitas hidup bagi ibu dan bayi. Pada jangka panjang, ibu dengan PPD yang tidak tertangani dapat menyebabkan anak mengalami permasalahan perilaku. Selain perilaku, terdapat berbagai efek lain PPD pada bayi yaitu terjadinya keterlambatan perkembangan pada bahasa dan IQ pada bayi. Efek ini menunjukan bahwa PPD bukan hanya menjadi masalah pada suatu generasi namun juga memiliki dampak besar pada generasi di bawahnya.4 Oleh karena itu, sangat penting untuk mencegah terjadinya PPD dan sampai saat ini, penelitian yang telah dilakukan di Indonesia telah menjelaskan beberapa faktor risiko yang dapat memicu PPD seperti komplikasi saat kehamilan dan ukuran bayi yang terlalu kecil. Sayangnya, belum ada penelitian yang menjelaskan lebih lanjut mengenai hubungan faktor-faktor sosioekonomi dengan terjadinya PPD. Oleh karena itu, peneliti tergerak untuk mencari hubungan faktor sosioekonomi dengan terjadinya postpartum depression. 1.2 Rumusan Masalah Apakah faktor sosioekonomi berhubungan dengan terjadinya post partum depression pada ibu di Indonesia. 1

1.3 Tujuan Penelitian 1.3.1. Tujuan Umum Mengetahui hubungan antara faktor psikososioekonomi dengan terjadinya post partum depression pada ibu di Indonesia. 1.3.2. Tujuan Khusus â&#x2014;? Mengidentifikasi status sosioekonomi pada ibu pasca melahirkan di Indonesia â&#x2014;? Mengidentifikasi ibu pasca melahirkan dengan post partum depression â&#x2014;? Mengidentifikasi faktor sosioekonomi yang berhubungan dengan post partum depression â&#x2014;? Mengidentifikasi faktor sosioekonomi yang tidak berpengaruh dengan post partum depression 1.4 Manfaat Penelitian 1.4.1. Ilmu Pengetahuan Penelitian ini dapat memperkaya ilmu pengetahuan mengenai insidensi post partum depression di Indonesia serta faktor sosioekonomi yang dapat mempengaruhi. 1.4.2. Masyarakat Awam Penelitian ini diharapkan dapat meningkatkan kesadaran masyarakat mengenai kesehatan mental secara umum serta post partum depression secara khusus. Selain itu penelitian ini diharapkan juga dapat memberikan pengetahuan pada masyarakat mengenai faktor-faktor sosioekonomi yang berpengaruh. 1.4.3. Layanan Kesehatan Penelitian ini diharapakan dapat menjadi dasar ilmiah untuk dilaksanakannya pencegahan atau tata laksana dari post partum depression. 1.4.4. Peneliti Penelitian ini dapat menambah pengetahuan peneliti terutama mengenai faktor-faktor sosioekonomi yang dapat mempengaruhi post partum depression.

BAB II TINJAUAN PUSTAKA 2.1. Postpartum Depression (PPD) 2.1.1. Definisi dan Epidemiologi Postpartum depression (PPD) merupakan disregulasi psikologis berupa depresi yang terjadi setelah kelahiran dan ditandari dengan gejala depresi mayor. PPD ditandai dengan gangguan pola hidup dan perubahan perilaku. Gangguan pola hidup dapat bermanifestasi sebagai gangguan pola tidur, kesulitan berkonsentrasi, tidak nafsu makan, dan tidak tertarik untuk melakukan aktivitas sehari-hari. Di lain pihak, perubahan perilaku dapat berupa takut mengalami luka, kekhawatiran serius terhadap bayi, sering merasa sedih dan sering menangis, merasa ragu dengan segala hal, hingga memiliki pikiran untuk bunuh diri. Intensitas depresif yang menyebabkan maternal merasa tidak berdaya dapat menyebabkan timbulnya pikiran-pikiran untuk bunuh diri. Hal ini berkontribusi terhadap 20% kematian ibu pasca-melahirkan.5 Prevalensi PPD di dunia berkisar sekitar 5% hingga 60,8%.5 Depresi pascamelahirkan berat diderita oleh 25% ibu dengan kelahiran pertama kali dan 20% ibu dengan kelahiran bukan pertama kali. Di Indonesia sendiri, prevalensi depresi pasca-kelahiran berkisar sekitar 11%-30%.6 Hal ini menunjukkan bahwa depresi pasca-kelahiran masih menjadi masalah kesehatan yang harus segera ditangani mengingat tingginya prevalensi depresi pasca-melahirkan dan angka mortalitas akibat depresi pasca-melahirkan. Depresi pasca-melahirkan (PPD) merupakan bagian dari gangguan kesehatan mental (CMDs). Beberapa literatur mengatakan bahwa gangguan kesehatan mental termasuk ke dalam penyakit tidak menular (non-communicable disease/NCD) karena program yang dicanangkan oleh World Health Organizaton (WHO), yaitu WHOâ&#x20AC;&#x2122;s Global Action Plan, yang bertujuan utuk mengurangi beban kesehatan NCDs dan kematian yang dapat dicegah, menginkorporasikan pencegahan dan kontrol gangguan kesehatan mental dalam target keberhasilannya. Oleh karena itu, dalam penelitian ini, peneliti mengklusterisasikan PPD sebagai bagian dari NCDs.2 2.1.2. Etiologi dan Faktor Risiko

Depresi pasca-melahirkan (PPD) dapat disebabkan oleh banyak hal, terutama dari faktor lingkungan. Faktor lingkungan yang memengaruhi kejadian PPD dapat berupa usia maternal, penyakit kronik, metode kelahiran, hingga kondisi bayi pasca-melahirkan. Berikut adalah faktor risiko yang berkontribusi terhadap kejadian depresi pasca-melahirkan7: No

Variabel

Angka PPD/10.000 Kelahiran

RR [95% CI]

p value

15-19

104

1.48 [1.26-2.72]

<0.01

20-24

1.12 [1.02-1.22]

<0.05

25-29

ref

30-34

1.11 [1.03-1.20]

<0.01

35-39

1.25 [1.13-1.37]

<0.01

â&#x2030;Ľ40

1.25 [1.07-1.47]

<0.01

0.95 [0.84-1.07]

Tidak

ref

Tidak ada

ref

Pregestasional

125

1.32 [0.98-1.78]

Gestasional

141

1.70 [1.36-2.13]

<0.01

1.08 [0.83-1.40]

Tidak

ref

Vaginal

ref

Vaginal dengan bantuan instrumen

1.18 [1.08-1.30]

C-section

1.37 [0.96-1.97]

<32 minggu

122

1.36 [1.05-1.75]

<0.05

32-36 minggu

1.20 [1.06-1.36]

<0.01

Usia maternal

Kohabitasi dengan ayah

Diabetes

Persalinan berkepanjangan

Metode persalinan

<0.01

Usia gestasional

37-41 minggu

ref

≥42 minggu

0.88 [0.78-0.99]

<0.05

< persentil ke-3

0.95 [0.77-1.18]

Persentil ke-3 s/d 14

0.87 [0.77-0.98]

Persentil ke-15 s/d 84

ref

Persentil ke 85 s/d 97

0.87 [0.74-1.02]

> persentil ke-97

0.91 [0.74-1.11]

1.14 [0.98-1.33]

Tidak

ref

Berat badan lahir

Ruptur sfingter

Tabel 2.1. Faktor Risiko Depresi Pasca-Melahirkan (PPD)

Berdasarkan data di atas, dapat dinyatakan bahwa kohabitasi dengan orang tua merupakan faktor protektif kejadian PPD, sedangkan BBLR rendah, usia maternal yang cenderung muda atau terlalu tua, penyakit kronis dan malformasi pada bayi, serta prematuritas merupakan faktor risiko kejadian PPD.7 2.1.3. Patogenesis dan Patofisiologi Depresi pasca-melahirkan (PPD) merupakan penyakit mental. Oleh karena itu, patogenesis penyakit ini dimulai dari persinyalan otak. PPD disebabkan oleh alterasi persinyalan neuroendokrin akibat adanya tekanan baik dari dalam maupun lingkungan. Persinyalan neuroendokrin yang berkontribusi pada kejadian PPD adalah hormon steroid, glukokortikoid, dan oksitosin.8 Hormon steroid (i.e. estradiol, kortikosteron, corticotropin-releasing hormone (CRH)) berfluktuasi selama kehamilan dan pasca-kelahiran. Kadar estradiol memuncak hingga trimester ketiga namun menurun secara dramatis setelah kelahiran. Hal ini menyebabkan “estradiol-withdrawal state” yang menyerupai gejala depresi. Kondisi ini ditandai dengan meningkatnya transporter serotonin (SERT) pada neokorteks wanita yang menyebabkan penurunan kadar serotonin sehingga terjadi gangguan mood. Persinyalan estradiol ini dapat dilihat secara epigenetik. Pada wanita dengan PPD, kadar metilasi CpG pada lokus HP1NP3 dan TTC9B mengalami modifikasi signifikan. Kedua logus gen tersebut berkontribusi terhadap persinyalan estradiol dengan meregulasi ekspresi reseptor estrogen (ERα dan β). Reseptor ini melemahkan perilaku depresif dan gelisah.8 5

Pada wanita dengan PPD, ditemukan abnormalitas fungsi pada aksis HPA yang menyebabkan hipersekresi kortisol. Kortisol merupakan salah satu jenis hormon glukokortikoid yang sangat terkait dengan etiologi stres dan depresi. Hipersekresi kortisol tersebut disertai dengan menurunnya kadar corticosteronebinding globulin (CBG) sehingga meningkatkan kadar transporter kortisol (CORT) bebas.8 Wanita dengan kadar oksitosin pada trimester ketiga yang lebih rendah dari wanita pada umumnya memiliki risiko PPD. Oksitosin merupakan inhibitor aksis HPA, sehingga penurunan kadar oksitosin berkontribusi terhadap kejadian depresi pasca-melahirkan.8 Selain neuroendokrin, neurobiology juga berpengaruh terhadap kejadian PPD. Hippocampus, korteks prefrontalis (PFC), dan amygdala berperan dalam kejadian depresi. Pasien dengan depresi kronis memiliki volume hippocampus yang lebih kecil dibandingkan dengan pasien tanpa depresi. Dalam hal ini, antidepresan dapat digunakan untuk mencegah penyusutan volume. Pengecilan volume dapat disebabkan akibat penurunan neurogenesis, densitas sinaps, hingga peningkatan apoptotik.8 2.1.4. Diagnosis Diagnosis depresi pasca-melahirkan (PPD) dapat ditegakkan serupa dengan nomenklatur psikiatrik gejala depresi mayor dengan spesifikasi onset dalam beberapa bulan setelah kelahiran. Namun, onset PPD dapat mencapai 6 bulan setelah melahirkan atau dapat mulai sebelum kelahiran. Gejala depresi dapat didefinisikan apabila perubahan perilaku dan mood terjadi selama minimal 2 minggu. Selain itu, gejala depresi dapat diperkuat dengan gangguan pola tidur, nafsu makan, letih, perasaan tidak berguna, hingga pikiran untuk bunuh diri. Diagnosis PPD menjadi lebih kompleks karena gejala seperti perubahan pada pola tidur, nafsu makan, dan rasa letih umum ditemukan pada ibu setelah melahirkan.9 Waktu yang paling optimum untuk screening PPD adalah 2 minggu hingga 6 bulan setelah kelahiran. Diagnosis PPD dapat dilakukan menggunakan Edinburgh Postnatal Depression Scale (EPDS). EPDS merupakan skala yang telah divalidasi dan digunakan secara luas untuk diagnosis PPD. EPDS terdiri dari 10 pertanyaan yang harus dijawab secara mandiri. Penilaian akan dilakukan berdasarkan numerisasi skala (0 hingga 3). Ibu yang memperoleh nilai â&#x2030;Ľ10 terindikasi

berpotensi

mengalami

depresi

pasca-melahirkan,

sedangkan

nilai

>13

diindikasikan dengan depresi pasca-melahirkan dengan intensitas yang bervariasi.9 2.1.5. Komplikasi dan Prognosis Depresi pasca-melahirkan (PPD) dapat memengaruhi maternal maupun bayi. Dari sudut pandang maternal, PPD dapat menyebabkan komplikasi berupa penurunan kesehatan akibat turunnya sistem imun. Imunokompromi tersebut disebabkan karena perubahan perilaku maternal yang memengaruhi homeostasis tubuh. Selain itu, perilaku bunuh diri yang dilakukan oleh maternal pada kasus depresi berat juga akan merugikan maternal dan lingkungan.8 Bunuh diri merupakan penyebab utama kematian maternal.9 Selain maternal, anak-anak adalah kelompok yang paling merasakan dampak PPD. Anak dengan ibu PPD mengalami risiko gangguan emosi, perilaku, dan psikologis. Gangguan emosi, perilaku, dan psikologis dapat disebabkan gagalnya attachment antara ibu dan anak. Selain itu, perkembangan kognitif dan bahasa juga akan terhambat akibat kurangnya stimulasi yang cukup dari ibu. Pada perkembangan lebih lanjut, anak dengan ibu PPD juga memiliki tendensi antisosial dan retardasi kognitif dan psikomotorik.8 Jika PPD tidak segera diantisipasi, maka PPD dapat bermanifestasi menjadi postpartum psychosis (PP). PP merupakan kelainan psikiatrik langka yang memiliki onset akut dengan gejala linglung, gangguan mood, delusi, paranoia, perilaku yang berantakan, pengambilan keputusan yang buruk, dan gangguan fungsi otak. Pada umumnya, pasien yang mengalami psikosis akan berujung pada rawat inap psikiatrik di rumah sakit jiwa. Infantisida dan neonatisida merupakan salah satu risiko serius psikosis pasca-melahirkan. Infantisida merupakan pembunuhan anak di bawah usia 12 bulan secara intensional, sedangkan neonatisida merupakan pembunuhan neonatus secara intensional dalam 24 jam setelah kelahiran. Infantisida dan neonatisida dapat ditandai dengan gejala seperti halusinasi, eksaserbasi, hinggga gejala depresif berat.9 2.1.6. Pencegahan dan Tatalaksana Depresi pasca-melahirkan (PPD) dapat dicegah dengan antisipasi gejala depresi dan psikoedukasi. Hal ini dapat dicapai dengan ante-natal care (ANC) dan post-natal care (PNC) yang rutin. Monitoring perilaku maternal sangat penting untuk mencegah kejadian PPD. Jika maternal memiliki riwayat gangguan psikologis, maka profilaksis antidepresan dapat dilakukan.8 7

Tatalaksana PPD dapat dilakukan menggunakan psikoterapi interpersonal (IPT),

yaitu

konseling

dengan

psikiater.

Psikoterapi

bertujuan

untuk

mengidentifikasi permasalahan interpersonal (i.e. hubungan pernikahan, dukungan sosial, stressor). Selain psikoterapi interpersonal, psikoterapi berupa terapi kognitif-perilaku (CBT) dan terapi psikodinamik juga dapat dilakukan. Meskipun efek psikoterapi tidak sesignifikan intervensi farmakologis berupa antidepresan, psikoterapi merupakan tatalaksana yang paling non-invasif. Di lain pihak, antidepresan (e.g. fluoxetine, paroxetine) terbukti efektif menangani PPD.9 Selain psikoterapi dan intervensi farmakologis, maternal dan bayi dapat diterapi dengan unit ibu-anak. Terapi ini memberikan dukungan terhadap attachment ibu dan anak dengan mengobservasi interaksi dan mencegah disrupsi pemberian ASI karena terapi ini bersifat multidisipliner. Alternatif lain untuk terapi PPD adalah dengan terapi elektrokonvulsif, intervensi gangguan pola tidur, olahraga, hingga pijat bayi.9 2.2. Determinan Sosial Kesehatan Determinan sosial kesehatan merupakan faktor-faktor yang memengaruhi kesehatan seseorang (i.e. usia, tempat tinggal, pekerjaan, dll.). Determinan sosial kesehatan yang paling umum digunakan dalam penelitian adalah model WHO Europe. Pada penelitian kali ini, model inilah yang akan digunakan sebagai rujukan. Ada 10 determinan sosial kesehatan yang dikemukakan oleh model ini. Determinan-determinan tersebut adalah gradien sosial, stress, kehidupan usia dini, ekslusi sosial, jenis pekerjaan (work), status pekerjaan dan pengangguran (unemployment), dukungan sosial, pangan, adiksi, dan transportasi.10 2.2.1. Gradien Sosial Gradien sosial berkaitan dengan fakta bahwa individu yang berada di bagian bawah pada tatanan sosial (social ladder) di masyarakat memiliki angka harapan hidup yang lebih rendah serta lebih rentan terhadap penyakit dibandingkan dengan individu yang berada di posisi atas pada tatanan sosial masyarakat. Individu yang berada di posisi bawah gradien sosial, baik secara materiil maupun psikososial memiliki risiko dua kali lebih besar untuk terjangkit penyakit serius dan kematian prematur dibandingkan individu yang menempati posisi atas pada gradien sosial.10

2.2.2. Stres Determinan stres berkaitan dengan kondisi sosial maupun psikologis yang membuat seseorang merasa cemas dan tidak dapat mengatasi masalah yang ada memiliki dampak buruk pada kesehatan dan dapat menimbulkan kematian prematur. Stres sebagai salah satu faktor psikososial dapat memengaruhi kondisi fisik tubuh, sebab kondisi kejiwaan tubuh berkaitan erat dengan hormon dan sistem saraf yang memegang peran kunci dalam menjalankan fungsi fisiologis tubuh.10 2.2.3. Kehidupan Usia Dini Determinan ini berkaitan dengan kondisi kehidupan yang dimulai sejak masa pre-natal hingga masa kanak-kanak. Termasuk di dalam determinan ini pada masa pre-natal (gestasi) adalah kondisi masa kehamilan tanpa tingkat stres maternal berlebih, tercukupinya nutrisi yang dibutuhkan selama kehamilan, dan faktor lainnya yang memengaruhi perkembangan fetus selama masa gestasi. Pada fase kanak-kanak, terutama dalam lima tahun pertama kehidupan (balita), determinan ini mencakup pemenuhan kebutuhan masa kecil yang memadai, adanya pendidikan anak usia dini (PAUD), pengawasan perilaku anak, penanaman kebiasaan keluarga dan aktivitas sehari-hari, serta kontrol hubungan anak dengan orang tua untuk mencegah keterikatan berlebih (attachment).10 2.2.4. Eksklusi Sosial Ekslusi sosial berarti adanya suatu halangan bagi individu atau kelompok tertentu dalam berpartisipasi atau mendapat pendidikan, pelatihan, akses ke pelayanan tertentu, ataupun aktivitas sosial masyarakat dalam artian luas. Eksklusi sosial dapat timbul dari kemiskinan, kekurangan relative (relative deprivation), rasisme, diskriminasi, stigmatisasi, kebencian terhadap kelompok tertentu, serta pengangguran. Kemiskinan dan eksklusi sosial meningkatkan angka perceraian dan perpisahan, disabilitas, risiko terjangkit penyakit, adiksi, serta isolasi sosial.10 2.2.5. Pekerjaan Determinan ini berkaitan dengan beban kerja pada suatu profesi yang dipengaruhi oleh gaya manajemen kerja, organisasi sosial pekerjaan, serta hubungan sosial yang terjalin di tempat kerja. Beban kerja yang dimaksud pada determinan ini berkaitan dengan tanggung jawab kerja, kontrol terhadap pekerjaan yang diampu, serta imbalan yang diterima dari pekerjaan yang diampu. 9

Tanggung jawab kerja yang tinggi, kontrol terhadap pekerjaan yang minim, serta imbalan kerja yang kecil memiliki dampak buruk pada kesehatan individu.10 Selain itu, jenis pekerjaan juga berpengaruh terhadap risiko kesehatan. 2.2.6. Pengangguran dan Status Kepegawaian Seorang individu yang memiliki pekerjaan yang tetap umumnya memiliki status kesehatan yang lebih baik. Seorang individu yang menganggur dan tidak memiliki sumber pendapatan tetap cenderung mengalami gangguan cemas dan perasaan tidak aman (insecurity). Determinan ini juga menekankan pentingnya kualitas pekerjaan yang diampu.

Pekerjaan yang tidak tetap, pengangguran,

maupun kualiitas pekerjaan yang rendah dapat menyulitkan pembiayaan layanan kesehatan tanpa didukung program jaminan sosial yang baik.10 2.2.7. Dukungan Sosial Dukungan sosial dan hubungan sosial yang baik memiliki dampak besar pada status kesehatan individu. Dukungan sosial memberi bantuan emosional serta dapat bertindak sebagai sumber daya praktis serta menjadi coping mechanism individu dalam menghadapi masalah. Orang â&#x20AC;&#x201C; orang yang kurang mendapat dukungan sosial dan emosional dari orang lain memiliki risiko terkena depresi, komplikasi kehamilan, serta tingkat disabilitas yang lebih tinggi saat terkena penyakit kronik.10 2.2.8. Adiksi (Ketergantungan) Yang dimaksud dengan adiksi pada determinan sosial ini adalah ketergantugan pada zat-zat adiktif, terutama yang berdampak buruk pada kesehatan. Dependensi berlebih terhadap alkohol dapat menyebabkan perubahan perilaku menjadi lebih agresif serta berisiko menimbulkan keracunan dan kerusakan organ. Dependensi alkohol juga menyebabkan penurunan mobilitas sosial, Di lain sisi, zat-zat adiktif,

terutama rokok bagi para pecanduâ&#x20AC;&#x201D;yang

umumnya berasal dari kalangan bawah pada gradien sosial, dapat menguras pemasukan serta dapat menyebabkan berbagai komplikasi kesehatan.10 2.2.9. Pangan Pola makan yang baik serta suplai makanan yang cukup memegang peranan kunci dalam mencapai status kesehatan yang baik. Kurangnya asupan maupun sumber daya pangan (shortage) dapat menyebabkan berbagai berbagai kasus malnutrisi dan penyakit-penyakit akibat defisiensi nutrisi. Kondisi sosioekonomi

individu akan menyebabkan terjadinya gradien pada kualitas pangan yang dapat berujung pada ketidakmerataan status kesehatan (health inequalities).10 2.2.10. Transportasi Determinan ini menekankan pentingnya untuk berjalan dan mengayuh sepeda sebagai sarana transportasi alih-alih mengendarai kendaraan bermotor. Hal ini dimaksudkan sebagai upaya untuk melawan pola hidup sedenter dan meningkatkan aktivitas fisik tubuh. Di lain sisi, hal ini juga bertujuan untuk mengurangi polusi udara yang dapat mengganggu kesehatan organ pernapasan serta mengurangi kemacetan yang dapat menjadi stresor bagi kesehatan mental.10 Pada periode perinatal dan masa perkembangan bayi, setiap determinan sosial ini memainkan peran penting dalam kejadian depresi pasca-melahirkan. Menurut Mandala of Health, faktor lingkungan atau sosioekonomi merupakan faktor yang paling berpengaruh terhadap kesehatan seseorang.11 Dalam hal depresi pasca-melahirkan, faktor sosioekonomi lain yang berpengaruh adalah kejadian persalinan, hubungan pernikahan, ante-natal care (ANC) dan post-natal care (PNC), antisipasi kehamilan dan kelahiran, serta rutinitas pemberian ASI.12

2.3. Kerangka Konsep

Bagan 2.1. Kerangka Konsep

BAB III METODE PENELITIAN 3.1. Ruang Lingkup Penelitian 3.1.1. Tempat Penelitian Penelitian berpusat pada center utama (CU) dan center institusi (CI) yang bersedia berpartisipasi dalam penelitian. 3.1.2. Waktu Penelitian Penelitian akan dilakukan pada periode November 2018 hingga Mei 2019. Waktu penelitian per institusi disesuaikan hingga tercapai jumlah sampel yang diingingkan. 3.1.3. Disiplin Ilmu Terkait Disiplin ilmu yang terkait dengan topik penelitian ialah Ilmu Kedokteran Komunitas (IKK) dan Psikiatri. 3.2. Desain Penelitian Penelitian ini merupakan studi observasional dengan desain penelitian crosssectional (potong-lintang) analitik untuk melihat hubungan antara faktor sosioekonomi dengan kejadian depresi pada perempuan pasca-melahirkan. 3.3. Identifikasi Variabel 3.3.1. Variabel Terikat Variabel terikat penelitian ini adalah ada atau tidaknya post partum depression yang didiagnosis menggunakan Edinburgh Postnatal Depression Scale (EPDS). 3.3.2. Variabel Bebas Variabel bebas dari penelitian ini adalah pendidikan, pekerjaan, penghasilan, jumlah anak sebelumnya, status pernikahan, jumlah kunjungan antenatal care, post-partum check-up, status menyusui, ekspektasi seks anak, dan kehamilan yang direncanakan/tidak. 3.3.3. Variabel Perancu Variabel perancu dari penelitian ini adalah determinan sosial lain seperti adanya riwayat gangguan psikis pasien, penggunaan zat adiktif, dan onset depresi yang sulit untuk ditentukan.

3.4. Definisi Operasional 3.4.1. Definisi Operasional Variabel Bebas Variabel Pendidikan

Definisi Operasional Pendidikan dasar di Indonesia terbagi menjadi tiga tahap yaitu sekolah dasar, sekolah menengah pertama dan sekolah menengah atas. Pada tiap tahap pendidikan terdapat berbagai kompetensi yang harus dicapai dalam berbagai dimensi yaitu sikap, pengetahuan, dan keterampilan.15

Satuan/Skala

Metode Pengukuran

1. Tidak tamat sekolah dasar 1. Tamat sekolah dasar 2. Tamat sekolah menengah pertama 3. Tamat sekolah menengah atas 4. Tamat pendidikan tinggi

Kuesioner

1. Tidak bekerja/ibu rumah tangga 2. Karyawan Swasta 3. Pegawai Negeri Sipil 4. Wiraswasta

Kuesioner

Penghasilan yang dimaksud dalam konteks ini adalah penghasilan total yang didapatkan keluarga.

1. Di bawah Rp 500.000,2. Antara Rp 500.000,sampai dengan Rp 1.500.000,3. Antara Rp 1.500.000,sampai dengan Rp 3.000.000,4. Antara Rp 3.000.000,sampai dengan Rp 5.000.000,5. Di atas Rp 5.000.000,-

Kuesioner

1. Suami bekerja 2. Suami tidak bekerja

Kuesioner

Jumlah anak sebelumnya

Jumlah anak sebelumnya adalah jumlah anak yang dimiliki sebelum kelahiran terakhir.

1. Tidak memiliki anak sebelumnya 2. 1-2 anak sebelumnya 3. 3-5 anak sebelumnya 4. Lebih dari 5 anak sebelumnya

Kuesioner

Status pernikahan

1. Belum menikah 2. Menikah 3. Cerai

Kuesioner

Pekerjaan ibu -

Penghasilan

Pekerjaan suami

4. Cerai Mati Jumlah kunjungan antenatal

1. Melakukan kunjungan antenatal di bawah 2 kali 2. Melakukan kunjungan antenatal 2-4 kali 3. Melakukan kunjungan antenatal lebih dari 4 kali

Kuesioner

Postpartum check up

1. Melakukan postpartum check up 2. Tidak melakukan postpartum check up

Kuesioner

Status menyusui

1. Memberikan ASI eksklusif 2. Tidak memberikan ASI eksklusif

Kuesioner

Dukungan keluarga

Dukungan keluarga dalam konteks ini adalah baik dukungan moral, finansial maupun emosional dari keluarga besar terhadap kehamilan ibu

1. Ada dukungan 2. Tidak ada dukungan

Kuesioner

Ekspektasi seks

Ekspektasi seks yang dimaksud dalam konteks ini adalah dugaan jenis kelamin bayi dan apakah sama dengan saat bayi lahir.

1. Bayi lahir dengan seks sesuai ekspektasi 2. Bayi lahir tidak sesuai dengan seks yang diekspektasi

Kuesioner

Perencanaan kehamilan

Kehamilan yang tidak berencana yang dimaksudkan dapat terjadi di dalam pernikahan ataupun di luar pernikahan (contohnya: akibat pemerkosaan).

1. Kehamilan direncanakan 2. Kehamilan tidak direncanakan

Kuesioner

Kekerasan verbal

Kekerasan verbal yang dimaksud adalah kekerasan dalam bentuk hinaan atau upaya untuk menakuti atau mengisolasi korban. Kekerasan verbal juga dapat berupa ancaman atau upaya untuk mengontrol korban secara paksa.16

1. Ya 2. Tidak

Kuesioner

Kekerasan

Kekerasan fisik adalah

1. Ya

Kuesioner

fisik

bentuk kekerasan dengan menggunakan kekuatan fisik sehingga dapat mencederai atau mencelakakan korban. Contoh dari kekerasan fisik adalah menjambak, menampar, menendang dan menggunakan pisau atau benda lain.12

2. Tidak

Kekerasan seksual

Kekerasan seksual adalah suatu bentuk kekerasan dimana pelaku melakukan paksaan untuk berhubungan secara seksual.17

1. Ya 2. Tidak

Kuesioner

Komplikasi kehamilan

Komplikasi kehamilan adalah komplikasi yang timbul selama proses kehamilan. Contoh dari komplikasi selama kehamilan adalah diabetes gestasional, preeklamsia, dan hiperemesis gravidarum.19

1. Ya 2. Tidak

Kuesioner

Pengalaman positif terhadap kehamilan

WHO mendefinisikan pengalaman kehamilan yang positif sebagai: â&#x2014;? Dipertahankannya normalitas fisik dan sosiokultural â&#x2014;? Dipertahankannya kehamilan yang sehat bagi ibu dan bayi â&#x2014;? Transisi antara kehamilan dan kelahiran yang efektif â&#x2014;? Mencapai tahap keibuan yang positif termasuk kepercayaan diri, kompetensi serta otonomi10

1. Merasa bahagia 2. Biasa saja 3. Tidak merasa bahagia

Kuesioner

Tabel 3.1. Definisi Operasional Variabel Bebas

3.4.2. Definisi Operasional Variabel Terikat Variabel

Definisi Operasional

Satuan/Skala Metode Pengukuran

Post Post partum depression dapat partum diukur dengan menggunakan depression Edinburgh Postnatal Depression Scale (EPDS). Seseorang dapat dikatakan memiliki post partum depression apabila mendapatkan nilai 10 atau lebih dari 10.

Tidak memiliki satuan.

Pengukuran post partum depression dilakukan menggunakan EPDS yang terdiri atas 10 pertanyaan dengan skor maksimal 30.

Tabel 3.2. Definisi Operasional Variabel Terikat

3.5. Populasi dan Subjek Penelitian 3.5.1. Populasi Penelitian Populasi target dalam penelitian ini adalah wanita Indonesia pascamelahirkan. Sementara itu, populasi terjangkau dalam penelitian ini adalah wanita Indonesia paca melahirkan yang mendatangi puskesmas. 3.5.2. Subjek Penelitian Sampel penelitian yang digunakan adalah populasi terjangkau yang memenuhi kriteria inklusi dan tidak memenuhi kriteria eksklusi penelitian. Subjek yang benar-benar diteliti adalah selisih antara sampel penelitian dengan sampel drop out. 3.6. Kriteria Inklusi dan Eksklusi 3.6.1. Kriteria Inklusi Kriteria inklusi penelitian meliputi: ● Subyek merupakan wanita yang baru saja melahirkan minimal 2 minggu sebelumnya ● Subyek belum pernah terdiagnosis dengan post partum depression ● Pasien belum pernah didiagnosis memiliki riwayat gangguan mental/penyakit lain. ● Pasien tidak memiliki riwayat kertergantungan terhadap narkoba, rokok, dan alkohol 3.6.2. Kriteria Eksklusi Kriteria eksklusi penelitian meliputi: ● Subyek tidak bersedia untuk diwawancarai ● Subyek tidak memberikan data yang lengkap 17

3.7. Teknik Pengambilan Sampel Sampel penelitian yang akan menjadi subjek penelitian didapat dari populasi terjangkau dengan menggunakan teknik consecutive sampling. Untuk menentukan hubungan antarvariabel, perkiraan besar sampel dapat dihitung dengan menggunakan rumus di bawah:

dengan: n

= jumlah sampel

= kesalahan tipe I, ditetapkan sebesar 5%.

Za/2

= deviat baku α (untuk uji dua arah dengan CI=95%, nilai Zα/2 = 1,96)

Zβ

= power penelitian, ditetapkan 80% dengan nilai Zβ = 0.842

= proporsi efek standar (diperoleh dari pustaka = 0.3)2

= 1-P1

= proporsi efek yang diteliti (clinical judgment), ditetapkan oleh peneliti 60%.

= 1-P2

= ½ (P1 + P2)

= 1-P

!"#$%$&'( = !"#$%$&'* = 41.98 ≈ 42 34567! Hasil yang dibutuhkan per kelompok adalah 41,98 pasien yang kemudian dibulatkan menjadi 42 pasien. Karena terdapat dua kelompok, maka jumlah sampel yang dibutuhkan adalah 84 pasien. 3.8. Instrumen Penelitian Instrumen yang digunakan untuk menilai adanya postpartum depression adalah Edinburgh Postnatal Depression Scale (EPDS). Untuk kepraktisan penggunaan kuesioner dengan subjek penelitian di Indonesia, maka akan digunakan kuesioner EPDS yang telah diterjemahkan dalam bahasa Indonesia yang digunakan dalam tesis Esther Tiarma Hutagaol yang berjudul “Efektivitas Intervensi Edukasi pada Depresi Postpartum” yang telah divalidasi dan diuji reliabilitasnya melalui penelitian-penelitian 18

terdahulu. Kuesioner EPDS terdiri atas 10 pertanyaan yang akan dijawab mandiri oleh subjek penelitian.15 Masing-masing pertanyaan kan dinilai melalui skala numerik 0-3. Total nilai akan dibandingkan dengan cut-off kuesioner dengan ketentuan nilai di atas atau sama dengan 10 berarti subjek berpotensi mengalami postpartum depression dan di atas 13 berarti terindikasi depresi postpartum dengan variasi intensitas. 3.9. Cara Pengumpulan Data Pengumpulan data akan dilakukan melalui sistematika berikut ini: 1. Subjek penelitian diambil dari populasi terjangkau, yakni perempuan Indonesia yang baru melahirkan dalam kurun waktu dua minggu di center utama dan center institusi. 2. Peneliti menjelaskan tujuan penelitian, lalu meminta kesediaan untuk ikut penelitian dengan memberikan informed consent pada calon subjek penelitian. 3. Pada calon subjek yang telah menandatangani informed consent, dilakukan seleksi sampel dari populasi terjangkau menurut kriteria inklusi dan eksklusi untuk mendapatkan subjek penelitian. 4. Subjek dikumpulkan hingga mencapai kuota penelitian yang telah ditetapkan dengan rumus. 5. Subjek mengisi instrumen uji depresi postnatal (Edinburgh Postnatal Depression Scale/EPDS) serta kuesioner determinan sosial secara pribadi. 6. Data yang telah didapat akan diolah dengan menggunakan piranti lunak IBM SPSS versi 20.0. 3.10. Rencana Analisis Data akan diolah dengan menggunakan piranti lunak IBM Statistical Package for Social Sciences (SPSS) v.20.0. Mengingat besar sampel yang lebih dari 50, akan dilakukan uji normalitas dengan uji Kolmogorov-Smirnov. Selanjutnya, mengingat jumlah variabel dependen yang akan diuji, akan dilakukan uji statistik regresi logistik bertahap. Tahap uji pertama akan dilakukan dengan menggunakan analisis univariat. Jika hasilnya bermakna signifikan, akan dilakukan uji analisis bivariat. Jika hasilnya signifikan, akan diuji kembali dengan analisis multivariat. 3.11 Etik Penelitian Etika dalam suatu penelitian sangat penting untuk diperhatikan agar penelitian tidak merugikan pihak lain. Terutama apabila penelitian yang dilakukan melibatkan pihak lain, terutama subjek yang berupa manusia. Karena hal itu, penelitian harus benar-benar menguntungkan sehingga nilai keuntungannya lebih tinggi daripada

resikonya. Penelitian juga harus dihentikan bila dianggap berisiko dan membahayakan. Oleh karena itu, penelitian harus memiliki aspekâ&#x20AC;&#x201C;aspek etika berikut ini : 1. Mendapatkan persetujuan Etik dari Komite Etika Penelitian. 2. Menghargai otonomi subjek 3. Menjaga kerahasiaan data pasien,

BAB IV DAFTAR PUSTAKA 1. Postnatal depression [Internet]. London: National Health Service; (n.d.) [cited: 2018 Oct 13]. Available from: https://www.nhs.uk/conditions/post-natal-depression/ 2. O’Neil A, Jacka FN, Quirk SE, Cocker F, Taylor CB, Oldenburg B, et al. A shared framework for the common mental disorders and non-communicable disease: key consideratoins for disease prevention and control. BMC Psychiatry. 2015;15:15 3. Idaiani S, Basuki B. Postpartum depression in Indonesian women: a national study. Health Sci J Indones. 2012;3(1):3-8 4. Closa-Monasterolo R, Gispert-Llaurado M, Canals J, Luque V, Zaragoza-Jordana M, Koletzko B et al. The effect of postpartum depression and current mental health problems of the mother on child behaviour at eight years. Matern Child Health J. 2017 Jul;21(7):1563-1572. 5. Ghaedrahmati M, Kazemi A, Kheirabadi G, Ebrahimi A, Bahrami M. Postpartum depression risk factors: a narrative review. J Educ Heal Promot. 2017;6:60. 6. Kusuma PD. Karakteristik penyebab terjadinya depresi postpartum. J Keperawatan Notokusumo. 2017;V(1):36-45. 7. Silverman M, Reichenberg A, Savitz D, Cnattingius S, Lichtenstein P, Hultman C, et al. The risk factors for postpartum depression: a population-based study. Depress Anxiety. 2017;34(2):178-87. 8. Brummelte S, Galea LAM. Postpartum depression: etiology, treatment and consequences for maternal care. Horm Behav. 2016;77:153–66. 9. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obs Gynecol. 2009;200(4):357–64. 10. Bartley M, Blane D, Brunner E, Dorling D, Ferrie J, Jarvis M, et al. The solid facts. In: Wilkinson R, Marmot M, editors. Social determinants of health. 2nd ed. Copenhagen: World Health Organization; 2003. 11. Coutts C, Forkink A, Weiner J. The portrayal of natural environment in the evolution of the ecological public health paradigm. Int J Environ Res Public Health. 2014;11(1):1005–19. 12. Dugravier R, Tubach F, Saias T, Guedeney N, Pasquet B, Purper-Ouakil D, et al. Impact of a manualized multifocal perinatal home-visiting program using

psychologists on postnatal depression: the CAPEDP randomized controlled trial. PLoS One. 2013;8(8):e72216. 13. Hutagaol ET. Efektivitas intervensi edukasi pada depresi postpartum [thesis]. Depok: Fakultas Ilmu Keperawatan Universitas Indonesia; 2010. 14. Standar kompetensi lulusan pendidikan dasar dan menengah: Peraturan Menteri Pendidikan dan Kebudayaan Republik Indonesia no. 20 tahun 2016. Jakarta: Kementerian Pendidikan dan Kebudayaan Republik Indonesia; 2016 Jun 6 15. Office on Women’s Health. Emotion and verbal abuse [Internet]. Washington D.C.: United States Department of Health and Human Services; (n.d.) [updated 2018 Sep 13; cited 2018 Oct 15]. Available from: https://www.womenshealth.gov/relationshipsand-safety/other-types/emotional-and-verbal-abuse 16. Office on Women’s Health. Physical abuse [Internet]. Washington D.C.: United States Department of Health and Human Services. (n.d.) [updated 2018 Sep 13; cited 2018 Oct 15]. Available from: https://www.womenshealth.gov/relationships-andsafety/other-types/physical-abuse 17. Office on Women’s Health. Sexual coercion [Internet]. Washington D.C.: United States Department of Health and Human Services. (n.d.) [updated 2018 Sep 13; cited 2018 Oct 15]. Available from: https://www.womenshealth.gov/relationships-andsafety/other-types/sexual-coercion 18. Office on Women’s Health. Pregnancy complications [Internet]. Washington D.C.: United States Department of Health and Human Services. (n.d.) [updated 2018 Oct 9; cited 2018 Oct 15]. Available from: https://www.womenshealth.gov/pregnancy/ youre-pregnant-now-what/pregnancy-complications 19. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization Press; 2016.

BAB V LAMPIRAN 5.1. Formulir Kuesioner 5.1.1. Karakteristik Responden Karakteristik responden (data diri responden) 1. Nama responden/inisial

2. Usia

3. Pekerjaan

4. Nomor Telepon/HP

5. Alamat

6. Riwayat penyakit

4.1. Apakah Anda pernah didiagnosis depresi oleh psikiater atau psikolog sebelumnya? Jawab: 4.2. Apakah Anda pernah didiagnosis oleh psikiater atau psikolog mengalami gangguan atau kelainan mental sebelumnya? Jika iya, kelainan/gangguan apa yang dimaksud? Jawab: 5.1.2. Kuesioner Edinburgh Postnatal Depression Scale Bagaimana perasaan Anda dalam tujuh hari terakhir termasuk hari ini setelah melahirkan bayi? Beri tanda silang (X) pada pernyataan di bawah ini yang paling sesuai dengan perasaan Anda: B

Pertanyaan

Saya dapat tertawa apabila melihat sesuatu yang lucu: A. Sering. B. Kadang-kadang. C. Jarang. D. Tidak pernah.

Saya dapat mengerjakan banyak hal dengan senang: A. Sering. B. Kadang-kadang. C. Jarang. D. Tidak pernah.

Saya menyalahkan diri saya sendiri apabila terjadi hal 23

Keterangan

yang tidak menyenangkan: A. Sering B. Kadang-kadang. C. Jarang. D. Tidak pernah. B4

Saya merasa khawatir dan cemas tanpa alasan yang jelas: A. Tidak pernah. B. Kadang-kadang. C. Jarang. D. Sering.

Saya merasa ketakutan atau panik tanpa alasan yang jelas: A. Sering. B. Kadang-kadang. C. Jarang. D. Tidak pernah.

Segala sesuatu terasa membebani saya sehingga: A. Hampir selalu saya merasa tidak bersemangat. B. Kadang-kadang saya merasa tidak bisa mengatasi sebaik biasanya. C. Hampir selalu saya merasa bisa mengatasi dengan baik. D. Selalu saya bisa mengatasi sebaik biasanya.

Saya merasa sangat tidak bahagia sehingga sulit tidur: A. Hampir setiap hari. B. Kadang-kadang. C. Jarang. D. Tidak pernah.

Saya merasa sedih dan jengkel tanpa alasan: A. Hampir setiap waktu. B. Kadang-kadang. C. Jarang. D. Tidak pernah.

Saya merasa sangat tidak bahagia sehingga saya menangis: A. Hampir setiap waktu. B. Kadang-kadang. C. Jarang. D. Tidak pernah.

B10

Pernah ada pikiran putus asa: A. Sering B. Kadang-kadang. C. Jarang. 24

D. Tidak pernah. 5.1.3. Kuesioner Determinan Psikososioekonomi Pilihlah jawaban yang sesuai dengan kondisi yang Anda alami: No

Indikator

Status pendidikan: A. Tidak tamat sekolah dasar (SD). B. Tamat sekolah dasar (SD). C. Tamat sekolah menengah pertama (SMP). D. Tamat sekolah menengah atas (SMA). E. Tamat pendidikan tinggi.

Apakah Ibu bekerja? A. Ya B. Tidak Apabila jawaban tidak, lompati pertanyaan nomor 3

Jika iya, apakah pekerjaan ibu: A. Karyawan swasta. B. Pegawai negeri sipil. C. Wiraswasta.

Penghasilan per bulan: A. Di bawah Rp500.000,00. B. Antara Rp500.000,00. - Rp1.500.000,00. C. Antara Rp1.500.000,00. - Rp3.000.000,00. D. Antara Rp3.000.000,00. - Rp5.000.000,00. E. Di atas Rp5.000.000,00.

Jika memiliki suami atau mantan suami, apakah bekerja? A. Ya. B. Tidak.

Jumlah anak sebelumnya: A. Tidak memiliki anak sebelumnya. B. 1-2 anak sebelumnya. C. 3-5 anak sebelumnya. D. Lebih dari 5 anak sebelumnya.

Status pernikahan: A. Belum menikah. B. Menikah. C. Cerai. D. Cerai akibat kematian.

Keterangan

Jumlah kunjungan asuhan antenatal: A. Di bawah 2 kali. B. 2-4 kali. C. >4 kali.

Postpartum check-up: A. Melakukan. B. Tidak melakukan.

Status menyusui: A. Memberikan ASI eksklusif. B. Tidak memberikan ASI eksklusif.

Apakah keluarga mendukung kehamilan Ibu? A. Ya B. Hanya sebagian C. Tidak

Ekspektasi seks: A. Bayi lahir dengan jenis kelamin sesuai ekspektasi. B. Bayi lahir dengan jenis kelamin tidak sesuai ekspektasi.

Perencanaan kehamilan: A. Direncanakan B. Tidak direncanakan

Apakah Ibu pernah menerima kekerasan verbal saat hamil? A. Ya B. Tidak

Apakah Ibu pernah menerima kekerasan fisik saat hamil? A. Ya B. Tidak

Apakah Ibu pernah menerima kekerasan seksual saat hamil? A. Ya B. Tidak

Dalam proses kehamilan, apakah Ibu mengalami komplikasi kehamilan? A. Ya B. Tidak Jika jawaban â&#x20AC;&#x153;Yaâ&#x20AC;?, tolong identifikasikan penyakitnya: _____________

Secara keseluruhan, apakah Ibu merasa bahagia dengan proses kehamilan Ibu? A. Ya B. Biasa saja C. Tidak

5.2. Formulir Persetujuan Mengikuti Penelitian FORMULIR PERSETUJUAN MENGIKUTI PENELITIAN (FORMULIR INFORMED CONSENT) Yang bertanda tangan di bawah ini, saya: Nama

: ______________________________________________________

Nomor Telepon/HP : ______________________________________________________ Alamat Rumah

: ______________________________________________________ ______________________________________________________

Umur

: _________________________________________________ tahun

Setelah mendapat penjelasan tentang maksud dan tujuan serta memahami penelitian yang dilakukan dengan judul: HUBUNGAN FAKTOR PSIKOSOSIOEKONOMI DENGAN KEJADIAN DEPRESI POSTPARTUM PADA PEREMPUAN DI INDONESIA: SEBUAH STUDI MULTICENTER Yang dibuat oleh: Nama Peneliti 1/NPM : Johan Cahyadirga/1606892743 Nama Peneliti 2/NPM : Gilbert Lazarus/1706030176 Nama Peneliti 3/NPM : Azis Muhammad Putera/1706982462 Dengan ini saya menyatakan kesediaan untuk berperan serta menjadi subjek penelitian dan bersedia melakukan wawancara sesuai dengan data yang diperlukan. Demikian pernyataan ini dibuat dengan penuh kesadaran tanpa ada paksaan dari pihak manapun. Yang membuat pernyataan

______________________

5.3. Anggaran Penelitian 1. Alat Penelitian Material Kuantitas Formulir informed consent 2500 Formulir kuesioner 2500 2. Transportasi Jenis Subsidi transportasi TOTAL ANGGARAN

Kuantitas 34

Harga Satuan (Rp) Biaya (Rp) Rp500,Rp1.250.000,Rp1.000,Rp2.500.000,SUB TOTAL (Rp) Rp3.750.000,Harga Satuan (Rp) Biaya Rp35.000,Rp1.190.000,SUB TOTAL (Rp) Rp1.190.000,Rp4.940.000,-

5.4. Timeline Penelitian Jenis Kegiatan

Oktober November Desember Januari Februari Maret April Mei 2018 2018 2018 2019 2019 2019 2019 2019

Pembuatan proposal penelitian dan instrumen penelitian Sosialisasi dan pengembangan wawasan untuk pengambilan data Pengambilan data Pengiriman data kembali ke center pusat Pengolahan data Penulisan laporan

PCC Eamsc 2019

Pre-conference competition east asia medical student conference

bundle of acads amsa-ui 2018/2019

PCC Eamsc 2019

scientific paper

bundle of acads amsa-ui 2018/2019

Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference (PCC EAMSC) 2019 Scientific Paper

The Role of Probiotics in Managing Obesity and its Progression in Healthy Overweight and Obese Individuals: A Systematic Review of Clinical Trials

By: Jessica Audrey Anthony William Brian Iskandar Christianto Elvan Wiyarta

The Role of Probiotics in Managing Obesity and its Progression in Healthy Overweight and Obese Individuals: A Systematic Review of Clinical Trials Jessica Audrey*, Anthony William Brian Iskandar, Christianto, Elvan Wiyarta *jsaudrey8@gmail.com, (+62) 89690781450 INTRODUCTION Obesity is defined as body-mass index (BMI, which is the weight in kilograms divided by the square of height in meters) of 30 kg/m2 or greater, while BMI between 25 to 30 kg/m2 is considered overweight (Heymsfield & Wadden, 2017; World Health Organization, 2018). Beneath these numbers is a more complicated phenotype, which is primarily associated with excess adiposity, which could manifest as serious diseases, such as type II diabetes mellitus, cardiovascular disease, respiratory conditions, osteoarthritis, and certain cancers (e.g. esophageal and colon cancer) (Hruby & Hu, 2015). Therefore, some organizations has pronounced obesity as a disease itself (Heymsfield, et al., 2017; Hruby, et al., 2015). Globally, the number of obese and overweight people has increased since the last three decades. By 2016, WHO estimated that more than 2.5 billion adults were affected, 1.9 billion were overweight and the remaining 650 million were obese. It is also estimated that by 2030, 57.8% of adult population around the world would have a BMI of 25 kg/m2 or higher. Furthermore, about 124 million children and adolescents are obese, double of the number in 1908 (WHO, 2018). This prevalence of obesity and its comorbidities accounts for an average of 0.7-2.8% of a countryâ&#x20AC;&#x2122;s total healthcare costs, which translates up to US$ 2 trillion (Mathur & Barlow, 2015; GonzĂĄlez-Muniesa, et al., 2017). The cause of obesity itself is multifactorial, involving interactions between genetic and environmental factors (WHO, 2018), though the most mentioned ones are the dysregulation of food intake and energy expenditure (Heymsfield, et al., 2017). Currently, personalized lifestyle intervention (control in diet and physical activity) remains as one of the most effective treatment for obesity. Additional physiological treatments induce peripheral signals to influence the neurons which act as main controllers of energy balance in the hypothalamus. Normally, these signals are reciprocally produced by cells and microbiota within adipose tissue, pancreas, stomach, or internal colonic microbiota (Heymsfield, et al., 2017). Microbiota or microbiome is a collection of microbes (bacteria, archaea, and eukaryotes) that colonize human body (Mathur, et al., 2015). In the last decade, gut microbiota has been studied in relation to obesity, energy metabolism, and macronutrient digestion (Hruby, et al., 2015; Mathur, et al., 2015). These organisms may contribute to obesity by influencing nutrient breakdown and absorption, gut permeability, and inflammatory responses. Many of these studies have observed changes in gut

microbiota in obese individuals, whether in range of diversity or ratio (Mathur, et al., 2015). For example, Firmicutes to Bacteroidetes ratio is increased in obesity and vice versa in weight loss (Mathur, et al., 2015; GonĹşalez-Muniesa, et al., 2017). Studies has shown that phenotype of obesity could be transferred through individuals via the donorâ&#x20AC;&#x2122;s microbiota, which is characterized by significant increase of body fat (Mathur, et al., 2015). This impact, which is majorly caused by microbiota interaction, reveals promising alternative therapy to alleviate the burden of obesity (Hruby, et al., 2015). Thus, consumption of probiotics, which are collections of one or more strains of microorganisms (mainly bacteria or yeast) is vigorously researched as a therapeutic agent to manipulate composition of gut microbiome (Hruby et al., 2015; Mathur, et al., 2015). Latest researches on the effect of probiotic consumption in obesity has developed into clinical trials, yet the results are not fully consistent. This in turn stresses the need of a comprehensive review, whether the use probiotics is an effective and safe method in reducing obesity. In this study, we conducted a systematic review on clinical trials on the use of probiotics, involving healthy overweight and obese individuals. We analyzed the resultant effects in these individuals, mainly the related benefits of probiotics. In the long term, we hope that probiotics may have a role in managing obesity and its progression, encouraging its application as a novel adjunct therapy in obesity and its associated metabolic diseases, thereby helping to reduce its global prevalence and burden. MATERIALS AND METHODS a. Study Search Strategy We conducted a systematic review of randomized controlled trials based on PRISMA statement from PubMed and EBSCOhost using the keywords ((probiotics) OR (lactobacillus) OR (bifidobacterium) OR (streptococcus) OR (enterococcus)) AND ((obesity) OR (overweight)) AND ((randomized controlled trials) OR (randomized controlled trial)). Afterward, inclusion criteria were set to filter the results including: randomized controlled trials, studies on the effect of probiotics administration on overweight and obese individuals, and published within the last five years, that is, studies published between January 2013 and September 2018. In addition, exclusion criteria were also set: studies involving immunocompromised patients, pregnant subjects or subjects with metabolic diseases were excluded. We also exclude unauthentic articles, studies with incompatible language, and inaccessible full-text articles. b. Data Extraction Subsequently, we set necessary data to be extracted from articles including: author and year of

publication, study design, location of study, participantsâ&#x20AC;&#x2122; characteristics including sample size, subject range of BMI, and subject mean or range of age, probiotic used in the trials, intervention and duration, and outcome which is presented by p value for each findings. c. Risk of Bias Assessment Finally, the articles will be assessed with Cochrane Risk of Bias Tool for Randomized Controlled Trials which consists of seven criteria. The assessment was conducted by four reviewers collaboratively and concluded after consensus were reached. RESULTS The literature search was conducted through PubMed and EBSCOhost. Articles were screened for relevancy and eligibility. The search yielded 12 randomized controlled trials with a total of 1099 subjects. The data extracted and characteristics of included studies are shown in Table 1. The probiotic supplementation given varies between groups, with six trials using single species of probiotics, and six others with multi-species probiotics. Intervention duration ranges from 4 to 24 weeks. The study selection process is shown in Figure 1. The studies were then further assessed with Cochrane Risk of Bias Tool for Randomized Controlled Trials. The result of risk bias assessment is shown in Table 2 in the Appendix at the last part of this paper.

Figure 1. PRISMA flow chart of search strategies

Table 1. Characteristics of included studies Author and Year

Study Design

Location

Participants characteristics

Probiotic

Intervention and duration

Outcome

Minami et al (2018)

Randomized, double-blind, Placebocontrolled trial

Japan

80 healthy pre-obese (placebo: 40, intervention: 40)

B. breve B-3

B. breve B-3 capsules

Probiotic group compare to placebo group: ↓ body fat mass (p=0.03, η2=0.060) ↓ percent body fat (p=0.02, η2=0.068) No significant changes in BMI

Szulińska et al (2018)

Randomized, double-blind, Placebocontrolled trial

Poland

BMI: 25 ≤ BMI < 30 kg/m2 Mean age: 45.50 years 81 obese Caucasian postmenopausal women (placebo: 24, low-dose: 24, highdose:23) BMI: 30–45 kg/m2 Mean age: 56.75 years

Dosage: 2 × 1010 CFU/day Duration: 12 weeks

Ecologic® Barrier containing: B. bifidum W23, B. lactis W51, B. lactis W52, L. acidophilus W37, L. brevis W63, L. casei W56, L. salivarius W24, L. lactis W19, Lactococcus lactis W58

2 g of freeze-dried powder of the probiotic mixture Ecologic® Barrier Dosage: Low-dose group: 2.5 × 109 CFU/day High-dose group: 1 × 1010 CFU/day Duration: 12 weeks

High-dose group: ↓ LPS (p=0.0008, SMD= – 0.77) ↓ waist circumference (p=0.0199, SMD= –0.54 ↓ fat mass (p=0.03974, SMD= –0.83) ↓ subcutaneous fat – (p=0.0002, SMD= –0.77) ↓ TC (p = 0.0019, SMD= −0.57 ↓ TG (p= 0.014, SMD= −0.43) ↓ LDL (p = 0.0149, SMD = −0.41) ↓ HOMA-IR (p = 0.0001, SMD = −0.82) Low-dose group:

↓ waist circumference (p=0.0001, SMD= –1.06 ↓ fat mass (p=0.0099, SMD= – 0.62) ↓ subcutaneous fat – (p=0.0022, SMD= –0.99) ↓ visceral fat (p=0.0336, SMD=–0.58) ↓ TC (p = 0.0124, SMD= −0.49) ↓ LDL (p = 0.0168, SMD = −0.59) ↓ HOMA-IR (p = 0.0001, SMD = −0.54)

Sanchez et al (2017)

Randomized, double-blind, Placebocontrolled trial

Quebec

45 obese men (placebo: 22, intervention: 23) and 60 obese women (placebo: 31, intervention: 29) BMI: 29 – 41 kg/m2 Mean age: 36.0 years

L. rhamnosus CGMCC1.3724 (LPR)

LPR formulation given twice a day (10 mg of LPR = 1.6 x 108 CFU/capsule, 210 mg of oligofructose, and 90 mg of inulin) Dosage: 3.24 × 108 CFU/day Duration: 24 weeks (Phase 1: first 12-weeks

Both groups show no significant effect in BMI and body mass Women: ↑ satiety efficiency (↑SQ) (Δ=3.5 ± 1.5; p = 0.02) ↓ TFEQ cognitive restraint (Δ=−2.0 ± −0.8; p = 0.01) ↓ TFEQ disinhibition (Δ=−1.1 ± 0.6; p = 0.05) ↓ TFEQ hunger (Δ=−1.7 ± 0.7; p = 0.02) Men:

Gomes et al (2017)

Randomized, double-blind, parallel, placebocontrolled trial

Brazil

43 healthy women, overweight and obese (placebo: 22, intervention: 21) BMI: 24.9 ≤ BMI ≤ 40 kg/m2 Age: 20-59 years

Stenman et al (2016)

Randomized, double-blind, parallel, placebocontrolled trial

Finland

134 healthy, overweight and obese (placebo: 36, B420: 25, LU: 36, LU + B420: 37)

Lactobacillus acidophilus, Lactobacillus casei, Lactococcus lactis, Bifidobacterium bifidum, Bifidobacterium lactis

of weight loss program; Phase 2: second 12-weeks of weight maintenance program)

↑ satiety efficiency (↑SQ) (Δ=2.6 ± 1.2; p = 0.03) ↓ TFEQ cognitive restraint (Δ=−3.4 ± 1.2; p = 0.05)

Probiotic mix sachets (109 CFU/strain/sachet) Dosage: 4 sachets/day (2 × 1010 CFU/day) Duration: 8 weeks

Greater change in waist circumference (-5.48% vs 3.40%, p=0.03), waist-height ratio (-5% vs -3.27%, p=0.02), conicity index (-4.09 vs -2.43, p=0.03), and plasma PUFA (18.63% vs +5.65%, p=0.04) compared to controls

Both groups: normocaloric diet (25-30 kcal/kg)

Bifidobacterium animalis ssp. lactis 420

1) Placebo (MC 12 g/day) 2) B420 (1010 CFU/day) 3) LU (12 g/day) 4) B420 (1010 CFU/day) + LU (12 g/day) Duration: 6 months

↑GPx activity (+15.62% vs 16.67%, p<0.01) ↓body fat mass in group 4 (4.5%, p=0.02) No significant changes in body fat mass between group 2 and placebo (p=0.28), group 3 and placebo (p=1.00)

Pediococcus pentosaceus LP28

1) Placebo (dextrin powder 7.5 mL/day)

↓BMI (0.45 kg/m2 (0.04, 0.86); p=0.035),

BMI: 28.0 ≤ BMI ≤ 34.9 kg/m2

Higashikaw a et al (2016)

Randomized, double-blind,

Japan

Age: 18-65 years 62 healthy, overweight (placebo:

placebocontrolled trial

20, living LP28: 21, heat-killed LP28: 21)

2) LP28 powder (10 mL/day or 1011 CFU/day) 3) Heat-killed LP28 powder (7.5 mL/day or 1011 CFU/day) Duration: 12 weeks

↓percent body fat (1.11% (0.39, 1.82); p=0.002), ↓body fat mass (1.17 kg (0.43, 1.92). p=0.004), ↓waist circumference (2.84 cm (0.74, 4.93), p=0.009)

Streptococcus thermophiles, Lactobacillus bulgaricus, Lactobacillus acidophilus LA5, and Bifidobacterium lactis BB12 Total minimum of 1x107 CFU

PY was to be consumed with the main meals (200 g twice/day) daily.

PY decrease total cholesterol better than LF (p = 0.024) PY decrease LDL better than LF (p = 0.018) PY decrease insulin resistant better than LF (p<0,001) PY decrease fasting insulin concentration better than LF (p=0,002)

VSL#3: Streptococcus thermophilus DSM24731, L. acidophilus

VSL#3 with ice cream and coconut milk (463 g) and contained 65 g of saturated fat and 81 g

BMI: 25 ≤ BMI ≤ 30 kg/m2 Age: 20-70 years Madjid et al (2016)

RCT, doubleblind

Tehran, Iran

89 healthy overweight and obese (Low-fatyogurt: 45, probiotic yogurt: 44) BMI: 27-40 kg/m2 Women aged 18–50 years, premenopausal status, habitual daily consumption of lowfat yogurt (200–400 g)

Osterberg et al (2015)

Randomized, double-blind, Placebocontrolled trial

Virginia, USA

20 healthy non-obese (Placebo: 11, intervention (VSL#3): 9)

Dosage: 1x107 CFU/dose Duration: 12 weeks

No significant differences were found for weight reduction, fasting plasma glucose, high-density lipoprotein cholesterol, or triglycerides between both groups Weight-loss diet with probiotic group: ↓ BMI (p<0.001) ↓ fat percentage (p<0.001)

BMI < 30 kg/m2 Mean age: 22,9 ± 0,9 years

Zarrati et al (2014)

Sanchez et al (2014)

Randomized doubled-blind controlled clinical trial

Tehran, Iran

Randomized, double-blind, Placebocontrolled trial

Quebec City

All participants were sedentary (<2 days, 20 min day 21 of lowintensity physical activity) 75 healthy overweight and obese individuals (RLCD: 25, PLCD: 25, PWLCD:25) 48 overweight men (placebo: 24, intervention: 24) and 77 overweight women (placebo: 39, intervention: 38) BMI: 29 ≤ BMI ≤ 41 kg/m2 Age: 18-55 years

DSM24735, L. delbrueckii ssp. bulgaricus DSM24734, L. paracasei DSM24733, L. plantarum DSM24730, B. longum DSM24736, B. infantis DSM24737, and B. breve DSM24732 L. acidophilus La5, B. BB12, and L. casei DN001

of total fat all combine in the form of milk shake 250 kcal for the high fat diet period. Duration: 4 weeks

200 g/day of conventional yogurt or probiotic yogurt Dosage: 108 CFU/g Duration: 8 weeks

Lactobacillus rhamnosus CGMCCI.3724 (LPR)

↓ leptin level (p<0.001)

LPR formulation capsules (10 mg of LPR powder = 1.62 x 108 CFU/capsule,300 mg of a mix of oligofructose and inulin (70:30, v/v), and 3 mg of magnesium stearate) Dosage: 2 capsules/day (3.24 × 108 CFU/day)

Weight-loss diet with probiotic group: ↓ BMI (p<0.001) ↓ fat percentage (p<0.001) ↓ leptin level (p<0.001) Women: ↓ Body weight (Δ=−2.6 ± 1.1; p=0.02) ↓ Fat mass (Δ=−2.54 ± 1.01; p=0.01) ↓ Leptin (Δ=−11.0 ± 2.9; p=0.0004) ↓ Lachnospiraceae family in faeces (38.2% vs 27.6 %, p=0.001 with V123 and 32.6% vs 24.5%, p=0.03 with V456) compared to placebo group

Zarrati et al (2013)

Randomized, doubled-blind, controlled clinical trial

Tehran, Iran

75 obese and overweight men and women (RLCD: 25, PLCD: 25, PWLCD: 25) BMI: 25 ≤ BMI ≤ 35 kg/m2 Age: 20-50 years

Streptococcus thermophiles, Lactobacillus bulgaricus, Lactobacillus acidophilus LA5, Lactobacillus casei DN001, Bifidobacterium-lactis Bb12

Duration: 24 weeks (Phase 1: first 12 weeks of weight-loss phase with supervised dietary restriction (500 kcal/day); Phase 2: second 12 weeks of weight-maintenance phase with supervision of dietary habits without restriction 200 g/day of either conventional yogurt or probiotic yogurt Conventional yogurt containing: S. thermophiles, L. bulgaricus Probiotic yogurt containing: S. thermophiles, L. bulgaricus, LA5, DN001, Bb12 Dosage: 108 CFU/g (each strain) Duration: 8 weeks

Men: No significance changes by treatment in body weight and fat mass

↓ IL4 (PLCD, p=0.01; RLCD, p=0.03; PWLCD, p=0.02) ↓ IL17 in PLCD and RLCD (Δ = −617 and −670 pg/mL, p<0.05 vs −217 pg/mL) compared to PWLCD ↓ ROR-γt (p=0.007) ↑ FOXP3 (Δ= 11.2 ± 6.7, 6.0 ± 2.5, and 6.3 ± 1.9 in PLCD, RLCD, and PWLCD groups respectively, p<0.001) ↓ T-bet gene (p<0.001) in PLCD and PWLCD groups ↓ IFN-γ (PLCD, p=0.001; PWLCD, p=0.01) ↓ TNFα (RLCD and PLCD, p<0.001)

Kadooka et al (2013)

Multi-centre, double-blind, parallel-group RCT

Japan

105 men with large visceral fat areas (107 dose: 33, 106 dose: 36, control: 36) 105 women with large visceral fat areas (107 dose: 36, 106 dose: 35, control: 34) Age: 35-60 years Large visceral fat areas: 80.2-187.8 cm2

Lactobacillus gasseri SBT2055 (LG2055)

200 g FM/day (as two portions of 100 g) containing LG2055 Dosage: 107 CFU/g, 106 CFU/g, or 0 CFU/g Duration: 12 weeks

↓ Abdominal visceral fat areas (Δ = −8.5%, 95% CI −11.9, −5.1; p<0.01 and (Δ = −8.2%, 95 % CI −10.8, −5.7; p<0.01) in 107 and 106 dose group repectively ↓ BMI, waist, and hip circumferences (p<0.01) ↓ Fat mass (p<0.01) No significant changes in the control group

Notes: ALT: alanine aminotransferase; AST: aspartate aminotransferase; BMI: body mass index; CFU: colony forming unit; HOMA-IR: homeostatic model assessment for insulin resistance; HDL: high-density lipoprotein; LDL: low-density lipoprotein; LPR: Lactobacillus rhamnosus CGMCC1.3724; LPS: lipopolysaccharide; LF: low fat yogurt; PY: probiotic yogurt; RLCD: regular yogurt with a low calorie diet; PLCD: probiotic yogurt with a low calorie diet; PWLCD: probiotic yogurt without a low calorie diet; SMD: standardized mean difference; SQ: satiety quotient; TFEQ: Three-Factor Eating Questionnaire; TC: total cholesterol; TG: triglycerides; PUFA: polyunsaturated fatty acids; GPx: glutathione peroxidase; LU: dietary fiber Litesse® Ultra polydextrose; MC: microcrystalline cellulose; LDL: low-density lipoprotein; TNF-α: tumor necrosis factor α; IL-6: interleukin 6; V123: hypervariable region (V) 1-3; V456: Hypervariable region (V) 4-6; LCD: low calorie diet;

DISCUSSION a. Analysis of Studies Plenty of studies have found the association between gut microbiota and several metabolic disorders such as obesity and type II diabetes. Further researches regarding gut microbiota highlight the beneficial role of probiotics in such metabolic disorders, especially obesity. Outcomes from studies selected for the above systematic review vary, including anthropometric measurements, lipid profiles, eating behavior, as well as inflammatory markers. Such variations show the numerous possible mechanisms by which probiotics modification of gut microbiota can affect bodily metabolism. Several researches found that probiotic supplementation plays a role in reducing body fat. A study by Minami et al (2018), shows significant reduction of percentage body fat and body fat mass in groups given capsules of B. breve B-3, confirming previous experimental study performed on induced obese mice.1 This result is consistent with seven other studies included in the systematic review, which also find a decrease in body fat mass of intervention groups when compared to placebo, although strains of probiotics given differ between studies, including various strains of Bifidobacterium, Lactobacillus, Streptococcus, or a combination of them (Szulińska et al., 2018; Stenman et al., 2016; Osterberg et al., 2015; Zarrati et al., 2014; Sanchez et al., 2014; Kadooka et al., 2013). The exact mechanism by which microbiota affects body weight still remains unclear; however, it is thought that that intestinal microflora plays an important role in determining host metabolism, thus affecting energy homeostasis and adiposity (Kobyliak et al., 2016). Furthermore, several studies also show a reduction in waist circumference, verifying the decrease in abdominal adiposity (Szulińska et al., 2018; Gomes et al., 2017; Higashikawa et al., 2016; Kadooka et al., 2013). However, although fat mass decreases in general in most studies, BMI outcomes show variations instead. Lipid profiles were also assessed in several studies included above, comprising of total cholesterol, triglycerides, LDL, and HDL levels. Szulińska et al (2018) found a reduction in total cholesterol, triglycerides, and LDL levels in groups given low-dose and high-dose of probiotic mixture Ecologic® Barrier, containing mixture of Bifidobacterium and Lactobacillus strains, as well as study by Minami et al (2018) proving a slight decrease in triglyceride level. On the other hand, effect on HDL levels is still limited in both studies, showing non-significant increase of its level. Obesity is highly associated with dyslipidaemia, with increase of both LDL and triglycerides level with low HDL cholesterol level, posing an increased risk of cardiovascular diseases (Klop et al., 2013). Another study by Madjid et al (2016), which compares low-fat yogurt with and without probiotic supplementation, also exhibit similar results. Probiotic yogurt is shown to decrease total cholesterol, LDL, insulin resistance, and insulin concentration better than the standard low-fat yogurt, that highlights the role of

probiotics in improving lipid profiles of obese individuals. These roles show its potentials in reducing the risk of cardiovascular diseases in obese individuals. Obesity is also highly associated with the risk of developing metabolic diseases, with insulin resistance acting as a crucial link between the two. Inflammation is found to be involved in the pathogenesis of such diseases. In obesity, adipose tissue is found to secrete pro-inflammatory cytokines, such as TNFα, IL-6, C-reactive protein (CRP), and plasminogen activator inhibitor-1 (PAI-1), as well as an elevated leptin level. These cytokines would then inhibit insulin signalling activity, contributing to insulin resistance (Ye, 2013). Several studies on the effects of probiotics show reduction in inflammatory markers as well as improvement in insulin resistivity. A study by Zarrati et al (2013) found a reduction in levels of IL-4, IL-17, IFN- γ, ROR-γt and TNF-α in subjects treated with probiotic Lactobacillus gasseri SBT2055 and low-calorie diet. IL-17 is associated with Th-17 cell activation, in which the transcription factor ROR-γt also plays a role in its differentiation. Th-17 is involved in inflammation and autoimmunity, further aggravating the obesity-induced inflammation. Furthermore, researches by Szulińska et al (2018) and Madjid et al (2016) found a decrease in insulin resistance, shown by a significant decrease in HOMA-IR (homeostatic model assessment for insulin resistance) values. These results show that probiotic supplementation has an excellent possibility in interfering with the progression of obesity into further metabolic diseases, such as type II diabetes. Aside from its direct impact in lowering adiposity and lipid levels, probiotics is also found to affect the gut-brain axis, though the exact mechanism is still unclear. Gut microbiota is thought to link enteric functions to the brain, both emotional and cognitive centres. Modulation of gut microbiota by probiotics therefore can possibly exert beneficial effects on appetite control and eating behaviours (Carabotti et al., 2015). Study by Sanchez (2017) found that supplementation of LPR containing the probiotic L. rhamnosus CGMCC1.3724 significantly increases satiety efficiency and decreases TFEQ cognitive restraint. Lower scores of cognitive restraint shows a lower restriction in energy intake needed to control weight. Moreover, TFEQ disinhibition and hunger scores are also significantly reduced in women, though not significant in men. Lower disinhibition and hunger values represents a lower susceptibility to overeat. This highlights the potential of probiotic supplements in decreasing energy intake by improving appetite control, thus help in obesity management. Finally, the use of probiotics has also been proven clinically safe. All studies included in our review reported no serious adverse effects following probiotic supplementation in the trials. This, therefore, further suggest probiotics as an excellent potential for adjunct therapy in obese individuals.

b. Limitation of the Study This study is not without limitations. Language restriction and the inaccessibility of several articles limited our systematic review. Furthermore, two of these trials are performed in only women, and some other trials also show unequal distribution of samples between gender, thus the results may not be equally applicable in men and women. The small number of sample in several studies as well as bias in the included studies may also affect the results. Thus, further clinical trials with reduced bias and larger sample size are still needed to confirm these results. c. Future Application and Research Although plenty of studies have shown a strong association between probiotics and its beneficial effects in obesity and its associated metabolic diseases, the mechanism by which probiotics exert these effects and the exact doses needed are still unclear. We therefore recommend further studies done to investigate this, as it would serve as a foundation for future research in probiotics. In addition, we also recommend more researches done in Asian countries to further confirm its applicability in Asia. CONCLUSION In conclusion, probiotics supplementation has an important role in body fat reduction, obesity intervention, and gut-brain-axis modulation. Probiotic supplementation, both containing single or multi-species probiotics, is found to reduce percentage body mass in obese individuals. It also shows its ability to interfere with the progression of obesity into further metabolic diseases, such as type II diabetes, due to its action in reducing inflammatory markers. Probiotics are also found to play a role in affecting the gut-brain axis, thus help control appetite. The use of probiotics is also proven to be safe, with no serious adverse effects reported in the studies. Our systematic review provides an evidence for the use of probiotics as a suitable adjunct therapy in treating obesity and its associated metabolic diseases. We hope, these results can be applied further to help governments consider the importance of encouraging the population to consume food rich in probiotics as well as giving probiotic supplementation to help halt the rise in obesity, thereby reducing its prevalence and healthcare burden worldwide

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Osterberg, K. L., Boutagy N. E., McMillan, R. P., Stevens, J. R., Frisard, M. I., Kavanaugh, J. W., Davy, B. M., . . . Hulver, M. W. (2015). Probiotic supplementation attenuates increases in body mass and fat mass during high-fat diet in healthy young adults. Obesity (Silver Spring), 23(12), 2364-2370. Sanchez, M., Darimont, C., Drapeau, V., Emady-Azar, S., Lepage, M., Rezzonico, E., . . . Tremblay, A. (2014). Effect of Lactobacillus rhamnosus CGMCC1.3724 supplementation on weight loss and maintenance in obese men and women. Br J Nutr, 111(8), 1507-1519. Sanchez, M., Darimont, C., Panahi, S., Drapeau, V., Marette, A., Taylor, V. H., Tremblay, A. (2017). Effects of a diet-base weight-reducing program with probiotic supplementation on satiety efficiency, eating behaviour traits, and psychosocial behaviours in obese individuals. Nutrients, 9(284), 1-17. Stenman, L. K., Lehtinen, M. J., Meland, N., Christensen, J. E., Yeung, N., Saarinen, M. T., . . . Lahtinen, S. (2016). Probiotic with or without fiber controls body fat mass, associated with serum zonulin, in overweight and obese adultsâ&#x20AC;&#x201D;randomized controlled trial. EbioMedicine, 13, 190-200. Szulinska, M., Lonieski, I., van Hemert, S., Sobieska, M., Bogdanski, P., (2018). Dose-dependent effects of multispecies probiotic supplementation on the lipopolysaccharide (LPS) level and cardiometabolic profile in obese postmenopausal women: a 12-week randomized clinical trial. Nutrients. 10(773), 1-16. World Health Organization. (2018). Obesity and overweight. Retrieved from http://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight. Ye, J. (2013). Mechanisms of insulin resistance in obesity. Front Med, 7(1), 14-24. Zarrati, M., Salehi, E., Nourijelyani, K., Mofid, V., Zadeh, M. J., Najafi, F., . . . Shidfar, F. (2014). Effects of probiotic yogurt on fat distribution and gene expression of proinflammatory factors in peripheral blood mononuclear cells in overweight and obese people with or without weight-loss diet. J Am Coll Nutr, 33(6), 417-425. Zarrati, M., Shidfar, F., Nourijelyani, K., Mofid, V., Hossein zadeh-Attar, M. J., Bidad, K., . . . Salehi, E. (2013). Lactobacillus acidophilus La5, Bifidobacterium BB12, and Lactobacillus casei DN001 modulate gene expression of subset specific transcription factors and cytokines in peripheral blood mononuclear cells of obese and overweight people. Biofactors, 39(6), 633-643.

APPENDIX Table 2. Risk of bias assessment

Study

Randomization

Concealed allocation

Cochrane Risk of Bias Tool Blinding of Blinding of Incomplete participants outcome outcome and personnel assessment data

Selective reporting

Other bias

Minami et al (2018)

SzuliĹ&#x201E;ska et al (2018)

Sanchez et al (2017)

Gomes et al (2017)

Stenman et al (2016)

Higashikawa et al (2016)

Madjid et al (2016)

Osterberg et al (2015)

Brahe et al (2015)

Sanchez et al (2014)

Zarrati et al (2013)

Kadooka et al (2013)

Note: “+”: low risk of bias, “–“: high risk of bias, “?”: unclear risk

ABSTRACT The Role of Probiotics in Managing Obesity and its Progression in Healthy Overweight and Obese Individuals: A Systematic Review of Clinical Trials Jessica Audrey1, Anthony William Brian Iskandar1, Christianto1, Elvan Wiyarta1 1

Faculty of Medicine, Universitas Indonesia

BACKGROUND: Obesity has been known to cause various metabolic diseases. Clinical trials regarding probiotic consumption in obesity have been conducted, but the results are not fully consistent. These probiotics exhibit various results regarding management of obesity progression. OBJECTIVE: We conducted a systematic review to assess the use probiotics as an effective and safe method in managing obesity and its associated metabolic diseases. MATERIALS AND METHODS: A comprehensive search was performed through PubMed and EBSCOhost, searching for randomized controlled trials (RCTs) published within the last five years which study the effect of probiotics administration on overweight and obese individuals. Studies were then further assessed for risk of bias with seven criteria from Cochrane Risk of Bias Tool for Randomized Controlled Trials. RESULTS: Twelve RCTs were included, with a total of 1099 subjects and intervention duration ranging from 4 to 24 weeks. We find that probiotics significantly reduces body fat, in both single and multi-species probiotic supplementation. It is also found to improve lipid profiles, by reducing triglycerides and LDL cholesterol levels, although effects on HDL cholesterol levels are still limited. Furthermore, probiotics is shown to reduce insulin resistance and inflammatory markers, which is often associated with the aggravation of obesity into various metabolic diseases. They also affect the gut-brain axis, helping to control appetite and eating behaviors, although the exact mechanism still remains unclear. The use of probiotics is proven to be safe without any reported serious adverse effects. CONCLUSION: We concluded that probiotic consumption presents beneficial effects in managing obesity and its related metabolic diseases, highlighting its potential as a possible adjunct therapy for obesity, aiming to reduce its global prevalence and associated health burdens. Keywords: obesity; probiotics; clinical trial

Intergenerational Association between Early Maternal Menarcheal Age and Risk of Childhood Obesity: A Systematic Review of Large Prospective Cohort Studies Angela K. Tjahjadi1, Angga W. Lokeswara1, Joanna E. Hanrahan1 From Faculty of Medicine, Universitas Indonesia1 Corresponding author: Angela K. Tjahjadi, Universitas Indonesia Medical School, Jl. Salemba Raya No. 6, Jakarta 10430, Ph. +6287852349810; e-mail: kimmtjahjadi@gmail.com.

Abstract Background Obesity is a rapidly growing global issue among children. Most current studies focus only on childâ&#x20AC;&#x2122;s own risk factors, leaving the intergenerational influence including maternal factors underestimated. Early maternal menarcheal age may have an intergenerational impact on childrenâ&#x20AC;&#x2122;s body mass index and risk of developing childhood obesity. Objective To evaluate the association between early maternal menarcheal age and risk of childhood obesity. Methods A systematic review was performed in 5 electronic databases from August 1985 - October 2018. Our review included all English language publications on large prospective birth cohort studies in children. The outcomes were body mass index or z score according to 2006 WHO Child Growth Standard. Risk of bias was assessed using the Revised Cochrane Collaboration Risk of Bias Tool for cohort studies (RoB 2.0). Results The search yielded 4 large prospective cohort studies. All reviewed studies revealed that children from mothers with earlier age of menarche were seen to have higher BMI compared to those whose mothers had older age of menarche, thus increasing the risk of developing childhood obesity in these children. However, this association was not consistently apparent from birth of the offspring to childhood period, and only in the childhood period the increased BMI and increased risk of obesity became more obvious. Epigenetics on hormonal programming were hypothesized to be the underlying cause of this association, yet environmental aspect also ought to play a role in the association. Conclusion This study affirms the association between early maternal menarcheal age and increased risk of childhood obesity. Understanding the knowledge gap of intergenerational factors might help to create the novel and multi-level strategy to end the vicious cycle of obesity. Keywords: early maternal menarcheal age, childhood obesity, body mass index

1. Introduction The World Health Organization (WHO) defines obesity in children (5-18 years old) based on 2006 Child Growth Standard as z score of body mass index (BMI) above +2 SD (equivalent to BMI 30 kg/m2 at 19 years old) for children of the same age and sex (World Health Organization [WHO], 2007). Global prevalence of childhood overweight and obesity had increased from 4.2% in 1990 to 6.7% in 2010 (WHO, 2010). The number of overweight children under the age of five, is estimated to be over 41 million in 2016 (WHO, 2017). Nearly one of six children is overweight or obese according to OECD countriesâ&#x20AC;&#x2122; Obesity Updates 2017. This trend is expected to reach 9.1% or 60 million in 2020 (OECD, 2017). Furthermore, Indonesia is included among 10 countries with the highest numbers of estimated overweight and obese children (5-12 years) of 11.9% based on Riskesdas 2013 (Depkes RI, 2013). Obesity in childhood are more likely to persist until adulthood, thus risking in the development of premature metabolic syndrome which precedes various non-communicable diseases, such as diabetes and cardiovascular diseases (Sahoo et al., 2015; Rankin et al., 2016). Raised body mass index is also a major risk factor for gastrointestinal cancers, cognitive and motor function impairment leading to reduction in the quality of life and a greater risk of teasing, bullying and social isolation (Rankin et al., 2016). In addition, increasing overall age morbidity, premature mortality, school attainment and forgone labor market productivity due to obesity in childhood have already been acknowledged (GNP, 2017). In the midst of this rapidly changing era, obesity in children is a global inevitable effect due to major alteration of daily dietary and physical activities pattern. In Indonesia, new emerging risk factors of obesity in children are still debated. Mueller et al. had reported that early age at menarche was associated with risk factors of cardio-metabolic diseases, such as wider waist circumferences, high nutritional status, elevated triglycerides and higher risk of adult diabetes (Mueller et al., 2014). Moreover, an association between early menarcheal age and higher risk of adulthood obesity in women was already established. A cross sectional study conducted among 13-15 years-old adolescent girls in Indonesia found that early menarche subjects had significantly higher nutritional status including higher body mass index (BMI) (p<0.001), CDC-percentile (p<0.001), WHO Z-score (p<0.001), and waist circumference (WC) values (p=0.02) compared to those with older age of menarche (Hariani R, Nouvrisia V, Yustikarani D, 2018). Unfortunately, existing studies merely confine to evaluate risk factors within one generation life-span, yet the possibility of current risk factors influencing the next generationâ&#x20AC;&#x2122;s quality is frequently overlooked. This may become the unrecognized cause of continuously growing of obesity.

Driven by the gap above, researcher nowadays instigate to learn about the relationship of early maternal menarche age to their offspringâ&#x20AC;&#x2122;s characteristics, particularly obesity through an inherited trait. Some previous studies showed significant association between early maternal menarcheal age with offspring rapid infancy growth, thus causing higher BMI or even obesity. Early maternal menarche age may become a significant potential risk factor of childhood obesity. However, until now, no agreement about the causality between the two conditions has been made. Therefore, this systematic review was conducted with the aim of evaluating association between early maternal menarcheal age and the offspringâ&#x20AC;&#x2122;s risk of developing childhood obesity. 2. Methods 2.1 Search strategy We searched all relevant published journal articles in MEDLINE, EBSCOHost, ProQuest, ScienceDirect, and ClinicalKey between August 1985 and October 15, 2018. We searched for articles containing maternal menarcheal age terms and body mass index analysis terms in children. The search strategy used both subject heading and text word searches. Initial search terms were updated after searching the reference lists of relevant articles. Table 1 summarizes the search terms used and Figure 1 shows the overview of the study selection process using a PRISMA flowchart. Table 1. Search terms used Database

Search terms

Pubmed

("maternal menarche age" OR "early menarche age" OR "maternal age of menarche") AND (child* OR offspring*) AND (obese OR obesity OR BMI OR body mass index)

ProQuest

("maternal age of menarche" OR "maternal menarcheal age") AND (offspring OR childhood) AND obesity

EBSCOHost

("maternal age of menarche" OR "maternal menarcheal age") AND (offspring OR childhood) AND obesity

ScienceDirect

("maternal early menarche" OR "maternal age of menarche" OR "maternal menarche") AND ("offspring") AND "obesity"

ClinicalKey

("maternal age of menarche" OR "maternal menarcheal age") AND (offspring OR childhood) AND obesity)

We searched the Cochrane Database for Systematic and Complete Reviews to identify systematic reviews and/or meta–analyses to ensure that no previous similar studies were conducted on this topic. Manual search of reference lists was also conducted to identify relevant articles that were not identified by the databases. The authors selected potential articles by screening titles and abstracts independently from each other. After accounting for duplication, we reviewed the titles and corresponding abstracts of all studies to identify articles that fulfill the inclusion criteria. If a study was deemed to potentially fulfil the inclusion criteria, full-text versions were retrieved and assessed to determine final study selection. Reference lists of all retrieved articles were also searched. 2.2 Selection of studies Criteria were developed in an iterative process after preliminary searches. We included studies based on original data from analytical epidemiological studies, among children (at birth-17 years). Body mass index (BMI) or weight-height z score had to be a study’s outcome. We included maternal menarcheal age (MMA) as a risk factor. Studies assessing not only MMA as a risk factor but also sex, age, gestational age, parity, mother's education and mother's BMI, and feeding practice during first 6 months were required to treat MMA as a continuous exposure (ie, linear models). We omitted non-observational studies and one cross sectional study is excluded due to homogeneity and consistency of cohort design of study in etiologic studies. All reviewed studies are English articles; however, we did not place any restriction on language, study location, publication status or year of publication. 2.3 Data extraction From each study, we extracted the study design, subjects’ characteristics, offspring’s BMI or weight-height z score according to 2006 WHO Child Growth Standard, and compared the results between the exposed and unexposed groups. 2.4 Assessing risk of bias The risk of bias assessment was based on the the Revised Cochrane Collaboration risk of bias tool for cohort studies (RoB 2.0), as shown in Figure 2. Each study is assessed separately for prespecified bias domains including confounding factors, missing outcome data or lost to follow-up, exposure measurement, outcome measurement, and selection bias. We also considered the validity of each cohort study based on the sampling of mother during pregnancy, children growth, numbers declining to participate, and their baseline characteristics. Overall bias of each articles was classified as low, unclear risk/some concerns and high risk.

3. Results 3.1 Search results We identified 174 papers based on the search terms used in respective databases. The articles were then analyzed for duplicates, screened for relevance, inclusion and exclusion criteria as shown in Figure 1. Five relevant observational studies were selected and assessed for eligibility. In order to maintain heterogeneity, 1 cross-sectional study was excluded, resulting in 4 cohort studies reviewed.

3.2 Study characteristics and findings The summary of the characteristics and results of the studies can be found in Table 2. All studies included were large, prospective cohort studies, conducted by following the pregnant mothers until their children are born and grown until the age of childhood. A pooled total of 558,351 children and their mothers were considered in the study. The ages of the children range from 2 â&#x20AC;&#x201C; 9 years old, except one study which included an extra set of analysis of BMI of the puberty group (8 â&#x20AC;&#x201C; 14 years

old). The maternal menarcheal age considered in the study ranges from 11 to 15 years old, the data of which is mostly taken from a self-reported questionnaire during mothersâ&#x20AC;&#x2122; pregnancies. Two of the studies are from Asian population, one from British population and one from American population. In terms of results, all four studies unanimously agree that earlier maternal menarcheal age is significantly associated with higher offspringâ&#x20AC;&#x2122;s childhood BMI, even after adjusting with various factors in the respective studies. One study even showed a nearly 3-fold increase in risk of obesity in mothers with menarcheal age of 11, compared to that of 15. Another study showed that even after adjusting with gestational weight gain (GWG), earlier maternal menarcheal age is still associated with higher childrenâ&#x20AC;&#x2122;s BMI and their rapid growth.

Table 2. Summary of Cohort Studies Article

Population

Risk Factor (Maternal Menarcheal Age)

Authors Study Method of Measures and Country Study size (Year) design Identification Classification Min J, Li Z, China Cohort 54,184 women Self reported MMA is divided into: Liu X, Wang and their recall interview a. early (≤13 years) Y (2014) children's (523, b. intermediate 096) growth c. late (≥ 16 years) trajectories during first 5 years of life (2000-2005) in South China

Lai TC, Hong Yeung SLA, Kong Lin SL, Leung GM, Schooling CM (2016)

Cohort 3172 children Maternal age from Children of menarche of 1997 obtained from (Chinese birth postal Survey cohort) in 2008-2009. recruited from Maternal and Child Health Centres in Hong Kong.

Outcome (Offspring BMI) Age 4-5 yr

Maternal age of menarche 2-8 yr is classified as: and ≤ 11 8-14 yr 12 13 14 ≥15

Method of Measurements Measuring weight and height using z score based on 2006 WHO Child Growth Standard

Results Children with early MMA (≤ 13 years) were more likely to be rapid growers (OR = 1.3 [1.2 – 1.4]) and overweight (OR = 1.4 [1.0 – 1.9] compared to those with late MMA.

BMI = weight/height2 Z score of BMI : After adjusted with GWG, MMA was ≥1: at risk of overweightstill associated with children's BMI ≥2: overweight and their rapid growth during the first and rapid weight gain 2 years of life. Children with early during infancy MMA and excessive GWG were more (Difference of weight z likely to have rapid weight gain (OR = scores between age 2 1.6 [1.4 – 1.8]) and overweight at age and birth >0.67) 4-5 (OR = 5.2 [2.0 – 13.5]) Birth weight was converted into sexspecific z scores, and BMI and height were converted into sexspecific z scores from scheduled measurements at 3, 9, and 36 months, relative to the 2006 WHO Child Growth Standards

Earlier maternal menarcheal age was not associated with infant BMI, yet associated with higher BMI in childhood and puberty.

Older maternal age of menarche was associated with lower BMI in childhood (-0.037 Z score per year older maternal menarcheal age, 95% CI : -0.064 – -0.010) and at puberty (0.073 z score, 95% CI : -0.10 – -0.042) Adjusting for pregnancy conditions Height was ascertained made little difference. Adjusting for as supine length in maternal BMI attenuated the infancy, but as standing associations (-0.019 z score, 95% CI : height subsequently. 0.043 – 0.0052)

Table 2. (continued) Article

Population

Risk Factor (Maternal Menarcheal Age)

Authors Study Method of Country Study size (Year) design Identification Ong KK, United Cohort 6009 children Self reported Northstone Kingdom from UKthrough K, Wells population questionnaire JCK, Rubin based Avon MMA during C, Ness AR, Longitudinal pregnancy Golding J, Study of Parents Dunger DB and Children (2007) birth cohort

Measures and Classification Mother’s age at menarche is divided into : a. ≤ 11 yr b. 12 yr c. 13 yr d. 14 yr e. ≥ 15 yr

Outcome (Offspring BMI) Age

Method of Measurements

Results

9 yr

Anthropometric measurement on children at age 9 yr; weight measured by Seca 724 or 835 scales and standing heights using Liester height measures (socks and shoes removed

Earlier mother's menarche predicted increased BMI (0.29 kg/m/y) ; all p <0.001. Most of the gain in BMI was attributed by fat mass index rather than lean mass index. Adjusted to mother's BMI : BMI in child (0.18 kg/m2/y; p<0.001

BMI = weight for height2 unit :(kg/m 2 ) Obesity in children was defined as BMI > 97th percentile for sex and age by comparison with the UK 1990 growth reference

Basso O, United Cohort 31,474 US Data was Pennel ML, States of Black and available, yet Chen A, America White children methods are Longnecker born from 1959 unclear MP (2010) to 1966 in the Collaborative Perinatal Project

MMA is divided into : a. ≤ 11 yr b. 12 yr c. 13 yr d. 14 yr e. ≥ 15 yr

Compared with children of mothers in the oldest menarche quintile (≥15 y), children of mothers in the earliest menarche quintile (≤11 y) had a nearly 3-fold increased risk of obesity (OR 2.91, 95% CI [2.02–4.19]; p < 0.001, adjusted for sex, age, and mother’s education). The risk of obesity was similar in boys and girls (p-value for interaction = 0.9 adjusted to mother's BMI : (OR 2.15, 95% CI [1.46–3.17]; p <0.001)

7-8 yr Measure BMI at birth, At age 7 yr, a difference of increased ages of 1,3,4,7,and 8 year BMI 0.4 kg/m 2 among early MMA using linear mixed models (adjusted with many factors). Children of women with earliest MMA on Children were measured average were taller and had a higher according to standardized BMI at ages 7 and 8 than children of procedures by trained women with latest MMA, adjusted personnel. Length/height with mother's BMI, study center, race, was measured to the child's sex, socioeconomic index, nearest 0.5 cm, in a s child/s age at measurement, p < 0.05 supine position through with linear tren. 20 months age, and standing thereafter. Scales Earliest MMA group had highest mean were calibrated at least BMI at 8 y =16.4, yet the latest MMA semi-manually group had lowest BMI = 15.9

3.3 Risk of bias assessment The results of the risk of bias assessment are shown in Figure 2, along with the justifications of the assessment in Appendix 1. In general, all four studies have low risk of bias in most of the criteria used in the assessment. The study by Ong KK, et al. is assessed to have the lowest risk of bias as it meets all the criteria. The other three studies were subject to high risk of bias due to either lack of information, or high percentage of loss to follow up. The studies by Lai TC, et al. and Min J, et al. also omitted the explanation and details of how the measurements of weight, height and BMI were performed, whereas the study by Basso, et al. and Min J, et al. pretermitted the explanation of how other prognostic factors were measured. However, each of the study was assessed to have low risk of bias in at least 4 out of 7 criteria. With that, the confidence put in drawing conclusions from these studies can be considered reasonable and justified.

Figure 2. Risk of bias assessment for individual studies 1 Selection of exposed and nonâ&#x20AC;?exposed cohorts drawn from the same population 2 Confidence in the assessment of exposure 3 Confidence that outcome of interest was not present at the start of study 4 Matching exposed and unexposed for all variables or statistical analysis adjust for these prognostic variables 5 Assessment of presence or absence of prognostic factors 6 Confidence in the assessment of outcome 7 Adequacy of follow-up 4. Discussion 4.1 Summary and interpretation of evidence Association between early maternal menarcheal age and childhood obesity Our systematic review analyzed 4 cohort studies investigating the intergenerational association between maternal menarcheal age and offspringâ&#x20AC;&#x2122;s obesity. We intend to explore whether earlier maternal menarcheal age could predict the development of obesity in the offspring. All

reviewed studies revealed that children from mothers with earlier age of menarche were seen to have higher BMI compared to those whose mothers had older age of menarche (Ong et al., 2007; Basso, Penell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, &Schooling, 2016; Min, Li, Liu, & Wang, 2016). Ong KK et al (Ong et al.,2007) reported that the gain in BMI in these children was attributable to greater fat mass index rather than lean index, hence increasing the risk of obesity in these children. At the age of 9, compared to children whose mothers were in the oldest menarche quintile, children of mothers in the earliest menarche quintile had nearly 3-fold higher risk of developing obesity (OR = 2.91, 95% CI [2.02 - 4.19]; p < 0.001). The similar trend was also found in the study by Basso O et al. and Lai TS et al. where early maternal menarcheal age was associated with higher risks of obesity in childhood (Basso, Pennell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, & Schooling 2016). The risk was found to be similar in boys and girls (p value of interaction = 0.9) (Ong et al., 2007). As mothers with earlier age of menarche tend to be heavier themselves, results of these studies (Ong et al., 2007; Basso, Pennell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, & Schooling 2016) were adjusted by mother’s BMI or mother’s anthropometry. After the adjustment, the association between earlier maternal age of menarche and higher risk of developing obesity in childhood remained and was just slightly attenuated (Ong et al., 2007; Basso, Pennell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, & Schooling 2016). However, Min J et al. (Min, Li, Liu, & Wang, 2014) did not state clearly whether the association between maternal menarcheal age and increased risk of overweight in the offspring was adjusted by the mother’s size. All these results provided good evidence in that mother’s age at menarche was not only a marker for her own risk of obesity, yet also a factor affecting the child’s obesity risk through the intergenerational relationship. Interestingly, the association of earlier maternal menarcheal age with higher offspring’s BMI was not consistently apparent throughout the period of children’s growth (from birth to childhood). At birth, it was reported that earlier maternal age of menarche was actually unrelated to the offspring’s size (Ong et al.,2007). In the first 2 years of life, though, the infants born from these mothers became rapid growers. However, from the second year of age to the years leading to childhood, the trend of increasing BMI was not seen clearly in these children. Then, only in childhood, the increased BMI and increased risk of obesity became more obvious (Basso, Pennell, Chen, & Longnecker, 2011). Later on as adults, these children may eventually attain shorter stature, leading to the tendency towards higher body max index and finally risk of obesity itself. In light of these unclear and inconsistent signs of obesity throughout the growth of the children, close monitoring on these children’s early growth parameters becomes a crucial aspect in the preventive efforts against childhood obesity, in the hope to lessen the risk of developing metabolic diseases in adulthood.

Vicious cycle of obesity Combining the results of this systematic review with previously established findings, we uncover an underemphasized vicious cycle of obesity. All 4 studies also provided evidence on the association between early maternal menarche age with faster weight gain and growth during infancy. This rapid growth during infancy leads to increased risk in developing childhood obesity (Basso, Pennell, Chen, & Longnecker, 2011; Ong et al., 2007; Lai, Au Yeung, Lin, Leung, & Schooling, 2016; (Min, Li, Liu, & Wang, 2014). This is consistent with the findings of a systematic review by Ong KK et al. in 2006 where he reported that rapid infancy weight gain predicted subsequent higher BMI and thus obesity in childhood (Ong & Loos, 2006). Moreover, it was also stated in a study by Keim et al. (Basso, Pennell, Chen, & Longnecker, 2011) that girls with higher BMI tend to experience earlier menarche and further, would have higher BMI as an adult. This is also supported by the results of the reviewed studies, where it was found that there was a tendency of mothers who had earlier age of menarche to develop adulthood obesity (Ong et al., 2007; Basso, Pennell, Chen, & Longnecker, 2011). Ong KK et al. (Ong et al.,2007) reported that mothers with earlier age of menarche (≤11 years old) were likely to have 5-fold increased risk of developing obesity herself compared to mother’s with older age of menarche (≥ 15 years old) (OR = 5.11, 95% CI [3.41-7.67]; p < 0.001). This trend was also seen in the study by Basso O et al. (Basso, Pennell, Chen, & Longnecker, 2011) where women with earlier age at menarche (≤ 11 years old) were frequently found to be overweight compared to those with older age of menarche (>15 years old). As the cycle went on, it was also found by Ong KK et al. (Ong et al., 2007) that daughters of mothers with earlier age of menarche were likely to report also an early menarche (before age 11) compared to that of mothers with oldest age of menarche. However, all 4 studies have also shown that the associated increased offspring BMI is seen in both boys and girls, suggesting that early maternal menarcheal age might be one of many markers related to the programming of the offspring’s overall growth, rather than being specific to female development only (Basso, Pennell, Chen, & Longnecker, 2011; Ong et al., 2007; Lai, Au Yeung, Lin, Leung, & Schooling, 2016; Min, Li, Liu, & Wang, 2014). Greater understanding of this intergenerational relationship would help shed a light on the potential intervention to reduce the global burden of obesity that is continuously growing. Proposed underlying mechanism The four studies have already summarized the evidence of intergenerational effects of early puberty and obesity, such as the strong association between early maternal menarcheal age and the risk of childhood obesity and infancy growth rate. There are two proposed theories underlying this association. First, hormonal programming and epigenetics in childhood growth and puberty have been acknowledged. Rapid growth during childhood may have a programming effect on later body composition in adulthood (Basso, Pennell, Chen, & Longnecker, 2011). Ong et al. also revealed

consistent association between early maternal menarche age, rapid infancy weight gain and later obesity risk is an inherited or transgenerational influence, related to genes that regulate early appetite and satiety (Ong et al., 2007). Second, Min et al. found that in-utero modification is a crucial period of controlling offspringâ&#x20AC;&#x2122;s growth trajectories. Increased maternal leptin level associated with gestational weight gain may enhance the transfer of fat storage and energy to the fetal growth, thus elevating risk of childhood obesity development. All in all, it remained unclear which theory is more likely to be the underlying mechanism of this association (Min, Li, Liu, & Wang, 2014). Environmental factors In terms of the external factors, Basso et al. and Min J et al. (Basso, Pennell, Chen, & Longnecker, 2011; Min, Li, Liu, & Wang, 2014) showed that mothers with higher socioeconomic class and level of education were inclined to have early age of menarche. It was not stated in both studies which aspect of socioeconomic status were assessed. One study showed an association between living in urban areas, representing one aspect of higher socioeconomic status, and higher BMI. It was hypothesized that nutritional factors might play a role in creating the association (BastoAbreu et al., 2018). Social environmental determinants, such as declined physical activity and increased consumption of dietary fat in urban areas, may enhance the expression of genetic factors relating to rapid maturers and obesity in children (Basso, Pennell, Chen, & Longnecker, 2011; Min, Li, Liu, & Wang, 2014; Lai, Au Yeung, Lin, Leung, & Schooling, 2016; Min, Li, Liu, & Wang, 2014). In this vein, childhood growth not only depends on genetic inheritance but also sociodemographic factors, as the estimated proportion of heritable factors is only 50-78% in childâ&#x20AC;&#x2122;s growth pattern and pubertal timing (Basso, Pennell, Chen, & Longnecker, 2011), thus environmental and behavior aspect ought to be considered as impactful risk factor. 4.2 Strengths and limitations of the selected studies The strengths and limitations of the four studies have also been considered in this systematic review. The strengths of the studies are largely based on their large number of subjects and their study design of prospective cohort. With prospective cohort, the mothers were inquired about the maternal menarcheal age during pregnancy, that is, before the children were even born. This means that when recalling their menarcheal age, the mothers had no idea of whether the children will be obese or not and the mothers would have put in the equitable amount of effort in recalling the menarcheal age, hence preventing bias in recalling the event. Unfortunately, this method of measurements of menarcheal age through recall is still the main limitations of the four studies. However, it is reasonable to take faith in the fact that menarche is known to be a hallmark, significant and one-in-alifetime event in a womanâ&#x20AC;&#x2122;s life. Therefore, it is more likely for mothers to give an estimate of their

menarcheal age with decent accuracy. Although it is unwise to overgeneralize this assumption, the recall method seems to be the only feasible method even at present, hence it was most likely to be the best available option during the time of the studies. In all four studies, confounders such as childâ&#x20AC;&#x2122;s diet and physical activity were not considered. This might lead to overestimation of the role of early maternal menarcheal age in causing childhood obesity. Nonetheless, it is important to acknowledge that multivariate analysis had been performed in all studies, in order to take into account some of the confounding factors. In the assessment of risk of bias, we have also found that three studies might be subjected to selection bias due to either high number or inadequate information regarding loss-to-follow up. This selection bias might lead to underestimation of risk factors which might otherwise affect the results of the studies. However, all the four studies are considered to have low risk of bias as each one of them met a minimum of 4 out 7 criteria. This means that these studies can still be reasonable and justified evidences to draw conclusions from. 4.3 Strengths and limitations of the review The strength of this review mainly lies on the uniformity of study design across the four studies. All four studies are large, prospective cohort studies whereby all the data of the maternal menarcheal age was obtained from the mothers during pregnancy, and the BMI of the children was then measured until the age of 5 â&#x20AC;&#x201C; 9 years old. This homogeneity in study design makes the studies comparable and hence, helps in drawing a fair and justified conclusion from the four studies. This review also considered a large number of subjects due to the large study done in all four articles. Looking to the subjects included in this review, there is a heterogeneity in the ethnicity of the subjects in that subjects were ranged from British, American, and Asian races. This could be a strength to this review as the different races might represent the global children population. More importantly, to the best of our knowledge, there has not been any similar systematic review on the association of maternal menarcheal age and increased risk of childhood obesity published previously. However, this systematic review is limited by the fact that the results of the studies were presented differently from one another, whereby only two studies expressed the odd ratios, and one study used beta value and another used z-score. This difference makes it difficult to have a pooled result in drawing quantitative conclusions. Nevertheless, this can be compensated by the confidence in the qualitative conclusion drawn. Another limitation would be that some of the studies only associate earlier maternal menarcheal age with higher BMI, not necessarily obesity. However, the association between earlier menarcheal age and obesity can still be justified based on the previous studies which have proven increased risk of obesity in children with higher BMI.

4.4 Recommendation In the future, it is recommended that similar cohort studies should be taken into account confounding external factors such as the childâ&#x20AC;&#x2122;s nutritional intake and physical activity. This will make the results of the assessment more comprehensive and applicable to real life situations. Moreover, it is also hoped that there will be more prospective cohort studies done, possibly following from the time the subject has menarche until pregnancy and until her children reach childhood. This will allow a more accurate dating of the menarche, relying less on the motherâ&#x20AC;&#x2122;s recall. Based on our results combined with previous studies, it seems that there is a vicious cycle whereby earlier menarcheal age may lead to obesity in childhood which in females may lead to earlier menarcheal age and so on. Therefore, the recommended strategy is a multi-level approach which consists of several plans to cut this vicious cycle targeted at various points, as shown in Figure 3. These strategies include: 1.

For women who have undergone puberty, to maintain a balanced diet and regular physical

activity, in order to prevent obesity and increased risk of excessive gestational weight gain. 2. For pregnant women with excessive gestational weight gain, to be educated on healthy weight gain and weight gain chart, self-monitoring and healthy diet options and physical activity designed for expecting mothers. 3.

For children with higher BMI, to be educated regarding healthy food and exercises early and

to have their diet and physical activity closely monitored by parents. It is also important to recognize that a concerted effort from different parties is necessary in alleviating the problem of obesity. Aside from individualâ&#x20AC;&#x2122;s own responsibility and awareness, parents play a monumental role in ensuring healthy lifestyle and inculcating healthy habits for their children since young. Schools and universities, as second home and place of education to many, are also responsible in enabling and enforcing healthy diet and exercises in their students. Doctors, as the leaders of community health also play pivotal role in becoming role models and educators for the community around them. Most importantly, the government is also responsible in ensuring the appropriate laws and measures are in place to support healthy lifestyle of its citizens such as nutrition labelling in goods. Last but not least, international community has to support countries and create an amiable social, environmental and political climate for the people to maintain a healthy lifestyle. Medical students have a particularly focal role in the joint efforts to prevent obesity. Medical students are the agents of change in the community, responsible to educate and influence the society to implement a healthy lifestyle. This can be done through social projects, where medical students work with community health workers to promote healthy eating, adequate physical activity and routine health check-ups. This can also be achieved through a more relevant and cost-effective strategy through social media campaign to reach a larger scope of audience. All things considered, it

is imperative for medical students to recognize and fulfil their responsibilities as agents of change to actively participate in relieving the unrecognized burden of obesity.

Figure 3 The scheme of recommended multi-level strategy to interrupt the vicious cycle of obesity 5. Conclusions This study confirms the association between early maternal menarcheal age and increased risk of childhood obesity. Our current understanding of the underlying mechanism is still limited, involving intergenerational epigenetics influence on hormonal programming and environmental factors. Although some studies only showed higher BMI as the outcome, the association of early maternal menarcheal age and increased risk of childhood obesity is still justifiable as previous studies have shown that higher BMI leads to increased risk of childhood obesity. Understanding the knowledge gap of intergenerational impact may be the primary key to alleviate the burden of obesity. Multi-level approaches on high risk populations, including women who have undergone puberty, pregnant women with excessive gestational weight gain and children with higher BMI, are recommended. These include having a balanced dietary intake, performing regular physical activities and watchful growth monitoring to interrupt the vicious cycle of obesity and eventually to relieve the unrecognized burden of obesity.

Conflict of interest None declared. Funding The authors received no specific grant from any funding agency in public, commercial, or not-forprofit sectors. References 1. World Health Organization. (2007). Growth Reference: Body Mass Index-for Age 5-19 years old. Retrieved from: https://.who.int/growthref/who2007_bmi_for_age/en/ 2. World Health Organization. (2017). Commission on ending Childhood Obesity. Retrieved from: https://www.who.int/end-childhood-obesity/facts/en/ 3. World Health Organization. (2010). Global prevalence and trends of overweight and obesity among

preschool

children.

Retrieved

from:

https://www.who.int/nutgrowthdb/publications/overweight_obesity/en/ 4. Organisation for Economic Co-operation and Development. (2017). Obesity Update 2017. Retrieved from: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf 5. Departemen Kesehatan Republik Indonesia. (2013). Riset Kesehatan Dasar 2013. Retrieved from: http://www.depkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf 6. Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., & Bhadoria, A. S. (2015). Childhood obesity: causes and consequences. Journal of Family Medicine and Primary Care, 4(2), 187–192. 7. Rankin, J., Matthews, L., Cobley, S., Han, A., Sanders, R., Wiltshire, H. D., & Baker, J. S. (2016). Psychological consequences of childhood obesity: psychiatric comorbidity and prevention. Adolescent Health, Medicine and Therapeutics, 7, 125–146. 8. GNP. (2017). Global Nutrition Report 2017: Nourishing the SDGs. Global Nutrition Report 2017, 115. 9. Mueller, N. T., Duncan, B. B., Barreto, S. M., Chor, D., Bessel, M., Aquino, E. M. L., … Schmidt, M. I. (2014). Earlier age at menarche is associated with higher diabetes risk and cardiometabolic disease risk factors in Brazilian adults: Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Cardiovascular Diabetology, 13, 22. 10. Hariani R, Nouvrisia V, Yustikarani D, B. S. (2018). Early-menarche as Determinant Factor for Metabolic-risks: An Epidemiology Perspectives among Adolescent Girls Age 13-15 years old in Jakarta-Indonesia. World Nutrition Journal, 66–73.

11. Ong, K. K., Northstone, K., Wells, J. C. K., Rubin, C., Ness, A. R., Golding, J., & Dunger, D. B. (2007). Earlier mother’s age at menarche predicts rapid infancy growth and childhood obesity. PLoS Medicine, 4(4), 737–742. 12. Basso, O., Pennell, M. L., Chen, A., & Longnecker, M. P. (2011). Mother’s age at menarche and offspring size. Int J Obes (Lond), 34(12), 1766–1771. 13. Lai, T. C., Au Yeung, S. L., Lin, S. L., Leung, G. M., & Schooling, C. M. (2016). Brief Report: Maternal Age of Menarche and Adiposity: Evidence from Hong Kong’s “Children of 1997” Birth Cohort. Epidemiology (Cambridge, Mass.), 27(3), 433–437. 14. Min, J., Li, Z., Liu, X., & Wang, Y. (2014). The association between early menarche and offspring’s obesity risk in early childhood was modified by gestational weight gain. Obesity (Silver Spring, Md.), 22(1), 19–23. 15. Ong, K. K., & Loos, R. J. F. (2006). Rapid infancy weight gain and subsequent obesity: systematic reviews and hopeful suggestions. Acta Paediatrica (Oslo, Norway : 1992), 95(8), 904–908. 16. Basto-Abreu, A., Barrientos-Gutierrez, T., Zepeda-Tello, R., Camacho, V., Gimeno Ruiz de Porras, D., & Hernandez-Avila, M. (2018). The Relationship of Socioeconomic Status with Body Mass Index Depends on the Socioeconomic Measure Used. Obesity (Silver Spring, Md.), 26(1), 176–184.

Appendix 1. Risk of Bias Assessment (detailed notes) Criteria

Basso O, et al. (2010)

Lai TC, et al. (2016)

Min J, et al. (2014)

Ong KK, et al. (2007)

Women enrolled from 12 US Academic Hong Kong’s “Children of 1997” birth cohort Exposed and unexposed drawn for 6009 were randomly recruited Medical centres during pregnancy and consisting a large, prospective, populationsame population-based health from UK-population based followed through delivery representative Chinese birth cohort recruited at surveillance system in four provinceALSPAC birth cohort 31.474 US Black and White children bornthe 49 Maternal and Child Health Centres of China at same points of care from 1959 to 1966 in the Collaborative (MCHCs) in Hong Kong over the same time frame (2000Perinatal Project. 2005) Exclusion : other than Black and White, low birth weight, infants with major malformation. Inclusion : valid birth weight and at least one later weight measurement

Available data was shown in tables and figures,yet it was not written explicitly

Maternal age of menarche were obtained from MMA is a hallmark event with a MMA is recorded using postal Survey in 2008–2009, good recall reliability questionnaire during pregnancy self-reported recall bias is unlikely because the assessment of exposure before the outcome occurred

Offsprings have not been delivered

Using multivariate analysis Using multivariate analysis Using chi-square test, t-tests, and Using chi-square test and adjusting for study centre, race, child’s adjusting for age, sex, maternal age, maternal multivariate statistical analysis multivariate logistic regression sex, socioeconomic index, child’s age at education, parental occupation and household multinomial logistic regression adjusting for sex, age, measurement, mother's age at recruitment, income, latest height z score. Linear regression models, adjusting for all possible gestational age, parity, mother's and mother’s height (in the length/height was used to obtain the adjusted associations for prognostic variables: education, mother's BMI, and model), weight (in the weight model) or birth weight z score and generalized estimating sex, gestational age, birth weight, feeding practice BMI (in the BMI model) equations for BMI exclusive breast feeding during first 6 months, parity, maternal age at pregnancy and height, education, occupation and urban or rural residences

Offsprings have not been delivered Offsprings have not been delivered

Appendix 1. (continued) Criteria

Basso O, et al. (2010)

Self-reported pre-pregnancy height and weight. Data was available, yet methods and timing were unclear

A self-administered questionnaire in Obstetricians examined the Chinese was used at baseline women's health before, during including parental birthplace, parental and after pregnancy and from height, parental BMI were obtained from filled individual booklets with postal Survey in 2008–2009 demographics data insufficient information about prognostic factor's measurement, hence impeding reproducibility

Loss to follow up reached 25% from 31.474 samples

Loss to follow up is found > 20%

Lai TC, et al. (2016)

Min J, et al. (2014)

Ong KK, et al. (2007)

Mother’s parity, smoking during pregnancy, mother’s highest educational achievement, prepregnancy mother's height and weight were recorded by a questionnaire completed during pregnancy. Gestation was estimated using the date of last menstrual period and confirmed by antenatal ultrasound reports; in cases of discrepancy the data were reviewed by a single experienced clinician. Measure BMI at birth, ages of Birth weight was converted into sex- Measuring weight and height Anthropometric measurement on children at age 1,3,4,7,and 8 years using linear specific z scores, and BMI and height using z score 2006 WHO Child 9 y; weight measured by Seca 724 or 835 scales mixed models were converted into sex-specific z scores Growth Standards and standing heights using Liester height from scheduled measurements at 3, 9, measures (socks and shoes removed) Children were measured and 36 months, relative to the World according to standardized Health organization (WHO) Growth BMI = weight for height^2 unit :(kg/m^2) procedures by trained personnel. Standards 2005 and, from annual Obesity in children was defined as BMI > 97th Length/height was measured to measurements at 6 to 13 years, relative to percentile for sex and age by comparison with the nearest 0.5 cm, in a supine the WHO Growth reference 5–19 years the UK 1990 growth reference position through 20 months age, and standing thereafter. Scales Height was ascertained as supine length All weight and length measurements were were calibrated at least semiin infancy, but as standing height converted to sex- and age-independent standard manually. subsequently. deviation (SD) scores in each participant by comparison with the UK 1990 growth reference At birth, 2 yr, 4 yr, 5 yr At birth,2 yr,5 yr, 7 yr, 9 yr no drop out information given consistent number of children in the beginning of the study and the last measurement of children's growth at age of 9 yr

Childhood Obesity as a Predictor of Diabetes Mellitus Type 2 in Adults: A Systematic Review and Meta-Analysis Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2019

By: Marco Raditya* Fabiola Cathleen Daniell Edward Raharjo Kristian Kurniawan

Faculty of Medicine Universitas Indonesia Depok 2018

INTRODUCTION

efforts against the disease. The UN itself has

Rationale

set an ambitious goal to reduce premature

Long acclaimed as a silent killer, diabetes

mortality by one third before 2030 as part of

mellitus type 2 (DM type 2) is now on the

the Sustainable Development Goals (World

troubling rise to become a global emergency.

Health

This non-communicable disease characterized

myriad of screening tools, obesity is often

by the bodyâ&#x20AC;&#x2122;s insensitivity to insulin, impaired

considered as it is the greatest risk factor of

hormonal production by the pancreas, and

DM type 2, with over 90% of patients being

resulting hyperglycemia has now become the

obese

top 10 leading causes of deaths worldwideâ&#x20AC;&#x201D;a

However, the seemingly unaffected escalation

whopping 3.7 million deaths in 2012. WHO

estimated that 422 million adults globally are

ineffectiveness of these programs in curbing

burdened with diabetes, beyond double the

the

prevalence recorded in 1980 and data gathered

discovery of a novel risk factor in DM type 2

across the world also proved a rampant rise in

which was previously unseen. Surrounding

diabetes-associated deaths between 2000 and

this matter, many research has been performed

2012 (World Health Organization, 2016). This

lately to assess the relationship between

undisputable burden of DM type 2 is further

childhood obesity and adult-onset diabetes,

corroborated by an increase in disability

and whether prevention of childhood obesity

adjusted life years generated by diabetic

can reduce the risk of diabetes during

complications

adulthood.

such

nephropathy

and

Organization, 2016). Among the

overweight type

disease,

(Whitmore, prevalence

therefore

2010). suggests

necessitating

the

neuropathy of 49.7 million in 1990 to 64.1 million in 2015, (Kassebaum et al., 2016).

Objectives

Unfortunately, collateral damage of this

As comprehensive reviews surrounding this

disease to the economy has also yielded US$

specific matter has yet to be done, this is the

827 billion in losses in 2013â&#x20AC;&#x201D;3 times higher

first systematic review and meta-analysis

than in 2003 according to the International

conducted to draw a sound and statistically

Diabetes Foundation. With such economic

significant conclusion on the link between

fall-out, DM type 2 is likely to impede

childhood obesity and diabetes in adulthood

national and global development if not

by comparing the occurrence of DM type 2

handled effectively (International Diabetes

across two variables: adults with and without

Foundation, 2013).

childhood obesity. To ensure feasibility of international

application,

research

from

As a result, the epidemic surge in DM type 2

various countries among different regions have

prevalence worldwide has mandated the

been reviewed. Furthermore, retrospective and

implementation

government-enforced

prospective cohort studies have also been

programs as both curative and preventive

specifically chosen as it allows exploration of

causative factors in DM type 2 alongside being

type 2 OR DM OR Diabetes Mellitus) AND

long term, follow-up studies.

(abdominal obesity OR central obesity OR Visceral Obesity) AND (Children OR Child

Through these endeavors, this review is

OR Pediatric OR Kid OR Childhood) AND

anticipated to increase public awareness on the

(Cohort) AND (Risk OR Factor). The concept

importance of dealing with childhood obesity

is then modified based on each database

along with its implication on future diabetes

boolean terms and conditions. Cohort studies

comorbidity. Furthermore, we hope that the

were used for this review as its time-approach

results of this review can be implemented into

design is more compatible to identify and

the

evidence-based

follow-up the association between childhood

guideline for early diabetes screening and

obesity and adulthood diabetes, which requires

prevention. We believe that by applying the

a long period of time. Only published studies

objectives stated above, this review will stand

with full text availability were searched.

in the forefront of new strategies in combating

Additional records were identified through

DM type 2 as a silent threat in achievement of

manual search, similar articles suggestion, and

the global Sustainable Development Goals by

bibliographies from other studies not identified

2030.

in electronic searches.

MATERIAL AND METHODS

Study selection

This systematic review and meta-analysis were

The study selection process follows the

conducted based on PRISMA Statements’

PRISMA Statements’ flow diagram. All of the

flow diagram and checklist to improve quality

records retrieved will be tested for duplicates,

of reporting. It is a four-phase flow diagram

then all duplicates found will be removed.

while the checklist consists of 27 items

Studies left after duplicates removal will be

pertaining to the content of systematic review

screened based on its titles and abstracts, and

and meta-analysis, including the title, abstract,

exclusion will be done to those irrelevant to

introduction, methods, results, discussion, and

the topic or objectives of this review. After

funding (“PRISMA,” 2015).

screening, the process continued to eligibility

pre-existing

practical

assessment of full-text articles based on Study Search

inclusion and exclusion criteria. The inclusion

A range of databases, including PubMed,

criteria of this review are cohort studies with

Scopus, PLOS, Cochrane, Science Direct,

minimum 1,000 participants at follow up, age

Clinical Key, ProQuest, and Wiley, was

of participants at baseline ≤ 18 years old,

sought up to 14th of October 2018. The search

measures obesity and diabetes mellitus type 2

strategy was structured using the following

indicators using any methods (such as BMI or

concept of keywords: (adult onset diabetes

CDC’s growth chart for obesity and HbA1c or

mellitus OR diabetes mellitus type 2 OR DM

fasting plasma glucose for diabetes), and

assessment of long-term association between

publication year, study design, definition of

childhood obesity and adult onset diabetes

childhood obesity and adult diabetes, study

mellitus type 2 is present. The sample size

location, statistical analysis, sample size, and

restriction was to ensure higher quality studies

outcome of study) and participants details (age

(as larger size reduces the risk of loss of

in baseline, follow-up age, numbers of control,

follow up and has higher power in detecting

exposure, positive outcome, and negative

any association of childhood obesity and adult

outcome group). When available, adjusted

onset diabetes) and to establish a more

outcome for potential confounders were used

statistically significant results in reporting.

if value is adjusted by exact age and gender

Moreover, exclusion criteria are language

only, without adjustment from other factors..

besides

Bahasa

Indonesia

and

English,

incomplete articles or insufficient data, and

Quality and Bias Assessment

publication year older than 2000. Records that

Quality and bias assessment within studies

are incompatible with inclusion criteria or

were done after the data extraction of every

corresponds with exclusion criteria were

included studies had been finished. The

excluded, resulting in studies directly included

methods used to assess quality and bias of

in qualitative synthesis. Only some of those

each study was the Newcastle-Ottawa Scale

were included in quantitative synthesis or

tools designed for Cohort Studies (NOS-

meta-analysis due to different definition of

Cohort). This scale uses a â&#x20AC;&#x153;star systemâ&#x20AC;? in

obesity or diabetes mellitus type 2 from our

which a study is judged on three broad

study, and unspecified number of control,

perspectives: the selection of the study, the

exposed, positive outcome, and negative

comparability

outcome group. This selection process were

ascertainment of either the exposure of

done by 2 reviewers and consulted to a third

interest.

reviewer.

categories, which only a star can be given to

Each

the

groups,

perspective

has

and

the

several

each category (Wells et al. 2018). The quality Data extraction

of individual studies was assessed by two

Data were extracted by 2 reviewers using

reviewer and then independently checked by a

standardized

were

third reviewer. Based on the result of the

independently checked and confirmed by a

assessment, studies with lesser bias and higher

third reviewer. Any consultation was done

quality will be taken more into consideration

with the third reviewer as well. There were no

in qualitative analysis, however no primary

multiple publications of identical studies.

included study was excluded.

forms.

Then,

they

Duplicates also have already been removed in the prior process, therefore identical data will

For the assessment of bias across this review,

not be extracted twice. Extraction of study

reviewer will refer to the handbook of

characteristics includes study details (author,

Cochrane regarding summary assessment of

risk of bias in 4 levels: Outcome, Domains,

Result for participants are reported as a unity

Studies, and Study as a Whole (“Cochrane

to represent all ages of children due to lack of

Handbook,” 2011).

studies available. Reason to group the result based on the age of the children was denied

Analysis

since they are considered indefinite and may

Studies included in qualitative analysis may

overlap. For example, children <7 years old

reported varieties of metabolic outcome, such

are often grouped as they may experience

and

adiposity rebound (AR), yet the universal

hypertension. Those were neglected and only

agreement for AR occurrence age has yet to be

data regarding diabetes mellitus type 2 is

done—adiposity rebound may happen to age

taken. A variety of definition in obesity and

3-7, 5-7, or even above 7 (WHO, 2006; Cole,

diabetes was also found. Any definition is

2004).

coronary

heart

disease,

stroke,

accepted for qualitative analysis. However, only those with similar manner for specific sex

The pooled size of control, exposed, positive

and age group will be included in meta-

and negative outcome group, or the OR, then

analysis to allow calculation of pooled ORs.

tabulated and analysed into a forest plot using

The accepted definition for obesity are BMI ≥

Review Manager 5.3 Software for Mac. To

95th percentile (CDC Growth Chart 2000) and

estimate the effect from individual studies

BMI ≥ +3SD Z Score in BMI for age per sex

against measure of each study’s size or

chart. Accepted definition for adult onset

precision and to assess publication bias, this

diabetes type 2 are fasting glucose plasma

meta-analysis used funnel plots, also generated

>7.0 mmol/L, 2-hr plasma glucose >11.1

by Review Manager 5.3 Software for Mac.

mmol/L,

and

physician.

self-reported

The

BMI

diagnosis standard

by was

RESULTS

acknowledged in this meta-analysis based on

Initaly, searches identified 218 total records

the assumption and evidence that BMI follows

from database searching, which are 37, 36, 2,

a normal distribution (Kapetanakis et al.,

2, 71, 70, 0 and 0, from Pubmed, Scopus,

2014).

also

PLOS, Cochrane, Science Direct, Clinical

acknowledged because it is a standardized

Key, ProQuest, and Wiley respectively. The

WHO’s recommendation and can be applied to

additional records were identified from manual

everyone.

Diabetes

standard

Self-reported

was

diagnosis

search (n=5), similar articles suggestion (n=8),

physician was accepted in assumption that the

and bibliographies from other studies not

physician also follows WHO’s guideline or

identified in electronic searches (n=6). From

other proven clinical guideline. Studies that

that, there were 237 total records retrieved.

use any other definition will be excluded,

Duplicates (n=7) is immediately removed,

unless it is accompanied by other accepted

leaving 230 records to be screened. 196

definition or acts as just an accessory.

records were further excluded as it is irrelevant

to topic or objectives of this review, resulting

follow up, no loss, or less than 20% loss.

in 34 studies to be assessed for its eligibility. 1

These 5 studies either have a follow up rate

study has incompatible study design, 10

less than 80% or show no description of

studies were review articles, data of 5 studies

follow up process. Erickson JG and Forsen T

did not correlate with topic, full-text articles of

did not define follow up, Hypponen had 74.7%

3 studies cannot be found, and 4 studies did

of follow up, Mamun AA et al. only had

not have sufficient data. With those 24 records

36.5%, and Power C had a 52.7% follow up.

had been excluded, there were 10 studies to be

This may arise from the extensive study

included in the qualitative synthesis.

length, which could result in loss of interest, migration or death. The most unbiased studies

Furthermore, there were 4 studies that did not

were by Hou D, 2016 and Liang Y, 2015 as a

use any of the accepted definitions of obesity

star was given to all categories.

and diabetes as mentioned above (Erickson et al., Forsen et al., Mamun et al., and Tirosh, et

Table 1 portrays the characteristics of the 10

al.). Lawlor et al. did not specify the number

studies with a total of 73,533 participants

of positive and negative outcome group

included in this review. All study uses Cohort

therefore impossible to calculate the OR. This

resulted in the exclusion of the 5 studies

retrospective. 5 studies were included in the

above, and the final 5 studies to be eligible for

meta-analysis. In the studies, the definition of

quantitative analysis (Hou D, 2016; Hyponnen

childhood obesity and adult diabetes type 2

E, 2003; Liang Y, 2015; Morrison JA, 2010;

still varied. Since these definitions were only

Power C, 2011). The summary of study search

used alongside the accepted definitions and act

and selection is depicted in accordance to the

four-phase PRISMA Statementsâ&#x20AC;&#x2122; flow diagram

appropriate for meta-analysis. Other childhood

in Figure 1.

obesity definition is Chinaâ&#x20AC;&#x2122;s Working Group

study

design,

either

prospective

ancillary, the studies were still

on Obesity (WGOC) growth chart in studies The result of risk of bias and quality

by Hou D and Liang Y. Other definitions of

assessment

the

diabetes type 2 in adult are current use in

Newcastle-Ottawa Scale is depicted in Figure

blood-glucose lowering agents by Liang Y and

2. Overall result suggests that all studies have

Power C, and HbA1c in Hou D and Power C.

for

each

study

using

the minimum score of 8/10, implicating low risk of bias and high validity. The most

The locations of the studies was fairly

apparent bias from the individual studies was

scattered, as it ranges from Asia, Europe,

from the Outcome Section number 3, whereas

Oceania, America, and Middle East. This is

5 studies did not manage to do follow up to a

beneficial meaning that these studies were able

number of subjects thatâ&#x20AC;&#x2122;s unlikely to introduce

to represent the global community. The age at

bias. An adequate follow up includes complete

which obesity was measured varied, however

the age of 7-16 is the most often represented (6

driven by the considerable consistent findings

studies). The outcome of the studies varied

across the studies that obese BMI in childhood

across studies. Lawlor et al. (2006). showed

increases the risk of diabetes in adulthood, the

the lowest OR in this review, which is 1.22,

similarity in obesity and diabetes cut off, and

while the OR reached 5.49 in the study from

the fairly equal distribution of age in baseline.

Morrison et al (2010).

Moreover, funnel plot generated showed a symmetrical appearance (Figure 4), proving the homogeneity of this review and a rather low publication bias.

Figure 1. Study search and selection process.

Figure 2. Bias and quality assessment of included studies with NOS-cohort

Figure 3 shows the forest plot for the association between childhood diabetes for all

The summary of risk of bias for this review

ages based on BMI and diabetes type 2 in

was done based on the four-level assessment

adulthood. The association found from this

in Cochrane Handbook as stated before. The

meta-analysis of 5 studies was positive and

potential bias could result from authorsâ&#x20AC;&#x2122;

significant (OR: 3.89; 95% CI 2.97-5.09) with

assumptions in accepting definitions used for

a p-value of <0,00001.

childhood obesity and adulthood diabetes type 2, such as the self-report of physician

Heterogeneity in this study with I2 statistics

diagnosis to DM type 2. This could lead to a

was 0% across cohort used. The p-value for

lower quality of evidence of this meta-

this heterogeneity test was 0.6. This describes

analysis.

the homogeneity of this review, which was

Figure 3. Forest plot analysis of included studies

of this meta-analysis is valid. Based on all the studies included in the systematic

review,

childhood

obesity

discovered to be a risk factor to adult-onset diabetes. The OR of the studies ranged from 1.22 - 5.49, all of which are higher than 1. Thus, it can be concluded that all studies have Figure 4. Funnel plot assessment of included studies

shown childhood obesity as a risk factor to adult-onset diabetes, and none of the studies has declared otherwise (Ericksson et al., 2015;

DISCUSSION

Forsen, 2000; Hou et al., 2016; Hypponen et

Based on this systematic review and metaanalysis, it is found that childhood BMI, particularly BMI >+3SD Z-score, is related to the

occurrence

adult-onset

children with obesity is more likely to become diabetic in adulthood with the OR: 3.89 [95% 2.97,

5.09].

Thus,

individuals

with

childhood obesity is 3.89 times more likely to have adult-onset diabetes. The variability between studies are I2 = 0% (P = 0.60), signifying

that

the

studies

2015; Mamun et al., 2009; Morrison et al., 2010; Power et al., 2011; Tirosh et al., 2011).

diabetes.

Through the forest plot, it is discovered that

al., 2013; Lawlor et al., 2006; Liang et al.,

shows

heterogeneity between one another. This means that results of the studies are highly similar with one another. P value for this metaanalysis is p < 0.00001, meaning that the result

In this meta-analysis, the study with the highest weight is Liang Y with 28.6%. This study, along with Hou D (second highest weight of 25.1%), suggests that childhood obesity promotes adulthood obesity due to early adiposity rebound. Early adiposity rebound would result in an increase in body fat composition

and

weight

gain,

causing

individual to enter the obesity cycle. Based on the obesity cycle, as the individual gains more and more weight, physical inactivity becomes more prominent as it becomes physically

Table 1. Summarize of study characteristics

harder for individuals to do physical activity.

becomes

As obesity progresses, performing physical

adulthood. Thus, the outcome of this review

activity becomes excruciating and exhausting,

could be implemented on early screening for

increasing sleep and eating frequency due to

diabetes and pediatric health guidelines.

fatigue. As it progresses further, it becomes

Childhood obesity should be added as a risk

harder and harder to reduce oneâ&#x20AC;&#x2122;s BMI, which

factor evaluated on diabetes early screening,

along with social pressure, could lead to

while pediatric health guidelines should also

mental

Increased

include this information in order to further

cortisol due to stress would result in increased

imply the necessity to prevent and reduce

appetite, aggravating the condition. Early

childhood obesity. Public awareness regarding

onset of this cycle increases risk for adult-

this study should also be increased to raise

onset obesity, where adulthood obesity itself is

awareness regarding this risk factor to parents,

a major risk factor to adult diabetes (Liang et

to further imply the need to reduce their

al., 2015; Hou et al., 2016). As both of this

childrenâ&#x20AC;&#x2122;s obesity.

stress

and

depression.

a determinant for diabetes

studies also has the least of risk of bias, with the score of 10/10, this explanation is largely

Strength and Limitations

possible.

The strength of this study includes: usage of structural guideline, low risk of bias in

A study by Hypponen E, which has the third

included studies, large cohort population,

highest weight, suggests that high numbers of

various countries representation, symmetrical

adipocyte

funnel plot, no study heterogeneity and high

sustained increment of insulin, as insulin

study specificity. This review is made based

functions to inhibit adipose tissue breakdown.

Prolonged high insulin concentration would

completion and comprehensiveness of the

result in insulin resistance. Childhood obesity

study, NOS as risk of bias in included studies

suggests that an individualâ&#x20AC;&#x2122;s adipocyte amount

assessment tools, and Cochrane Handbook as

is higher than normal, causing a sustained high

risk of bias across this review assessment

insulin condition. This mechanism explains

tools. 100% of included studies has the

how childhood obesity causes adult-onset

minimum scale of 8/10. All included studies

diabetes as it requires a certain amount of time

has minimum of 1,000 participants to ensure

for insulin resistance progression to reach a

the quality of each study. There are 8 countries

diabetic state (Hypponen et al., 2003).

included in this review, all of which originates

tissues

would

also

result

PRISMA

Statement

ensure

the

from either Europe, Asia, America, Oceania, The results of this review revealed that risk

and Middle-East. Funnel plot data has also

factors

proven to be symmetrical, meaning that

of diabetes

adulthood.

Health

are not limited to conditions

during

studies included are highly homogen. As

childhood, in this case childhood obesity,

stated above, the result of this study shows no

heterogeneity and p value < 0.00001, which

adult-onset diabetes. The most likely cause is

represents a specific and trusted result as it has

due to early adiposity rebound and early-onset

statistically included enough studies and

insulin resistance from childhood obesity (Hou

enough data varieties.

et al., 2016; Hypponen et al., 2013; Liang et al., 2015).

On the other hand, limitation of this systematic review

and

few

The findings of this study are applicable in the

accepted

field of public health, both as a screening

definitions, and lifestyle changes. Out of the

method and prevention for adult diabetes. As

230 original studies retrieved, only a total of

the determinant for childhood obesity in this

10 studies are used in the qualitative review,

review uses BMI for age, further research

and 5 studies in the quantitative review.

regarding

Though there are no heterogeneity and high

obesity itself and other body compositions

specificity, the final OR from this review

could also be done to discover presence of a

would be more representable for worldwide

use if there are more studies included in the

measurement and to analyse other variables

forest plot. Though BMI is believed to follow

during childhood that is related to adult-onset

normal distribution, bias can occur. Definition

diabetes respectively. As BMI-for-age is not

of self-reported diagnosis by physician for

the only value used to evaluate childhood

adulthood diabetes was accepted, but bias can

obesity, research on other markersâ&#x20AC;&#x2122; specificity

also arise. Third, as cohort studies needed for

and sensitivity towards adult-onset diabetes is

this review requires a long follow up period,

crucial to increase treatment effectivity. Other

and our review includes studies published

body compositionsâ&#x20AC;&#x2122; effect on adult-onset

from the year 2000, the childhood lifestyle of

diabetes should also be evaluated as obesity is

cohort samples belong to lifestyle in the 1900s

a broad term used for general changes to the

instead of 2000s. The follow up period ranged

body composition. This is also essential in

from 12 years up to 52 years. As obesity is

order to provide a more detailed and precise

highly correlated with lifestyle, evaluation of

guideline in early screening and prevention of

these studies might not represent the condition

adult-onset diabetes itself. Age stratification

and area-specific research should also be done

childhood obesity today might differ from the

in order to have a more detailed causality for

results included in the review.

each age group and certain areas.

Conclusion

Funding

In conclusion, this systematic review and

This review is not funded by any organisation,

meta-analysis has found that individuals with

institution or other third-parties.

included

meta-analysis

studies,

children

today.

bias

Thus,

includes: from

incidence

childhood obesity has higher risk of having

other

sensitive

measurements

and

specific

evaluating

obesity

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ABSTRACT Childhood Obesity as a Predictor of Diabetes Mellitus Type 2 in Adults: A Systematic Review and Meta-Analysis *Marco Raditya, Fabiola Cathleen, Daniell Edward, Kristian Kurniawan *marco.raditya@gmail.com

Introduction: DM type 2 is now on the troubling rise to become a global emergency. It is now the top 10 leading causes of deaths worldwide and WHO estimated 422 million adults worldwide are diabetic. DALY generated by diabetic complications has also increased from 49.7 million (1990) to 64.1 million (2015). Escalation in DM type 2 prevalence despite governmentenforced programs like SDGs suggests its ineffectiveness, necessitating the discovery of a novel risk factor in DM type 2, such as the relationship between childhood obesity and adultonset diabetes. Objectives: This review is conducted to conclude the link between childhood obesity and adulthood obesity type 2. Results are hoped to increase public awareness, be implemented into the preexisting practical evidence-based guideline of diabetes screening and prevention, and to achieve WHOâ&#x20AC;&#x2122;s Sustainable Development Goals by 2030. Materials and method: This review was conducted based on PRISMA Statementsâ&#x20AC;&#x2122; flow diagram and checklist to improve quality of reporting. Cohort studies were chosen for its long term follow-up. For bias and quality assessment, Newcastle-Ottawa Scale for Cohort was used for included studies and Cochrane Handbook was used towards this review. Analysis was depicted in forest plot and funnel plot using RevMan 5.3 Software for Mac. Results: From 8 databases and additional searches, total 237 records with 73,533 participants were retrieved, and final 5 studies were included in meta-analysis. The most common bias from NOS were inadequacy of follow-up. Analysis through forest plot show statistically significant association of childhood obesity to adulthood diabetes (OR: 3.89; 95% CI 2.97-5.09; I2 :0%; p-value<0.00001). Funnel plot assessment is symmetrical. Discussion: Based on forest plot, individuals with childhood obesity is 3.89 times more likely to have adult-onset diabetes. Studies suggest that childhood obesity cause early insulin resistance and

early adiposity rebound, which promotes adulthood obesity, a diabetic risk factor. Review limitation includes few included studies, missing obesity universal definition, and questionable study results validity. Conclusion: In conclusion, childhood obesity can be used as a predictor for adulthood diabetes. Early diabetes screening and prevention guidelines should include childhood obesity as plausible risk factor. Keywords: Childhood obesity, Adult diabetes mellitus type 2, Meta-analysis

PCC Eamsc 2019

scientific poster

bundle of acads amsa-ui 2018/2019

Table 1. Characteristic of Studies

Figure 2. Cochrane Collaboration Tools

Figure 1. Literature Search We compare between ketogenic diet, VLCK diet, isocaloric KD, and low calories diet. Inclusion criteria: RCT, publication year 2014 or sooner, full-text only, human participants, adult. Exclusion criteria: suplement modification in ketogenic diet, effect of ketogenic diet on other diseases

Effectiveness of Ketogenic Diet on Body Fat as An Obesity Management in Adult: A Systematic Review Ugiadam Farhan*, Aruni Cahya, Ekida Rehan, Yehezkiel Alexander *ugiadamfarhan@yahoo.co.id, +6281287970973 Universitas Indonesia Introduction Obesity or overweight can lead to various adverse metabolic effect including blood cholesterol, blood pressure, triglycerides and insulin resistance. In 2016, 1.9 billion adults at 18 years or older were overweight and 650 million were obese. Diet and change of lifestyle are becoming the main treatment of type 2 diabetes mellitus and obesity. One recommendation to treat obesity is very low calories ketogenic diet. Although many studies are still being continued to demonstrate the effects and effectiveness of low carbohydrate diet in order to treat obesity. Objectives (1) To review several types of ketogenic diet (2) To analyse the effectiveness of ketogenic diet as obesity management (3) develop further holistic approach to manage obesity through diet intervention Methods This systematic review of several randomized controlled trial studies of ketogenic diet effect on obese or overweight adult. We searched literatures through PubMed, ScienceDirect, and Scopus (n = 16907) journal database. Six eligible studies which meet inclusion and exclusion criteria were assessed with Cochrane Collaboration Tools for assessing risk of bias for further review. Results and Discussion 1) Mechanism of ketogenic diet 2) Type of ketogenic diet 3) Effect of ketogenic diet Conclusion This systematic review concluded that ketogenic diet significantly can increase body fat loss in obese people. The most effective type of ketogenic diet is very-low ketogenic diet. Correspond with WHO programs to decrease number of obesity which lead to many NCD, ketogenic diet could simply applies as treatment of obesity. Keywords Adult, ketogenic diet, body fat, obesity, overweight

Integrated Multimodal Preventive Approach for Type 2 Diabetes Mellitus in Asia: Systematic Review Adriana Viola Miranda1,*, Eko Ngadiono1, Refael Alfa Budiman1, Aji Wahyu Wardhana1 1Undergraduate

Program, Faculty of Medicine, University of Indonesia

*adriana.viola@ui.ac.id

4 Results

Type 2 diabetes mellitus (T2DM), or non-insulin-dependent diabetes, is a condition when the body lacks the capacity to utilize insulin effectively. It has shown a rapid prevalence increase since 1980 – from a total of 102 million to 422 million (Roglic, 2018) Around 80% of patients with T2DM originated from low and middle-income countries. Asia region contributes to 60% of those number. This is important to notice as diabetes in Asia differs from other parts of the world due to distinct profile of genes and diet (Nanditha et al, 2016). Without a proper management, diabetes may cause long-term consequences that impact quality of life, as well as large economical burden (Zhang et al, 2017). To address the issue, researchers around the world have been developing numerous amount of effective preventive programs, aligning with Sustainable Development Goals (SDG) number 3 (UNSC, 2017). Based on differences in population characteristics, Asian populations require distinct preventive approaches from other regions (Ramachandran et al, 2012). Here, we systematically review preventive programs that have been done in Asia.

2 Objective This review aims to: 1.  Evaluate preventive approaches of type 2 diabetes mellitus in Asian countries 2.  Synthesize a integrated multimodal prevention program of diabetes mellitus type 2 based on evaluation of currently-available preventive approaches in Asia

Table 1. Study characteristics and quality assessments result. Assessments were done using Jadad scoring for RCT and STROBE Statement for cohort studies. Study Bani Salameh, 2017

Location Irbid, Jordan

Rekha K et Chennai, al, 2014 India

RCT

Ramachandran A South East et al, 2013 India, India RCT

TanigunichFukatsu A Tokushima, et al, 2012 Japan RCT

Saito T et al, 2011

Japan

Kawamori R, et al 2009 Japan

Kosaka et Tokyo, al, 2004 Japan

RCT

Quality Assessment

Preventive Approach(es)

School-based n Intervention = educational preventive 205, n control = Adolescent (mean age = programs 196 15.3 years)

Significant reduction in body weight (p <0.000) and fasting blood glucose (p <0.000)

n intervention = 74, n control = Adult Male & Female (aged 30-70 years) Fenugreek consumption 66

Significant reduction in diabetes incidence (x2 = 13.4; p <0.01),reduced LDLc (low density lipoprotein cholesterol, p <0.05), reduced FPG (p <0.05) and post prandial blood glucose (p <0.01); significant increase in serum insulin level (p <0.01) and HOMA IR (p <0.05); treatment positively associated with serum insulin (p <0.01) and negatively associated with HOMA IR (p <0.001)

n = 53, divided Significant difference in fasting blood into control and glucose level and quality of life; reduced Home-based monitored intervention Males and females (35 to FPG (p <0.0001);); significant increase in aerobic exercise 55 years old) group quality of life (QoL) (p <0.0001)

Educational and motivational advice Reduced diabetes incidence (p <0.015) about lifestyle n intervention = 271; n control= modification through mobile phone messaging 266 Adult male (35-55 years)

Demography of Participants

Outcome

Reduced acute glucose and insulin responses; improvements in composite insulin sensitivity index (CISI, p <0.05); significant decrease in levels of serum total cholesterol, LDL-cholesterol, Overweight subjects with malondialdehyde-modified LDL and N 1IGT and hyperinsulinaemia carboxymethyllysine

Lifestyle modification (control dietary intake of fat and increased n intervention = 311; n control = Adult male and female physical activity to 330 200kcal/day) (aged 30-60 years)

Weight reduction (p <0.001) at 36 months

High risk Japanese n intervention = individuals with glucose 897; n control = tolerance (average age 55.7) Voglibose consumption 883

Lower risk of progression to type 2 diabetes (HR = 0.595, p = 0.0014)

Diet modification and increased physical activity

n intervention = 102; n control = Adult male (aged 30-60 356 years)

Significant decrease in weight (p <0.001); glucose tolerance improvement from impaired glucose tolerance (IGT) to non IGT (p <0.001); decreased FPG (p <0.02)

Diet, exercise, combination of diet & exercise

Fasting glucose of the diet, exercise, and diet-plus-exercise interventions were 577; divided into three group (diet Individual classified (using associated with 31% (p <0.03), 46% (p only, exercise WHO criteria) as having <0.0005), and 42% (p <0.005) reductions in only, diet plus impaired glucose tolerant risk exercise) (IGT) of developing diabetes, respectively

Intensive Lifestyle Modification (I-LSM)

Aged 5-40 years, 50% n I-LSM= 1807, n subject under 16 years, 48% males LI-LSM=1878

RCT

Wijesuriya, 2014 Sri Lanka

RCT (Abstract) 1

Cohort

Number of Participants

Natto (viscous fermented soybeans) and viscous vegetables consumption 11

Pan XR et Da Qing, al, 1997 China

Momma H Tokyo, et al, 2017 Japan

12 Observational Studies

RCT

Gaddam et Hyderabad, al, 2015 India RCT

3 Method Systematic Review

Study Design

19,5

Yoon DH et Cohort al, 2016 South Korea (Abstract) N/A

Exercise

2235

Workplace improvement program 83

Reduced risk of T2DM onset (p = 0.04) and IGT onset (p = 0.002)

Males = mean age 43 years; median follow-up periods : 15 years

Significant difference between fit and unfit category based on cumulative incidence curve of Type 2 diabetes mellitus (T2DM) with age-adjusted (HR = 1.72) and multivariate-adjusted (HR = 1.33)

Employee

Improvement in HDLc, HbA1c,body weight, BMI, body fat percentage and waist hip circumference (p not available)

From Pubmed, ScienceDirect, Scopus, Google Scholar and additional records

Quality Assessment Jadad Scoring for RCT, STROBE Statement for cohort studies

Qualitative Analysis

Total Samples

Figure 1. Selection and Analytical Methods

Records identified through Google Scholar database searching (n = 343)

Records identified through ScienceDirect database searching (n = 54)

Records identified through Pubmed database searching (n = 73)

Records identified through Scopus database searching (n = 60)

Additional records identified through other sources (n = 8)

Records after duplicate removed (n = 538) Records screened (n = 538)

Records excluded (n = 516)

Full-text articles assessed for eligibility (n = 22)

Full-text articles excluded, with reasons (n = 10)

Studies included (n = 12)

Figure 2. PRISMA Flow Diagram

References Bani Salameh, A., et al. (2017). Effectiveness of a 12-week school-based educational preventive programme on weight and fasting blood glucose in "at-risk" adolescents of type 2 diabetes mellitus: Randomized controlled trial. Int J Nurs Pract, 23(3). doi: 10.1111/ijn.12528. Roglic, G. (2016). WHO Global report on diabetes: A summary. Int J Non-Commun Dis,1, 3-8. Available from: http://www.ijncd.org/text.asp?2016/1/1/3/184853 Cha, E., et al. (2016). Understanding how overweight and obese emerging adults make lifestyle choices. Pediatr Nurs, 31(6), e325-e332. doi: 10.1016/j.pedn.2016.07.001 Gaddam, A., et al. (2015). Role of Fenugreek in the prevention of type 2 diabetes mellitus in prediabetes. J Diabetes Metab Disord, 14, 74. doi: 10.1186/s40200-015-0208-4 Glanz, K., Rimer, B.K., Viswanath K., (Eds.). (2015). Health behavior: theory, research, and practice (5th ed). San Francisco: Jossey-Bass. p. 49. Kawamori, R., et al. (2009). Voglibose for prevention of type 2 diabetes mellitus: a randomised, double-blind trial in Japanese individuals with impaired glucose tolerance. Lancet, 9, 373(9675), 1607-14. doi: 10.1016/S0140-6736(09)60222-1 Kosaka, K., et al. (2005). Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diab Res Clin Pract, 67(2),152-162. doi: 10.1016/j.diabres.2004.06.010 Ma R., C., W., Chan, J., C., N. (2013 Apr). Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States. Ann N Y Acad Sci, 1281(1), 64–91. Epub 2013 Apr 1. doi: 10.1111/nyas.12098. Momma, H., et al. (2018). Importance of achieving a “fit" cardiorespiratory fitness level for several years on the incidence of type 2 diabetes mellitus: a Japanese cohort study. J Epidemiol, 28(5), 230-236. doi: 10.2188/jea.JE20160199 Nanditha, A., et al. (2016). Diabetes in Asia and the Pacific: implications for the global epidemic. diabetes care. Diabetes Care, 39(3), 472-485. doi: 10.2337/dc15-1536 Pan, X., R., et al. (1997). Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and diabetes study. Diabetes Care, 20(4),537-544 Phillips, J. & Springer, J., F. (2007). The Institute of Medicine framework and its implication for the advancement of prevention policy, programs and practice. Santa Rosa: Center for Applied Research Solutions. Ramachandran, A., et al. (2012). Trends in prevalence of diabetes in Asian countries. World J Diabetes, 3(6), 110–117. doi: 10.4239/wjd.v3.i6.110 Ramachandran, A., et al. (2013). Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol, 1, 191-198. doi: 10.1016/ss2213-8587(13)70067-6 Rekha, K., et al. (2014). Home based therapeutic intervention for type 2 diabetes mellitus. J Chem Pharm Sci (Online), 7, 275-280. Saito, T., et al. (2011). Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels: a randomized controlled trial. Arch Intern Med, 171(15), 1352-1360. doi: 10.1001/archinternmed.2011.275 Taniguchi-Fukatsu, A., et al. (2012). Natto and viscous vegetables in a Japanese-style breakfast improved insulin sensitivity, lipid metabolism and oxidative stress in overweight subjects with impaired glucose tolerance. Br J Nutr, 107, 1184-1191. doi: 10.1017/S0007114511004156 United Nations Statistical Commission. (2017). Resolution adopted by the General Assembly on Work of the Statistical Commission pertaining to the 2030 Agenda for Sustainable Development (A/RES/71/313). United Nation. Retrieved from: https://unstats.un.org/sdgs/indicators/Global Indicator Framework after refinement_Eng.pdf Wijesuriya, M., et al. (2014, Nov). OP49 a low cost primary prevention tool: effects of non pharmacological lifestyle modification in prevention of type 2 diabetes mellitus in young urban Sri Lankan - “DIABRISK-SL”. Paper presented at Proceedings of the 10th Internagtional Diabetes Federation-Western Pacific Region Congress and the 6th AASD Scientific Meeting. Diabetes Research and Clinical Practice. doi: 10.1016/ S0168-8227(14)70255-4 Yoon, D., H., et al. (2016, Jun). The effect of circuit training and workplace improvement program on the prevention of metabolic syndrome and the improvement of physical function in office workers [Abstract]. Korean J Health Promot, 16(2), 134-143. doi: 10.15384/kjhp.2016.16.2.134 [Article in Korean] Zhang, P. & Gregg, E. (2017). Global economic burden of diabetes and its implications. Lancet Diabetes Endocrinol, 5(6), 404-405. doi: 10.1016/S2213-8587(17)30100-6

Figure 3. Location map of included studies. Each pointer marks the location of one included study. Most of the studies were conducted in East Asia. Quantitative measurements of study results 6

Number of studies

1 Introduction

5 4 3 2 1 0

Outcome of study

Figure 4. Outcomes distribution of included studies. Note that while the programs are designed to prevent diabetes, some of which do not directly reduce the disease incidence, but rather reduce the prevalence its risk factors. •  The total participants included in this review are 10,601 people from 12 studies. •  The programs could be divided into three types based on their approach: lifestyle modification, educational programs, as well as nutraceutical and pharmacological strategies. •  The two most discussed outcomes in the study are reduced diabetes incidence and reduced fasting blood glucose, respectively.

5 Discussion Assessed prevention programs focus on improving lifestyle and health literacy Asian populations are more prone to diabetes compared to populations from other region. This is caused by their genetic susceptibility and recent changes in diet; the latter becoming the consequences of westernization (Ramachandran et al, 2012 & Ma et al, 2013). Furthermore, despite health literacy in Asia being considered among the standards, the aspect still needs to be improved (Cha et al, 2016). Based on these situations, many programs designated to prevent diabetes in the region focus on improving lifestyle and health literacy among the populations. This approach is also adopted by the studies assessed in this review, thus helping the programs improve diabetes condition in Asia significantly. The need to develop an integrated multimodal preventive approach for universal diabetes prevention While the described preventive approaches showed favorable results, each program still focused only on one social ecological level. This is important as theoretically, the most effective approach to public health prevention and control needs to use a combination of interventions at all levels (Yoon et al, 2016). Furthermore, it is known that effects from addressing single risk factor is unlikely to be sustainable (Bani Salameh, 2017). This implies that in order to prevent the increasing prevalence of diabetes in Asia, development of a preventive approach that addresses all levels and risk factors in the region is needed.

Proposed integrated multimodal preventive approach for Asian population Besides considering all levels in social-ecological model and occurring risk factors in Asia, there are several other aspects that need to be assessed before an integrated multimodal preventive approach could be proposed. Considering characteristics diversity among Asian population, generalizability of the program needs to be a priority (Ramachandran et al, 2012 & Ma et al, 2013). Furthermore, it also needs to be context-specific in order to be successful. This includes consideration of culture and socioeconomic status of the targeted population (Bani Salameh, 2017 & Saito T, 2011). At least, the program should be flexible enough so that when it is adapted into various cultures, it will not lose its core strategy.

We based our proposed approach on IOM Model of Prevention. This model divides prevention strategies into three types based on targeted populations: universal, selective and indicated strategies (Phillips & Springer, 2007).

Asian population

1 Universal

Educational programs

2 Selective

Diet and lifestyle modification

3 Indicated

Nutraceutical & pharmacological intervention

Lower diabetes incidence Figure 5. Proposed integrated multimodal preventive approach of diabetes in Asian population. The first line of diabetes prevention requires universal strategy that targets every individual in a population. For our proposed approach, we believe educational programs, mainly in schools, should implemented in this line considering the need to improve health literacy in Asia. On the other hand, individuals with higher risk of developing diabetes requires ‘selective’ intervention. Diet and lifestyle modifications are highly recommended for this type of intervention. Indicated strategy is addressed to individuals with early symptoms of diabetes. This strategy suggests nutraceuticals & pharmacological interventions as first choice of interventions. (Theory adapted from Phillips & Springer, 2007) Limitation of study Limited number of available studies that match with our inclusion and exclusion criteria may result in the designed preventive approach not universally acceptable for all Asian populations.

6 Conclusion and Recommendations From this systematic review, we were able to conclude that while several programs are significantly proven to reduce diabetes incidence in Asia, they still focus on one social ecological level. Moreover, each study focuses on certain population only. Therefore, to achieve universal health coverage (UHC) on diabetes in the region, we developed a integrated multimodal preventive approach This model accommodates various risk factor management, as well as various characteristics of population in need of diabetes prevention. However, this model needs to be researched more extensively before wide implementation could be done. Other further research opportunity regarding this preventive approach includes adaptation of the model into various cultural backgrounds.

Integrated Multimodal Preventive Approach for Type 2 Diabetes Mellitus in Asia: Systematic Review Adriana Viola Miranda1,*, Eko Ngadiono1, Refael Alfa Budiman1, Aji Wahyu Wardhana1 1

Undergraduate Program, Faculty of Medicine, University of Indonesia *

adriana.viola@ui.ac.id

Background: Type 2 diabetes mellitus has shown a rapid prevalence increase since 1980 â&#x20AC;&#x201C; from a total of 102 million to 422 million. Around 60% of these numbers are contributed by Asian countries. Without proper management, it will cause detrimental effects. Therefore, in alignment with Sustainable Development Goals (SDG) number 3, numerous diabetes prevention programs have been developed. Asian populations, on the other hand, require distinct preventive approaches as their population characteristics differ from populations from other region. In this review, we systematically evaluate diabetes prevention approaches in Asia. Objective: This review aims to evaluate preventive approaches of type 2 diabetes mellitus in Asian countries and synthesize a multi-modal prevention program based on the evaluations. Method: This review was conducted based on PRISMA Statement. From database searching, a total of 538 articles were found. Articles that do not align with our inclusion criteria were eliminated. We then assessed 22 studies for eligibility. Twelve articles were selected as our final research database in this study. Results and Discussion: The total participants of this review were 10,601 people. Intervention programs collected from these studies can be categorized as lifestyle modification, educational programs, as well as nutraceuticals and pharmacological strategies. While each intervention shows significant improvement in diabetes condition in Asia, a combination of interventions at all levels is needed. Based on this approach, we proposed an integrated multimodal preventive approach consists of three layers of prevention, which are universal, selective and indicated. Limitation of our study is the number of studies available for reviewing. Conclusion and Recommendations: Integrative multimodal preventive approach is needed in order to achieve universal health coverage of diabetes in Asia. However, this model needs to be researched extensively before implementation could be done widely. Further research opportunity includes adaptation of the model into various cultural backgrounds. Keyword: diabetes prevention approach, Asia, SDG, universal health coverage

ASSESSMENT OF DIETARY RISK FACTORS ASSOCIATED WITH CHILDHOOD OBESITY IN ASIA: A SYSTEMATIC REVIEW AND META-ANALYSIS Ko Abel Ardana Kusuma*, Johan Cahyadirga, Ariel Valentino Soetedjo, Christine Lieana abelardanakusuma@gmail.com

METHODS

INTRODUCTION According to the World Health Organization (WHO), childhood obesity is a serious emerging global health problem, as over 41 million children are obese in 2016, when compared to 32 million in 1990. If left untreated, this number would trend up to 70 million in 2025. Moreover, this potentially pathological condition affects mainly urban settings in low and middle-income countries, most of which are located in Asia. The rate of burden increase in developing countries is 30% higher than developed countries. This is serious because obesity in children tend to persist until adulthood and cause various complications such as cancers, musculoskeletal degenerative disorders, cardiovascular diseases, and diabetes. In addition, children with obesity has higher risk to have those adult-onset diseases in a younger age. Moreover, together, malnutrition and obesity are a double burden that affects all countries globally. The WHO has responded to this problem by applying recommendations from the reports of the Commission of Ending Childhood Obesity in 2016 to address obesity in children. To achieve this target, WHO supports the making of childhood obesity prevention policies and interventions, population-based initiatives and community-based policies. Among these interventions, the population-based policies rely heavily on nutritional control. Sadly, even though these initiatives have been implemented, the incidence of childhood obesity still keeps on increasing. In order to aid the WHO and other governmental and non-governmental health organizations, it is important to address dietary risk factors to spread the importance of decreasing the worldwide burden of childhood obesity and reducing the incidence of obesity-related complications. Identification of dietary risk factors was chosen as childhood eating habits may persist and become lifelong dietary habits. This review will assess the dietary risk factors associated with higher incidence of childhood obesity in Asia.

Figure 1. Study Screening Method Study identification using Pubmed Database (n = 334) Excluded studies (n=210) 1. Duplication (n=6) 2. Topic nonconformities (n=204)

Study screening (n=124)

Excluded studies (n=104) 1. Not extractable data (n=38) 2. Discussing other aspects besides risk factors (n=48) 3. Adult research subjects (n=1) 4. Studies not found (n=5) 5. Irrelevant outcome (n=12)

Studies included (n=16)

RESULTS

Studies included (n=13), assessed with STROBE Statement

Table 1. Characteristics of Studies and STROBE’s Scoring Study Type

Method of Analysis

Guo X (2013)

Study Location China

Cross-sectional

Shan XY (2010)

China

Cross sectional

multivariable logistic regression Multinominal logistic regression analysis

He Q (2000)

China

Case control

Logistic regression analysis

208513

Do LM (2015)

Vietnam

Cross-sectional

Multiple logistic regression

5354

5 6 7

Zong XN (2015) Naja F (2015) Gokler ME (2015)

China Lebanon Turkey

Case-control Cross-sectional cross-sectional

Multivariate logistic regression Multivariate logistic regression Multiple logistic regression

3298 446 3918

Zhang J (2015)

China

cross-sectional

Multivariate analysis

1282

Multivariate logistic regression

200

Multivariate logistic regression

396

10-12

nighttime snacking (OR = 1.59)

17.8

Conditional logistic regression Multilevel logistic regression logistic regression

138029 1644 72399

1month-7 10-13 12-18

fast eating speed (OR = 3.986) high fat content of school lunch (OR = 2.35) fast food consumption (OR: 1.18); unhealthy snacks (OR: 1.11)

17.1 15.2 14.4

9 10 11 12 13

Rathnayake KM Sri Lanka case-control (2014) Gonzalez-Suarez CB Phillipines Cohort (2013) Zong X-N (2012) China Case-control Kim B (2011) Korea Cross-sectional Lim H, 2013 South Korea cross-sectional

Study Size Age (years) 4094 21198

Risk Factor (95% ci)

5-18

For girls not having breakfast everyday (OR: 1.45) Snack consumption >=3 times a week (OR: 1.53); Fast food consumption 2-18 >= 3 times/week (OR: 1.50) For children age 0.1-2.9 years old: High eating speed (OR: 1.8). For 0,1-6,9 children age 3-6.9 years old: High eating speed (OR: 3.04) Fatty foods ≥7 times/week (OR=7.64), fried food ≥7 times/week 4.3 (OR=1.72) 3-7 fast eating speed (OR=4.351) 13-19 3rd tertile western diet (OR=2.31) 15.72 ± 0.99 having no breakfast (OR=1.3) highest quartiles of the modern and traditional north dietary patterns 7-17 (OR=3.1) Skipping breakfast (OR=3.99), consumption of fruits < 4 days per week 14-18 (OR=2.18)

STROBE Score 18.17 17.2 17.9 17.1 16.7 16.7 15.9 16.2 16.5

Table 2 and Figure 3. Meta-analysis of Risk Factors of Obesity No. Author (Year) 1 He Q (2000) 2 He Q (2000) 3 Shan XY (2010) 4 Shan XY (2010) 5 Kim B (2011) 6 Zong XN (2012) 7 Lim H (2013) 8 Lim H (2013) 9 Guo X (2013) 10 Gonzalez-Suarez CB

Risk Factor of Childhood Obesity High eating speed for children age 0.1-2.9 years old High eating speed for children age 3.6-9 years old Fast food consumption 3 times/week or more Snack consumption 3 times a week or more High fat content of school lunch Fast eating speed Fast food consumption Unhealthy snacks Girls not having breakfast everyday Nighttime snacking

OR (95% CI) 1.80 (1.32-2.45) 3.04 (2.49-3.71) 1.5 (1.12-2.01) 1.53 (1.35-1.73) 2.35 (1.14-4.85) 3.99 (3.07-5.18) 1.18 (1.00-1.39) 1.11 (1.03-1.20) 1.45 (1.11-1.89) 1.59 (0.78-3.24)

Proportion 6.20% 6.60% 6.30% 6.80% 4.10% 6.40% 6.70% 6.90% 6.40% 4.20%

Log[OR]±SE 0.5878±0.1582 1.1119±0.1018 0.4055±0.1491 0.4253±0.0639 0.8544±0.37 1.3828±0.1336 0.1655±0.0844 0.1044±0.0382 0.3716±0.1363 0.4637±0.3634

11 Rathnayake KM (2014)

Skipping breakfast

3.99 (1.81-8.80)

3.80%

1.3828±0.1336

12 Rathnayake KM (2014)

Fruit consumption less than 4 days/week

2.18 (1.02-4.66)

3.90%

0.7793±0.3875

4.80% 5.70% 6.70% 4.10% 6.10%

2.0334±0.2944 0.5423±0.2098 0.2624±0.0852 0.8372±0.3694 1.4704±0.1679

4.20%

1.1314±0.3636

13 14 15 16 17

Do LM (2015) Do LM (2015) Gokler ME (2015) Naja F (2015) Zong XN (2015)

Zhang J (2015)

Fatty foods ≥7 times/week 7.64 (4.29-13.60) Fried food ≥7 times/week 1.72 (1.14-2.59) Skipping breakfast 1.30 (1.10-1.54) 3rd tertile western diet 2.31 (1.12-4.76) Fast eating speed 4.35 (3.13-6.05) Highest quartiles of the modern and traditional 3.10 (1.52-6.32) north dietary pattern Total OR (95% CI) 2.12 (1.69-2.66) 2 2 Heterogenity: Tau = 0.19; Chi = 259.76. df= 17 (p < 0.00001); i2=93% Test for overall effect: Z-score= 6.44 (p < 0.00001)

100%

VARIABLE DISTRIBUTION OF OBSERVATIONAL STUDIES Special dietary patterns 2 studies

Breakfast habits 3 studies

Consumption of fruits 2 studies

Eating speed 3 studies

13 observational studies in Asia

Study quality assessment with STROBE Statement and

Studies did not meet metaanalysis criteria (n=3)

This scientific poster is aimed to evaluate dietary risk factors associated with childhood obesity among Asian population, which can potentially be used as recommendation and consideration to develop future health interventions.

Author (Year)

Systematic review and meta-analysis

460,771 total samples

OBJECTIVES

No.

Figure 2. Conceptual Framework

Qualitative and quantitative analysis

DISCUSSION BREAKFAST INTAKE HABIT Guo X (2013) explains that lack of breakfast in girls (aOR = 1.45) is an important determinant of obesity in childhood, as breakfast in associated with higher intake of carbohydrate, micronutrients, and fibers, along with lower intake of fat. This habit is common in girls as girls are more likely to be concerned about their body weight and shape. In another studies, Gokler (2015) found that having no breakfast (OR = 1.3) makes children at a higher risk to acquire obesity, while Rathnayake (2014) found that lack of breakfast is a stronger risk factor for obesity (OR = 3.99). CONSUMPTION OF FATTY FOODS AND SNACKS Shan (2010) states that frequent consumption (≥3 times/week) of snacks (aOR = 1.53) and fast food (aOR = 1.50) is associated with obesity through increase of fat intake, as well as the fact that snacks and fast food are also widely affordable throughout the country. Lim (2013) also shows slight correlation between fast food (OR = 1.18) and snacks (OR = 1.11). Gonzalez-Suarez (2013) found that among Filipino girls, consumption of snacks especially at night (OR = 1.59) is also risk factor. Nighttime is described by lack of physical activity and the rest-and-digest state of the body. The similar mechanism of excess fat intake is also demonstrated in consumption of fatty foods ≥7 times/week (OR = 7.64) and fried foods ≥7 times/week (OR = 1.72) in a study by Do (2015). In another study, Kim (2011) explains that high fat content of food, particularly school lunch in the study, renders children at 2.35 times higher risk of acquiring obesity. EATING SPEED He (2000) explains the discrepancy of eating speed in children below 3 years old (OR = 1.8) and children aged 3-6.9 years (OR = 3.04). Higher eating speed causes delay of satiety and increased hunger through mechanical stimulation mechanisms of the small intestine along with release of hunger-associated peptide hormones (ghrelin and cholecystokinin). Results regarding higher risk of obesity caused by higher eating speed is also shown by Zong (2015) (OR = 4.351) and Zong (2012) (OR = 3.986). CONSUMPTION OF FRUITS Rathnayake (2014) also found that consumption of fruits <4 days/week (OR = 2.18) is considered inadequate, hence it is considered as a risk factor because it is associated with lower intake of dietary fibers. Furthermore, a study done by Sharma SP (2016), explains the anti-obesity mechanisms of fruit consumption. The various ways are by decreasing the total calorie intake, prolonging satiety, provision of micronutrients and non-essential phytochemicals as well as modulation of gut ecology. Consumption of fruits with a high dietary fiber will delay gastric emptying and also slows down enzyme activity responsible for digestion of carbohydrate and fat. Fruits rich with micronutrients such as vitamins A, E and C are also known to have a negative association with central obesity. The mechanism involved is by reducing adipocyte generation and differentiation through leptin resistance and downregulation of the genes involved. Fruits containing non-essential phytochemicals such as blueerries and blackberries, are also shown to reduce incidence of obesity through reduction of oxidative stress. SPECIAL DIETARY PATTERN Other than aforementioned dietary habits, there were special kinds of dietary pattern discussed. In a study by Naja (2015), western dietary pattern (OR = 2.31) is associated with unhealthy lifestyle, characterized by less breakfast consumption, higher frequency of eating out (in restaurants), and less physical activity, all of which contributes to excess fat deposition and thus, higher body mass index (BMI). Zhang (2015) discusses about modern and traditional north dietary patterns in China. Modern dietary pattern (OR = 3.1) is described by high intake of eggs, milk, and fast food, while traditional (OR = 3.1) north dietary pattern is described by high intakes of wheat, tubers, and cereals. Higher intake of eggs, milk, and fast food in the modern pattern is associated with higher cholesterol levels which contributes to increased adiposity. Traditional pattern is a carbohydrate-rich diet, which may induce dyslipidemia by increasing triglycerides and decreasing high-density lipoprotein (HDL), resulting in higher BMI. This review has several strengths, which includes having a vast study scope of Asia. Other than that, it has a relatively large sample size, with a total of 460771 participants. These strengths make our findings potentially be used in a larger population. Aside from the strengths, this review also has a limitation. Almost half of the studies presented in the results section are conducted in China, making its' representability of Asia rather questionable.

Consumption of fatty foods & snacks 4 studies

• The total of participants included were 460,771 from 13 observational studies • STROBE Statement or Strengthening the Reporting of Observational Studies in Epidemiology, was used to evaluate included observational studies for systematic review and meta-analysis to enhance the quality of reporting. The best study regarding to the protocol is by Guo X, 2013 with score 18.17 out of 22. • Dietary factors which are most discussed in Asia is consumption of fatty foods and snacks (4 studies) • Unhealthy snacks become the most contributing risk factor of childhood obesity (proportion: 6.90%) • Highest Odds Ratios is consumption of fatty foods ≥7 times/week (OR:7.64) • Overall, dietary habits has OR:2.12 as a risk factor of childhood obesity shown by meta-analysis

CONCLUSION From this systematic review and meta-analysis, we found that the most contributing risk factor for childhood obesity is consumption of unhealthy snacks with proportion of 6.90% and overall OR of dietary habits is 2.12. The most discussed risk factor category is the excessive consumption of fatty foods. Hopefully, these risk factors can be utilized as consideration by the government, scientific communities, and health professionals to develop evidence-based interventions to reduce global burden of childhood obesity. To the general public, we hope that these risk factors can increase childhood obesity awareness. Future interventions should mainly focus on reduction of unhealthy foods while maintaining a proper dietary pattern.

REFERENCES 1. World Health Organization (2018, February 16). Obesity and overweight. Retrieved from http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight 2. World Health Organization (2017, October 13). Facts and figures of childhood obesity. Retrieved from http://www.who.int/end-childhood-obesity/facts/en/ 3. World Health Organization (2017, February 3). Childhood overweight and obesity. Retrieved from https://www.who.int/dietphysicalactivity/childhood/en/ 4. Bhuiyan, M. U., Zaman, S., & Ahmed, T. (2013). Risk factors associated with overweight and obesity among urban school children and adolescents in Bangladesh: a case–control study. BMC Pediatrics, 13(1). https://doi.org/10.1186/1471-2431-13-72 5. Li, M., Deng, Y., Ren, Y., Guo, S., & He, X. (2013). Obesity status of middle school students in Xiangtan and its relationship with Internet addiction. Obesity, 22(2), 482–487. https://doi.org/10.1002/oby.20595 6. Guo, X., Zheng, L., Li, Y., Zhang, X., Yu, S., Yang, H., … Sun, Y. (2013). Prevalence and risk factors of being overweight or obese among children and adolescents in northeast China.

Pediatric Research, 74(4), 443–449. https://doi.org/10.1038/pr.2013.116 7. Shan, X.-Y., Xi, B., Cheng, H., Hou, D.-Q., Wang, Y., & Mi, J. (2010). Prevalence and behavioral risk factors of overweight and obesity among children aged 2–18 in Beijing, China. International Journal of Pediatric Obesity, 5(5), 383–389. https://doi.org/10.3109/17477160903572001 8. Lafta, R. K., & Kadhim, M. J. (2005). Childhood obesity in Iraq: prevalence and possible risk factors. Annals of Saudi Medicine, 25(5), 389–393. https://doi.org/10.5144/0256-4947.2005.389 9. He, Q., Ding, Z., Fong, D., & Karlberg, J. (2000). Risk factors of obesity in preschool children in China: a population-based case–control study. International Journal of Obesity, 24(11), 1528– 1536. https://doi.org/10.1038/sj.ijo.0801394 10. Do, L. M., Tran, T. K., Eriksson, B., Petzold, M., Nguyen, C. T. K., & Ascher, H. (2015). Preschool overweight and obesity in urban and rural Vietnam: differences in prevalence and associated factors. Global Health Action, 8(1), 28615. https://doi.org/10.3402/gha.v8.28615 11. Zong, X.-N., Li, H., & Zhang, Y.-Q. (2015). Family-related risk factors of obesity among preschool children: results from a series of national epidemiological surveys in China. BMC Public

Health, 15(1). https://doi.org/10.1186/s12889-015-2265-5 12. Naja, F., Hwalla, N., Itani, L., Karam, S., Mehio Sibai, A., & Nasreddine, L. (2015). A Western dietary pattern is associated with overweight and obesity in a national sample of Lebanese adolescents (13–19 years): a cross-sectional study. British Journal of Nutrition, 114(11), 1909– 1919. https://doi.org/10.1017/s0007114515003657 13. Gökler, M. E., Buğrul, N., Metintaş, S., & Kalyoncu, C. (2015). Adolescent Obesity and Associated Cardiovascular Risk Factors of Rural and Urban Life (Eskisehir, Turkey). Central European Journal of Public Health, 23(1), 20–25. https://doi.org/10.21101/cejph.a3958 14. Zhang, J., Wang, H., Wang, Y., Xue, H., Wang, Z., Du, W., … Zhang, B. (2015). Dietary patterns and their associations with childhood obesity in China. British Journal of Nutrition, 113(12), 1978–1984. https://doi.org/10.1017/s0007114515001154 15. Minematsu, K., Kawabuchi, R., Okazaki, H., Tomita, H., Tobina, T., Tanigawa, T., & Tsunawake, N. (2014). Physical activity cut-offs and risk factors for preventing child obesity in Japan. Pediatrics International, 57(1), 131–136. https://doi.org/10.1111/ped.12446

16. Rathnayake, K. M., Roopasingam, T., & Wickramasighe, V. (2014). Nutritional and behavioral determinants of adolescent obesity: a case–control study in Sri Lanka. BMC Public Health, 14(1). https://doi.org/10.1186/1471-2458-14-1291 17. Nasreddine, L., Naja, F., Akl, C., Chamieh, M., Karam, S., Sibai, A.-M., & Hwalla, N. (2014). Dietary, Lifestyle and Socio-Economic Correlates of Overweight, Obesity and Central Adiposity in Lebanese Children and Adolescents. Nutrients, 6(3), 1038–1062. https://doi.org/10.3390/nu6031038 18. Gonzalez-Suarez, C. B., Lee-Pineda, K., Caralipio, N. D., Grimmer-Somers, K., Sibug, E. O., & Velasco, Z. F. (2013). Is What Filipino Children Eat Between Meals Associated With Body Mass Index? Asia Pacific Journal of Public Health, 27(2), NP650-NP661. https://doi.org/10.1177/1010539513491416 19. Zong, X.-N., & Li, H. (2012). Secular Trends in Prevalence and Risk Factors of Obesity in Infants and Preschool Children in 9 Chinese Cities, 1986–2006. PLoS ONE, 7(10), e46942. https://doi.org/10.1371/journal.pone.0046942

20. Kim, B., Lee, C. Y., Kim, H. S., Ko, I. S., Park, C. G., & Kim, G. S. (2011). Ecological Risk Factors of Childhood Obesity in Korean Elementary School Students. Western Journal of Nursing Research, 34(7), 952–972. https://doi.org/10.1177/0193945911401430 21. Chan, T.-F., Lin, W.-T., Huang, H.-L., Lee, C.-Y., Wu, P.-W., Chiu, Y.-W., … Lee, C.-H. (2014). Consumption of Sugar-Sweetened Beverages Is Associated with Components of the Metabolic Syndrome in Adolescents. Nutrients, 6(5), 2088–2103. https://doi.org/10.3390/nu6052088 22. Yamborisut, U., Kosulwat, V., Chittchang, U., Wimonpeerapattana, W., Suthutvoravut, U. (2006). Factors Associated with Dual Form of Malnutrition in School Children in Nakhom Pathom and Bangkok. Journal Medical Association Thailand, 89(7), 1012-1023. 23. Lim, H., & Wang, Y. (2013). Body weight misperception patterns and their association with health-related factors among adolescents in South Korea. Obesity, 21(12), 2596–2603. https://doi.org/10.1002/oby.20361

Assessment of Dietary Risk Factors Associated with Childhood Obesity in Asia: A Systematic Review and Meta-analysis Ko Abel Ardana Kusuma, Johan Cahyadirga, Ariel Valentino Soetedjo, Christine Lieana Universitas Indonesia AIM The objective of this review and meta-analysis is to evaluate dietary risk factors of childhood obesity in Asia which can be used as recommendation and consideration to develop future health interventions. INTRODUCTION Childhood obesity is a serious emerging global health problem and is projected to be a much bigger burden in the later years. Childhood obesity leads to various complications later in adulthood. The WHO has responded to this problem by supporting governmental policies and developing plausible interventions. However, the incidence of childhood obesity keeps on increasing. Public knowledge regarding risk factors associated with childhood obesity must be enhanced. Thus, this review and metaanalysis is conducted to assess dietary risk factors associated with childhood obesity in Asia. METHOD A systematic literature search was conducted in the PubMed database. There were 334 studies identified, then 210 studies that did not meet the inclusion criteria were eliminated. From the 124 studies left, 16 studies were considered eligible for full-text screening. Out of the 16 studies, 3 did not meet metaanalysis criteria. The 13 studies that were left was then assessed with STROBE statement. RESULT Out of 13 studies, 460,771 participants were included. The best study according to STROBE statement is the study by Guo X (2013) with a score of 18.17 out of 22. The most discussed dietary risk factor is consumption of fatty food and snacks and the most contributing risk factor is unhealthy snacks with proportion of 6.90%. The highest odds ratio is consumption of fatty foods more than 7 times a week with OR=7.14. The overall dietary factor has an OR of 2.12. CONCLUSION The most contributing risk factor for childhood obesity is the consumption of unhealthy snacks while the most discussed risk factor category is excessive consumption of fatty food. Therefore, these dietary risk

factors are essential to increase public awareness of childhood obesity and to help develop future evidence-based interventions. Keywords: Risk factor, dietary, childhood, obesity, Asia

PCC Eamsc 2019

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Public Poster Abstract PCC EAMSC 2019: Thailand Project title: Let’s Nurture our Children’s Future Author:

Amino Aytiwan Remedika, Nathasha Brigitta Selene, Fransesco Bernado Hubert Jonathan

(AMSA-Universitas Indonesia) Objective: To increase awareness of diabetes during pregnancy (gestational diabetes) which has been associated with adverse health outcomes for the mothers and their newborns. Introduction Diabetes is a serious chronic disease which has been rendered as the health burden worldwide. The global prevalence has doubled from 4.7% (1980) to 8.5% of adult population in 2014. In regards to socioeconomic status, diabetes prevalence has faster growth in low to middle-income countries in which plethora of Asian countries are situated in this level economically.1 The prevalence of gestational diabetes (GDM) in Eastern and Southeastern Asia is estimated to be 10.1% which is considered as high.2 GDM is associated with increased risk of fetal macrosomia, large-for gestational-age neonates, perinatal mortality, glucose intolerance, and metabolic syndrome from the fetal side (in conjunction to fetal programming hypothesis) as well as increase risk of preeclampsia, maternal type 2 diabetes, and obesity. Therefore we purpose NURTURE (Nutritional therapy, Undergo postpartum follow up, Routine physical activity, Two step approach of screening GDM, Use oral antidiabetic agents and insulin therapy, Realize risks and complications of GDM, Ensure routine antenatal care) to minimize the adverse pregnancy outcomes and complications, maternal and fetal risks of chronic health conditions in later life.3,4 References: 1. World Health Organization. Global report on diabetes. World Health Organization; 2016. 2. Nguyen CL, Pham NM, Binns CW, Duong DV, Lee AH. Prevalence of Gestational Diabetes Mellitus in Eastern and Southeastern Asia: A Systematic Review and Meta-Analysis. Journal of diabetes research. 2018. 3. Xiong X, Saunders LD, Wang FL, Demianczuk NN. Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes. Int J Gynaecol Obstet 2001;75:221–8. 4. Wang C, Yang HX. Diagnosis, prevention and management of gestational diabetes mellitus. Chronic diseases and translational medicine. 2016 Dec;2(4):199.

Stop Hypertension with Proper Nutrition Balance your Diet with More Vegetables and Fruits, Less Salt, No Trans-Fat Authors: Mariska Andrea Siswanto, Pamela Basuki, Amanda Natalie Wijaya, Andreas Suryo Wijaya Universitas Indonesia, Depok Background Hypertension or high blood pressure is a condition where blood pressure is higher than 130/80 1

mmHg. As a major health issue, hypertension is in fact one of the leading causes of deaths worldwide. According to WHO, approximately 1 billion people suffered from hypertension in 2008. Other adverse health consequences of hypertension are heart attack, stroke, kidney failure, blindness, and cognitive impairment.2 Obesity and diabetes is a risk factor for developing hypertension. This triad usually occurs together and is commonly known as the metabolic syndrome. Both obesity and diabetes causes clotting of the arteries known as atherosclerosis. This will increase vascular resistance and eventually lead to hypertension.3 Diets play the biggest role to prevent hypertension. Appropriate diet includes salt reduction to maximum 1 teaspoon (5 g) daily, trans-fat replacement to polyunsaturated fats which is contained in fish or nuts, and consumption of 5 servings (400 g) of fruits and vegetables daily. This diet should also be accompanied by yearly blood pressure check-up.2 Objectives To raise awareness of regular blood pressure check-up and to promote a healthy lifestyle in the community by eating more vegetables and fruits, limiting consumption of salt, and replacing trans-fat. References: 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 guideline for high blood pressure in adults [Internet]. Washington DC: American College of Cardiology; 2017 [updated 2018 May 7; cited 2018 Oct 22]. Available from: https://www.acc.org/latest-in-cardiology/ten-points-toremember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults 2. World Health Organization. A global brief on hypertension. Geneva: World Health Organization; 2013. 3. International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome. Belgium: International Diabetes Federation; 2006.

Abstract Project Title

: Tackling Obesity with Courage

Name of the University : Universitas Indonesia Authors

: - Jason Phowira - Mochammad Izzatullah A - Sakinah Rahma Sari - Varalisa Rahmawati

Background Obesity is one of the most dangerous health problems worldwide. It has become an important global health issue and requires urgent attention. In 2014, according to World Health Organizations, 700 million people are regarded as obese. Particularly in developing countries, peopleâ&#x20AC;&#x2122;s awareness of the danger of obesity are low in spite of the fact that obesity and diseases linked to obesity are the leading cause of death. Medical complications associated with obesity are increased risk of diabetes mellitus, hypertension, fatty liver, heart disease, osteoarthritis, sleep apnea and numerous types of cancer. Asians are proven to have a higher fat percentage, thus, prevention of obesity is vital to combat the harmful effects of obesity. Objective -

To inform people how to prevent obesity by adapting a healthy lifestyle, which we summarize as a mnemonic, COURAGE. Consume food rich in Omega 3 and Fatty Acid Obtain and monitor ideal weight Utilize more time for physical activities and exercise Reduce consumption of processed/junk food and food high in sugar Always drink sufficient amount of water Get enough quality sleep per day Eat more fruits and vegetable

To raise peopleâ&#x20AC;&#x2122;s awareness regarding the danger of obesity along with its complications.

Reference 1. World Health Organizations. 2015. 2. Asian Development Bank Institute. The imminent obesity crisis in asia and the pacific: first cost estimates. 2017. 3. Cheong WS. Overweight and obesity in Asia. Barkshire Hathaway Company. 2014.

ABSTRACT

Cut The Sweet Tea, So You Won’t Get Sweet Pee Daniell Edward Raharjo*, Fabiola Cathleen, Marco Raditya *daniell.edward.raharjo@me.com

Diabetes Mellitus type 2 is among the top 10 leading cause of mortality worldwide and commonly leads to kidney failure, blindness, amputation, even death. WHO estimated 422 million adults have it and 3,7 million died due to diabetes in 2012. Unfortunately, these numbers are rising. One to be concerned is the kinds of sweet tea consumption, such as bubble milk tea which lately has become very trending. One cup has almost 50 grams of sugar which is far beyond the recommended daily sugar intake for women and men. This explains how over consumption of sweet tea can lead to DM type 2 with glucose-containing urine—sweet pee. This becomes the foundation to our poster and campaign concept, since a popular topic can draw more people to engage in the poster and be warned about DM, which is our main objective. Furthermore, since reduction of other risk factors is also needed to prevent DM type 2 as a lifestyle disease holistically, we creatively made “S-WE-E-T-T-EA.” an mnemonic of those factors from sedentary lifestyles to poor diet. As the title says, cutting “sweet tea”, literally and in terms of the mnemonic, will be the best way to prevent sweet pee.

Reference: 1. World Health Organization. (2016). Global report on diabetes. Geneva. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/204871/9789241565257_eng.pdf;jses sionid=A7912CC161AA96C10897A5FDFD182DA4?sequence=1 2. Min, J.E., Green, D.B., Kim, L. (2017) Calories and sugars in boba milk tea: implications of obesity risk in Asian Pacific Islanders. Food Science and Nutrition, 5(1):38-45. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217910/ 3. American

Heart

Association.

(2018).

Added

sugars.

Retrieved

https://www.aarp.org/food/wine-beverages/info-09-2010/sweet-tea-nation.html

from

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Indonesia medical students' training and competition

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imstc 2019

Scientific paper

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The Effectiveness of Health Care Mobile Application on Influencing Healthy Maternal Behavior in Developing Countries

Created by : Clarissa Agatha Debora Ananda Kukuh Adishabri

Universitas Indonesia 2018

The Effectiveness of Health Care Mobile Application on Influencing Healthy Maternal Behavior in Developing Countries Clarissa Agatha Debora, Ananda Kukuh Adishabri Faculty of Medicine, Universitas Indonesia

Introduction Mobile health as defined by World Health Organization is a practice of medical and public health by using mobile devices, monitoring devices and other wireless devices that provides information about health care.1 For example, mobile application has been used for optimizing maternal health behavior in several countries including developing countries. As we know, perinatal morbidity remain significant health issues globally, with impact on the health of women and their families.2 In low and middle income countries (LMIC), women face a risk of maternal death of one in 160, compared with one in 3700 in high income countries.3 Further, due to preventable causes related to poor maternal health, it is estimated that 2,65 million stillbirth occur worldwide.4 Pregnant women who practice and maintain healthy behaviour can improve the health of themselves and their babies.2 Health communication methods such as mass media and audio-visual clips have been developed for decades to encourage healthy behaviours of pregnant women. Nowadays, women prefer these modalities over traditional, paper-based formats, in finding information during pregnancy. The appearance of mobile health modalities expands the opportunity to reach, connect, and empower individuals to address specific concern in health field. Broadly, mobile health technology has the potential to increase perinatal outcomes by increasing health information access and modifying demand for services.2 Aim This review aims to assess the effectiveness of health care mobile application interventions during pregnancy on influencing healthy maternal behaviour in developing countries. Material and Methods The literatures were collected from databases such as PubMed, Science Direct, BMC, and Research Gate. The key word that used for this study are “health care”, “mobile application”, “effectiveness”, “developing countries” and “maternal”. This search of studies

results of twelve references and three studies are reviewed to evaluate the effectiveness of health care mobile application on influencing maternal health behavior. The suitable studies include meta-analysis, systematic review or clinical trials. This diagram below shows our method to search the studies.

20 literatures were selected

12 literatures were selected for review

3 literatures were reviewed to evaluate the effectiveness of maternal health mobile application

8 studies was excluded because of the intervention model

9 literatures were reviewed for others application

Figure 1. Diagram showing methods of searching literatures Results and Discussions The characteristic of health care mobile application for maternal woman All of the mobile applications have a primary outcome to improve the quality of maternal health behavior. Maternal health data is needed to identify the problem, inform the decision maker, and take action to change the condition. We reviewed three mobile application such that influence healthy maternal behaviour in developing countries. The first mobile application is ReMind Program. ReMiND (reducing maternal and newborn deaths) program was started in Uttar Pradesh specifically in district Kaushambi. This program use

health workers named Accredited Social Health Activist (ASHA) as a link between health care service and the community. The pregnant woman registered in the application, updated the data, tracked the progress from pregnancy until the baby is born. The main goals from this program is reducing maternal and newborn mortality The ASHA workers could easily give counselling to the pregnant woman. The participant of this program are 300.000 individuals served by 259 ASHAs.5 The second mobile application is Mobile Midwife. Mobile Midwife is a reminder application that sends messages to the pregnant woman for giving information about health and notifying about appointment. This application was first implemented in Upper East Region in Ghana. Awutu Senya District has 1776 pregnant woman that use this Mobile Midwife. The participants of the study are 29 pregnant and nursing woman and already used Mobile Midwife one until three years.6 The third mobile application is MomConnect. MomConnect is a programme of South African National Department of Health that connect to 1,5 million pregnant women. MomConnect provides postpartum and pregnant women with twice-weekly information and access to a helpdesk for patient feedback and queries. The helpdesk has received 300.000 queries with average of 250 queries per day. The rapid growth of smartphone user presents big opportunities to reduce costs, increase real-time data collection, and improve the reach of MomConnect to serve.7 Effectiveness of health care mobile application for maternal woman To see the effectiveness of health care mobile application for maternal woman, we can observe the costs and benefits.8 ReMind Program has a primary outcome to enhance preventive care such as complications during pregnancy. The result shows that thereâ&#x20AC;&#x2122;s a positive change because of the intervention from the mobile application. For example, maternal illness number decrease from 34,598,786 to 31,444,322. Besides that, maternal deaths number decrease from 96,921 to 96,609. ReMIND implementation is also cost effective. Intervention of ReMIND results cost saving of USD 105 per maternal and neonatal illness and USD 2567 per death averted from societyâ&#x20AC;&#x2122;s viewpoint. Reduction of the maternal illness is the reason why the cost of maternal health care decreased. Based on the data, ReMiND intervention has surpass the goal because there is a improvement in identifying and recognizing complication and illness. The care seeking was about 71.9 % in the intervention area as compared to the control area about 46.2%.5 This percentage shows that pregnant woman become more aware of the complication or illness that can happened in pregnancy.

The second mobile application, Mobile Midwife has a primary outcomes such as give advice related to pregnancy, recognize the need for pregnancy care, and gain the self confidence of pregnant woman to raise children. Mobile Midwife provided many information such as birth preparedness, breastfeeding, and balanced diet. This intervention has such success such as the pregnant woman able to save their money because of the free health maternal services. The participant also become more aware of the risk to pregnancy and newborn also know the solution for that problem. However, this study doesn’t include exactly how much money is saved by this implementation.6 This program could be replicated in others country because it can helped to improve the maternal health behavior. The third mobile application, MomConnect, grew fastly to national scale. In the first month, 50.000 pregnant women were registered. By 2016, MomConnect celebrated its 1.000.000 users and by August 2017, this programme has reached over 1,7 million pregnant women. This programme users report high satisfaction about the messaging services and its function in supporting pregnancy and their health. Overall, this programme has been well received by both pregnant women and health workers. This programme can be seen as the catalyst to transform South Africa’s public health care system through the use of technologies.7

Further implementation of health care mobile application for maternal woman in Indonesia Even though there is lack of studies about effectiveness of mobile application implementation for maternal woman in Indonesia, Hana Yuanita, et al. proposed an idea to improve maternal woman behaviour by targeting the husband of pregnant woman. The husband will download an app called Suami Siaga Plus. The participants of this study are about 38 couples which randomly selected. There are four main features that included in this application such as characteristic of woman, pregnancy, childbirth and postpartum. Husband will be the one who notice the danger signs of his wife’s pregnancy. Because of this intervention, it shows positive results. The husband’s knowledge about key danger signs and birth preparedness and complication readiness has increased, the same goes with the pregnant wife.9 To achieve the Millenium Development Goals Number 4(reduce child mortality) and number 5(improve maternal health), barriers have to be removed such as geographical, financial and psychosocial. These barriers can be removed by mHealth intervention such as

mobile application for maternal woman.10 Based on the data, we can see that 220 women per 100,000 died because of complications of pregnancy and childbirth. One of the solution for this problem is mobile phone technology. Indonesian government has already collaborated with FrontlineSMS firm, for mapping the health data in rural areas, but there is still no mobile application that focuses on pregnant woman.11 This will be a challenge to Indonesia government to make policy how to improve maternal health behaviour using mobile application. This intervention has been tested in several countries and shows a positive results. The development of m-Health especially mobile application for maternal woman will show a promising benefits for the future.12 Indonesia government can learn from another developing countries to enhance the maternal health behavior by reviewing the recommendations from the previous studies about this.

Conclusion This study reviews the effectiveness of health care mobile application for maternal woman on influencing maternal health behavior in developing countries. There are three mobile applications that reviewed to evaluate the effectiveness of this intervention. The first mobile application is the ReMiND Program that was established in India. This program has a primary goal to enhance the preventive care for maternal woman. This application shows a success reducing maternal deaths, neonatal deaths and also a cost saving program. The pregnant woman become more aware about the risk in pregnancy. The second mobile application is Mobile Midwife. This application was first started in Ghana. This intervention has a goal to recognize the need of pregnancy care especially about balanced diet and birth preparedness. Mobile Midwife shows positive results because the pregnant woman get a free maternal health services even though there isnâ&#x20AC;&#x2122;t any exact number how much the money is saved. The third mobile application is MomConnnect. This programme was launched in august 2014 by South African National Department of Health. The primary goal of MomConnect is to strengthen the quality of infant and maternal health services by providing vital health information and helpdesk for queries and feedback. Overall, this programme has been well received by both pregnant women and health workers. In Indonesia, this intervention is still not established in an large scale group. One of the example is an app called Suami Siaga Plus which the participants are about 38 couples. This implementation also give a great results for improving maternal health behaviour.

Indonesian government has to make policies about m-Health especially mobile application to reach the Millennium Development Goals number four and five. With this kind of intervention, the barriers will be removed. This will improve the quality of maternal health behaviour

and will reduce the maternal and neonatal death in Indonesia. Indonesian

government can review the implementation in several developing countries that already successful.

References 1. WHO (2011). New horizons for health through mobile technologies. 2. Daly LM, Horey D, Middleton PF, Boyle FM, Flenady V. The effect of mobile application interventions on influencing healthy maternal behaviour and improving perinatal health outcomes : a systematic review protocol. 2017;1–8. 3. Feroz A, Perveen S, Aftab W. Role of mHealth applications for improving antenatal and postnatal care in low and middle income countries : a systematic review. 2017;1– 11. 4. Lund S, Nielsen BB, Hemed M, Boas IM, Said A, Said K, et al. Mobile phones improve antenatal care attendance in zanzibar : a cluster randomized controlled trial. 2014;1–10. 5. Prinja S, Bahuguna P, Gupta A, Nimesh R, Gupta M, Thakur JS. Cost effectiveness of mHealth intervention by community health workers for reducing maternal and newborn mortality in rural Uttar. Cost Eff Resour Alloc [Internet]. 2018;1–19. Available from: https://doi.org/10.1186/s12962-018-0110-2 6. Entsieh AA, Emmelin M, Pettersson KO. Learning the ABCs of pregnancy and newborn care through mobile technology. 2015;1:1–10. 7. Barron P, Peter J, Lefevre AE, Sebidi J, Bekker M, Allen R, et al. Mobile health messaging service and helpdesk for South African mothers ( MomConnect ): history , successes and challenges. 2018;1–6. 8. Boulos MNK, Brewer AC, Karimkhani C, Buller DB, Robert P. Mobile medical and health apps : state of the art , concerns , regulatory control and certification. 2014 9. Yuanita H, Santoso D, Sc M, Supriyana S, Ph D, Bahiyatun B, et al. Android Application Model of “ Suami Siaga Plus ” as an Innovation in Birth Preparedness and Complication Readiness ( BP / CR ) Intervention. 2017;11(1):30–6. 10. Fotso JC, Tsui A. Leveraging mobile technology to reduce barriers to maternal , newborn and child health care : a contribution to the evidence base. 2015 11. Daga G. Reducing maternal mortality in indonesia post modern era. 2014 12. Cahya D, Nugraha A. An overview of e-health in Indonesia : Past and Present Applications. 2018

imstc 2019

Scientific poster

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Andrea Laurentius* laurentiusandrea@gmail.com Third-year medical student

INTRODUCTION Indonesia, consisting of approximately 362 million inhabitants spreading over the entire nations, is considered as megadiverse country in the world. This would pose challenges in providing health service equality. Indonesia has been implementing single-payer model of universal health coverage system, named as Badan Penyelenggara Jaminan Sosial (BPJS), to support equal health care protection, hoping to achieve Sustainable Development Goals no. 3. Recently, BPJS is facing its Rp16.5 trillion health fund deficits that further deteriorates both state budget reserve and quality of medical services, for obligatory monthly fee paid by member could not sufficiently cover the facilities’ claim on health expenses. Another source of funding is urgently important to maintain BPJS’ functional capacity in reaching 95% national coverage target in 2019. Therefore, establishment of carbon emission-based vehicle tax would be a solution to cover potential BPJS future deficits. Revenues obtained in the tax would be used to cover claimed medical service purposed to provide equal and optimal health access for people.

Deficit Health Funding

2016 Rp9.7 trillion 2015 Rp5.7 trillion

2017 Rp9.75 trillion

2018 Rp16.5 trillion

RESULTS AND DISCUSSION From numerous literature browsing and profound analysis, most of BPJS income credits are obtained via obligatory premium fee paid per person that up to a total of Rp234.06 trillion or 82.34% increase budget reserves. Expanding its target to reach 95% population from 75.64% at this moment would be a challenge for government to accomplish. Increasing value of obligatory premium fee People sense that medical services are not compatible with its increasing premium tariff. President rules no. 28 year 2016 has been legislated for increasing class I and II monthly fee.

Limitation of claimed health expenses Unethical for long term purpose as it would not pose cost-effective result. Recent funding limitation for cataract operation, parturition, and rehabilitation has caused national rejection, since it does not comply to constitution SJSN no. 40 year 2004.

Figure 3. Prior solutions offered by governments in handling great deficits in BPJS. Analysis of risk results could offer insights on its future implementation.

A solution on using carbon emission-based vehicle tax could be beneficially granted in such developing countries, especially Indonesia. Proposed taxation is based on machine proportion, region of operation, or fuel type, for it will add value on private property taxation up to percentage defined by governments.

2014 Rp3.3 trillion Figure 1. Annual accumulated deficits on unpaid claim in health facilities via either capitation or INA-CBG of BPJS. This could potentially halt the coverage of national equal health access through achieving SDG goals 3 – Good Health and Well-Being.

Encouraging Active Transport

• Minimizing habits of unhealthy lifestyles. • Healthcare-related cost savings through decreased obesity level.

MATERIAL AND METHODS Materials were obtained predominantly through online databases accessed via remote library. News and articles could be extracted for novel information regarding topic discussion. Search terms might include ‘BPJS’, ‘Deficit’, ‘Carbon Tax’, and ‘Universal Health Coverage’ for obtained journal selection. Abstract screening and validation should be done based on subtopic clarification. Additionally, constructing mind map is done to aid assessment of qualitative studies in literature searching and analyses.

BPJS Coverage Financial Deficits

Funding Reallocation to adequately cover claimed medical expenses

Side Benefits of Carbon Pricing

• Collective news and articles on BPJS and health system. • Official BPJS information on Ministry of Health website.

• Carbon-Based Vehicle Taxation System • Obligatory Monthly Fee under its constitutional rules

• Public active transport benefits • Management of transportation growth and pollution

Controlling Vehicle Usage

Figure 4. General predicted taxation model of side benefits and its funding reallocation towards covering of BPJS financial deficits.

Additional Funding for BPJS

• Similar to fiscal policies in reducing CO2 emission • Decreasing rate of congestion in megacities

• Exposing further funding to cover deficits • Mixed-model obligatory fee and taxation to obtain optimal revenues.

CONCLUSION Governments action in relieving such devastating costs of maintaining universal health coverage system could not be sufficiently executed as external factors might affect its results and performances. Carbon emission-based vehicle taxation would be the solution to cover additional BPJS financial deficits. Mixed model of premium fee and taxation is an optimal revenue system for BPJS funding in Indonesia. Therefore, utilization of this proposed taxation would enable BPJS in reaching its 95% coverage and achieve the main SDG goal no. 3.

REFERENCES Wiseman V, Thabrany H, Asante A, Haemmerli M, Kosen S, Gilson L et al. An evaluation of health systems equity in Indonesia: study protocol. International Journal for Equity in Health. 2018;17(1).

Figure 2. Method of analysis via mind map model to obtain deeper information regarding several subpoints on problems and solutions.

Springmann M, Sacks G, Ananthapavan J, Scarborough P. Carbon pricing of food in Australia: an analysis of the health, environmental and public finance impacts. Australian and New Zealand Journal of Public Health. 2018;42(6):523-529.

Indonesian Medical Students’ Training & Competition (IMSTC) 2019 ABSTRACT Carbon Emission-Based Vehicle Taxation: An Alternative Funding Source in Covering BPJS Financial Deficits Andrea Laurentius1 1Third

Year Medical Student, Universitas Indonesia, (085372724042, laurentiusandrea@gmail.com)

Introduction Indonesia has been implementing single-payer model of universal health coverage system, named as Badan Penyelenggara Jaminan Sosial (BPJS), to support equal health care protection. Recently, BPJS is facing its Rp16.5 trillion health fund deficits that further deteriorates both state budget reserve and quality of medical services, for obligatory monthly fee paid by member could not sufficiently cover the facilities’ claim on health expenses. Another source of funding is urgently important to maintain BPJS’ functional capacity in reaching 95% national coverage target in 2019. Therefore, establishment of carbon emission-based vehicle tax would be a solution to cover potential BPJS future deficits. Materials and Methods Materials were obtained predominantly through online databases accessed via remote library. Search terms might include ‘BPJS’, ‘Deficit’, ‘Carbon Tax’, and ‘Universal Health Coverage’ for obtained journal selection. Additionally, constructing mind map is done to aid assessment of qualitative studies in literature searching and analyses. Results and Discussion Most of BPJS income credits are obtained via obligatory premium fee paid per person that up to a total of Rp234.06 trillion budget reserves. Expanding its target to reach 95% population from would be a challenge for government to accomplish. Carbon emission-based vehicle tax could be beneficially granted in such developing countries, especially Indonesia. Proposed taxation is based on machine proportion, region of operation, or fuel type, for it will add value on private property taxation up to percentage defined by governments.

Conclusion Governments action in relieving such devastating costs of maintaining universal health coverage system could not be sufficiently executed. Carbon emission-based vehicle taxation would be the solution to cover the additional BPJS financial deficits. Mixed model of premium fee and taxation is an optimal revenue system for BPJS funding in Indonesia. Therefore, utilization of this proposed taxation would enable BPJS in reaching its 95% coverage and achieve the main SDG goal no. 3.

Implementation of Early Warning System and Optimization of Referral System in Primary Healthcare System in Decreasing High Incidence of Postpartum Hemorrhage in Indonesia Muhammad Alifian Remifta Putra, Jason Phowira, Raya Makarim Penantian Faculty of Medicine, Universitas Indonesia, Indonesia Background: Postpartum hemorrhage (PPH) is a condition of losing more than 500 mL of blood within 24 hours post-delivery. Based on World Health Organization, PPH contributes to about 35% of maternal death, and in Indonesia, the number remains very high with 305 deaths in every 100.000 delivery in 2015. Cases of PPH are preventable if the early signs are detected and there is effective referral system established. Therefore, the authors propose application of early warning system and optimization of referral system to be implemented in Indonesia’s primary health care system, serving as keys to reduce maternal mortality rate in Indonesia. Material and methods: This scientific poster is based on literature searching done by three people through Google Scholar, PubMed, and NCBI, Ministry of Health Republic of Indonesia, and International Federation of Gynecology and Obstetrics (FIGO) data. Journals, systematic reviews, and non-governmental and governmental guidelines published from 2008-2018 are selected for eligibility. The search term covers “postpartum hemorrhage”, “early obstetric warning system”, “referral system”, and “Indonesia”. Results: Early Warning System and referral system play an important role in constructing a comprehensive healthcare system. Based on our findings, there are numerous types of EWS, however, Modified Early Obstetric Warning System, as one of the earliest and most advanced EWS, has been established across national hospitals in United Kingdom since 2007 and proven to successfully reduce maternal mortality rate in United Kingdom. Referral system is defined as a coordinated process of directing and redirecting patient to higher quality healthcare facilities. A suitable referral system, comprehensive cooperation between health subsystems, and adequate transports to the facilities are required to refer patients effectively, thus, improving patients’ survival rates.

Conclusion: Implementation of a well-established and effectively proven EWS, and comprehensive referral system are potential solutions in decreasing high maternal mortality rate in Indonesia.

imstc 2019

public poster

bundle of acads amsa-ui 2018/2019

PREION: SERVE BETTER, LESS REFERRAL Background Indonesia, a developing country with the 4th largest population in the world, has thrived in a matter of healthcare system. With the presence of Jaminan Kesehatan Nasional (JKN), non specialistic primary health care and secondary advanced referral health services becomes easier. But sadly, this does not significantly reduce the number of sick people in the community. It is stated that 95% of government’s budget in terms of health are used for treatment and care, whereas only 5% are for prevention issues and promotion. This issue means that most people would only focus on treating the sick that is right in front of them, and not really focusing on determining the long term needs of prevention to people who are susceptible to a disease in the future. Therefore we should raise our ambition and voice, prevent the preventable, promote health for all. Objectives Our objective is to portray the current situation of healthcare services in Indonesia which we consider still have more room for improvement. This is portrayed by the range of colours used as the background. The shift from pink colour to white colour signify the imperfection of healthcare services. With this poster, we hope to provide for a solution to the on going problem for the better healthcare services in Indonesia. PREION /prīˈôn/, is an abbreviation of Prevention and Promotion that we would like to advertise on. With this idea, overall healthcare services will tend to grow and the services would be efficient as less referral would be done. Most of the services could be done primarily with the indication of PREION. Our target audience are healthcare professionals as well as the government who have the largest saying on this matter. Preventing diseases and promoting health could both be done by establishing partnerships with given guidance to those prone to the disease risk factors and to build community development and advocacy in promoting public health.

Conclusion With this poster, we would like to advertise the idea of health prevention and promotion as the core of healthcare services in Indonesia. Community empowerment can be done through partnerships by building community development and advocacy in public health care to support promotion of health care. To decrease number of sick people, we can work together with community organization to guide people with risk factors of the disease. In conclusion, prevention and promotion in healthcare should be our priorities in primary health care and we must raise our ideas, prevent the preventable, and promote health for the community. References: 1. Ginting M, et al. Promosi kesehatan di daerah bermasalah kesehatan: Panduan bagi Petugas Kesehatan di Puskesmas. Jakarta: Kementrian Kesehatan Republik Indonesia; 2011 Oct. 2. The primary health care approach [Internet]. Ontario: Canadian Nurses Association; 2000

Jun

[cited

2018

Dec

24].

Available

from:

https://www.cna-

aiic.ca/~/media/cna/page-content/pdfen/fs02_primary_health_care_approach_june_2000_e.pdf 3. Admin BPJS. Manfaat [Internet]. Jakarta: Badan Penyelenggaran Jaminan Sosial; 2017 [cited

2018

Dec

24].

Available

kesehatan.go.id/bpjs/index.php/pages/detail/2014/12

from:

https://bpjs-

imstc 2019

photography

bundle of acads amsa-ui 2018/2019

Elvira Lesmana

Brigitta Setiawan

waaw 2019

world antibiotic awareness week

bundle of acads amsa-ui 2018/2019

waaw 2019

scientific paper

bundle of acads amsa-ui 2018/2019

Comprehensive Assessment of Risk Factors Associated with MethicillinResistant Staphylococcus aureus (MRSA) Infection in Asia: A Systematic Review Gilbert Lazarus1, Jessica Audrey1 1

First Year Student, Faculty of Medicine, Universitas Indonesia, Depok

ABSTRACT Background Antibiotic resistance persists as a global health challenge, among which methicillin-resistant Staphylococcus aureus (MRSA) is the most common and serious threat. Although certain control strategies have been implemented, the incidence and prevalence of MRSA remain high, especially in Asia Objective To analyze the risk factors associated with MRSA infection in Asia Methods A systematic review was conducted through PubMed, Scopus, and EBSCOhost, searching for observational studies which analyze the risk factors associated with MRSA infection in Asia. Studies selected were reviewed and assessed with STROBEâ&#x20AC;&#x2122;s criteria. Results Sixteen observational studies were included, with a total of 10,253 subjects, consisting of 4 cohort studies, 4 cross-sectional studies, and 8 case-control studies. We find that certain social behaviors, such as sharing of personal items, limited daily activities and exposure to postsurgery individuals increases the risk of MRSA infection. Antibiotics use, especially when used extensively, is also found to elevate the risk. Furthermore, invasive medical procedures ease the entry of MRSA into the body, thus increasing risk of infection. Conclusion The knowledge of these factors is hoped to help in establishing guidelines for infection prevention and control strategies, helping to halt the rise in antibiotics resistance, as well as reducing the prevalence of MRSA infection worldwide. Keyword: MRSA, risk factors, Asia INTRODUCTION Antibiotic resistance constitutes a major infectious disease burden worldwide. Among them, drug-resistant Staphylococcus aureus is the most common yet serious threat.1 It is the leading cause of bacteremia and other infections such as infective endocarditis, osteoarticular,

pleuropulmonary, skin and soft tissue, and device-related infections.2 In terms of prevalence, about one-third of worldwide population is colonized by Staphylococcus aureus. Additionally, methicillin-resistant Staphylococcus aureus (MRSA) infection is the most common form of S. aureus infection, ranging from 13 to 74%.1 Asia, including Indonesia, is among the regions with the highest incidence of MRSA. A study in 2011 stated that 28% of all S. aureus infection in Indonesia is MRSA.3 Staphylococcus aureus is a Gram-positive, commensal bacterium, yet it can also cause pathogenicity in human. Staphylococcus aureus bacteremia (SAB) is the most common manifestation of S. aureus infection. It may cause central nervous system damage2, infective endocarditis1-3, osteomyelitis2, necrotizing pneumonia2, embolism phenomenon2, urinary tract infections2, and ultimately, mortality1-3. The overall mortality rate of S. aureus infection ranges from 22 to 66% and is consistently higher than other bacteremia and infective endocarditis cause. Its high mortality rate indicates the emergency to find an appropriate and effective treatment.2 Methicillin, a semi-synthetic β-lactam antibiotic, was first introduced in 1959 in response to benzylpenicillin-resistant S. aureus, a β-lactamase (blaZ)-producing strain which is able to inactivate β-lactam. However, as soon as methicillin was introduced, methicillin-resistant S. aureus (MRSA) strains were isolated. MRSA expresses methicillin-hydrolyzing β-lactamase as well as an additional penicillin-binding protein (PBP2a) which can take over the transpeptidation reactions of the host’s penicillin-binding protein (PBP), causing the inactivation of methicillin’s action. Furthermore, the utilization of various types of antibiotics over the years gives rise to multi-resistant MRSA strains, which was achieved by mutations in genes coding for target proteins. Obviously, this phenomenon makes treatment of MRSA far more challenging.4 Sadly, MRSA is highly preventable by comprehensive control of infection and treatment.5 The Indonesian Ministry of Health has agreed to adopt a situation analysis tool developed by South East Asia Regional Office (SEARO) of World Health Organization (WHO) to implement global action plan on antimicrobial resistance (GAP-AMR) initiated by WHO. It is a stepwise and incremental approach consisting of five phases, where the last phase is defined as a fully operational antimicrobial containment program. Even though Indonesia has achieved the third phase by implementing initial control, the incidence and prevalence of MRSA remains high. 6 Therefore, we conducted a review to identify the risk factors of MRSA infection which could be prevented and applied to reduce incidence and prevalence of MRSA, which could lead to severe

complications and mortality. Moreover, MRSA infection is chosen because it is the most prevalent form of S. aureus infection and causes a huge clinical burden from health standpoint. METHODS We conducted a systematic review of observational studies based on PRISMA statement from PubMed, Scopus, and EBSCOhost using the keywords “methicillin-resistant Staphylococcus aureus OR MRSA”, “risk factors OR factors OR factors associated”, and “Asia”. Subsequently, inclusion criteria were set to filter the results including: observational study and study identifying preventable risk factors. In addition, exclusion criteria were also set: irretrievable full-text articles, immunocompromised patients, unknown or inappropriate study types and settings, and incompatible language (articles not in English or Bahasa Indonesia). Afterward, we extracted essential data from articles including: author and year of publication, study design and setting, sample size, mean or range of sample age, method of statistical analysis used, and outcome which is picturized by odds ratio, confidence interval 95%, and p value for each factor. Lastly, the articles will be assessed through STROBE’s criteria (Strengthening the Reporting of Observational Studies in Epidemiology) of combined observational study which includes 22 criteria where 1 point is given for every criterion met. The quality assessment was conducted by two reviewers collaboratively and concluded after consensus were reached.

Figure 1. Flow chart of literature search strategy for this systematic review

RESULTS a. Search results and study selection Articles from the literature search were selected based on the inclusion and exclusion criteria set above. Contents were screened for eligibility, study design, and extractable outcomes. The studies were further assessed with STROBEâ&#x20AC;&#x2122;s criteria to ensure its quality. The search yielded 16 observational studies, consisting of 4 cohort studies, 4 cross-sectional studies, 8 case-control studies. b. Study characteristics and findings The data extracted and characteristics of included studies are shown in Table 1. A pooled total of 10,253 subjects were included in the study. Outcomes were given in terms of odds ratio (OR).

Table 2. Included study designs and characteristics Author and Year (STROBE’s score) Suh HJ et al7, 2018 (19.47/22)

Study Design Multicenter cohort study

Location South Korea

Sample Size

Range/ mean of sample age

752

62 years

Method of analysis Student’s t-test Chi-square test Fisher’s exact test Multivariate logistic regression

Outcome

Post-surgery Dialysis History of MRSA isolation Long-term hospitalization

Shirai Y et al8, 2017 (18.13/22) Yoon YK et al9, 2016 (21.67/22)

Gu FF et al10, 2016 (17.77/22)

Retrospective cohort study

Tokyo, Japan

120

Prospective multicenter crosssectional study

South Korea

345

Crosssectional study

Shanghai, China

443

36.30 weeks 67 years

84 years (47-101 years)

Univariate analysis Multivariate logistic regression Pearson’s chi-squared test Fisher’s exact test McNemar’s test Student’s t-tests Mann-Whitney U test Wilcoxon’s signedrank test Multivariate conditional logistic regression analysis Chi-squared test Fisher’s exact test Student’s t-test Mann-Whitney U test

Central venous catheterization

OR [95% CI] 2.050 [1.640-2.563] 1.679 [1.297-2.173] 1.475 [1.075-2.024] 4.456 [2.974-6.677]

p value

<0.001 <0.001 0.016 <0.001

4.843 [1.975-11.878]

0.001

Nosocomial infection

2.62 [1.28-5.37]

0.009

Prior exposure to glycopeptides

3.24 [1.08-9.67]

0.035

Severe sepsis or septic shock

5.45 [2.14-13.87]

<0.001

Charlson’s comorbidity index (per 1-point increment)

1.52 [1.27-1.83]

<0.001

Previous hospitalization

2.56 [1.21-5.42]

0.014

Presence of an invasive device

3.46 [1.68-7.11]

0.001

Multilevel regression analysis

Chloramphenicol therapy Macrolides therapy Respiratory infection Impaired mobility Senile pruritus Any antibiotic therapy Broad-spectrum cephalosporins therapy Quinolones therapy

Wong JG et al11, 2016 (18.27/22)

Case-control study

Singapore

1200

69 years

SEM statistical technique Chi-squared test Kruskal-Wallis test Multinomial logistic regression GSEM package

Length of stay Cumulative antibiotic exposure Prior hospitalization

Prior hospitalization Community care Case-control study

Guangzhou , China

275

Chi-squared test Univariate and multivariate logistic regression models

0.006 <0.001 0.030 0.024 0.008 0.001 0.013 0.028

HA-MRSA

CO-MRSA Cumulative antibiotic exposure

Yao Z et al12, 2015 (20.33/22)

7.67 [1.81-32.58] 2.80 [1.06-7.40] 2.02 [1.06-3.86] 2.03 [1.09-3.78] 2.29 [1.21-4.30] 2.91 [1.50-5.64] 3.23 [1.36-7.66] 2.08 [1.07-4.07]

Prior hospitalization â&#x2030;Ľ 3 COPD

1.49 [8.70-25.50] 3.50 [2.30-5.30] 6.20 [3.30-11.50] 1.60 [1.10-2.40] 12.30 [8.40-17.90] 2.60 [1.50-4.50] 2.80 [1.30-5.80] 5.90 [1.70-20.70]

<0.010 <0.010 <0.010

0.010 <0.010 <0.010 0.007 0.006

Wald test

Respirator Tracheal intubation

Chou YH et al13, 2014 (18.26/22)

Case-control study

Taipei, Taiwan

100

46.30 years

Logistic regression analysis Multivariable logistic regression

Receiving antibiotic treatment for SSTIs in the year before infection Previous exposure to an individual who had had surgery within the last year MRSA nasal carriage

Jung WJ et al14, 2013 (18.57/22)

Leung YH et al15, 2012 (18.17/22.00)

Wang CY et al16, 2012 (16.43/22.00)

Lu S et al17,

Retrospective cohort study

Matched case-control study

Case-control study

Cross-

Seoul, South Korea

Hong Kong

Taiwan

943

254

541

502

≥ 20 years

34.00 years

62.00 years

56.03 years

Chi-squared test Fisher’s exact test Mann-Whitney U test Multivariate logistic regression Hosmer-Lemeshow test Receiver operating characteristic (ROC) curve analysis Bivariate analysis Multivariate analysis Logistic regression model Student’s t-test Chi-square test Fisher’s exact test

Multiple logistic

Hospitalization for ≥2 days in the preceding 90 days Intravenous antibiotic treatment within 30 days Single infiltrate on chest radiography MRSA history in the previous 1 year Pneumonia Severity Index (PSI) score ≥ 120 Sharing of personal items

3.80 [1.00-13.90] 8.20 [1.50-45.10]

0.020

3.63 [1.05-12.60]

0.040

4.46 [1.25-15.89] 1.77 [0.99-3.15] 2.23 [1.15-4.32] 0.55 [0.33-0.94] 6.05 [2.99-12.22] 2.40 [1.18-4.86] 4.71 [1.43-15.59] 0.21 [0.06-0.72]

Congestive heart failure (OR=4.23)

4.23 [1.86-9.58] 40.99 [2.19-765.95] 5.29 [1.27-22.02] 3.174

Nasogastric tube feeding in 3 months Diabetes mellitus

0.016

6.02 [1.28-28.23]

Frequent hand-washing (10-19 times a day)

Nursing home admission

0.047

0.020 0.053 0.018 0.029 <0.001 0.015 0.010 0.010 0.001 0.013 0.022 0.017

2011 (19.17/22.00)

sectional study

regression analysis Chronic kidney disease Current use of catheters or tubes Urinary complaints

Al-Talib et al18, 2010

Retrospective cohort study

Malaysia

1979

Fisherâ&#x20AC;&#x2122;s exact test Multiple logistic regression analysis

Duration of hospitalization Previous antibiotic Bedside invasive procedures

Wang SH et al19, 2010

Retrospective case-control study

China

118

60.80 years

Conditional univariate Multivariate logistic regression model

Duration of diabetes Osteomyelitis Surgery

Gadepalli R et al20, 2009

Crosssectional study

New Delhi, India

781

34.20 years

Multiple logistic regression analysis

Glycosylated hemoglobin (HbA1C) Duration of hospital stay (â&#x2030;Ľ20 days) Intra-hospital transfer Osteomyelitis Non-infectious dermatosis Neurological disorders Aminoglycosides Clindamycin

[1.231-8.186] 3.47 [1.186-10.152] 4.192 [1.587-11.071] 3.758 [1.178-11.986] 1.03 [1.002-1.811] 10.107 [2.027-81.571] 20.493 [4.145-83.949] 1.13 [1.05-1.221] 20.89 [6.49-67.27] 5.14 [1.52-17.42] 1.46 [1.13-1.88] 2.83 [1.67-4.78] 1.91 [1.17-3.12] 2.90 [1.55-5.44] 3.64 [2.40-5.52] 2.22 [1.24-3.97] 1.74 [1.18-2.56] 4.73

0.023 0.002 0.017 0.034 0.005 <0.001 0.001 <0.001 0.009 0.003 <0.001 0.01 0.001 <0.001 <0.01 <0.01 <0.001

[2.38-9.40] Lo WT et al21, 2008

Case-control study

Taiwan

Washio M et al22, 1997

Case-control study

Japan

1615

285

14 years

79.28 years

Multivariate unconditional logistic regression model Chi-square test Logistic regression analysis

Antibiotic use in the past 12 months Hypoalbuminea Use of antibiotics other than third-generation cephems Administration of thirdgeneration cephems Limited in activities of daily living (ADL)

29.37 [10.72-80.50]

<0.001

1.73 [1.27-2.36]

0.043

1.73 [1.20-2.50]

0.020

3.12 [2.16-4.50] 2.50 [1.64-3.82]

0.010 0.017

DISCUSSION a. Analysis of the Study Based on the above included studies, we grouped the risk factors of MRSA infection into 3 main categories: social behaviors, antibiotics use, and medical procedures. Social Behaviors Some social behaviors are associated with elevated risk of MRSA infection. There are three social behaviors associated with risk factors of MRSA infection, they are: sharing of personal items, limited daily activities, and exposure to post-surgery individuals. According to Yiu-hong L et al15, patients who usually share their personal items (i.e. nail clippers, towels, razors, underwear, cosmetics) with other persons are three times more susceptible to MRSA infection than those who donâ&#x20AC;&#x2122;t (OR = 4.71, 95% CI = 1.43-15.59). MRSA tends to colonize predilection sites such as intertrigo areas (e.g. axillae, groin), gastrointestinal tract, and anterior nares. Colonization of MRSA provides a reservoir for the bacteria to infect the host when host defenses are breached, either by shaving, aspiration, insertion, or surgery. The utilization of razors and nail clippers are clearly capable of breaching physical barrier.23 On the other hand, towels, underwear, and cosmetics can cause skin occlusion, a phenomenon where the skin is blocked off by something which cause elevation of pH which favors the growth of Staphylococcus aureus.24 Limitations of activities of daily living (ADL) were assessed by the ability of geriatrics to do simple movements such as: ability to eat by themselves, walk by themselves, and urinate and have bowel movements by themselves. Those with completely limited ADL were given zero points, while those without any limitation were given three points.22 M Washio et al22 found that the risk of MRSA infection gets higher as the limitation of ADL gets more severe (OR = 2.50, 95% CI = 1.64-3.82). This is achieved because contacts from person to person are more frequent in patients with limited ADL. MRSA, which is commonly colonized on the skin, is commonly spread from patient to patient via the hands of healthcare workers. Therefore, it is highly reasonable if MRSA infections occur more often in patients with limited ADL.22 Antibiotics Use The use of antibiotics is found to have a significant effect in increasing the risk of MRSA colonization and infection. Chou13, Jung14, Al-Talib18, Lo21, and Washio22, in their studies, found that previous antibiotic exposure elevates the risk of MRSA by 6.02, 2.23, 10.11, 29.37, and

1.73 times respectively. Gu et al10, in his study, specifically found that therapy with chloramphenicol, macrolides, and quinolones raises the risk by 7.67, 2.80, and 2.08 times respectively. Furthermore, study by Wong et al11 further confirm these findings, as he found that cumulative antibiotic exposure increases the risk of MRSA, both hospital-acquired and community-acquired MRSA, by 3.50 and 1.60 times respectively. These results show consistency with a previous meta-analysis done by Tacconelli E et al25, which investigates specifically on the association between antibiotic exposure and risk of MRSA isolation. Extensive usage of antibiotics, especially when not given appropriately, gives a competitive advantage to bacteria with resistance, therefore allowing them to persist and multiply further. This in turn, enhances the spread and transmission of MRSA, especially in hospitals where there is an extensive use of antibiotics. Moreover, hospitals are associated with those who are vulnerable, such as the elderly and those with weakened immune system, thus easing the pathway for MRSA infection. This is confirmed by 6 of 16 studies, in which hospitalization is found to increase the risk of MRSA infection. Studies by Suh7, Gu10, Wong11, Yao12, Jung14, and Al-Talib18 found that hospitalization elevates this risk by 4.46, 2.56, 6.20, 2.80, 1.77, and 1.03 times respectively. In addition, Wang et al16 in his research also found that nursing home admission significantly increases risk of MRSA by 40.99 times. This shows that those who are vulnerable, such as the elderly and those with weakened immune system in hospitals are easy targets for MRSA infection. Therefore, it is important to establish a stricter guideline and antibiotic policy to enforce a better antibiotic stewardship and prevent antibiotics overuse, especially in hospitals and nursing centers, to keep those at vulnerable risk from further harm. Medical Procedures Invasive medical procedures, as well as insertion of medical devices, are found to be one of the major risk factors for MRSA infection. Gu et al10, in his study, found that presence of medical devices increases the risk of MRSA infection by 3.46 times. This result is further justified by 7 other studies assessing more specific invasive procedures and devices, including surgery, dialysis (OR=1.68), central venous catheterization (OR=4.84), use of respirator (OR=3.80), nasogastric tube feeding (OR=5.29), tracheal intubation (OR=8.20), and use of catheters and tubes (OR=4.19). Invasive medical procedures breach the bodyâ&#x20AC;&#x2122;s barrier. This eases the pathway of

pathogens into the body, such as the bloodstream, urinary and respiratory tract, as well as the abdominal cavity, making the body susceptible to MRSA infections.26 Proper sterilizations and the avoidance of unnecessary procedures are therefore needed to reduce transmission of MRSA in clinical settings. One important method of infection control is hand hygiene. Hands are the most common means of horizontal transmission of infections, especially between patients and health care personnel, showing the significance of hand washing.27 This is consistent with a study by Leung YH et al15 included in the above review, which stated that frequent hand washing is a protective factor which reduces the risk of MRSA infection (OR=0.21, 95% CI = 0.06â&#x20AC;&#x201C;0.72). These results emphasize the importance on educating the public and health care personnel on the importance of sterilization and hygiene in preventing the transmission of infectious diseases, including MRSA infection. b. Limitation of the Study The strength of this study lies on the relatively large number of samples included and the comprehensive analysis of risk factors from each study. However, this study is not without limitation due to the exclusion of inaccessible articles and incompatible language. Moreover, thirteen out of sixteen studies included in the review were conducted in East Asia (Japan, South Korea, China, and Taiwan), and thus, there is a chance that these factors are not fully applicable in other regions of Asia. c. Future Application and Research The result of the above systematic review can be further applied and help guidelines-making process to help primary health care providers in educating the public to prevent MRSA infection by maintaining good hygiene, as Leung YH et al15 showed that frequent hand-washing reduces the risk of MRSA infection. This is especially true since only 19% of the world population washes their hands regularly.28 In addition, the studies were mainly studying medical interventions such as extensive antibiotic use and invasive medical procedures (i.e. surgery, dialysis, catheterization, use of respirator, intubation, and nasogastric tube feeding) which is universal and occurs frequently in various parts of the world. However, more researches need to be conducted in order to explore more applicable protective factors, as there are only few protective factors currently known. CONCLUSION

This systematic review comprehensively analyze the risk factors associated with MRSA infection in Asia. Based on our review, we grouped and concluded the outcomes into 3 main factors: social behaviors, antibiotics use, and medical procedures. Sharing of personal items, limited daily activities and contact with post-surgery individuals are among the behaviors associated with increased risk of MRSA infection. Antibiotic exposure, especially when used extensively and inappropriately, also significantly increases this risk. Finally, invasive medical procedures elevate the risk of MRSA infection due to the breaching of bodyâ&#x20AC;&#x2122;s natural behavior, easing the entrance of the pathogen. We hope that the results of this systematic review could serve as a basis to make guidelines regarding infection prevention and control strategies through better antibiotic stewardship and regulations. The implementation of such control strategies is hoped to help increase public awareness concerning antibiotics resistance, encourage future proper use of antibiotics, thereby helping to reduce the prevalence of MRSA infections worldwide.

BIBLIOGRAPHY 1. Hassoun A, Linden PK, Friedman B. Incidence, prevalence, and management of MRSA bacteremia across patient populationsâ&#x20AC;&#x201C;a review of recent developments in MRSA management and treatment. Crit Care. 2017;21:211 2. Tong SYC, Davis JS, Eichenberger E, Holland TL, Fowler VG. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev. 2015 Jul;28(3):603-61 3. Chen CJ, Huang YC. New epidemiology of Staphylococcus aureus infection in Asia. Clin Microbiol Infect. 2014 Jul;20(7):605-23 4. Harkins CP, Pichon B, Doumith M, Parkhill J, Westh H, Tomasz A, et al. Methicillinresistant Staphylococcus aureus emerged long before the introduction of methicillin into clinical practice. Genome Biol. 2017;18:130 5. Lee AS, Huttner B, Harbarth S. Prevention and control of methicillin-resistant Staphylococcus aureus in acute care settings. Infect Dis Clin North Am. 2016 Dec;30(4):931-52 6. Parathon H, Kuntaman K, Widiastoety TH, Muliawan BT, Karuniawati A, Qibtiyah M, et al. Progress towards antimicrobial resistance containment and control in Indonesia. BMJ. 2017;358:j3808 7. Suh HJ, Park WB, Jung S, Song K, Kwak YG, Kim K, et al. A risk-scoring system for predicting methicillin resistance in community-onset Staphylococcus aureus bacteremia in Korea. Microb Drug Resist. 2018 Jun;24(5):556-62 8. Shirai Y, Arai H, Tamaki K, Konishi H, Kawase Y, Shimizu N, et al. Neonatal methicillinresistant Staphylococcus aureus colonization and infection. J Neonatal Perinatal Med. 2017;10(4):439-44 9. Yoon YK, Park DW, Sohn JW, Kim HY, Kim YS, Lee CS, et al. Effects of inappropriate empirical antibiotic therapy on mortality in patients with healthcare-associated methicillinresistant Staphylococcus aureus bacteremia: a propensity-matched analysis. BMC Infect Dis. 2016 Jul 15;16:331 10. Gu FF, Zhang J, Zhao SY, Yang ZR, Zhang YL, Xiao SZ, et al. Risk factors for methicillinresistant Staphylococcus aureus carriage among residents in 7 nursing homes in Shanghai, China. Am J Infect Control. 2016 Jul 1;44(7):805-8

11. Wong JG, Chen Mi, Win MK, Ng PY, Chow A. Length of stay an important mediator of hospital-acquired methicillin-resistant Staphylococcus aureus. Epidemiol Infect. 2016 Apr;144(6):1248-56 12. Yao Z, Peng Y, Chen X, Bi J, Li Y, Ye X, et al. Healthcare associated infections of methicillin-resistant Staphylococcus aureus: a case-control-control study. PLoS One. 2015 Oct 15;10(10):e0140604 13. Chou YH, Lee MS, Lin RY, Wu CY. Risk factors for methicillin-resistant Staphylococcus aureus skin and soft-tissue infections in outpatients in Taiwan. Epidemiol Infect. 2015 Mar;143(4):749-53 14. Jung WJ, Kang YA, Park MS, Park SC, Leem AY, Kim EY, et al. Prediction of methicillinresistant Staphylococcus aureus in patients with non-nosocomial pneumonia. BMC Infect Dis. 2013 Aug 9;13:370 15. Leung YH, Lai RW, Chan AC, Lo JY, Wong MM, Chuang SK, et al. Risk factors for community-associated methicillin-resistant Staphylococcus aureus infection in Hong Kong. J Infect. 2012 May;64(5):494-9. 16. Wang CY, Wu VC, Wang WJ, Lin YF, Lin YH, Chen YM, et al. Risk factors for nasal carriage of methicillin-resistant Staphylococcus aureus among patients with end-stage renal disease in Taiwan. J Formos Med Assoc. 2012 Jan;111(1):14-8. 17. Lu S, Chang F, Cheng C, Lee K, Huang Y. Methicillin-resistant Staphylococcus aureus nasal colonization among adult patients visiting emergency department in a medical center in Taiwan. PLoS One. 2011; 6(6): e1862 18. Al-Talib HI, Yean CY, Al-Jashamy K, Hasan H. Methicillin-resistant Staphylococcus aureus nosocomial infection trends in Hospital Universiti Sains Malaysia during 2002-2007. Ann Saudi Med. 2010 Sep-Oct;30(5):358-63 19. Wang SH, Sun ZL, Guo YJ, Yang BQ, Yuan Y, Wei Q, et al. Meticillin-resistant Staphylococcus aureus isolated from foot ulcers in diabetic patients in a Chinese care hospital: risk factors for infection and prevalence. J Med Microbiol. 2010 Oct;59(10):121924 20. Gadepalli R, Dhawan B, Kapil A, Sreenivas V, Jais M, Gaind R, et al. Clinical and molecular characteristics of nosocomial meticillin-resistant Staphylococcus aureus skin and soft tissue isolates from three Indian hospitals. J Hosp Infect. 2009 Nov;73(3):253-63

21. Lo WT, Lin WJ, Tseng MH, Wang SR, Chu ML, Wang CC. Risk factors and molecular analysis of panton-valentine leukocidin-positive methicillin-resistant Staphylococcus aureus colonization in healthy children. Pediatr Infect Dis J. 2008 Aug;27(8):713-8 22. Washio M, Mizoue T, Kajioka T, Yoshimitsu T, Okayama M, Hamada T, et al. Risk factors for methicillin-resistant Staphylococcus aureus (MRSA) infection in a Japanese geriatric hospital. Public Health. 1997 May;111(3):187-90 23. Gordon RJ, Lowy FD. Pathogenesis of methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008 Jun 1;46(Suppl5):350-9 24. Grice EA, Segre JA. The skin microbiome. Nat Rev Microbiol. 2011 Apr;9(4):244-53 25. Tacconelli E, de Angelis G, Cataldo MA, Pozzi E, Cauda R. Does antibiotic exposure increase the risk of methicillin-resistant Staphylococcus aureus (MRSA) isolation? A systematic review and meta-analysis. J Antimicrob Chemother. 2008 Jan 1;61(1):26-38 26. Johnson AP. Surveillance of antibiotic resistance. Philos Trans R Soc Lond B Biol Sci. 2015 Jun 5;370(1670):20140080 27. Mehta Y, Gupta A, Todi S, Myatra SN, Samaddar DP, Patil V, et al. Guidelines for prevention of hospital acquired infections. Indian J Crit Care Med. 2014 Mar;18(3):149-63 28. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health. 2014 Aug;19(8):906-16

STROBE Statementâ&#x20AC;&#x201D;checklist of items that should be included in reports of observational studies Ite m No Title and abstract

Introduction Background/rati onale

Objectives

Methods Study design

Setting

Suh HJ et al

Shira i Y et al

Yoon YK et al

FeiFei et al

Won g JG et al

Yao Z et al

Chou YH et al

Jung WJ et al

Yes

Explain the scientific background and rationale for the investigation being reported State specific objectives, including any prespecified hypotheses

Yes

Present key elements of study design early in the paper Describe the setting, locations, and relevant dates, including periods

Yes

Recommendation (a) Indicate the studyâ&#x20AC;&#x2122;s design with a commonly used term in the title or the abstract (b) Provide in the abstract an informative and balanced summary of what was done and what was found

Leun g YH et al

Wan g CY et al

Lu S et al

AlTabi b et al

Wan g SH et al

Gade palli R et al

Lo WT et al

Was hio M et al

Participants

of recruitment, exposure, followup, and data collection (a) Cohort study— Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up Case-control study—Give the eligibility criteria, and the sources and methods of case ascertainment and control selection. Give the rationale for the choice of cases and controls Cross-sectional study—Give the eligibility criteria, and the sources and methods of selection of participants (b) Cohort study— For matched studies, give matching criteria and number of exposed and unexposed Case-control study—For matched studies, give matching

Yes

N/A

Yes

N/A

Yes

Variables

Data sources/ measurement

Bias

Study size

Quantitative variables

Statistical

criteria and the number of controls per case Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group Describe any efforts to address potential sources of bias Explain how the study size was arrived at Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why (a) Describe all

Yes

methods

Results Participants

statistical methods, including those used to control for confounding (b) Describe any methods used to examine subgroups and interactions (c) Explain how missing data were addressed (d) Cohort study— If applicable, explain how loss to follow-up was addressed Case-control study—If applicable, explain how matching of cases and controls was addressed Cross-sectional study—If applicable, describe analytical methods taking account of sampling strategy (e) Describe any sensitivity analyses 13*

(a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing

Yes

Descriptive data

Outcome data

14*

15*

follow-up, and analysed (b) Give reasons for non-participation at each stage (c) Consider use of a flow diagram (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders (b) Indicate number of participants with missing data for each variable of interest (c) Cohort study— Summarise followup time (eg, average and total amount) Cohort study— Report numbers of outcome events or summary measures over time Case-control study—Report numbers in each exposure category, or summary measures of exposure Cross-sectional study—Report numbers of

Yes

N/A

Yes

N/A

Yes

N/A

Yes

N/A

Yes

N/A

Yes

N/A

Main results

Other analyses

Discussion Key results

Limitations

outcome events or summary measures (a) Give unadjusted estimates and, if applicable, confounderadjusted estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included (b) Report category boundaries when continuous variables were categorized (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Report other analyses doneâ&#x20AC;&#x201D;eg analyses of subgroups and interactions, and sensitivity analyses Summarise key results with reference to study objectives Discuss limitations of the study, taking

Yes

N/A

Yes

Interpretation

Generalisability

Other information Funding 22

into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence Discuss the generalisability (external validity) of the study results Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based TOTAL

Yes

19.47

18.13

21.67

17.77

18.27

20.33

18.26

18.57

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies. Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org. 23

waaw 2019

Public poster

bundle of acads amsa-ui 2018/2019

NANO: A systemic attempt in reducing Antibiotic Resistance on Global Community

Background: In this poster, our main idea is symbolized by the philosophy of an hourglass. The two most important characteristics of an hour-glass is the 2 containers where the sands are placed and the sand itself that mobiles following the law of gravity. In this poster, we have chosen to symbolize the two containers as Antibiotics (top) and Microorganisms (below). With the philosophy of the hourglass, we could imply that the microorganisms placed at the bottom will be opposed by antibiotics placed at the top. The two areas would have to come across each other, hence, will have an effect towards each other as a whole. But in contrary, the fall of the ‘sand’ from the top happens so quickly that, sometimes, it is hard to keep track of the activities that is going on inside the body itself. Eventually, microorganisms will be resistant to the ‘attacks’ carried out by antibiotics and will eventually disrupt the human body system in a long term. This change in response to the usage of antibiotics leads to a condition called as antibiotic resistance. (1) If this occurs, the number of hospital stays would continue to rise resulting in an escalation of medical expenses, and an increase of mortality rate in the community. Some antibiotics can be obtained without prescription, and in countries with no definite regulation regarding medical treatment, it is often prescribed excessively by health workers. (1) In addition, some people are dependent towards the use of antibiotics as a remedy for any type of illness. Because of that mindset, people will try to use various ways to obtain antibiotics even though the indication is not necessarily right. (4) Therefore, as a medical student it is our duty to encourage and raise the awareness of proper antibiotics usage in the community. Objective The interdepency of Antibiotic’s usage in the community has become an outgoing issue that should have been already kept in mind since the first usage of the drug itself. (5) Many years after the first discovery of antibiotics, once again bacterial infection have again become a menace. (3) Antibiotics, known as a powerful drug that could fight bacterial infections, (1)

has been labelled as one of the most essential and desired form of dependency towards healing any type of diseases and sickness. With that mindset and idealism, a specific antibiotic resistance has occured on some people and has block all mechanism of the drug in the human body. The crisis caused by antibiotic resistance has been associated with the misuse and also the overuse of these drugs, also coupled with the lack of new medicine development by it’s industry who is affected by economic changes and complicated regulations. (3) Through this poster, we want to increase the awareness of the society towards this issue and hope to promote the correct way of handling antibiotics by remembering the four easy steps which we choose to shortened as “NANO”. Content This poster contains an abbreviation that encourages people to use antibiotics properly and accurately. Those encouragements are abbreviated as “NANO” which stands for “Never, Always, Never, Only”. The first “Never” includes “Never demand antibiotics”, “Never forget to wash your hands”, “Never use antibiotics for viral infections”, and “Never use leftover antibiotics”. Following on to the next letter, the term “Always” consists of “Always finish your prescriptionn even if you already feel better”, “Always prepare food hygienically”, and “Always keep your vaccinations up to date”. The second “Never” comprise of “Never share or use another person’s prescription drugs”, “Never combine other drugs unless prescribed”, and “Never keep unused or expired antibiotics at home”. Last but not least, the word “Only” encompasses “Only use antibiotics if prescribed by certified medical personnel”, “Only follow your medical personnel’s advice when using antibiotics”, and “Only postpone the usage of antibiotics until really need”. On top of that we have add on some elements of design that have meaning for its placement in the light of the issue. The background, placed as two different colours with the same shade, emphasized dimensions of Dark and Bright. These dimensions we chose to add on also resembles the normal balance of body functions. (2) Solely, the purple colour has been chosen as one of the primary colour to emphasize the restoration of mental health equilibrium that could result in an unbalanced health by the busy urban life. While blue, as another primary colour indicates harmony, calmness, and happiness towards the bright future of medicine. (2)

Conclusion In conclusion, the usage of antibiotics is still one of the most dependent way of medical consumption in the community. It has progressed from an alternative to a necessity of healing and has become a habit in oneâ&#x20AC;&#x2122;s attempt to heal or restore their own health. This habit has become a way of living which indeed, is a key of a progressive life for the future. Oneâ&#x20AC;&#x2122;s mindset has the greatest impact on their preferences and how they choose to continue on following their old habits or shift to the way it is supposed to be. Therefore, in this opportunity, we would like to make a leap on the attempts of reviving the better way of medical consumption in the community. By the creation of our public poster made with a well-thought philosophy and simple directions, we hope to aspire the community to change and be wiser about their antibiotics usage.

References 1. Antibiotic resistance [Internet]. Jenewa: World Health Organization; 2018 Feb 5 [cited 2018

Okt

11].

Available

from:

http://www.who.int/news-room/fact-

sheets/detail/antibiotic-resistance 2. Maund, Barry. Color [Internet]. Stanford: The Stanford Encyclopedia of Philosophy; 1997 Dec 1 [cited 2018 Oct 25]. Available from: https://plato.stanford.edu/entries/color/ 3. Ventola CL. The Antibiotic Resistance Crisis. P T. 2015 Apr; 40(4): 277â&#x20AC;&#x201C;283. 4. Wu PE, and Juurlink DN. Unused prescription drugs should not be treated like leftovers. CMAJ. 2014 Aug 5; 186(11): 815â&#x20AC;&#x201C;816. 5. How to reduce the spread of antibiotic resistance [Internet]. Jenewa: World Health Organization;

2018

[cited

2018

Okt

11].

Available

from:

http://www.euro.who.int/en/health-topics/disease-prevention/antimicrobialresistance/news/news/2012/11/antibiotic-resistance-a-growing-threat/how-to-reduce-thespread-of-antibiotic-resistance

pcc amsc 2019

Pre-conference competition asia medical students conference

bundle of acads amsa-ui 2018/2019

pcc amsc 2019

scientific paper

bundle of acads amsa-ui 2018/2019

Evaluation of Mass Drug Administration for Filariasis in West Papua on 2015

Author Assyifa Gita Firdaus

Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia (AMSA-Indonesia) 2019

Evaluation of Mass Drug Administration for Filariasis in West Papua on 2015 Assyifa Gita Firdaus1 1. Medical student, Faculty of Medicine Universitas Indonesia, Salemba, Jakarta, Indonesia E-mail: assyifagitagifi@gmail.com

1. Introduction Lymphatic filariasis is a tropical transmittable disease caused by Filarioidea type of roundworms, transmitted through mosquito vector. It affects more than 120 million people in 73 countries, Indonesia is one of the countries with highest filariasis cases (WHO, 2016). In 2015, there were 13,032 filariasis cases in Indonesia. Five provinces that have the most filariasis cases are East Nusa Tenggara (2,864 cases), Aceh (2,372 cases), West Papua (1,244 cases), Papua (1,184 cases) and West Java (904 cases). Most of filariasis cases occur in under-served rural areas with low sanitation, a perfect place for mosquito as filariasis vector to live (Kemenkes RI, 2016; Huicho et al., 2017). Clinical manifestation of lymphatic filariasis, including hydrocele and lymphedema, is the main cause of global disability, accounts for 2.8 million disability cases in the world. It causes permanent disability that leads the patients to social and economic hardship. Therefore, World Health Organization (WHO) declares filariasis as global public health problem and must be eliminated in 2020 through mass drug administration (MDA) (WHO, 2010). MDA is done by giving diethylcarbamazine citrate (DEC) 6 mg/kg bw and albendazole 400 mg, single dose, once a year in five consecutive years. MDA is carried out in filariasis endemic area where microfilaria rate (mf rate) from finger-prick blood test of its 300 residents is â&#x2030;Ľ1% (Kemenkes RI, 2016). To break the transmission chain of filariasis, MDA coverage target determined by WHO and Indonesia Ministry of Health is >65% of total population and >85% of targeted population (WHO, 2010). On 2015, out of 13 districts in West Papua, only one district had mf rate <1%, while other districts had varying mf rate (5.5%-87.5%). Consequently, West Papua became a high filariasis endemicity area and MDA was started to be carried out on the year of 2015, but until now the success of the program has not been evaluated. Responding to the serious impact of filariasis, MDA evaluation is currently in need, and this research aims to evaluate MDA program in West Papua on 2015. Additionally, MDA evaluation is really important since most of filariasis cases occur in under-served areas that have limited access to healthcare workers and adequate qualified health; a condition worsens filariasis infection and transmission (Kemenkes RI, 2016; Huicho et al., 2017). MDA evaluation is counducted by determining 1

the MDA coverage, calculated by dividing the number of people ingest the medicine with the total population and targeted population. To date, most of studies on the evaluation of MDA for filariasis are only carried out in small scale: in one particular district (Ipa, Astuti, Hakim & Fuadzy, 2016; Habibah & Sungkar, 2015). Evaluation conducted in West Papua is expected to depict a larger population. This research also aims to find the association between filariasis endemicity level and MDA coverage; study on this is important to be conducted since it has never been done before. The outcomes of this study are expected to be evaluation material for policy framework to improve MDA coverage and eliminate filariasis by 2020.

2. Materials and Methods 2.1. Study Design The design of this study is cross-sectional (descriptive and analytic), using secondary data of MDA coverage in West Papua on the year of 2015. 2.2. Research Period February 2018-April 2019 2.2. Data source Secondary data was obtained from West Papua Health Department. The data consists of numbers of population ingesting MDA, MDA targeted population and total population of each district in West Papua. 2.3. Population and sample The population targeted in this study is secondary data of population pariticipated in MDA program that is recorded at West Papua Health District while the accessible population is secondary data of population pariticipated in MDA program that is recorded at West Papua Health District on the year of 2015. Study sample is all people of the population pariticipated in MDA program that is recorded at West Papua Health District (total sampling) on the year of 2015. 2.4. Inclusion and Exclusion Critera Inclusion criterion for the subject is data of population pariticipated in MDA program in West Papua on 2015 that is recorded at West Papua Health District. There is not any exclusion criterion; all data of population pariticipated in MDA program in West Papua on 2015 is included in the study. 2

2.5. Variable Identification First, to evaluate MDA program in West Papua, the independent variables are numbers of total population and targeted population of MDA program while the dependent variable is MDA coverage in West Papua on 2015. Second, to find out the association between filariasis endemicity level and MDA coverage, the independent variable is level of filariasis endemicity (low endemicity, high endemicity, hyperendemic, or holoendemic) and the dependent variable is MDA coverage (not achieved or achieved). 2.6. Outcome Measurement The primary outcome of this study is the evaluation of MDA for filariasis in West Papua on 2015 and the association between filariasis endemicity level and MDA coverage. Evaluation of MDA is counducted by determining MDA coverage among total population and targeted population. MDA coverage among total population is expressed as a percentage, calculated by dividing the number of people ingest the medicine with the number of total population. Total population is all people that live in a filariasis endemic district (Kemenkes RI, 2014). Calculation formula:

This coverage shows MDA attainment, determines the number of people living in endemic areas that have been treated. MDA coverage among targeted population; expressed as a percentage, calculated by dividing the number of prople ingest the medicine with the number of targeted population. Targeted population is people who are not pregnant, are not seriously ill, all children >2 years old, all adults <70 years old who live in filariasis endemic area, so that they are eligible to take MDA drug (Kemenkes RI, 2014). Calculation formula:

This coverage shows MDA effectivity, determines the success of MDA. Filariasis endemicity is depicted from the result of a finger-prick blood test that gives an mf rate. Area with an mf rate â&#x2030;Ľ1% is declared as filariasis endemic area. The higher the mf rate, the higher the level of filariasis endemicity in the area (Kemenkes RI, 2014). The filariasis endemic level in the districts of West Papua is categorized into four groups: low endemicity (1%â&#x2030;¤ mf rate <6.8%), high endemicity 3

(6.8%≤ mf rate <12%), hyperendemic (12%≤ mf rate <16%) and holoendemic (mf rate ≥16%) (Kumar, 1996). MDA coverage is categorized into not achieved and achieved. If the number of people who don’t comply MDA is high, then MDA coverage is low, does not achieve the target of MDA coverage determined by WHO, >65% of total population and >85% of targeted population (WHO 2010, Kemenkes RI, 2014).

2.7. Statistical Analysis Data was analyzed using Statistical Package for the Social Sciences (SPSS) software version 20. First, the MDA coverage was analyzed descriptively. Second, the association between filariasis endemicity level and MDA coverage was analyzed by using chi-square test with a significance level of 5%. 2.8. Ethical consideration The study used secondary data and had obtained permission from Papua Barat Health District and Ethics Committee of Faculty of Medicine University of Indonesia. 3. Results Based on the data from West Papua Health District on 2015, from 13 districts there were 12 filariasis endemic districts that has mf rate ≥1%. District which has the highest filariasis endemicity level were South Sorong with an mf rate of 87.5% and districts with the lowest endemicity were Raja Ampat and Teluk Bintuni which has an mf rate of 5.5%. All of the 12 endemic districts must conduct MDA for eliminating filariasis. The Arfak Mountains district was the only district in West Papua that was not a filariasis endemic area with an mf rate of 0.8%. Table 1 shows that there were 9 districts that conducted MDA in 2015. Kaimana was the only district that had conducted MDA for 3 years in 2015. There were 3 filariasis endemic districts that did not conduct MDA: Bintuni Bay, Fak-fak and Sorong Regency. For MDA coverage among total population, Kaimana had the highest coverage (91.4%) and Maybrat had the lowest coverage (4.3%). For MDA coverage among targeted population, Manokwari Selatan had the highest coverage (102,7%) and Maybrat had the lowest coverage (8.6%). In West Papua, out of nine provinces that conducted MDA, there were only two districts that had achieved target of MDA coverage determined by WHO, >65% of total population and >85% of targeted population. Those districts were South Manokwari and Kaimana. South Manokwari had 82.2% for MDA 4

coverage among total population and 102.7% for MDA coverage among targeted population. Kaimana had 91.4% for MDA coverage among total population and 99.2% for MDA coverage among targeted population.

Table 1. MDA for Filariasis Coverage among Total Population and Targeted Population in West Papua on 2015

District

South

People

MDA

Total

Targeted

Ingest

Coverage

Rate

Population

MDA

among Total

Drug

Population

MDA Coverage

Year

among

Targeted

MDA

Population

43.0%

21,907

17,525

18,001

82.2%

102.7%

14.9%

54,165

49,875

49,491

91.4%

99.2%

87.5%

43,036

34,428

26,737

62.1%

77.7%

31.5%

29,791

23,832

18,020

60.5%

75.6%

Manokwari

71.0%

158,326

120,230

78,175

49.4%

65.0%

Tambrauw

13.5%

10,014

8,876

3,024

30.2%

34.1%

Raja Ampat

5.5%

49,048

39,238

7,352

15.0%

18.7%

8.0%

225,588

180,470

24,494

10.9%

13.6%

20.4%

59,196

30,023

2,568

4.3%

8.6%

5.5%

15.0%

21.5%

Manokwari Kaimana South Sorong Wondama Bay

Sorong City Maybrat Bintuni Bay Fak-Fak Sorong Regency

Arfak Mountains West Papua

0.8%

26.0%

651,071

504,497

227,862

35.0%

45.2%

Overall, West Papua had an average mf rate of 26%. Out of the 9 provinces that had conducted MDA, the number of total population was 651,071 people, the number of targeted population wass 504,497 people, the number of people who ingested the drug was 227,862 people, the average number of MDA coverage among total population was 35.0%, the average number of MDA coverage among targeted population was 45.2%, and most of the districts in West Papua had just conducted MDA for the first time. In West Papua, out of 9 districts that had conducted MDA, there were only 2 districts that had achieved the target of MDA coverage determined by WHO, >65% of total population and >85% of targeted population: South Manokwari and Kaimana. Association between Filariasis Endemicity and MDA Coverage Area that had low filariasis endemicity level was Raja Ampat and area that had high filariasis endemicity level was Sorong City. Areas that had hyperendemic filariasis endemicity level were Kaimana and Tambrauw. Areas that had holoendemic filariasis endemicity level were Maybrat, Sorong Regency, South Manokwari, Wondama Bay and South Sorong. Table 2. Association between Filariasis Endemicity and MDA Coverage

MDA Coverage p Among Total Population

Among Targeted

Population

Filariasis Endemecity

Unachieved

Achieved

Unachieved

Achieved

Low

85.0%

15.0%

81.3%

18.7%

High

89.1%

10.9%

86.4%

13.6%

Hyperendemic

18.2%

81.8%

10.6%

89.4%

Holoendemic

54.0%

46.0%

36.6%

63.4%

<0.001

Table 2 shows the percentage of MDA compliance based on filariasis endemicity level that was calculated among total population and targeted population. First, for MDA coverage that was calculated 6

among total population, the percentage of population who did not ingest MDA drug to prevent filariasis in low endemic, high endemic, hyperendemic and holoendemic areas were 85.0%, 89.1%, 18.2% and 54.1% respectively. Second, for MDA coverage that is calculated among targeted population, the percentage of population who did not ingest MDA drug to prevent filariasis in low endemic, high endemicity, hyperendemic and holoendemic areas were 81.3%, 86.4%, 10.6% and 36.6%, respectively. Based on this data, we can conclude that areas with lower filariasis endemicity have higher percentage of people who do not comply MDA, so that the MDA coverage is lower, compared to areas with higher filariasis endemicity. To determine whether there is an association between filariasis endemicity level and MDA coverage, a chi-square test was performed. The result shows that there is an association between filariasis endemicity level and MDA coverage in both among total population (p <0.001) and targeted population (p <0.001). Overall, descriptive analysis shows that areas with lower filariasis endemicity have lower MDA coverage than areas with higher filariasis endemicity. The bivariate analysis of chi-square test shows that there is an association between filariasis endemicity level and MDA coverage.

4. Discussion Lymphatic filariasis is a transmittable disease caused by Filarioidea type of roundworms. Degenerated microfilariae and filarial worms trigger inflammation, block the lymph system, finally lead to lymph-edema and hydrocele contributes to 2.8 million cases of disability in the world (Sherwood, 2011; Rubin & Strayer, 2014). To eliminate filariasis, WHO established a strategy by conducting MDA in all endemic areas to prevent filariasis (WHO, 2016). Within a period of 13 years (2000-2012), MDA managed to prevent approximately 96.71 million filariasis cases, before MDA there were 120 million people infected with filariasis (Ramaiah & Ottesen, 2014). Therefore, MDA is an appropriate solution to eliminate filariasis. MDA is done by giving diethylcarbamazine citrate (DEC) 6 mg/kg bw and albendazole 400 mg, single dose, once a year in five consecutive years (WHO, 2016; Kemenkes RI, 2016). Combination of DEC and Albendazole can kill microfilariae in the patient's body so that the transmission chain in the area can be stopped. Even if DEC can only kill some of the adult filariasis worms, DEC is capable of spaying adult worms so it cannot produce microfilariae in a period of 9-12 months. Therefore, MDA is carried once a year to keep the level of microfilaria in the patient's body low that there will not be any filariasis transmission and is carried out for five consecutive years because the life span of an adult worm is 5

years. It is expected that after MDA is completed, the patient's body is clear of adult filarial worms and microfilarias (Kemenkes RI, 2014). MDA is performed in filariasis endemic areas which have mf rate ≥1%. To determine which area requires POPM, a finger-prick blood test survey is carried out in a village suspected of filariasis transmission occurence, such as in area that has one case of chronic filariasis. If there is one chronic filariasis case, it is considered that in that area there are also 10 cases of acute filariasis and 100 people with positive microfilariae, since one chronic filariasis case is an extremely source of filariasis transmission. If from that finger-prick blood test survey of 300 villagers is found ≥1% of the sample (≥3 people) show positive results, then all people live in the village’s district need to take MDA. Those people live in filariasis endemic areas, categorized as high-risk population and need to take MDA, except for people that do not meet the requirements of taking MDA including pregnant women, children <2 years old, elderly >70 years old and patients with severe illness (WHO, 2011; Kemenkes RI, 2014). Based on the finger-prick blood test data of population in 13 districts, there were 12 districts that had mf rate ≥1%, including Sorong Selatan, Manokwari, South Manokwari, Wondama Bay, Sorong Regency, Maybrat, Fak-fak, Kaimana, Tambrauw, Sorong City, Bintuni Bay and Raja Ampat. The overall average number of mf rate in West Papua was 26.0%. District with the highest endemicity level was South Sorong (mf rate 87.5%) and district with the lowest endemicity level were Raja Ampat and Bintuni Bay (mf rate 5.5%). Therefore, MDA had to be conducted in all 12 endemic districts in West Papua, but there were 3 endemic districts that did not conduct MDA, including Sorong Regency (mf level 21.5%), Fak-Fak (mf level 15.0 %) and Bintuni Bay (mf rate 5.5%). MDA must be conducted in all endemic districts so that mf rate does not increase and make filariasis harder to be eliminated in the future. One district in West Papua that was not a filariasis endemic was the Arfak Mountains with an mf rate of 0.8 since it is located in the mountains with relatively low temperature approximately 19-22°C so that mosquito as filariasis vector cannot live there (Salosa, Awang, Suryanto & Purwanto, 2014). In order to break the transmission chain of filariasis, WHO set MDA coverage target; it is >65% of total population and >85% of targeted population in each district (WHO, 2010; Kemenkes RI, 2016). MDA coverage among total population shows MDA attainment, determines the number of people living in endemic areas that have been treated. MDA coverage among targeted population shows MDA success rate, depicts its effectiveness (Kemenkes RI, 2014).

In West Papua, out of nine districts that had conducted MDA, there were only 2 districts that had achieved MDA coverage target determined by WHO, namely South Manokwari and Kaimana. For MDA coverage among total population, Kaimana District had the highest coverage (91.4%) and Maybrat had the lowest coverage (4.3%). Kaimana had high MDA coverage because it was the only district in West Papua that had conducted MDA for three years. Overall, the average of MDA coverage among total population was 35%, which shows that MDA attainment was still low. For MDA coverage among targeted population, South Manokwari had the highest coverage (102.7%) and Maybrat had the lowest (8.6%). MDA coverage that exceeds 100% can be caused by population migration that changes the number of targeted population. It also can be caused by misconduct where MDA is given to the population who do not qualify for having MDA (pregnant women, children <2 years old, elderly >70 years old and patients with severe illness). Training for MDA supervisors needs to be conducted more often to improve their comprehension about population at risk who can take MDA, the urgency of MDA and good communication skill that is needed when handing out the MDA drug (Babu & Satyanarayana, 2003; Mahalakshmy, Kalaiselvan, Parmar & Dongre, 2010; Njomo, Nyamongo, Magambo, Ngure & Njenga, 2015). Babu & Kar (2004) reports that village which MDA drug is distributed by trained volunteers and healthcare worker has a high MDA coverage. Overall, the average of MDA coverage among targeted population was low (45.2%) which shows that the effectiveness of MDA in West Papua was still low (Kemenkes RI, 2014). Study shows that areas with lower filariasis endemicity level have higher percentage of people who do not comply MDA, so that MDA coverage is lower, compared to areas with higher filariasis endemicity level. The bivariate analysis, chi-square test, shows that there is an association between filariasis endemicity level and MDA coverage in both among total population (p <0.001) and targeted population (p <0.001). Based on studies in Sri Lanka from Gunawardena, Ismail, Bradley & Karunaweera (2007), Vanuatu from Fraser et al. (2005) and India from Cantey, Rout, Rao & Fox (2008) and Cantey, Rout, Rao, Williamson & Fox (2010), one of the important factors associated with high MDA coverage is the populationâ&#x20AC;&#x2122;s comprehension about lymphatic filariasis and MDA (p <0.05). Things that they need to comprehend include what filariasis is transmission process of filariasis, how filariasis can be prevented, the losses come from filariasis and the fact that MDA is useful to prevent filariasis. Study in Philippines shows that wrong comprehensions such as ingesting MDA causes fainting, infertility and death preventspeople from ingesting MDA drug. MDA does have mild to severe side effects, such as fever, dizziness, vomiting, drowsiness, diarrhea and allergies. In West Sumatra, 9

Indonesia, after MDA was conducted in an elementary school, all the students there fell asleep in class. Therefore, before conducting MDA, it is necessary to hold a socialization program so that people will understand that MDA is safe and not be panic when they experience side effects after ingesting MDA drug (Kemenkes RI, 2014). Another factor associated with MDA is awareness. People who are aware of filariasis (p = 0.01), of the importance of MDA (p = 0.02) and of the association between MDA and filariasis (p = 0.01), comply MDA (Amarillo, Belizario, Sadiang-Abay, Sison & Dayag, 2008). In low endemic areas people are less aware of the danger of filariasis and the role of MDA that the coverage becomes low. Therefore, people who live in low endemic filariasis areas need to be educated about filariasis and MDA so that they will be aware of filariasis existence in their area and the importance of MDA. Gunawardena et al. (2007) reports that in a population where the people have seen a person with clinical manifestations of filariasis has higher MDA compliance. To improve the awareness, economic burden of filariasis patient also needs to be socialized since patient who has lymphedema finds it difficult to do activites and work like any other healthy people does (Hotez, Fenwick, Savioli & Molyneux, 2009; Mehrara B, 2017). Person who plays role in handing out MDA drug also affects MDA coverage. Amarillo et al. (2008) reports that people comply MDA because they are motivated by healthcare workers' advice that they got when the healthcare workers handing the drug. In India, MDA compliance is 5.6 times higher (95% CI: 3.4-9.1) if the drugs are handed out by healthcare workers than local volunteers (Mahalakhsmy et al., 2010). Studies in Indonesia from Ipa et al. (2016), in Ghana from (Gyapong, Gyapong & OwusuBanahene (2001) and in India from Babu & Kar (2004), Nandha, Sadanandane, Jambulingam & Das (2007) and Mahalakhsmy et al. (2010), show that in areas which drugs are handed out by healthcare workers which also involves cadres in the process can improve MDA compliance. Therefore, if healthcare workers and cadres work together in conducting MDA, MDA coverage will be increased. Healthcare workers play a role in motivating people and cadres play a role in reaching the population effectively and efficiently Most of filariasis cases occur in under-served areas with low sanitation, a perfect place for mosquito as vector to live (Kemenkes RI, 2016; Huicho et al., 2017). Those areas have difficulty in accessing health care. Thus, there is an urgent need for government to make sure that there is enough number of healthcare workers to conduct MDA in under-served areas. Four published papers from Sempowski (2004), Chopra, Munro, Lavis, Vist & Bennett (2008), Lehmann, Dieleman & Martineau (2008) and Grobrel et al. (2009) analyzed various strategies that have been done to increase access to 10

health workers in rural and remote areas. There are three domains of intervention including education and regulatory interventions, financial incentives as a monetary compensation and management, environment and social support. First, for education and regulatory interventions, things that can be done are targeting enrollment of students from rural background, improving medical curricula about healthcare system and community outreach, increasing early exposure to rural practice during undergraduate, holding loan repayment program (Government pay for the studies in turn of service in rural for 4-6 years) and producing various types of healthcare workers such as mid-level cadres, task shifting and substitution. Second, for monetary compensation, things can be done are giving higher salaries for one who works in rural, giving rural allowances, making different remuneration method (service fee, capitation, etc), loaning vehicle and housing also granting for family education. Lastly, for management, environment and social support, things can be done are improving rural infrastructure (roads, housing, water supplies, phones etc), improving living and working conditions (providing opportunities for spouse employment and child schooling, ensuring adequate supplies of drugs and medical device), supporting career development path, conducting good supervision, reducing the feeling of isolation of healthcare workers by providing remote contact through telehealth and telemedicine to other specialist networks. Coordination between all elements in a country is crucial for succeeding these strategies in order to provide a proper healthcare to all communities. Besides doing efforts to increase MDA coverage, active case finding also need to be carried out that patients with filariasis can be treated properly, immediately and prevents them for being a source of filariasis transmission to other people (Habibah & Sungkar, 2015). This study shows that in low endemicity areas, MDA coverage is also low. If people in low endemicity areas do not take drugs, the number of filariasis infections continues to be increased and those areas will finally end up as a high filariasis endemic area. Therefore, efforts to increase MDA coverage need to be done in both low and high filariasis endemic areas to completely eliminate filariasis. If the efforts in increasing MDA coverage can be done properly, then MDA coverage will fulfill WHO target, such as in West Sierra Leone, Africa, which has 85.8% MDA coverage. The key of its success is a coordinated and intense MDA socialization (Hodges et al., 2010).

5. Conclusion MDA for filariasis coverage in West Papua on 2015 was low, had not been fulfilling WHO target both among total population and among targeted population. The average of MDA coverage in West Papua on 2015 among total population was 35% and among targeted population was 45.2%. 11

Filariasis endemicity level is associated with MDA coverage both among total population and among targeted population. Areas with lower filariasis endemicity level have lower MDA coverage than areas with higher filariasis endemicity level.

6. Recommendations MDA coverage must be increased in all West Papua filariasis endemic districts, both districts with low and high filariasis endemicity. Efforts in increasing knowledge and concern for filariasis and MDA need to be carried out more intensely especially in areas with low filariasis endemicity. These efforts can be done through: 1. Giving education to population regarding filariasis and MDA. A good comprehension can increase population awareness of filariasis existence in their area and the importance of eliminating filariasis through MDA. 2. Collaboration between healthcare workers and local cadres in handing out MDA drug to population. Healthcare workers play a role in motivating people to take MDA and local cadres play a role in reaching out the entire population effectively and efficiently. 3. Assuring that there is enough number of healthcare workers to conduct MDA in all areas, especially under-served areas where most of filariasis cases occur, through three domains of interventions: education and regulatory intervention, monetary compensation and management, environment and social support. In addition, active-case finding also needs to be conducted that filariasis patients can be immediately treated and prevents them for being source of filariasis transmission for other people.

EVALUATION OF MDA FOR FILARIASIS, WEST PAPUA, 2015

References Amarillo, M., Belizario, Jr V., Sadiang-Abay, J., Sison, S., Dayag, A. (2008). Factors associated with the acceptance of mass drug administration for the elimination of lymphatic filariasis in Agusan del Sur, Philippines. Parasit Vectors, 1(1), 14. doi: 10.1186/1756-3305-1-14 Babu, B., Kar, S. (2004). Coverage, compliance and some operational issues of mass drug administration during the programme to eliminate lymphatic filariasis in Orissa, India. Trop Med Int Health, 9(6), 702-709. doi:10.1111/j.1365-3156.2004.01247.x Babu, B., Satyanarayana, K. (2003). Factors responsible for coverage and compliance in mass drug administration during the programme to eliminate lymphatic filariasis in the East Godavari District, South India. Trop Doct, 33, 79-82. doi:10.1177/004947550303300208 Cantey, P., Rout, J., Rao, G., Fox, L. (2008). Predictors of compliance with a mass drug administration programme for lymphatic filariasis in Orissa State, India 2008. Trop Med Int Health, 15(2), 224-231. doi: 10.1111/j.1365-3156.2009.02443.x Cantey, P., Rout, J., Rao, G., Williamson, J., Fox, L. (2010). Increasing compliance with mass drug administration programs for lymphatic filariasis in India through education and lymphedema management programs. PLoS Negl Trop Dis, 4(6), e728. doi: 10.1371/journal.pntd.0000728 Chopra, M., Munro, S., Lavis, JN., Vist, G., Bennett, S. Effects of policy options for human resources for health: an analysis of systematic reviews. (2008). Lancet, 371(9613), 668-674. doi: 10.1016/S0140-6736(08)60305-0 Fraser, M., Taleo, G., Taleo, F., Yaviong, J., Amos, M., Babu, M., Kalkoa, M. (2005). Evaluation of the program to eliminate lymphatic filariasis in Vanuatu following two years of mass drug administration implementation: results and methodologic approach. Am. J. Trop. Med. Hyg, 73(4), 753-758. doi:10.4269/ajtmh.2005.73.75

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Grobler, L., Marais, BJ., Mabunda, SA., Marindi, PN., Reuter, H., Volmink, J. (2009). Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev, (1), CD005314. doi: 10.1002/14651858.CD005314.pub2 Gunawardena, S., Ismail, M., Bradley, M., Karunaweera, N. (2007). Factors influencing drug compliance in the mass drug administration programme against filariasis in the Western province of Sri Lanka. Trans R Soc Trop Med Hyg. 101, 445-453. doi:10.1016/j.trstmh.2006.09.002 Gyapong, M., Gyapong, J., Owusu-Banahene, G. (2001). Community-directed treatment: the way forward to eliminating lymphatic filariasis as a public-health problem in Ghana. Ann Trop Med Parasitol, 95(1), 77-86. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11235557 Habibah, Z., Sungkar, S. (2015). Cakupan pemberian obat pencegahan massal filariasis di Kabupaten Sumba Barat Daya tahun 2012-2013. eJKI, 3(3), 199-203. Retrieved from http://journal.ui.ac.id/index.php/eJKI/article/view/5648 Hodges, M., Smith, S., Fussum, D., Koroma, J., Conteh, A., Sonnie, M.,... Zhang, Y. (2010). High coverage of mass drug administration for lymphatic filariasis in rural and non-rural settings in the Western Area, Sierra Leone. Parasit Vectors, 3, 120. Hotez, P., Fenwick, A., Savioli, L., Molyneux, D. (2009). Rescuing the bottom billion through control of neglected tropical diseases. Lancet, 373, 1570-1575. doi: 10.1016/S0140-6736(09)60233-6 Huicho, L., Dieleman, M., Campbell, J., Codjia, L., Balabanova, D., Dussault, Dolea, C. (2010) Increasing access to health workers in underserved areas: a conceptual framework for measuring results. Bull World Health Organ, 88(5), 357-363. doi: 10.2471/BLT.09.070920 Ipa, M., Astuti, E., Hakim, L., Fuadzy, H. (2016). Analisis cakupan obat massal pencegahan filariasis di Kabupaten Bandung dengan pendekatan model sistem dinamik. BALABA, 12(1), 31-38. doi: 10.22435/blb.v12i1.4470.31-38

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Kemenkes RI. (2014). Peraturan Menteri Kesehatan Republik Indonesia Nomor 94 Tahun 2014 tentang Penanggulangan Filariasis. Jakarta: Kementerian Kesehatan RI. Retrieved from http://www.depkes.go.id/ Kemenkes RI. (2016). Profil kesehatan Indonesia tahun. Jakarta: Kementerian Kesehatan RI. Retrieved from http://www.depkes.go.id/ Kumar, A. (1996). Human filariasis: infection rate as the uniform measurable criterion for filarial endemicity. J Commun Dis, 28(3), 163-167. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8973014 Lehmann, U., Dieleman, M., Martineau, T. (2008). Staffing remote rural areas in middle- and lowincome countries: a literature review of attraction and retention. BMC Health Serv Res, 8, 19. doi: 10.1186/1472-6963-8-19 Mahalakshmy, T., Kalaiselvan, G., Parmar, J., Dongre, A. (2010). Coverage and compliance to diethylcarbamazine in relation to filaria prevention assistants in rural Puducherry, India. J Vector Borne Dis, 47, 113-5. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20539050 Mehrara, B. (2017). Clinical staging and conservative management of peripheral lymphedema. Retrieved from https://www.uptodate.com/ Nandha, B., Sadanandane, C., Jambulingam, P., Das, P. (2007). Delivery strategy of mass annual single dose DEC administration to eliminate lymphatic filariasis in the urban areas of Pondicherry, South India: 5 years of experience. Filaria J, 6, 7. doi:10.1186/1475-2883-6-7 Njomo, D., Nyamongo, M., Magambo, J., Ngure, P., Njenga, S. (2015). Factors associated with the motivation of community drug distributors in the lymphatic filariasis elimination programme in Kenya. S Afr J Infect Dis, 27(2), 66-70. doi:10.1080/10158782.2012.1144148

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Ramaiah, K., Ottesen, E. (2014). Progress and impact of 13 years of the global programme to eliminate lymphatic filariasis on reducing the burden of filarial disease. PLoS Negl Trop Dis, 8(11), e3319. doi:10.1371/journal.pntd.0003319 Rubin, R., Strayer, D., Rubin, E. (2014). Rubin's pathology (6th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Salosa, S., Awang, S., Suryanto, P., Purwanto, R. (2014). Hutan dalam kehidupan masyarakat hatam di lingkungan cagar alam Pegunungan Arfak. JML, 21(3), 349-355. doi:10.22146/jml.18563 Sempowski, IP. (2004). Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: systematic review of the literature. Can J Rural Med, 9(2), 82-88. Sherwood, L. (2011). Human physiology from cells to system (7th ed.). PaciďŹ c Grove: Brooks/Cole Cengange Learning. WHO. (2010). Progress report 2000-2009 and strategic plan 2010-2020 of the global program to eliminate lymphatic filariasis: halfway towards eliminating lymphatic filariasis (1st ed.). Geneva: WHO Press. Retrieved from http://www.searo.who.int/ WHO. (2011). Monitoring and epidemiological assessment of mass drug administration in the global program to eliminate lymphatic filariasis: a manual for national elimination programs. Geneva: WHO Press. Retrieved from http://www.who.int/ WHO. (2016). Lymphatic filariasis. Retrieved from http://www.who.int/

Evaluation of Mass Drug Administration for Filariasis in West Papua on 2015 Assyifa Gita Firdaus1 1.

Medical student, Faculty of Medicine Universitas Indonesia, Salemba, Jakarta, Indonesia E-mail: assyifagitagifi@gmail.com

Abstract Aim -

To evaluate Mass Drug Administration (MDA) for filariasis in West Papua on 2015

To analyze the association between filariasis endemicity level and MDA coverage

Background Indonesia is a high filariasis endemicity country (13,032 cases in 2015) and West Papua is the third highest province with filariasis (1,244 cases). World Health Organization (WHO) states filariasis as a global public health problem that must be eliminated through mass drug administration (MDA) by giving diethylcarbamazine citrate (DEC) and albendazole, single-dose, once a year in five consecutive years.

Method A cross-sectional study was conducted using MDA participant data that has been recorded by Papua Barat Health Department (total sampling) in 2015. The data includes the numbers of total population ingesting MDA drug, targeted population and total population in each West Papua district. MDA coverage was analyzed descriptively and the association between filariasis endemicity level and MDA coverage was analyzed by using chi-square test with a significance level of 5%. Filariasis endemic level is categorized into four groups: low endemicity (1%≤ mf rate <6.8%), high endemicity (6.8%≤ mf rate <12%), hyperendemic (12%≤ mf rate <16%) and holoendemic (mf rate ≥16%). MDA coverage is categorized into not achieved and achieved.

Key Findings The MDA coverage in West Papua on 2015 per total population was 35% and per targeted population was 45.2%, did not achieve the WHO target. Filariasis endemicity level is associated with MDA coverage

both among total population (p <0.001) and among targeted population (p <0.001). Areas with lower filariasis endemicity level have lower MDA coverage than areas with higher filariasis endemicity level. Keywords :

Endemicity, lymphatic filariasis, Mass Drug Administration (MDA) for filariasis, MDA

coverage, West Papua

Effectiveness of Health Insurance in Tackling Health Problems of the 21st Century: A Systematic Review Scientific Paper

Author(s) Nico Gamalliel Reynardi Larope Sutanto Mochammad Izzatullah Gita Fajri Gustya

Faculty of Medicine Universitas Indonesia 2019

Effectiveness of Various Health Insurances in Tackling Health Problems of the 21st Century: A Systematic Review Nico Gamalliel, Reynardi Sutanto, Mochammad Izzatullah, Gita Fajri Gustya University of Indonesia INTRODUCTION Health insurance can be said has strong relation in achieving Goal 3 of Sustainable Development Goals (SDGs), “Ensure healthy lives and promote well-being for all at all ages”. (United Nations, 2015) One of the key factor in reaching ‘healthy lives’ is the access to medical care. Health insurance has been implemented across many countries in order to facilitate access for good quality medical care. Risk-sharing mechanism such as social insurance is said to provide resources to access healthcare and to promote health. On the other hand, social insurance protects individuals and households against while the potentially devastating direct financial costs of illness.(Stone et al., 2015) The ultimate aim of health insurance is to improve the quality of health. (Schoeps et al., 2015) The impact of health insurance on health care utilization is said to be closely associated with the characteristics of the system, such as premiums, benefits, location of healthcare services, and for whom the services are intended.(Wang, Temsah, & Mallick, 2017) Some health insurance program, for example, the one in Indonesia, raise debate about its effectiveness in increasing the utilisation of health services, especially among the poor.(Vidyattama, Miranti, & Resosudarmo, 2014) Some studies indicated that health insurance have positive effect to improve health quality of patient. A study showed women managed under national health insurance scheme of Nigeria had better maternal and perinatal indices.(Lawani et al., 2016) Insurance coverage also associated with decreased in-hospital mortality.(Stone et al., 2015) Another study indicated there is inverted effect between ownership of health insurance and health quality, where enrollees of Ohio Appalachian Medicaid were more likely to have health problems such as hypertension, cardiovascular disease, and overall poorer health than non-Medicaid enrollees.(Kariisa & Seiber, 2015) The link between health insurance and this ultimate goal therefore should be thoroughly investigated. Studies these time mostly investigated the relation between participation in health insurance and mortality or survival in certain diseases. Advanced investigation and research about the link between health insurance and health problems in general, not only based on certain disease, is needed in order to find out and improve efficacy of health insurance. Here explained systematic review of literatures showing link of health insurance and health problems.

METHODS The systematic review was conducted using keywords "Insurance, Health"[Mesh]) AND "Health Care Quality, Access, and Evaluation"[Mesh] on the database of Pubmed. From there, we proceed to look for studies which are related to our topic by using our inclusion criteria. The inclusion criteria include: studies which were published less than five years ago, observational studies, and studies which look upon the effects of health insurance on the health of the users. On the other hand, exclusion criteria were also used. These include: inaccessible articles, articles written in languages other than English or Indonesian, and irrelevant articles. Afterwards, we begin to collect important data from each study, including: author(s) name, year of publication, STROBE score, type of insurance used, research design, location, sample size, type of disease assessed, method of analysis, result, and limitations of the study. The review was done qualitatively by three assessors and conclusions were then drafted after consensus had been achieved. All of this process could be viewed on Figure 1.

Identifika si

Initial search from database of Pubmed based on inclusion criteria (n = 449)

(n = 5)

Screening

Title screening of relevancy and duplication (n = 444)

Irrelevant, doubled titles excluded (n = 396)

Abstract screened (n = 43) Full-text articles excluded (n = 12): Full articles assessed for eligibility (n = 18)

Included

Inaccesible articles and articles written in foreign languages

Articles included in review and assessed with STROBEâ&#x20AC;&#x2122;s criteria (n = 6)

Insurance data is only used as control variable

Effectiveness of insurance is not measured by health outcome

Figure 1. Flow chart of the systematic review

RESULT The search was conductud via database of Pubmed. Titles were screened for relevancy and duplication. Contents were screened for inclusion and exclusion criteria. Articles went over criteria were fully assessed for eligibility and study design. Lastly, six suitable observational studies were reviewed and included in this systematic review. Articles were assessed with STROBE’s criteria to ensure its quality. STROBE result of all articles could be seen in Table 2, located on the appendix, while the entire process can be seen in Figure 1. Included study design and the respective characteristics of each study are further shown in Table 1. DISCUSSION Based on the study conducted by Xie, et.al in 2017, the usage of insurance has a very high correlation with a better condition of patients. In this study showed that people who use the high-cost share group has a lower risk of hyperglycemia rather than the low-cost share group. This means that people who pay for the insurance more will have a better condition and receive more health service than people who pay only a little amount of money for insurance. (Xie, 2017) Other study conducted by Andersen ND, et.al. reveals that people who suffer cardiac arrest and underinsured will have a higher risk for a thoracic aortic operations. This condition could be happened due to the fact that underinsured people will receive less medication and less screening. Less medication and less screening in this study mean that people will have a higher rates of hypercholesterolemia and hypertension. These two events will lead to an acute cardiac arrest. A severe acute cardiac arrest result in the demand of a thoracic aortic operation. (Andersen, 2014) The same result is also explained through a study by Hiroi, et.al. In this study the researcher discovers the correlation of H.pylori infection gastritis with the coverage of insurance. The result is positive which means that the usage of insurance will decrease the event of H.pylori infection gastritis. (Hiroi, 2017). There are other studies that showed significant improvement of healthcare outcome when using health insurance. Those studies include the study conducted by Stecker et al in 2017 that showed the significant reduction in out-of-hospital cardiac arrest in patient with health insurance. (Stecker, 2017) Another study is conducted by Saunders et al, in which the samples used are 934 individuals with urine albumin-to-creatinine ratio ≥ 30 mg/g, which is a diagnostic value of albuminuria. The study also discusses about cardiovascular mortality as one of the complication of kidney disease. The aim of the study is to compare rate of mortality between uninsured, individuals with public insurance, and individuals with private insurance. Individuals with public insurance and those who are uninsured showed higher rates of all-cause mortality compared with individuals with private insurance. Also, simi-

Author and Year of Publication (STROBE scores) Xie Y, et al; 2017 (19,33/22)

Type of Insuran ce

Resear ch Design

Locati on

Sample size Disease

Method of Analysis

Results

Limitation of Study

Private

Obser vation al Retros pectiv e

Nether lands

Type I Diabetes Mellitus

SAS 9.4: t-test, Pearsonâ&#x20AC;&#x2122;s chi-square, modified Poisson model

Higher rate of continued testing strip fills in low-cost share group than high-cost share group (89% vs 82%, P<0.001)

Pharmacy fills do not necessarily confirm actual use of dispensed testing strips, all patients were from a single large commercial insurer

Andersen MD, et al; 2017 (STROBE 16,16/22)

Private and govern mental (Medica re, USA)

Retros pectiv e

United states

7,155 patients (3,575 lowcost share group, 3,580 highcost share group) 826 patients; 736 had insurance; 90 were underinsure d

Acuity of Thoracic Aortic Operation s

Mann-Whitney rank sum test, chi-square test; logistic regression, Cox proportional-hazards regression; STATA 11.1

Underinsured patients were at greatest risk of requiring nonelective thoracic aortic operations (OR: 2.67; P<0.0001)

Hiroi S, et al; 2017 (19,1/22)

Japanes e health insuranc e

Retros pectiv e observ ational

Japan

81,119 and 170,993 patients in two databases;

Helicobac ter pylori gastritis

SAS 9.4

Insurance coverage may reduce the prevalence of H. pylori infection.

Stecker EC, et al; 2017

Govern mental (Afford

Retros pectiv e

Multn omah Count

Adult residents of Multnomah

Out-ofHospital

PASS 13, SAS 9.4

Health insurance expansion was associated with significant reduction in OHCA incidence. (middle-aged

Study only includes patient who underwent operation; does not account for unmeasured confounders, such as social variables; single-institution analysis Success rate of eradication was obtained from previous studies, potential bias of health insurance claims database Single urban geographic area as location,

(18,94/22)

able Care Act)

observ ational study

y, Orego n, United States

County (636,000)

Cardiac Arrest

population: 102 per 100,000 to 85 per 100,000 with P = 0.01; elderly population: 275 per 100,000 to 269 per 100,000 with P = 0.70)

Saunders MR, et al.; 2016 (16,4/22)

Govern Cohort ment observ and ational private insuranc e

United States

934 individuals with UACR ≥ 30 mg/g;

Albuminu ria

Cox model, Schoenfeld residuals

Higher crude rates of all-cause mortality in the uninsured and individuals with public insurance compared with those with private insurance (17.8 and 24.1 vs 10.4, respectively); similar pattern can be seen in cardiovascular mortality rates.

Wang Z, et al; 2015 (17,43/22)

New Cohort Coopera prospe tive ctive Medical Scheme (NCMS ) and the Urban Employ ees’ Medical Insuran ce (UEMI)

PD Center , Wuha n no. 1 Hospit al, China

564 patients(41 5 (77.0%) with UEMI and 149 (23.0%) with NCMS); has received continuous ambulatory PD for >3 months

Peritonitis

SPSS 17.0; chi-square test, unpaired t-test, Kaplan-Meier method, Cox regression model.

Biomedical parameters for diseases were inferior in patients with NCMS compared with patients with UEMI. (P<0.05)

Table 1. Included study designs and characteristic

underpowered regression-based techniques, assumption that OHCA can be a surrogate of SCA The study only had access to a single UACR and eGFR determination, rather than using multiple measures; limited time, data can be biased since uninsured individuals may have subsequently lost their insurance. Data were from a single center and the sample was small.

lar pattern can be seen in cardiovascular mortality rates. However, the cardiovascular mortality rate between those individuals are not significant. (Saunders, 2016) There is one study that also compare two medical insurances in China, those are New Cooperative Medical Scheme (NCMS) and the Urban Employeesâ&#x20AC;&#x2122; Medical Insurance (UEMI). NCMS is mainly for rural residents. The study is conducted by Wang et al. The result of this study is that individuals with NCMS are more inferior to those with UEMI in biomedical parameters, which include hemoglobin levels, phosphorus in blood, nutrition, and residual renal function. For example, individuals with NCMS have lower hemoglobin levels that can be due to low-income-related-malnutrition. Hypophosphatemia does exist in individuals with NCMS which also correlates with economic status in rural residents. In conclusion, individuals with NCMS does have higher rate of mortality associated with peritoneal dialysis compared with individuals with UEMI due to different economic status. (Wang, 2015) The study conducted by Wang et al also correlates with other studies that compare uninsured and insured individuals like the study conducted by Stecker et al and Saunders et al. Those three studies showed significant differences in patients with insurance or those with private insurance when compared to public insurance. Higher economic status (those with private insurance) associated with more compliance in check-ups and drug intake compared to those with lower economic status. However, compared to those who were uninsured, individuals with insurance (public or private) do have higher survival rate almost in all studies. Even though a profound connection between quality health insurance and health outcomes of its users could be seen, this systematic review has several limitations. Firstly, the studies included were quite heterogenous in location, sample size, as well as in type of insurances and diseases. This heterogenicity could become a potential source of bias. However, this should be understandable given the small amount of current literature on the effects of health insurance. Secondly, as a systematic review, it could suffer from bias of its assesors. This could also be understandable given the nature of systematic review as a qualitative literature. CONCLUSION This review using systematic method shows that ownership of health insurance may indicate better prognosis of the patient, regardless of the disease. Furthermore, government of countries may try to consider to administer a social insurance system, or at least government may try to improve level of participation of health insurance. Community also may consider to enroll health insurance in order to improve their health quality by facilitate better access to health care services, etc. These attempts may be one of many way to achieve better health level of the community. Further research should be

conducted with more homogeneous data, especially related to location the research conducted. Research also may be conducted in developing country, seeing that most of the studies related to the linking between health insurance and health quality conducted in developed country. More database also may be used in order to get more studies related to the relation between health insurance and health quality.

REFERENCES Andersen ND, et.al. (2014). Insurance status predicts acuity of thoracic aortic operations. The American Association of Thoracic Surgery, 148(5), 2082-2086. Hiroi S, Sugano K, Tanaka S, Kawakami K. (2017). Impact of health insurance coverage for Helicobacter pylori gastritis on the trends in Japan: retrospective observational study and simulation study based on real-world data. British Medical Journal Open, 7(7). Kariisa, M., & Seiber, E. (2015). Distribution of cardiovascular disease and associated risk factors by county type and health insurance status: results from the 2008 Ohio family health survey. Public Health Reports, 130(1), 87–95. Lawani, L. O., Iyoke, C. A., Onoh, R. C., Nkwo, P. O., Ibrahim, I. A., & Ekwedigwe, K. C. (2016). Obstetric benefits of health insurance: A comparative analysis of obstetric indices and outcome of enrollees and non-enrollees in southeast Nigeria. Journal of Obstetrics and Gynaecology, 36(7), 946– 949. Saunders MR, Ricardo AC, Chen J, Chin MH, Lash JP. (2016) Association between insurance status and mortality in individuals with albuminuria: an observational cohort study. BMC Nephrology, 17, 27. Schoeps, A., Lietz, H., Sie, A., Savadogo, G., De Allegri, M., Muller, O., & Sauerborn, R. (2015). Health insurance and child mortality in rural Burkina Faso. 8, 27327. Stecker EC, Reinier K, Rusinaru C, Uy-Evanado A, Jui J, Chugh SS. (2017).Health insurance expansion and incidence of out-of-hospital cardiac arrest: a pilot study in a US metropolitan community. Journal American Heart Association, 6(7), e005667. Stone, G. S., Tarus, T., Shikanga, M., Biwott, B., Ngetich, T., & Andale, T. (2015). The association between insurance status and in-hospital mortality on the public medical wards of a Kenyan referral hospital. Global Health Action, 7(1), 23137. United Nations. (2015). Goal 3: Ensure healthy lives and promote well-being for all at all ages. Retrieved

from

Sustainable

Development

Goals

website:

https://www.un.org/sustainabledevelopment/health/ Vidyattama, Y., Miranti, R., & Resosudarmo, B. (2014). The role of health insurance membership in health service utilisation in Indonesia. Bulletin of Indonesian Economic Studies, 50(3), 393–413. Wang, W., Temsah, G., & Mallick, L. (2017). The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda. Health Policy and Planning, 32, 366–375.

Wang Z, Zhang Y, Xiong F, Li H, Ding Y, Gao Y, Zhao L, Wan S. (2015) Association between medical insurance type and survival in patients undergoing peritoneal dialysis. BMC Nephrology, 16, 33. Yiqiong X, Agiy A, Bowman K, DeVries A. (2017). Lowering cost share may improve rates of home glucose monitoring among patients with diabetes using insulin. Journal of Managed Care & Specialty Pharmacy, 23(8), 884-891

APPENDIX Table 2. STROBE Score Table

N o

Title and abstract

Anderse

Xie,

Wang,

Stecker

Saunders

Hiroi S,

et.al.

EC, et.al

, et.al

et.al

(2017)

(2015)

(2017)

(2016)

(2017)

n ND et al. (2014)

Introduction Background/rationale

Objectives

Study design

Setting

Participants

0,5

Variables

Bias

Study size

Quantitative variables

Statistical methods

0,8

0,6

0,4

0,6

Methods

Data sources/measurement

Results Participants

0,33

0,67

0,33

Descriptive data

0,67

Outcome data

Main results

0,33

Other analyses

Key results

Limitations

Interpretation

Generalisability

19,3

17,43

18,94

16,4

19,1

16,16

Discussion

Other Information Funding Total

Effectiveness of Various Health Insurances in Tackling Health Problems of the 21st Century: A Systematic Review Nico Gamalliel1, Reynardi Larope Sutanto1, Mochammad Izzatullah1, Gita Fajri Gustya1 1. Medical student, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

Objective: To investigate the relationship between health insurance and health quality using systematic method. Background: Health insurance can be said has strong relation in achieving Goal 3 of Sustainable Development Goals (SDGs), “Ensure healthy lives and promote well-being for all at all ages”. One of the key factor in reaching ‘healthy lives’ is the access to medical care. Health insurance has been implemented across many countries in order to facilitate access for good quality medical care. Some studies indicated that health insurance have positive effect to improve health quality of patient. Another study indicated there is inverted effect between ownership of health insurance and health quality. The link between health insurance and its ability to tackle health problems therefore should be thoroughly investigated. Methods: Systematic review was conducted using keywords “Insurance, Health”[Mesh] AND “Health Care Quality, Access, and Evaluation”[Mesh] on Pubmed. Afterwards, titles are screened for relevancy and duplication. Contents then were then screened for inclusion criteria, which include studies with publication age less than five years, observational studies, and studies which look upon effects of health insurance on its users’ health, and exclusion criteria, which include inaccessible articles, articles written in foreign languages, and irrelevant articles. A total of 6 suitable studies were included in the final review and were subjected to STROBE analysis. Key Findings:

Increased usage of proper health insurance is related to an increase in overall health outcomes of various diseases, including type 1 Diabetes Mellitus (7% decrease of hyperglycemia on patients with more expensive insurance), acuity of thoracic aortic operations (underinsured patients were at greatest risk of getting acute nonelective operation; OR: 2.67), gastritis (insurance coverage reduce prevalence of H. pylori), cardiac arrest (102/100.000 to 85/100.000 incidence after insurance expansion), albuminuria (higher mortality for individuals without private insurance), and peritonitis (better prognosis for individuals with better insurance). These conditions could be explained by increase in health awareness and accessibility of medication by patients with quality health insurance. This finding could become a basis for governments to highly consider quality insurances as means to improve the health of the nation. Keywords: Health insurance, Healthcare, Quality Healthcare, Health outcome, Prognosis

pcc amsc 2019

scientific poster

bundle of acads amsa-ui 2018/2019

wntd 2019

world no tobacco day

bundle of acads amsa-ui 2018/2019

wntd 2019

scientific paper

bundle of acads amsa-ui 2018/2019

Community-based intervention strategies to reduce tobacco use in Asia: a systematic review of randomized controlled trials ABSTRACT Introduction Tobacco use remains a global health challenge as one-tenth of worldâ&#x20AC;&#x2122;s population consume it regularlyâ&#x20AC;&#x201C;thereby increasing its disease burden. Among all programs implemented, community-based interventions showed great potential, considering its ubiquity and practicableness. However, since tobacco consumptionâ&#x20AC;&#x2122;s prevalence persists, especially in Asia, further reviews are needed. Objective To analyze prior community-based tobacco control programs in Asia and identify potential approaches to be implemented as a mean to reduce tobacco use Methods A systematic review was conducted through PubMed, Scopus, and CENTRAL, searching for randomized controlled trials (RCT) implementing community-based programs to control tobacco usage in Asia. Studies selected were assessed for bias risk with Cochrane riskof-bias tool for randomized trials. Results The search yielded eleven RCTs with a total of 28,805 subjects. Smoking cessation interventions focusing on education and counselling are proven to be effective in reducing tobacco consumption and increasing quit rate. Moreover, prevention programs which include school-based interventions, reduce the likeliness of adolescents to smoke in the future and also prevent further tobacco use in recent youth smokers. Conclusions To conclude, community-based interventions showed promising results to be widely implemented as tobacco control and prevention strategies, helping to raise public awareness towards tobacco hazards and reducing the number of tobacco-related diseases and mortality worldwide. Keyword: community-based, tobacco use, smoking cessation, Asia INTRODUCTION The world has fallen into an alarming pandemic of tobacco use with an estimation of 1 billion smokers worldwide, mainly amounting to 30% of men and 7% of women.1 An epidemiologic study stated that Asia, led by China, is leading tobacco consumption. This enormous prevalence is followed by a massive number of deaths caused by tobacco consumption.2 Tobacco smoking accounts for 6 million premature deaths annually, characterized by loss of 10 years of life expectancy. Morbidities associated with tobacco use

varies from cardiovascular disease (i.e. coronary heart disease, cerebrovascular disease), neoplasm (i.e. lung and upper airways cancers), chronic obstructive pulmonary disease, to miscarriage and fetal anomalies.1 Despite various approaches in overcoming tobacco consumption, its’ prevalence remained relatively high (20.2%).3 These approaches include media advocacy4, increase of tobacco taxes and prices2, smoke-free laws and tobacco regulations2, provision of cessation assistance2, social marketing4 and many more. Among them, media advocacy (e.g. warning labels, social marketing) proves to be the most ubiquitous interventions available.4 Recent studies have shown the effectivity of community-based interventions to control substance use.5,6 Although they are more challenging due to heterogenous communal characteristics, they occur in natural settings and thus highly applicable and representable to populations around the world.7 Community-based framework consists of multidimensionality, coordination in order to successfully reach all communities, and widespread support for nonsmoking behavior. Practically, community-wide initiatives are sought as tobacco regulations (i.e. age-of-purchase law), media utilization, curriculum integration, and smokefree public places.5 In order to establish effective yet practical programs to further decrease tobacco use, we conducted a systematic review to seek out prior community-based tobacco control programs and identify potential approaches to be implemented as a mean to reduce tobacco consumption–which in turn may alleviate disease burdens caused by tobacco. METHODS Search strategy This systematic review of clinical trials is conducted based on PRISMA statement8 and Cochrane Handbook9. We explored PubMed, Cochrane Controlled Register of Trials (CENTRAL), Scopus databases from inception to 23 April 2019 using keywords as follows: “tobacco OR cigarette* OR nicotine", "addict* OR "use* OR usage OR consum* OR intake OR using", "community* OR population* OR peer*", "prevent* OR reduc* OR intervent* OR promot* OR educ*", and “Asia”. The search was limited to human participants and no language restrictions were applied. However, studies included in the review was restricted to Bahasa Indonesia and English, which were the only languages readable by the authors. Details of the literature search strategy are shown on Figure 1. Inclusion and exclusion criteria Inclusion criteria were set to filter the results as follows: (1) study design, randomized controlled trials identifying community-based program implementations to reduce tobacco use;

and (2) study population, healthy subjects with confirmed tobacco use. Conversely, exclusion criteria were also set: (1) irretrievable full-text articles, (2) unknown and/or inappropriate study types and settings, (3) studies using pharmacological interventions, and (4) incompatible language (articles not in English or Bahasa Indonesia). Data extraction and risk of bias assessment Essential data from articles were extracted, including: author and year of publication, study design and location, sample size and mean or range of sample age, intervention implemented, duration of follow-up, and outcome which is picturized by point prevalence of abstinence (PPAs), validated abstinence rate, p value, and any other reported outcome. Lastly, the articles were assessed for risk of bias through Cochrane risk-of-bias tool for randomized trials (ROB 2)10, which consist of 5 domains and illustrated by bias judgements of low (-), high (+), and some concerns (?). Risk of bias assessment was conducted by two reviewers collaboratively and discrepancies were resolved by consensus between reviewers. Appendix 1 provides details of risk of bias assessment of included studies RESULTS Study selection The selection process for included studies in this systematic review is illustrated in Figure 1. The initial search yielded 1716 relevant studies from PubMed, Scopus, and Cochrane Controlled Register of Trials (CENTRAL) databases. Among them, 956 were deduplicated, while the other 893 were excluded after screening the titles and abstracts. In addition, 52 studies were excluded since 16 were not conducted in community settings (e.g. health center, hospital settings), 14 used pharmacological interventions, 13 includes non-healthy participants (e.g. tuberculosis, psychosis), 7 were irretrievable, and lastly 2 were neither in English nor Bahasa Indonesia. At the end, 11 clinical trials were included for qualitative analysis, all of which were randomized controlled trials (RCT).

Figure 1. Diagram flow of literature search strategy for this systematic review

Study characteristics and outcomes The main patient characteristics of included studies in this systematic review are shown in Table 1. A total of 28,805 patients, ranging from adolescents to adults, were recruited in this study, comprising of studies published between 2006 and 2018. All trials are RCT, most of which were clustered, varying from non-blinded to double-blind design. Almost half of the studies were conducted in India, while Hong Kong, Taiwan, Thailand, and China share smaller proportion in this review.

Table 1. Study characteristics and outcomes Author and Year (Cochrane RoB2 Score)

Study Design

Location

Sample Size

Hong Kong

1077 (559 CDTQ, 518 QI)

Wang MP et al12, 2017 (-)

Singleblind, 3arm, pragmatic cluster RCT

Hong R-M et al13, 2017 (?)

Mixedmethod study

Wang MP et al11, 2018 (-)

Cluster RCT

Range/ mean of sample age

Intervention

Duration of followup

42.8 years

Brief advice on smoking reduction using AWARD model

6 months

Hong Kong

1226 (818 I, 408 C)

42.0 years

Active referral and model-guided brief advice about smoking cessation using AWARD model

6 months

Taiwan

100 (50 I, 50 C)

16-20 years

Art therapy interventions

6 weeks

Outcomea

Cut-down-to-quit arm (CDTQ)b Validated abstinence 5.4%; aOR 0.99 (0.58-1.70) Smoking reduction 20.9%; aOR 1.54 (1.11-2.14); P<0.01 Quit attempt 39.8%; aOR 1.07 (0.77-1.49) Quit immediately arm (QI) Validated abstinence 5.6% Smoking reduction 14.5% Quit attempt 41.1% Active referral arm (AR) Response rate 72.9% PPA 17.2%; OR 1.59 (1.07-2.37); P=0.03 Validated abstinence 9.0%; OR 1.81 (1.04-3.16); P=0.04 Smoking reduction 22.9%; OR 0.91 (0.66-1.26); P=0.59 SC service use 25.1%; OR 9.44 (5.29-16.85); P<0.001 Brief advice arm (BA) Response rate 71.9% PPA 9.4%; OR 0.80 (0.51-1.24); P=0.36 Validated abstinence 5.0%; OR 0.98 (0.53-1.82); P>0.99 Smoking reduction 23.3%; OR 0.94 (0.68-1.29); P=0.69 SC service use 2.4%; OR 0.69 (0.30-1.58); P=0.41 Control arm Response rate 72.3% Art therapy effectively reduced smoking addiction (B 7.07, P<0.001) by reducing nicotine dependence (FTND score) (B 2.50, P=0.007), and increasing self-efficacy and selfesteem (B 66.39, P<0.001; B 23.46, P<0.001, respectively)

India

1213 (611 I, 602 C)

46.3 years

Face-to-face quit advice session and single training session on yogic breathing exercises (BA-YBE)

India

6023 (3034 I, 2989 C)

14.4 years

Community-based multi-component tobacco control

Nonblinded RCT

Thailand

201 (132 I, 69 C)

51.06 years

Team commitment contracts: commitment savings account, abstain rewarding system, and weekly follow-up

6 months

Jayakrishnan R et al17, 2013 (+)

Cluster RCT

South India

928 (474 I, 454 C)

44.56 years

Anti-tobacco leaflets and reference guide for tobacco cessation

12 months

Lam TH et al18, 2012 (+)

Singleblinded RCT

Hong Kong

1154 (928 I, 226 C)

42.04 years

Smoking reduction counselling and adherence counselling for NRT

6 months

Sarkar BK et al14, 2017 (?)

Pragmatic cluster RCT

Harrell MB et al15, 2016 (-)

Cluster RCT

White JS et al16, 2013 (-)

6 months

2 years

Abstinence for 6 months 2.6%; aRR 5.10 (1.46-17.84); P<0.01 PPAs 3.1%; aRR 2.87 (0.92-8.93); P=0.07 Breathing exercises are helpful in reducing smoke use (mean 5.2, SD 1.8), and no adverse events were reported Intervention reduced tobacco use (-20.9% vs -3.3%), smoking prevalence (-33.1% vs. -24.6%), and SLT use (37.5% vs. -27.6%) effectively. However, the intervention arm had more susceptibility to smoke (-77.1% vs. -66.7%), to use SLT (-83% vs. -84.1%), and less reduced intention to smoke (-38% vs. -52.2%) and to use SLT (-62.5% vs. 67.5%) compared to that of the control arm Abstinence rate in intervention group (44.3%) better than that of control group (18.8%) with aOR 4.2 (1.8-9.7), P<0.001. The intervention enhanced abstinence by 91136% relative to the control group and offered a viable and cost-effective alternative to smoking cessation approaches in low-resource settings (P<0.001). PPA in intervention group compared to control 14.7% vs. 6.8%; RR 1.85 (1.05-3.25); P<0.05 Intervention successfully reduced smoking by 50% (41.3% vs 13.6%), while also lowering the number of cigarettes (RR, 95%CI = 1.1, 1.01-1.20;P<0.05)/bidi (RR, 95%CI = 1.1, 1.02-1.18;P<0.05) used, nicotine dependence (RR, 95%CI = 1.15, 1.01-1.34;P<0.05), and increasing the number of doctors visit (RR, 95%CI = 2.42,1.503.87;P<0.05) Lower mean daily cigarette consumption (p<0.001) Higher quit rate than controls (17% vs 10.2%, p=0.012) Higher self-reported cigarette reduction â&#x2030;Ľ50% (50.9% vs 25.7%, p<0.001)

Kumar MS et al19, 2012 (+)

Perry CL et al20, 2009 (-)

Cluster RCT

Group RCT

India

366 (181 I, 185 C)

14063 (6365 I, 7698 C)

30.45 years

6th to 8th grade students

Two sessions of health education with self-help material on tobacco cessation

Multicomponent, school-based intervention

2 months

2 years

Higher PPA than control (aOR=2.66, p=0.016) Higher quit attempt (aOR=1.83, p=0.033) Higher harm reduction (aOR=2.79, p=0.003) Significant differences in trajectories of cigarette smoking (p<0.05), bidi smoking (p<0.01), and any tobacco use (p<0.04). Tobacco, cigarette and bidi smoking increased in control population, but decreased in intervention group. Lower intention to chew tobacco (p=0.03) and smoke cigarettes (p<0.01) than control

Chou CP et al21, 2006 (?)

Longitudi nal RCT

China

2454 (1197 I, 1257 C)

12.5 years

School-based smoking prevention program

1 year

No significant primary prevention effect Lower risk of remaining a recent smoker (OR, 95% CI=0.45, 0.23-0.98)

(-), low risk of bias; (?), some concerns; (+), high risk of bias; RCT, randomized controlled trial; I, intervention; C, control; PPA, point prevalence of abstinence; SC, smoking cessation; OR, odds ratio; FTND, Fagerstorm Test for Nicotine Dependence; aOR, adjusted OR; aRR, adjusted relative risk, SD, standard deviation; SLT, smokeless tobacco; BI, brief intervention; BI-FS, brief intervention with family support; SIS, smoking involvement score; BSS+, behavioral support plus 7 wk of bupropion therapy; BSS, behavioral support sessions; aOR/RR (95% CI) between intervention and control group; bAdjusted OR between CDQT and QI arms; NRT, nicotine replacement therapy

DISCUSSION Based on the above included studies, we classified the interventions into 2 main groups, based on the objectives of the trials: interventions aimed for prevention and interventions aimed towards smoking cessation. Both types of community-based interventions mostly showed positive results towards tobacco reduction within a community. Smoking cessation interventions Community-based tobacco cessation interventions have gained popularity over the years, especially in developing countries, due to their accessibility and cost-effectivity. Eight out of eleven studies included in the above review were interventions given to smokers aiming to reduce their tobacco or cigarette consumption as well as to encourage them to quit. The interventions given varied considerably between trials, but mostly focused on counselling or education sessions in which participants were given materials regarding the tobacco-related health problems along with advice on how to quit smoking. Overall, such methods yielded favorable outcomes, mostly shown by a higher rate of abstinence, quit attempt, and cigarette or tobacco reduction. Studies by Wang11, Jayakrishnan17, Lam18, and Kumar19 emphasized solely on health education and counselling. Education materials were given through booklets, leaflets, or delivered directly in sessions. Meanwhile, counselling sessions were carried out either through telephone or face-to-face sessions with a counsellor. The studies by Jayakrishnan17 and Kumar19 showed a higher point prevalence of abstinence (PPA) in intervention group compared to control (RR=1.85 and OR=2.66 respectively). Jayakrishnan17 and Lam18 also showed that the interventions succeeded in lowering the mean number of daily cigarette consumption (p<0.05 and p<0.001 respectively), as well as increasing the proportion of subjects who were successful in reducing their tobacco consumption by more than 50%. These results were consistent with previous large population-based surveys which indicated that smokers with lower level of education were less likely to intend to quit, make a quit attempt, or successful in quitting.22,23 Another study also showed that subjects with higher level of education were more likely to benefit from counselling sessions, as they would have a better comprehension and health knowledge in addition to the psychological support given.24 Integrating both education and counselling methods is therefore important to create effective ways to help individuals quit smoking. Aside from the standard smoking cessation programs mentioned above, several studies adapted additional strategies to aid cessation. Study by Wang et al actively referred smokers to smoking cessation (SC) services in addition to quitting advices given to smokers, so that

subjects could be dealt with more intensively.12 Meanwhile, Hong et al in his study innovated a creative way of combining art therapy into smoking cessation programs, especially targeting adolescents who may perceive traditional cessation programs as boring or useless. Art helps smoking youths express their feelings non-verbally, allowing them to achieve a better sense of self-understanding, better control over self-emotion, and a higher self-esteem, which would psychologically support smokers to cease smoking. Results were promising, with a significant reduction in smoking addiction, nicotine dependence, and increased in self-efficacy and selfesteem in these adolescents.13 Aside from art, a trial by Sarkar et al evaluated the effects of yogic breathing exercises in addition to standard quit advice. Results were again positive, showing a higher cessation rate in the intervention group (RR=5.32, p=0.013).14 This is consistent with a previous study which showed that yogic breathing exercise was effective in reducing cigarette cravings and withdrawal symptoms, possibly through its actions in the insular cortex.25 Incentives, both monetary and social forms, are also found to play a role in enhancing the effectivity of cessation programs. A study by White et al tested the impact of giving monetary incentives to smokers who successfully quit smoking in addition to smoking-cessation counseling. The subjects were grouped in pairs, in which they would receive cash bonus when both individuals succeed to quit smoking, creating a form of social commitment and inducing peer pressure. A significantly higher abstinence rate was found in intervention groups (aOR=4.2, p<0.001).16 These methods mentioned above highlighted the potential of incorporating new, creative ideas into standard non-pharmacological smoking cessation programs in order to further enhance the effectiveness of the interventions. Preventive interventions Three of the studies included in the review focused on smoking prevention programs, which were mostly aimed at adolescents. Harrell15, in his study, investigated the effect of multicomponent intervention, such as youth leader training, peer-led interactive activities, and other strategies which would promote awareness regarding tobacco use among youths. Meanwhile, Perry20 and Chou21 applied school-based smoking interventions. Studies by Harrell15 and Perry20 found that students given intervention were significantly less likely to smoke in the future. Moreover, Chou21 also demonstrated similar results, in which the programs prevent further tobacco use in recent youth smokers, although effects for primary prevention is not significant in his study. From all preventive methods implemented, peer-led activities as well as parental involvement posed as the most successful method to reduce smoking intention (cigarette, p<0.01; chew tobacco, p=0.03) and prevalence (cigarette, p<0.05; bidi, p<0.01;

tobacco use, p<0.04) among adolescents. This may be true since adolescence is a period characterized by acceptability and peer-reinforcements, thereby implying that support from peers and families are highly essential.20 Other than peer-led activities, community-based interactive activities and outreach programs comprising followed by text message campaign also showed reduction in tobacco usage. Psychosocial aspects to control tobacco utilization were also improved, showing remarkable difference between intervention and control group on knowledge about tobaccoâ&#x20AC;&#x2122;s harmful effects (p=0.02), its control policies (p=0.06) as well as increased normative belief to not use tobacco (p=0.036) and motivation to advocate on promoting tobacco-free communities (p<0.001).15 Lastly, anti-smoking social norms and resistance skill training (e.g. public commitment) as implemented by Chou21 showed the least amount of smoking reduction for baseline non-smokers. However, this method is useful to show deterrent effect for recent smokers to quit smoking (OR, 95% CI = 0.45, 0.23-0.98). Both Harrell15 and Perry20 applied social cognitive theory, which contains personal (i.e. self-efficacy support), behavioral (i.e. reinforcement based on operant conditioning), and environmental (i.e. promotion on tobacco-free environment) approaches.26 Both studies also showed significant reduction in the usage of cigarette, bidi, and other tobacco forms, except chewing tobacco.15,20 Chewing tobacco is a smokeless tobacco with a gum-like shape, usually flavored with artificial sweeteners, making it more popular for children and adolescents.20 These approaches provide new, relevant methods to cut down tobacco use especially in low- to middle-income countries in which pharmacological interventions may be unaffordable for such populations. Moreover, since the assistance provided is mostly non-physician based and could be performed by trained community health workers, these non-pharmacological methods are potentially scalable in settings where healthcare system is still lacking with limited access to professional physicians and medications. Study strengths and limitations The strength of this study lies on the fact that most studies included in our review were carried out in developing countries, where socioeconomic and environmental factors are mostly similar, making the results more applicable in Asia. Moreover, samples included in our study is also relatively large. However, this study is not without limitation as inaccessible articles and studies with incompatible languages were excluded. Furthermore, plenty of results in the trials were self-reported outcomes, which may be subjected to memory bias.

Future application and research The result of above systematic review can be further implemented to help guidelinesmaking process to reduce tobacco use since community-based interventions showed great efficacy in reducing the intention to and prevalence of smoking. Furthermore, it is practical, ubiquitous, and cost-effective, thus making it more applicable in resource limited settings. As a preventive mean, it may be implemented based on social cognitive theory (i.e. personal, behavioral, and environmental approaches) by peer-led design and parentsâ&#x20AC;&#x2122; involvements. On the other hand, more researches on community-based prevention need to be conducted in order to identify more diverse preventive methods, as school-based prevention was the only preventive measure available in this study. CONCLUSIONS To conclude, community-based interventions are proven to be effective in preventing and reducing tobacco use in the population, shown by a reduction in cigarette consumption, higher quit rate, quit attempt, and abstinence. Most interventions focused on education and counselling, in an attempt to increase awareness towards smoking health hazards as well as giving useful advices on quitting. Novel strategies, such as art and incentives, can be integrated with these interventions to enhance participation and effectiveness of the programs. Prevention programs of tobacco use, mostly school-based interventions aimed for adolescents, also showed positive outcomes. It may be best implemented by using peer-led design and parentsâ&#x20AC;&#x2122; involvement since adolescence period is characterized by identity exploration, making them demand more acknowledgement and peer-reinforcements. We hope that the results of this systematic review could encourage the implementation of such community-based interventions in the prevention and reduction of tobacco use. Moreover, these approaches are relatively simple, cost-effective and could be performed by community health workers, hence are suitable in low- and middle-income settings. The implementation of such community-based strategies is hoped to raise public awareness regarding tobacco health hazards, encourage further reduction of tobacco use, thus helping to reduce tobacco-related diseases and mortality worldwide. REFERENCES 1. West R. Tobacco smoking: health impact, prevalence, correlates and interventions. Psychol Health. 2017 Aug 3;32(8):1018-36

2. Yang JJ, Yu D, Wen W, Shu X, Saito E, Rahman S, et al. Tobacco smoking and mortality in Asia: a pooled meta-analysis. JAMA Netw Open. 2019;2(3):e191474 3. WHO global report on trends in prevalence of tobacco smoking 2000-2025. 2nd ed. Geneva: World Health Organization; 2018 4. Golechha M. Health promotion methods for smoking prevention and cessation: a comprehensive review of effectiveness and the way forward. Int J Prev Med. 2016;7;7 5. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Preventing tobacco use among youth and young adults: a report of the surgeon general. Atlanta: Centers for Disease Control and Prevention; 2012. 6. Sheikhattari P, Apata J, Kamangar F, Schutzman C, O’Keefe A, Buccheri J, et al. Examining smoking cessation in a community-based vs. clinic-based intervention using community-based participatory research. J Community Health. 2016 Dec;41(6):1146-52 7. Merzel C, D’Afflitti J. Reconsidering community-based health promotion: promise, performance, and potential. Am J Public Health. 2003 Apr;93(4):557-74 8. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097 9. Higgins JPT, Green S, editors. Cochran handbook for systematic reviews of interventions version 5.1.0 [updated 2011 Mar]. The Cochrane Collaboration. 2011. Available from: www.handbook.cochrane.org. 10. Higgins JPT, Sterne JAC, Savović J, Page MJ, Hróbjartsson A, Boutron I, et al. A revised tool for assessing risk of bias in randomized trials In: Chandler J, McKenzie J, Boutron I, Welch V, editors. Cochrane methods. Cochrane Database of Systematic Reviews. 2016;10(Suppl 1). 11. Wang MP, Suen YN, Li WH, Lam CO, Wu SY, Kwong AC, et al. Intervention with brief cessation advice plus active referral for proactively recruited community smokers: a pragmatic cluster randomized clinical trial. JAMA Intern Med. 2017 Dec;177(12):1790-7 12. Wang MP, Li WH, Cheung YT, Lam OB, Wu Y, Kwong AC, et al. Brief advice on smoking reduction versus abrupt quitting for smoking cessation in Chinese smokers: a cluster randomized controlled trial. Nicotine Tob Res. 2017 Dec 13;20(1):67-72 13. Hong R-M, Guo S-E, Huang C-S, Yin C. Examining the effects of art therapy on reoccurring tobacco use in a Taiwanese youth population: a mixed-method study. Subst Use Misuse. 2017;53(4):548-58

14. Sarkar BK, West R, Arora M, Ahluwalia JS, Reddy KS, Shahab L. Effectiveness of a brief community outreach tobacco cessation intervention in India: a cluster-randomised controlled trial (the BABEX trial). Thorax. 2017 Feb;72(2):167-73 15. Harrell MB, Arora M, Bassi S, Gupta VK, Perry CL, Reddy KS. Reducing tobacco use among low socio-economic status youth in Delhi, India: outcomes from project ACTIVITY, a cluster randomized trial. Health Educ Res. 2016 Oct;31(5):624-38 16. White JS, Dow WH, Rungruanghiranya S. Commitment contracts and team incentives: a randomized controlled trial for smoking cessation in Thailand. Am J Prev Med. 2013 Nov;45(5):533-42 17. Jayakrishnan R, Uutela A, Mathew A, Auvinen A, Matthew PS, Sebastian P. Smoking cessation intervention in rural kerala, India: findings of a randomised controlled trial. Asian Pac J Cancer Prev. 2013;14(11):6797-802 18. Lam TH, Chan SS, Abdullah AS, Wong VT, Chan AY, Hedley AJ. Smoking reduction intervention for smokers not willing to quit smoking: a randomised controlled trial. Hong Kong Med J. 2012;18 Suppl 3:4-8. 19. Kumar MS, Sarma PS, Thankappan KR. Community-based group intervention for tobacco cessation in rural Tamil Nadu, India: a cluster randomized trial. J Subst Abuse Treat. 2012 Jul;43(1):53-60 20. Perry CL, Stigler MH, Arora M, Reddy KS. Preventing tobacco use among young people in India: project MYTRI. Am J Public Health. 2009 May;99(5):899-906. 21. Chou CP, Li Y, Unger JB, Xia J, Sun P, Guo Q, et al. A randomized intervention of smoking for adolescents in urban Wuhan, China. Prev Med. 2006 Apr;42(4):280-5 22. Zhuang Y-L, Gamst AC, Cummins SE, Wolfson T, Zhu S-H. Comparison of smoking cessation between education groups: findings from 2 US national surveys over 2 decades. Am J Public Health. 2015 Feb;105(2):373-9 23. Reid JL, Hammond D, Boudreau C, Fong GT, Siahpush M, ITC Collaboration. Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: findings from the International Tobacco Control Four Country Survey. Nicotine Tob Res. 2010 Oct;12(Suppl1):S20-33 24. Wu L, He Y, Jiang B, Zuo F, Liu Q, Zhang L, et al. Relationship between education levels and booster counselling sessions on smoking cessation among Chinese smokers. BMJ Open. 2015;5(8):e007885

25. Shahab L, Sarkar BK, West R. The acute effects of yogic breathing exercises on craving and withdrawal symptoms in abstaining smokers. Psychopharmacology (Berl). 2013 Feb;225(4):875-82 26. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:126

Appendix 1. Risk of bias assessment of studies included in this review. Description/Support for judgement Bias domain

Signaling questions

Bias arising from the randomization process

1.1 Was the allocation sequence random?

Domain 2: Risk of bias due to deviations from the intended interventions (effect of assignment to intervention)

1.2 Was the allocation sequence concealed until participants were enrolled and assigned to interventions? 1.3 Did baseline differences between intervention groups suggest a problem with the randomization process? Risk of bias judgement 2.1. Were participants aware of their assigned intervention during the trial? 2.2. Were carers and people delivering the interventions aware of participants' assigned intervention during the trial? 2.3. If Y/PY/NI to 2.1 or 2.2: Were there deviations from the intended intervention that arose because of the experimental context?

Response options

Y / PY / PN / N / NI Y / PY / PN / N / NI Y / PY / PN / N / NI -/+/? Y / PY / PN / N / NI Y / PY / PN / N / NI NA / Y / PY / PN / N / NI

Wang MP, 2018

Wang MP, 2017

Hong R-M, 2017

Sarkar BK, 2017

Harrell MB, 2016

White JS, 2013

Jayakrishnan R, 2013

Lam TH, 2012

Kumar MS, 2012

Perry CL, 2009

Chou CP, 2006

2.4. If Y/PY to 2.3: Were these deviations from intended intervention balanced between groups?

NA / Y / PY / PN / N / NI

2.5 If N/PN/NI to 2.4: Were these deviations likely to have affected the outcome?

NA / Y / PY / PN / N / NI

2.6 Was an appropriate analysis used to estimate the effect of assignment to intervention?

Y / PY / PN / N / NI

Domain 2: Risk of bias due to deviations from the intended interventions (effect of adhering to intervention)

Bias due to missing outcome data

2.7 If N/PN/NI to 2.6: Was there potential for a substantial impact (on the result) of the failure to analyze participants in the group to which they were randomized?

NA / Y / PY / PN / N / NI

Risk of bias judgement 2.1. Were participants aware of their assigned intervention during the trial?

-/+/? Y / PY / PN / N / NI

2.2. Were carers and people delivering the interventions aware of participants' assigned intervention during the trial? 2.3. If Y/PY/NI to 2.1 or 2.2: Were important co-interventions balanced across intervention groups? 2.4. Were there failures in implementing the intervention that could have affected the outcome? 2.5. Was there non-adherence to the assigned intervention regimen that could have affected participantsâ&#x20AC;&#x2122; outcomes? 2.6. If N/PN/NI to 2.3 or 2.5 or Y/PY/NI to 2.4: Was an appropriate analysis used to estimate the effect of adhering to the intervention? Risk of bias judgement 3.1 Were data for this outcome available for all, or nearly all, participants randomized? 3.2 If N/PN/NI to 3.1: Is there evidence that the result was not biased by missing outcome data? 3.3 If N/PN to 3.2: Could missingness in the outcome depend on its true value?

Y / PY / PN / N / NI NA / Y / PY / PN / N / NI Y / PY / PN / N / NI Y / PY / PN / N / NI NA / Y / PY / PN / N / NI

3.4 If Y/PY/NI to 3.3: Is it likely that missingness in the outcome depended on its true value? Risk of bias judgement

-/+/? Y / PY / PN / N / NI NA / Y / PY / PN / N NA / Y / PY / PN / N / NI NA / Y / PY / PN / N / NI -/+/?

Bias in measurement of the outcome

Bias in selection of the reported result

4.1 Was the method of measuring the outcome inappropriate? 4.2 Could measurement or ascertainment of the outcome have differed between intervention groups? 4.3 If N/PN/NI to 4.1 and 4.2: Were outcome assessors aware of the intervention received by study participants? 4.4 If Y/PY/NI to 4.3: Could assessment of the outcome have been influenced by knowledge of intervention received? 4.5 If Y/PY/NI to 4.4: Is it likely that assessment of the outcome was influenced by knowledge of intervention received? Risk of bias judgement 5.1 Were the data that produced this result analyzed in accordance with a prespecified analysis plan that was finalized before unblinded outcome data were available for analysis? Is the numerical result being assessed likely to have been selected, on the basis of the results, from... 5.2. ... multiple outcome measurements (e.g. scales, definitions, time points) within the outcome domain? 5.3 ... multiple analyses of the data?

Y / PY / PN / N / NI Y / PY / PN / N / NI Y / PY / PN / N / NI NA / Y / PY / PN / N / NI NA / Y / PY / PN / N / NI -/+/? Y / PY / PN / N / NI

? +

Y / PY / PN / N / PN PN N N N N PN NI Y / PY / PN / N / N N PN N N N PN NI Risk of bias judgement -/+/? ? ? + Overall bias Risk of bias judgement -/+/? Y, yes; PY, probably yes; PN, probably no; N, no; NI, no information; NA, not available; +, high risk of bias; ?, some concerns; -, low risk of bias

wntd 2019

public poster

bundle of acads amsa-ui 2018/2019

TRUTTIES: Throw and Replace Cigarettes with Fruits and Veggies Background Our poster described the truth that is happening in our environment around us. Cigarette smoking has been something that is very common, however there seems to be little to no benefit at all for human’s health. Nicotine, has been studied as one of the causative factors in tobacco smoke. Carcinogens in cigarette smoke have been implied to be one of the most leading factors for cancer.1 In a research directed by Group Health Center for Health Centre in USA, the study found that smokers have poorer diets than non-smokers. In the research, they stated that smokers consumed less fruits and vegetables than non smokers and fewer smokers actually manage to meet the CDC’s Minimum 5 A Day recommendation.2 This clearly concludes that without enough consumption of fruits and vegetables, supported by smokers’ habit of cigarette smoking, illness will be a lot easier to invade the smoker’s body. The most important thing that smokers can do to improve their health and protect them is, of course, to stop smoking permanently. However, almost all smokers know how difficult it is to get out from the addiction of tobacco smoking. Therefore, smokers have to be encouraged to make other lifestyle changes, including eating more fruits and vegetables.2 Eating more fruits and vegetables have been proven to bring many health benefits. These health benefits include decreased blood pressure, improved weight management, and decreased risk of diabetes type II, stroke, and certain type of cancers. Smoking is known to be one of the leading factors of those diseases. Therefore the health benefits from consuming fruits and vegetables and with the addition of taking certain dietary supplements, underlines the importance of smokers to eat (and better off replacing it with) the ideal amount of fruits and vegetables.2 Objective Smoking addiction has been a deadly health problem for a long time and is responsible for the deaths of six million people each year across the globe. Many of these deaths occurred prematurely and more than 41,000 people died as a result of secondhand smoke.3,4 One substance that is well known for inducing addiction to smoking is nicotine.2 It generates strong urges to smoke despite knowing the negative consequences of smoking, this prevents smokers from quitting their habits.1 Cigarette smoking became a modifiable risk factor for many diseases especially cancer and organ system related diseases, but remains as a common habit found globally.5

There are various efficacious interventions for cessation of smoking, both pharmacologic and non-pharmacologic therapies. With the abundance of effective therapies to stop smoking, commitment from health and public health workers to promote smoking cessation is required in order to reduce both smokers and non-smokers’ exposure to tobacco smoke.4 As mentioned before, smoking cause various diseases regarding organ system and cancers. Therefore, approaches to put an end to smoking habits should be accompanied by healthy habits. In this poster, we proposed a solution to cease smoking habits by replacing cigarette smoking with healthy habits including consuming fruits and vegetables. Fruits and vegetables are known as an excellent source of vitamins and minerals, dietary fibres, and also reduce the risk of getting various diseases.6 They contribute to a healthy, balanced diet and their delicious taste could be a solution to overcome the unpleasant taste of cigarettes. With this poster, we hope to increase awareness of the global community about the dangers of smoking and propose a solution to stop the habit. As outlined in the acronym "TRUTTIES" which means “Throw and Replace Cigarettes with Fruits and Veggies”. Content The enthusiasm that this poster wants to bring is collected in the form of an acronym "TRUTTIES" which is short for "Throw and Replace Cigarettes with Fruits and Veggies". This poster encourages smokers to switch their smoking habits to a healthy, balanced diet by eating fruits and vegetables. Therefore, the centerpiece of this poster is half cigarette with a dark background and half fruits with a light background. The dark background illustrates the bad effects of smoking and the possibility of a dark future awaiting smokers. Whereas, the bright background represents the bright future as a result of beneficial substances from fruits and vegetables consumption. Other than the background, we picked the color palette for the main topic “TRUTTIES” with bright pop color, which represent the positive effects of eating vegetables and fruits. Tobacco smoking influenced the body in myriad ways, generating the development of cancers and chronic organ system diseases. Tobacco in cigarettes are transported from lungs to bloodstream and spread systemically.6 Organ system diseases which are the consequences of tobacco smoking include asthma, chronic obstructive pulmonary disease (COPD), periodontitis, delayed conception, hip fractures, pneumonia, fetal deaths, cataracts, stillbirths, low bone density, and many more.7 Cross sectional studies conformably find that tobacco smokers consume less fruits and vegetables each day than nonsmokers do, even though the health benefits of consuming fruits and vegetables outweighs the pleasure of smoking. Diet rich in vegetable and fruits shows a

significant reduction in the risks of getting cancers in the lung, stomach, colorectum, breast, and bladder.8 Chronic organ system diseases such as hypertension, stroke, coronary heart disease, COPD, and asthma, also have significant evidence that increasing the consumption of fruits and vegetables decreases the risk of the disease. There is also a probable evidence that it will prevent body weight gain, which is a risk factor for type 2 diabetes.9 Conclusion Smoking has been a global problem and will always be one of the biggest leading factors of chronic organ system diseases and cancers if they never try to stop their desire to smoke. Reducing their risk to have the diseases means to change their lifestyle and will lead them to a better health. This type of change must be really difficult knowing the addictive contents that cigarette smoking has. Therefore, a small step toward a brighter future is needed. Desire often greatly affects one's mindset to persistently continue their habit or switch it to an ideal lifestyle. Thus, with this poster that we made by thoughtful concepts and wellresearched sources, we aim to open the eyes of cigarette smokers to at least try replacing their usual smoking habit by taking fruits or vegetables (or both) every time they have the urge to smoke. A simple act of change could be a way to invest a long and healthy life. References 1. Maritz GS, Mutemwa M. Tobacco smoking: patterns, health consequences for adults, and the long-term health of the offspring. Global journal of health science. 2012 Jul;4(4):62. 2. West R. Tobacco smoking: Health impact, prevalence, correlates and interventions. Psychol Health. 2017 Aug;32(8):1018-36. 3. McClure JB, Divine G, Alexander G, Tolsma D, Rolnick SJ, Stopponi M, Richards J, Johnson CC. A comparison of smokers' and nonsmokers' fruit and vegetable intake and relevant psychosocial factors. Behavioral Medicine. 2009 Apr 1;35(1):14-22. 4. WHO global report on trends in tobacco smoking 2000-2025 - First edition [Internet]. Geneva: World Health Organization; 2015 Mar 13 [cited 2019 May 14]. Available

from:

https://www.who.int/tobacco/publications/surveillance/reportontrendstobaccosmok ing/en/ 5. Health effects of secondhand smoke [Internet]. Chicago: American Lung Association; 2019 Apr 4 [cited 2019 May 14]. Available from: https://www.lung.org/stopsmoking/smoking-facts/health-effects-of-secondhand-smoke.html

6. Onor IO, Stirling DL, Williams SR, Bediako D, Borghol A, Harris MB, et al. Clinical effects of cigarette smoking: Epidemiologic impact and review of pharmacotherapy options. Int J Environ Res Public Health. 2017 Oct; 14(10): 1147. 7. Why 5 a day? [Internet]. London: Department of Health and Social Care (DHSC); 2018 Oct 8 [cited 2019 May 15]. Available from: https://www.nhs.uk/live-well/eatwell/why-5-a-day/ 8. Riboli E, Norat T. Epidemiologic evidence of the protective effect of fruit and vegetables on cancer risk. The American journal of clinical nutrition. 2003 Sep 1;78(3):559S-69S. 9. Boeing H, Bechthold A, Bub A, Ellinger S, Haller D, Kroke A, Leschik-Bonnet E, MĂźller MJ, Oberritter H, Schulze M, Stehle P. Critical review: vegetables and fruit in the prevention of chronic diseases. European journal of nutrition. 2012 Sep 1;51(6):637-63.

QUITTING STARTS WITH YOU!

ABSTRACT Tobacco use is arising as a global pandemic with approximately up to one-fourth of worldwide population becoming its victims. This enormous prevalence is accompanied with its significant mortality rate, where one in ten deaths around the world is associated tobacco consumption. Furthermore, its mortality rate is predicted to increase to 8.3 million deaths by 2030. Among all countries, China, India, and Indonesia led tobacco usage, thereby establishing Asia as the most contributable region in terms of prevalence. The ubiquity of tobacco use signifies the urge to implement programs to cease smoking in order to reduce the risk of developing tobacco-associated diseases. Smoking, which is the most prevalent form of tobacco, increases the risk of developing lethal diseases by several times folds. Morbidities associated with smoking include non-communicable diseases (i.e. cardiovascular diseases, cancer, respiratory diseases) as well as infectious diseases (i.e. tuberculosis, pneumonia, respiratory tract infections). Among them, cancers (lip, oropharyngeal, larynx, lung) and cardiovascular disease (coronary heart disease, stroke) stand out, contributing to two-third of worldwide mortality cause. Therefore, through this public poster, authors propose “STOP” as a potential solution to cease smoking. First, “S” stands for substituting the urge to smoke with healthy and positive activities. By doing so, the intention to smoke will be diverted by doing something positive, thus decreasing the urge to smoke. Then, “T” encourages people to try nicotine replacement therapies (NRT). Since some people may find it difficult to quit nicotine addiction, NRT, such as gum, transdermal patch, nasal spray, and inhaler, may ease the transition from cigarette smoking to complete abstinence–increasing abstinence rate by 150 to 200%. Third, “O” is for organizing and calling for reinforcement, such as counselling with professionals. Counselling conducted with professional may include practical counselling for problem-solving skills and emotional support. Last, “P” encourages people to practice saying no. The act of smoking begins with self-intention, even if triggered by environmental factors. Therefore, forcing oneself to resist smoking plays a major role in reducing smoking prevalence.

As smoking ceases, the risk to develop associated diseases diminishes greatly, eventually returning to non-smoking rates in several years. Furthermore, it may prevent premature death by at least 10 years and increase quality of life. To conclude, authors hope that STOP will be effective in reducing smoking prevalence as a mean to alleviate its burden on disease burden worldwide.

REFERENCE 1. West R. Tobacco smoking: health impact, prevalence, correlates and interventions. Psychol

Health. 2017 Aug 3;32(8):1018-36 2. Yang B-Y, Dong G-H. Tobacco smoking in Asiaâ&#x20AC;&#x201C;a public health threat. JAMA Netw Open.

2019;2(3):e191471 3. Behavioural science learning modules: encouraging people to stop smoking. Geneva: World

Health Organization; 2001 4. Wadgave U, Nagesh L. Nicotine replacement therapy: an overview. Int J Health Sci

(Qassim). 2016 Jul;10(3):425-35 5. Dunbar MS, Scharf D, Kirchner T, Shiffman S. Do smokers crave cigarettes in some

smoking situations more than others? situational correlates of craving when smoking. Nicotine Tob Res. 2010 Mar;12(3):226-34 6. Reid RD, Pritchard G, Walker K, Aitken D, Mullen K-A, Pipe AL. Managing smoking

cessation. CMAJ. 2016 Dec;188(17-18):E484-92

DON’T LET YOUR BUTT OUT! ABSTRACT By Daniell Edward Raharjo Countless efforts have been done to mitigate and eventually abolish the use of harmful cigarettes, the most common form of tobacco used in society. Posters depicting the grotesque effects of smoking, schoolchildren being taught about it, and nauseating pictures of lung cancer patients labeled with “smoking kills you” on cigarette packs are just a few of the efforts done to stop people form smoking. Amidst all these, statistics still show a rampant use of cigarettes to this day, although trends show the use has been declining marginally. According to WHO there are still 1.1 billion smokers around the globe, with half of those predicted to die due to smoking-related complications. How can this still be the case? Many people are well aware of the lethality of smoking, especially smokers who read how it may kill them everytime they try to get a smoke, yet in the end they still do it anyway and harm themselves and those around them. This is clearly a problem that must be dealt with vigorously. It is evident that new strategies must be established to accelerate the world’s trajectory to a global community free of cigarette smoke and other forms of tobacco. Seeing how things are, we should solve this problem by observing the root of tobacco’s problem: addiction. Nicotine supplied by smoking stimulates nicotinic cholinergic receptors in the brain, triggering the release of dopamine which then causes feelings of relaxation. The brain becomes accustomed to the higher levels of circulating dopamine and become tolerant, creating a vicious cycle of addiction in which the smoker needs even more nicotine to feel normal and functional again. This cycle is very difficult to break as anytime they try to quit, very debilitating withdrawal symptoms appear and coax them to smoking again. Thus, being aware of how immensely challenging it is to stop addiction, policies and strategies to prevent addiction from occuring in the first place should become main priority while maintaining aid to those seeking to relinquish their tobacco addiction. To help prevent addiction to smoking from occuring altogether, we must first note the underlying reasons why people begin cigarette smoking in the first place. Research shows that influence from close relatives and peers play some of the most important roles in smoking initiation, with studies suggesting that children of parents who smoke are much likelier to smoke later on themselves—twice that of children whose parents did not smoke. Being

surrounded by a group of people who smoke also create peer pressure, pushing non-smoking children and adolescents to try out smoking, until they finally become addicted. This combined with low socioeconomic status, mental health problems, and a desire to ‘rebel’ become the most important factors to smoking initiation. From here, we can observe another cycle forming, one that is less physiological and more sociological. People who smoke serve as a driving force within their social circles—their family and friends, increasing the likelihood of non-smokers to start smoking themselves. Children and teenagers who see their parents smoking routinely may see it as something interesting to try out amidst all the warnings they may have heard before. A boy might try out smoking in fear of feeling left out by his friends who smokes. “If they can do it, so can I” is one of the mentalities beginning smokers use to justify trying out smoking, not knowing it will bring them down to a difficult to escape addicition. Once they start smoking, then they become the new driving forces within their groups. They will be the ones others may be tempted to follow or be the ones pressuring others to start. This is the cycle we must break to prevent more people from becoming addicted and entrenched in the grip of tobacco. One of the simplest methods that can be established is to prevent smokers from smoking in front of other people, especially non-smokers. Not only does this evade the non-smokers from the harmful effects of second-hand smoking, it also prevents them from having that initial curiosity of trying out cigarettes. Laws and regulations should be created and enforced to prevent people from smoking in public areas. So far only some countries have established smoking bans, such as the United Kingdom, Canada, Slovakia, and Australia, with these countries showing some of the lowest prevalence of smokers worldwide. By preventing nonsmokers from being exposed to smokers, we can effectively decrease the incidence of smoking initiation by breaking the cycle of smokers triggering others to start smoking.

academic amsa-ui 2018/2019