Indonesia 2006 Depok - World Health Organization

MONITORING and EVALUATION of the INTEGRATED COMMUNITY-BASED INTERVATION for the PREVENTION of NONCUMMUNICABLE DISEASES in DEPOK, WEST JAVA, INDONESIA

General contacts information for this study : Ekowati Rahajeng Phone : 6221 – 4244693 Email : ekowatir@ yahoo.com [email protected] [email protected] [email protected] i

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

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

Principal Investigator: Ekowati Rahjeng, PHD

Co-Investigator: Nunik Kusumawardhani, MSc

Consultant: Stephanus Indradjaja, MD. PHD

Institutional Address : National Institute Health Research and Development Ministry of Health Indonesia Jalan Percetakan Negara 23 A Jakarta Pusat Indonesia Telpon/Fax : 6221 – 4244693 General contacts information for this intervention study: Ekowati Rahjeng Email: [email protected] [email protected] Nunik Kusumawardani Email : [email protected] [email protected] iii

ABBREVIATION AC

Air Conditioning

BKKBN

Family planning board

BMI

Body Mass Index

Puskesmas (CHC)

Community Health Center

DM

Diabetes Mellitus

DPRD

Local Peoples Representative Assembly

HDL

High Density Lipoprotein

LDL

Low Density Lipoprotein

PSP (KAP)

Knowledge Attitude and Practice

MSG

Mono Sodium Glutamate

NGO

Non Governmental Organization

Kabupaten

District

Kelurahan

City Block (in rural areas : Village)

Kota

City /Municipality

PTM (NCD)

Non Communicable diseases

Posbindu

Integrated Health Service and Promotions Post

RT

City neighborhood (under RW)

RW

Village Block (under kelurahan)

SD

Elementary School

SLTP

Junior High School

SLTA

Senior High School

Tuak

Traditional alcohol drink of Indonesia

WHR

Waist Hip Ratio

Yandu PTM

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

iv

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

Page iv v vii ix xi

1. INTRODUCTION 1.1 Background 1.2 The purpose of the study 3. The benefit of study

1 1 2 3

2. STUDY DESIGN 2.1 Goal and objectives 2.1.1 Goal 2.1.2 Objectives 2.2 Type of study design 2.2.1 The intervention area 2.2.2 Target population 2.2.3 Evaluation design

3 3 3 3 3 4 4 4

3. PLANNING 3.1 Situation analysis 3.1.1 Geographic aspect 3.1.2 Demographic aspect 3.1.3 Socioeconomic condition 3.1.4 Socio-cultural aspect 3.1.5 Health system development 3.1.6 Local health office program 3.1.7 Health seeking behaviour of the community 3.1.8 Health city forum of Depok 3.2. Community diagnosis 3.3. Intervention strategy. 3.3.1 Concept development of strategy 3.3.2 The main of strategy intervention 3.3.3 Frame work of CBI

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

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

31 31 32 44 44 44 44 45 47

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

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

6. CONCLUSION 7. RECOMMENDATION

66 67

vi

List of Table Table 1. Difference of mean score of knowledge test in pre and post training 2004 Table 2. Difference of mean score of knowledge test in pre and post training 2005 Table 3. Ratio of ‘Posbindu PTM’ at the selected Villages in Depok……………... Table 4. Target achievement of Posbindu PTM by budgeting system applied ……… Table 5 Target achievement of Posbindu PTM by Constraints which found in implementation…………………………………………………………… Table 6. Target achievement of Posbindu PTM by Constraints which found in Counseling activity…………………………………………………………. Table 7 Target achievement of Posbindu PTM by Knowledge and Skill of Health volunteers……………………………………………………………………… Table 8. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2003 ………………… Table 9. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2004 …………………. Table 10. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2005 …………………. Table 11 . Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2006 …………………. Table 12. Percentage who currently smoke tobacco daily ……………………… Table 13. Average age started smoking (years) for those who smoke tobacco daily Table 14. Average years of smoking ……………………………………………. Table 15. Percentage smoking manufactured cigarettes ………………………… Table 16. Mean number of Cloves manufactured cigarettes smoked per day ……. Table 17. Mean number of Non-Cloves manufactured cigarettes smoked per day Table 18. Percentage of Abstainers (who did not drink alcohol in the last year) … Table 19. Mean number of servings 0f fruit consumed per day ………………….. Table 20. Mean number of servings of vegetable consumed per day ……………. Table 21. Percentage who ate 5 or more combined servings of fruit & vegetables per day ……………………………………………………………….. Table 22. Percentage with low levels of activity (defined as = 30.0 kg/M2 3) Central obesity, which is calculated by waist-hip ratio (WHR), was defined as WHR >= 1 for men and WHR >= 0.85 for women. 4) Hypertension was determined as systolic blood pressure >=140 mg/Hg and/or diastolic blood pressure >= 90 mm Hg. 5) Hypercholesterolaemia was defined as a total cholesterol concentration of >= 6.5mmol/L, while borderline hypercholeterolaemia was defined as a total cholesterol concentration of >= 5.2mmol/L. 6) Diabetes mellitus was defined on the basis of measurement of venous blood glucose concentration, after on overnight fast of 10-14 hours which was >= 7mmol/L, and measurement of two hours after a 75 gr. oral glucose load which was >=11mmol/L. Weighting process was applied to calculate the mean value and prevalence/proportion of NCD risk factors. Weight was calculated according to: 1) Cluster (village) inclusion probability out of all clusters available in Depok city (W1) 2) The non response rate for each strata of STEPS (W2S1-3) 3) Sample proportion to population was based on stratum of age group and sex (W3). In weighting data analysis for outcome evaluation, all data was calculated base on standard population size, which was taken from Depok population on stratum of age group and sex distribution on the middle years of intervention time period it was on 2004. Level of Confidence Interval 95% was used to estimate the significance of deference of the intervention result. The whole process of data management and analysis used WHO STEPS Data Analysis Manual. Primary Sampling Unit (PSU) was determined base on inclusion probability of RW (block village unit), while the stratum was determined base on age group and sex.

15

3. PLANNING 3.1 Situation analysis 3.1.1 Geographic aspect Depok is one of 433 districts in Indonesia and one of the fast growing cities in West Java Indonesia, The location of Depok is directly under boundary of Jakarta, and as a buffer area to alleviate the high population growth in Jakarta, the capital city. The distance between and Jakarta is approximately 30 Km (see attachment 1 figure 1.Map of Depok). Depok, as a new autonomy city, was established on April 27, 1999 and has already started applying decentralization approach for local government system. Previously, Depok was part of Bogor district. In administrative point of view, the location of Depok is a strategic, especially in consideration of political aspect, economy, social cultural, and safety. Depok is directed to be a residential area in which working opportunity is more equally distributed, as stated in the President’s instruction number 13 in 1976, regarding the area development of Jakarta-Bogor-Tangerang-Bekasi. Instead of residential area, Depok was now growing into trading city, centre of education and services as well.17 Geographically, Depok is located on the coordinate of 6o19’00” - 6o28’00” South and 106o43’00”- 106o55’30” East side, with area of 200,29 km2. Borderline of the Depok area consists of : - Northern area : in the border with DKI Jakarta and sub district of Ciputat, District of Tangerang. - Southern area : in the borderline to sub district of Bojong Gede and Cibinong in Bogor district. - Western area : in the borderline to sub district of Gunung Sindur and Parung in Bogor district. - Eastern area : in the borderline with sub district of Gunung Putri, Bogor dan Pondok Gede in Bekasi Depok consists of 6 sub districts, which in total has 63 villages, 801 administrative units and 4200 neighborhoods block. The 6 sub districts include Sukmajaya, Beji, Pancoran Mas, Cimanggis, Limo, and Sawangan. Sub district of Swingman has the largest number of villages, 14 villages, followed by coming’s which has 13 villages, Sukmajaya and Pancoran Mas each has 11 villages, Limo has 8 villages, and Beji has 6 villages. Those number of villages shows that the population distribution in each village in Depok has not equally distributed, as well as the number of population in each sub district. Although, almost all the villages have became a self-determining village, and each village has similar characteristic. (see attachment 1, Figure 2. Map of village and sub district in Depok, and Graph 1.number of Population per sub district). The location of NCD risk factor surveillance was in village of Abadijaya, which was located in sub district of Sukmajaya.

16

Area characteristic of Depok is varies. Depok has urban areas including exclusive residential areas such as real estate, and rural areas, educational area, industrial and trading areas. Meanwhile, some part of Depok is rural areas, which include village areas, farm and poultry areas (see attachment 1, Graph 1. Distribution of land use in Depok) . 3.1.2 Demographic aspect Demographically, based on data from Statistical Bureau during 2000-2004 the population size and density of Depok are as follow: − In 2000 : 973.036 people; population density : 4.858 people/Km2. − In 2001 : 1.204.684 people; population density : 6.015 people/Km2. − In 2002 : 1.247.233 people; population density : 6.227 people/Km2. − In 2003 : 1.335.734 people; population density : 6.669 people/Km2. − In 2004 : 1.369.461 people; population density : 6.837 jiwa/Km2. Population in Depok has significant migration level, and the population size was bigger every year. The descriptions of migration in Depok are as follow: − In year 2000, number of new comers was 52.383 people, while number people who migrate was 8892 people. − In year 2001, number of new comers was 7066 people, while number people who migrate was 2721 people − In year 2002, number of people who move in was 9418 people, while number people who migrate was 2753 people − In year 2003, there was 19950 people move in and 7419 people migrate. − In year 2004, there was 11899 people move in and 4503 people migrate Life expectancy in Depok was 71.8 years in 2002, which was the highest compare to other districts in West Java. The high achievement of life expectancy is closely related to the decline of Infant Mortality Rate (IMR) in Depok. The IMR, that indirectly calculated by the Depok Statistical Bureau, was 24.90/1000 life birth in 2004. During 2001 to 2004, the IMR in Depok was a significantly decreased. The IMR was decline from 44.67/1000 life birth in 2001 to 44.20/1000 life birth in 2002, 33.38/1000 life birth in 2003, and 24.90/1000 life birth in 2004. In 2003, the education participation was fairly high in Depok. The percentage of junior high school was 75.1% among the population age 10 years above, while the average school year was 10 years. Most of the Depok citizen was working as a government employee. Recent policy of early retirement lead to productive or potential retired population, who able to voluntarily working on health development as well on economy and education in their area.

17

3.1.3 Socioeconomic condition A report by Indonesia Statistical Bureau, Institute of National Development, and UNDP in 2004, the Human Development Index (HDI) in Depok in 2002 was in the highest rank among other districts in West Java, and in number 11 compare to national level. However, the purchasing power index was lower than the other HDI (such as education and life expectancy). This is showed by very low consumption capacity per capita, as showed on attachment 1, Graph 3. Meanwhile, the economy growth rate of Depok was increasing, based on the development parameter as shown on Graph 3. However, the biggest contribution of economy growth rate was on consumption, not infestation. Population distribution based on GINI ration was 0.152 on 2001, 0.121 on 2002, and 0.281 on 2003 (see attachment 1, Graph 2a). In this case, the purchasing power parity was fairly hard in purchasing other life standard commodity. Local commodity for economic development in Depok are food and drink industries, textile industries, house ware industries, machinery industries. During 20002003 chemical industries had given most vital contribution to Depok’s economic development. Meanwhile, textile industry was the biggest industry during 2003 – 2004. There are several types of market in Depok, modern market (16 units), traditional market (9 units), and open market (4 units). Regarding district budgeting for Depok, the financial sources were from real district income, and other income including tax, non tax, general allocation budget, specific allocation budget, provincial budget, national budget and other official district income. In 2003, the highest regional/district income was from public budget allocation, as much as Rp 209.550.000.000,00, with the total income was Rp389.586.439.710,16. In 2004 the total income was Rp458.730.058.473,53, which mostly from district budget income (Rp.264.268.717.275,00). The budget was mostly spent for public need (education, health, economy, infrastructure, and others) and for government necessity. Highest amount of budget allocated from the Regional Expenditure Revenue for District level in 2003 was on health sector (Rp.39,722,000,-) while the lowest amount was for education sector (Rp 13.841.682,00). In 2004 the biggest amount was allocated for education (Rp. 7.825.429.200,00), while it was lower (Rp260.992.000,00.) for health. Meanwhile the budget from National Expenditure Revenue in 2003 for Depok, the biggest was for education (Rp4.293.078.000,00), and only Rp. 70.580.000,00 for health, while in 2004 the budget for health was higher than 2003 (Rp 5.500.000.000,00). The detail figure of budget allocation for Depok can be seen on attachment 1(Graph5,6,7)

3.1.4 Socio-cultural aspect

18

Depok has heterogeneous community with variety of ethnic and cultural. Approximately 90% of 26 ethnics in Indonesia were available in Depok. The highest proportion was Java, Sunda, Betawi, and Minang. Cultural aspect is one of the important parts in city development. As typical of metropolitan city, Depok is open city and has specific economic power for investor and visitor. From the ethnic point of view, Depok has various kind of ethnicity. Mainly, there are two different groups, local or native citizen and visitor. Visitors are differed by migration motivation. There were some people migrate from Jakarta to Depok due to economy condition or known as socio urban movement. Other type of visitors was those who move to Depok because of their demand to live in Depok as they work mostly in Jakarta. Based on those typical characteristic, it can be determined that the native population is from Dutch generation while the first type of visitors are from Betawi ethnic in Jakarta and the 2nd type is from out side Jakarta with huge variation of ethnicity (suku jawa, sunda, minang etc). Those three groups are basically influenced by social cultural development of metropolitan city. Relationship within the community in Depok still remains close to each other and help each other as one big family. Alike Indonesian tradition in general, Depok society like to have group activity for any social or religious event, such as religious club, neighborhood club, elderly association, sport association, or particular Indonesian ethnic association, and others. Influences of cultural aspect on health and economic that is specifically felt by the community in Depok were behavior aspect and motive of achieving wellbeing for all. Sense of belonging as a Depok citizen can be as a measure to achieve wellbeing for all. For example, activities on poverty elimination not actually involve cohesive social intra strata. For those who have higher economy status was able to help the poor and vice versa. Helping each other is a cultural basis which is in fact become very rare at the moment. Indonesian women culturally have equal position to men in improving family welfare. This also occurred among Depok women, especially a housewife, who has a vital role in the family and the neighborhood environment. In the family, a housewife can also be a household educator, household planner, and manager for the household financial. Within the neighborhood environment, women have significant contribution in community welfare through actively involve and organize the neighborhood activities and organization. The famous women association that available almost in every village in Indonesia is “PKK” (Family Welfare Educator). All women can joint the ‘PKK” group, and usually the “PKK” is coordinated by the wife of government and military employee. Leadership structure of this organization is based on the structural position of their husband in all administrative level of the government office, starting from district level, sub district, village, administrative unit, and neighborhood block. The organization has routine monthly

19

meeting in village level, when all members participate for the coordination meeting and capacity building training. The capacity building mostly consists of knowledge and skill improvement for family welfare includes family health status improvement. Women who actively joint the “PKK” usually have better capacity in enhancing community welfare and well known in the surrounding community. Therefore, this organization has been utilized as the entry point of promoting health including community based NCD risk factors prevention and control program. 3.1.5 Health system development Indonesia Health Development corresponding to country basic constitution 1945 (UUD 45) which states that health is a basic human right, and according to national health legislation number 23/2004, which says that health is under responsibility of government as well as community including private sectors. Measures of health development should be sustainable and comprehensive with considering promotion, curative, and rehabilitative aspects. Also, the measures is based on Healthy Indonesia 2010, which consists health policy formed by the Ministry of Health, parliament legislative, as well as intermediate term of planning development, and directed to increase quality of life and human resources. National health development has been formed according to National Health System, which had been developed since 1982. In conjunction with the application of district autonomy in 1999, government has established Regional/District Health System, which consists of Province Health System and District/City Health System. Regional Health System is a guideline for health development in the regional or local level, which is part of National Health System, and should be implemented by all health development providers in government sector as well as in community including private sectors.26 According to government policy on decentralization system of health sector and district autonomy, the Ministry of Health had established the decentralize system on health policy and strategy (MOH decree number 004/2003). The main goal of the decentralize system in health sector is to develop health system which accommodates community aspiration and initiative using several approach. The approach includes community empowerment, integrating, and optimize the local potential to accomplish local or district needs and to achieve national priority targeting Healthy Indonesia 2010, which includes to build a healthy city/district promptly based on point of time target determined by each district/city.14, 20 With considering the decentralization policy, the strategy and program on health in Depok have been focused on several important points as follow: 1) The program have been implemented addressing the main issue in community of all social economy status and using available resources, community demand and ability with the supports of management, knowledge and technical medic from local health

20

2)

3)

4)

5)

6)

office. The program should be monitored and supervised by local provincial health office. The program have been carried out within the local capacity, but still using standardized method (measurement and diagnostic) and services (diagnostic and treatment), which are accurate and liable in medical point of view. Implementation program, particularly for treatment service (service fee, health workers authority, etc), have been in line with the regulation in the local district applied and not against the national regulation. Regional/District Legislative Organization has substantial contribution or responsibility in the implementation prevention and control program in their own district/city, in the mater of legislation function, supervision, and financial. Ministry of Health, have obligation to facilitate the prevention and control program in district/city level, with the focus on capacity building on knowledge , advocacy, health promotion, diagnostic technique, treatment, and case management. Guidance or assistantship on health management, referral system development, outbreak management, disaster management, and other urgent health issue, are also potential to be done as contribution to prevention and control program.

3.1.6 Local health office program Several of Public Health Centers (PHC) had been provide by the district government to overcome the public health issues in Depok community. There were 27 PHC in 6 sub districts (on average 4 PHC in each sub district), 7 assisting PHC, and 93 midwives who work in the PHC. Private health service networking, includes mother and child hospital, has provided obstetric and neonatal emergency service which available evenly in every villages. A general district hospital was still under construction, and it will be utilized as a referral hospital to accommodate demand of further health treatment among cases from the PHC. Approximately 75% RW (administrative unit) in Depok has developed variety of community participation activities on health aspect, such as integrated health post for under five children (“Posyandu Balita”), elderly health post (“Posyandu lansia”), NCD integrated health post (“Posbindu PTM”), Indonesian Cancer Association, Healthy Health Club, and other sport or exercise clubs). Also, some non government organizations (NGO) have positively supported health development (medical doctor association, midwives association, dentist association, Green Depok, Lempalhi, Mitra Bunda Foundation and other). Budget allocation for health sectors was substantially lower than it was proposed ($2 per capita vs. $5 per capita). The budget was mostly spent for office facility use and very less for the community development and programs. Other limitation in health services were as follow:

21

1) Unavailability of clear strategy on roles or functions of private sector in Depok health system. 2) Health workers in PHC still had limited skill in providing services on obstetric emergency, disaster management, NCD case management, and drugs addict case management. 3) Limited number of professional workers in health services (PHC) as well in health administration (Health Office). This lead to less optimum program implementation. 4) Some health care activities and cross sector activity that not yet supported by district regulation or law aspect that may lead to more satisfaction services for the community. In example, improvement in Public Health Center fee and availability of specific health treatment, private PHC, and more better contribution of health insurance from PT ASKES. The local health office and primary health care don’t have specific unit which is represent for NCD control program neither the NCD is not the health priority issue. Because of that, the information on the magnitude of NCD problem and risk factors was very important in giving inputs to decisions maker as regard to order who capable to concern in NCD control program, support policy and planning program for NCD risk control in the city of Depok. As NCD is not priority in health development, it is important to obtain policy support in prevention and control of NCD in Depok. Therefore, the strong and sustainable advocacy to decision makers to overcome NCD issues in Depok is strongly required. 3.1.7 Health seeking behaviour of the community Results of pilot study in Depok that had been conducted in 2001 – 2002 showed some findings as following, most community has perception that NCD is assumed as unpreventable degenerative diseases and occurred mostly among higher income population. NCD is known as elderly diseases, and genetic factor. Observation of the health seeking behaviour has been found that the people, who never check their health in 1 year was 52.2 %, never check their blood pressure was 51.3 %, never check their blood glucose was 8.8 %, and never check their blood cholesterol was 90.4 %. Beside that, most of the cases that found are not aware of having the risk factors (51.7 %, DM, 38.2 % hypertension, 98.2 % Hypercholesterol). In general, NCD prevalence and NCD risk factors prevalence in Depok, are higher than national prevalence. Most of the NCD cases and people with high risk were not aware of the diseases and even they didn’t realize of having the diseases or the risk, that because of the community knowledge of NCD and its risk factors, but they have high interest to prevent the NCD and its risk factors. Community is never check their health because afraid of knowing the diseases because of inability to pay the treatment

22

There was community’s habit in Depok that they ate in their office or bought on food seller especially the young’s family didn’t eat at home because they worked all day. Most of family who cooked at home, used to utilize MSG as little as food seller. A part of the community has used to do the disease prevention or take care of their body by consuming vitamin, food supplement, etc. Eat more and provide more food are symbol of prosperity in the family and overweight means wealthy. However, as the goal of lifestyle’s change on diet, it will be effective if the intervention do to both of food seller and housewife. Because of that, we will use to change the lifestyle by PKK (Woman’s welfare) activity, especially for the housewife. Most of them, especially the teenager had to use smoking in heavy category (> 4 cigarette/day}. Commonly that community known the effect of smoking is bad. Part of them wanted to stop smoking but it’s difficult to begin and they didn’t know how the way it. The goal of changing health’s lifestyle (to stop smoking) is priority on teenagers or risk group. The changing strategy was being done systematically with paying attention on goal’s segmentation. We also think several options on stop smoking. The promotion can be held by dialog, individual or group consulting, sport activity and by radio broadcasting. Most of the community used to do physical exercise at least one time a week. A part of them also spends their money for sport like gymnastic. The kind of sport was variety according to community group. The teenager and male’s adult like volleyball, football, badminton, and basketball. Female’s teenager and adult used to do gymnastics sport {aerobic gym, etc} and jogging. There was a field for sport in each block village, sport’s club like gymnastic, health’s heart club, badminton’s club, football’s club, basketball’s club. The promotion can use sport club to change the lifestyle. The strategy that can do, involves sport’s instructor by adding the knowledge of lifestyle healthy and medical to them. The Healthy Heart Club and others sport clubs are can be gotten an embryo or entry point development to make community like sport. The clubs existed and had many members who want to spend the money to the club. However, this organization must be involving to controlling risk factors of NCD. There are some potential community figures and health volunteers interest to promote healthy lifestyle. Beside, the community figure has had enough knowledge and prevention of some NCD risk factors. The appropriate ways to promote healthy lifestyle are promotion, create cadres, and involve the community figure to set an example is. The goal of change should be appropriated promoters characteristic and material promotion. We will use the organization/club that it exists, such as Healthy Heart Club or others clubs/gathering. If the new way will be informed, it should be taken negotiation among community. Represent by the community figure and the board will be taken by community who lives there. The changing will be appropriated gradually on material promotion.

23

Beside it also are informed health’s cadres to promote it, to involve the community figure to set an example for healthy lifestyle properly. 3.1.8 Health city forum of Depok Health City Forum of Depok (“FKDS”) is an umbrella organization of activity across sector and program beyond Healthy Depok in 2009 with legitimating from the major. There are many stakeholder in Depok Municipality which consists of representative from local government, Health NGO, industry, private business and community figures.

3.2 Community diagnosis To keep of the sustainability of NCD prevention and control program, it is potential to consider the concept ‘supply creating demand approach’ and ‘demand creating supply approach’, currency flow as a kind of fuel which should be always available to maintain the activity running, and the success will depends strongly on the driver, which is usually applied by private business and community resources (self funding and self managing) are more exceptional. Based on the concept mentioned above, people are economically better to spend their money, especially for those who prefer to private institution, on services and goods offered by positive health market e.g. fitness centre, self-defense club and dance machine. However for the low segment social class and some unprofitable business of risk factor prevention, smoking, role of NGO and health services are still required and funding should be always allocated by the local parliament accordingly. Therefore, the activity for prevention and control on risk factors of NCD could be conducting by a combination of the two approaches (‘supply creating demand approach’ and ‘demand creating supply approach’) should be conducting through ‘FKDS’ by synergistic and integrated. Base on situation analysis as regard to condition of health in community include the health seeking behavior of community, their limitation and potential resources, intervention program which are required and possible to be effective and also applicable for integrated prevention and control of NCD risk factors are: 1) Facilitating the Healthy Heart Clubs and others of sport clubs in physical activities 2) Capacity building of the ‘PKK’ member skill and knowledge in diet and stop smoking programs 3) Developing a gathering/clubs in community to be “Posbindu PTM” as an integrated health post for monitoring and early prompt counseling on common risk factors of NCD by community participant) 4) Increasing the active roles of private sector in program for physical activities and reducing body weight 5) Reorienting a health services program in PHC to be “Yandu PTM” as integrated health care for common risk factors of NC, which also integrated with the general health care.

24

3.2. Intervention strategy 3.2.1 Concept development of strategy It is known that the prevalence of particular non-communicable diseases tends to increase due to environmental changes such as age structure, life style, and social cultural. An effective and efficient prevention and control of NCD should be developed through promotion and prevention to control the risk factors (primary prevention), and through an effective curative action to prevent further complication diseases (secondary prevention), and through rehabilitative programs to manage the disability resulted by NCD for better quality of life. It will be less effective if the programs don’t involve the community itself, as an individual, household, or community including private sector, non-government organization, and others. Based on the result of pilot study, the promotion programs and providing facilities for NCD programs at local health centre had not achieved the target. This is because the programs mostly depend on skill and availability of health workers of the local health centre, meanwhile, community sometimes feel healthy and doesn’t fully aware of their health need. In that case, community should be proactively participate in an intervention program. 8,13, 27,33, 37-40 Besides, health behavior changes in community related to government policy and other non-health sectors policy, and it will need a cross program approach as well to gain their view point on public health. Therefore, it is very important to increase motivation and education of community health behavior by involving individual, household, organization, private, and other related sector. It is very crucial to have commitments from local government, local parliament, and other related sectors to manage NCD problems. These include: NCD control programs and its operational responsibility at health office and health centre level; adequate facilities for NCD control programs; legitimating for community participation in primary prevention program; and policy and regulation which give opportunity for the community to apply healthy life style (for instance: free tax for fitness centre, restriction for tobacco advertisements by high tobacco tax ). In other word, the community must proactively involve in health care even though it is government responsibility, and on the other hand the government has to give more concern to public health problems and gives necessary support to health programs. However, commitment from local government and parliament will not accrue without evidences for policy support regarding NCD control program. Therefore facilitation is needed to improve health worker’s skill and ability at local health office to evaluate NCD problems and its determinants in the environment and then should be disseminate of adequate information for policy makers through advocacy and planning for comprehensive NCD control programs. 14, 18, 23, 24 Unhealthy life style strongly influences the increasing of NCD risk factors, in the meantime, recent community life style closely relates to social economy cultural status.

25

Therefore, by improving community participation, we can conduct more integrated community-based intervention program and effective NCD risk factors control program. In this case, the community should be given responsibility in improving their health behavior and life style through ‘community based development’. By gaining the community participation, the community will participate and capable to proactively improve their life style and controlling NCD risk factors independently. Hence, the NCD control programs should be focused on integrated measures as well as involve the community themselves in planning, operating, monitoring and evaluating activities. Consequently, it requires health workers who have adequate skill and capability to motivate the community and to give optimum health care concerning NCD. However, the community and health providers basically cannot work effectively unless supported by conducive environment including adequate facilities. 3.2.2 The main of strategy intervention In regard to its definition, it is described that community-based prevention program as being integrated (across risk factors and diseases, across services and disciplines), and comprehensive across levels of prevention and care, and are not limited to clinical care settings. They use multiple interventions, target change among individuals, groups, and organizations, and often incorporate strategies to create policy and environmental changes. The role of the community is target of change, the community as agent with developmental capacity, and the community as resource with a high degree of ownership and participation. Accordingly, strategy and activity that had been applied in the CBI of NCD risk factor prevention and control program, were basically addressed to solve community problems, and developed by involving community in adjusted to local need, available resources and community readiness. The strategy was developed using conceptual framework of health promotion strategy of Ottawa Charter.29 Six strategies had been applied in Depok, started with NCD risk factors surveillance activity. The NCD risk factors surveillance results were utilized as evidence based for program development. Providing evidence base program is substantially important in the CBI strategy and results of NCD risk factors surveillance can be a starting point or baseline for program plan and as evaluation of intervention programs. The CBI on NCD prevention and control program in Depok has been developed in line with the community setting and available government system from the lowest administrative unit until the district government level. The development of health service system and management of NCD involved all sectors in community, PHC, hospitals, and health administration in Depok Health Office. Several activities regarding NCD prevention and control program had been carried out. Those activities included exploration, trial and development of STEPS survey and intervention strategy during 2001 to 2002.The intervention for NCD risk factors control programs requires a comprehensive program

26

with the focus on common risk factors control, which needs to be supported by several aspects such as policy, social environmental aspect, community participation, individual capability, and health service function. The strategy of CBI was developed in line with decentralization system in Depok, which is also applied in other districts in Indonesia. This study is expected to obtain effective CBI model for the NCD prevention program, which is can be adopted by other districts or village in Indonesia, by applying integrated strategy of community and market based approach. The study has been conducted base on structure that has been provided in their community. At the end, it is expected that the prevalence of non-communicable diseases can be controlled continuously. Health Promotion strategy from Ottawa Charter is used as a concept which emphasizing on local potential resources and its limitation. There strategies include: 1) NCD risk factors Surveillance Implementation of NCD risk factors Surveillance and mortality survey are required to carry out regularly to obtain accurate information as an evidence base and to gain awareness among the policy makers at the local government and parliament. Data from the surveillance activities is used for the baseline and evaluation data of the intervention strategy. The STEPS survey implementation should be conducted to completely. (Step1,2,3), to obtain information of non communicable diseases, because information of risk factors only, was not sufficient to get the policy support from to the policy makers. 2) Coordinating policy Information from the NCD risk factors surveillance activity have been utilized for advocacy to integrate NCD control program to other sectors at the local government to support policy to accelerate Healthy Depok 2009. Integrating policy for NCD control program and local government policy for Healthy Depok through activities on a forum of healthy city of Depok This means ‘linking’ the healthy life style program and orienting health services for NCD on health service management to increase Life Expectancy and Human Development Index. This strategy should be done to obtain a policy support for NCD program and to make it sustainable. 3) Strengthening individual skills Several activities had been done to strengthening the individual skills include capacity building of the health workers, volunteers, and local community. This is aimed to increase individual skill to perform healthy life style and strengthening individual capability in controlling NCD’s risk factors independently, by conducting series of training for health workers, volunteers, and other interested community member. Also, this strategy gives focus on gaining skill of health workers in NCD control management program, including

27

physician’s and paramedic’s skill, conducting public seminars on NCD and its risk factors control programs, and distributing poster of health behavior. 4) Enhancing social environment This substantially means certifying that social organization increase wellbeing. The strategy is aimed to create supportive environment in regard to prevent the occurrence of NCD and its risk factors and to increase people awareness of healthy behavior by involving several NGO such as local healthy heart club, workers association, health insurance, etc. Motivating and facilitating community organization and private sectors to actively participate in controlling NCD and developing ‘Posyandu Usila’ (integrated health post for elderly) to become ‘Posbindu PTM’ (integrated health post for NCD). ‘Those activities must have legitimacy from local government, and guided by local health centre, and facilitated by local health office for the implementation and program development. Other activity, includes build an active partnership between government, non-government organization and the local community to increase community awareness concerning NCD and its risk factors. It also activates ‘Healthy and Clean Friday’ activity, which is a routine activity of cleaning the workplace environment among the government institutions on every Friday, that have been applied since several years ago, but less active recently 5) Enabling strong community action Activities in this strategy were intensive community campaign, public seminar, poster distribution, and publish a book. As a health extension material to arise community knowledge about integrated NCD risk factors control, “CERDIK” poster (The meaning is SMART behavior which contain message for controlling risk factors of NCD)” and guidance book “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, were created. Some of public seminars were aimed to increase people awareness to NCD and its risk factors. The target is local community, especially the high risk age group (25 to 64 years old), diabetes patient and hypertension. 6) Reorienting health services Previously, the Public Health Centre in Depok is only provided a basic/general of health services. Considering potential resources and some limitations, there are two main aspect of health service that need to be focused on, which are: a) Improve and facilitate the function of the gathering activities in community to become ‘Posbindu PTM’ (integrated health post for NCD). ‘Posbindu PTM’ is an outcome of community participation in promotion and preventive measure for early detection of NCD risk factors (hypercholesterolemia, hypertension, hyperglycaemia, unhealthy diet, and smoking), which includes risk factors monitoring activities, gaining knowledge of NCD risk factors preventions by health counseling, and refer of cases who have risk factors of NCD to PHC. Those activities are conducted by community (trained health

28

volunteer) and for community, which have legitimacy from local government, guided by local public health centre, and facilitated by local health office for the implementation and program development. Management and financial support of ‘Posbindu PTM’ are arranged according to agreement among the community of ‘rembug warga’, and reported to the public health centre. ‘Posbindu PTM’ is a generic name for the activity that can be carried out either at residential environment, working environment, or other public places. Detail information of ‘Posbindu PTM, monitoring procedure, and forms, can be seen on attachment 8. b) Improve of health services function in PHC to providing clinical health service for controlling of risk factors of NCD. The program called a ‘Yandu PTM’ (integrated curative for patient with common of risk factors of NCD). The ‘Yandu PTM’ is an activity that is managed by local public health centre for curative and rehabilitative aspects to control NCD risk factors (hypertension, hyperglycaemia, hypercholesterolemia, obesity, unhealthy diet, and smoking) by counseling therapy and medication. This also includes improving referral system and collaboration with the general hospital that has been providing services by internists. The activities have been supported by the legitimacy, fund adequate and facilities from the local government. The price for activities in ‘Yandu PTM’ are managed by the health centre board, and how much the patient should pay for the health service at ‘Yandu PTM’ was decided by the agreement among the community of what it called ‘rembug warga’ or community agreement. 3.2.3 Frame work of CBI The frame work of CBI on prevention and control of NCD and risk factors, can see diagram 1 as bellow.

29

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

• • •

Social Structure Surveill ance Risk Factors Of Major NCDs

Environment

Life style

Social status Age Gender

• • • •

Geographic Access Work Place Housing

• • •

Smoking Diet Low activity

Organization and

Enabling Strong Community Action

In te gra ted

Enhancing Social Environment

N C D’s

Community

Public Primary Health Cervices

Strengthening Individual Skills

and

Physiology

• • • •

Blood pressure Blood cholesterol Overweight Blood Glucose

Private Primary Health Cervices

Reorienting services

Information of NCD’S and Risk Factors

Pro gram and Po licy

A D

N E T

V O

Work ing

C

for

A

Co or dina ting

C Y

MONITORING

EVALUATION BASE PROCESS EVALUATION IMPACT EVALUATION EFFECT/OUTCOME EVALUATION

30

4. IMPLEMENTATION 4.1 Program and activities In the process of program development and activities we carried out series of meetings with policy makers, local health office, other sector related, FKDS as forum of stake holder in Depok, and experts from Ministry of Health, involving directorate of health promotion, directorate of medical service, directorate of community health, as well as from Cipto Mangunkusumo general hospital, Harapan Kita hospital, and from NGOs such as Healthy Heart Club, Cancer Association, and Stop Smoking Association. During the project implementation we develop several activities, which were arranged according to the intervention strategy. The programs/activities which had been plan, target intervention and objectives each program can be find in Matrix 3. The implementation of community based intervention (CBI) of NCD risk factors prevention and control program had been initiated since February 2003 and completed on July 2006. The activities of CBI was in collaboration with several related institutions at central level, province level, as well as district level of government office. Institutions involved from the central level were: a. Ministry of health (Center of Health Promotion, Directorate of Medical Service, Directorate of Community, and National Institute of Health Research and Development). b. RSCM – Faculty of Medicine University of Indonesia General Hospital c. Cardiology unit, Harapan Kita Hospital d. Center of Indonesia Healthy Heart e. Smoking Control Organization f. Ministry of Education g. Ministry of Agricultural Institutions involved from the Province level were as follow: a. Sub unit of Surveillance system in West Java Health Office b. Sub unit of Health Promotion in West Java Health Office c. Sub unit of Primary Health Service, West Java Health Office Institutions involved from the District level were as follow: a. Depok Health Office and other related sectors (education, agriculture, city planning, and demography). b. Depok Government Office (City Major and District Development Office) and District Parliament for Depok. c. Public Health Centers (intensively with Abadijaya PHC) d. Health and non health NGOs

31

e. Industry and Business Association in Depok f. Local community member, health volunteer, public figure in Depok, particularly in Abadijaya village. 4.2 Monitoring programs and activities The indicator of each activity and the monitoring methods can see in Matrix 4. Program/activities were conducted simultaneously, as in the agenda or time frame (see Matrix 5).

32

Matrix 3 : Objectives, targets, and facilitators of the activities on each Strategy Strategies Surveillance of risk factor of NCD

Policy development and Coordinating

Activities Socialization of goals and benefits of NCD risk factors surveillance to stakeholders and community Training of NCD RF surveillance for local health workers

Objectives

Targets

Increasing community response to • Community the NCD RF surveillance • Stakeholders in Depok •

Implementation of NCD RF surveillance

Transfer knowledge and skill in NCD RF surveillance, coordinated by Depok Health Office To provide evidence based of NCD and its risk factors

•

Community age 25 to 64 years old.

Dissemination of NCD RF surveillance to the related stakeholders and community

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

District policy makers Program coordinator for PC of NCD

Establishment of Healthy Depok City Forum

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

• to develop comprehensive a PC of NCD and its risk factors program according to local community condition, needs, and resources Advocacy about NCD and its risk • To gain awareness to get policy factors as public health problem in suport of NCD problems Depok among policy makers and stakeholders in Depok.

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

•

Health workers in Depok Health Office NGO in Depok

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

All stakeholders and NGOs in • NIHRD Depok • Health office • Center of HP • Program coordinator at Depok health office. • FKDS • District Development Office

• NIHRD • Local health office • Center of Health promotion City major, District parliament , • NIHRD-MOH local health official, statistical • Dir general of bureau, and other related sectors, Medical Services FKDS • Center of HP

33

Round table discussion of the • To expose other regions with implementation of NCD health success and constraints of NCD service (“Yankes PTM”) in the control programs in Abadijaya public health center and integrated village. health post of NCD (“Posbindu • To motivate other regions to PTM”) in the community. actively develop of NCD control programs. • To build collaboration and commitment in developing NCD risk factors control program with other district health office in West Java.

• Program coordinator at Depok health office. • Healthy Depok City Forum • District Development Office • Abadijaya Public Health Center (PHC) • Other PHC in Depok • Coordinator of “Posbindu PTM” in Abadijaya village • Coordinators of other “Posbindu PTM”

• NIHRD-MOH • Directorate general of Medical Services • Center of Health promotion • Directorate of Communities MOH-RI • NIHRD-MOH • WHO

Round Table Discussion of To accomplish the NCD building commitment to PT medicines requirement in Public ASKES (health insurance) in Health Center. Depok

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

Conducting forum of Strengthening the networking and communication and coordination collaboration for sustainability of of stakeholders and health PC of NCD and its risk factors. workers in NCD control programs in Depok.

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

• NIHRD-MOH • Dit.general of Medical Services • Center of Health promotion • Dit Communitas MOH-RI • NIHRD-MOH • WHO • NIHRD-MOH • Dit.general of Medical Services • Center of Health promotion • Dit Communities MOH-RI • NIHRD-MOH • Local Health

34

Strengthening Individual Skills

Round Table Discussion of Diet and Physical Activity

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

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

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

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

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

Training in management of “PosBindu PTM” and for potential and active volunteer. Training for potential health volunteers, with the topics of

Gaining community’s skill in managing “PosBindu PTM”

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

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

District Health Office District Education Office City Planning Office NGOs Depok Government Office Physicians, nurses, and dietitians in Depok (priority for health workers of public health center and health volunteer in Abadijaya)

• Health worker in Depok health office. • FKDS • Health workers from PHC Active and potential individual in community Active of health volunteers with educational background of minimum of three years health diploma.

office • WHO • District Health Office

• Center of Lipid and Dibates Mellitus, e of Ciptomangunkusu mo hospital • Social cardiology of Harapan Kita hospital. • Social Oncology of Dharmais Cancer hospital • Dit. General of Community MOH-RI • Health insurance safety (JPKM) • Healthy heart association • Other health association (Persadia, LM3)

35

heart and Diabetes mellitus., Stop smoking program

activity stop smoking program.

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

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

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

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

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

Active health volunteers of “Posbindu PTM

Enhancing Social Environment

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

• To develop surveillance program and control program for NCD’s risk factors in working environment. • To develop of partnership in NCD’s promotion and preventive programs

Enabling Strong Community

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

• Enhancing community awareness of healthy life style. • Improving community’s

• Industrial sectors in Depok • Private sectors in Depok, which relate to NCD’s risk factors (fitness center, restaurants, etc) • Entrepreneur Association • Trade Association Depok • Community, health volunteer

• Center of Lipid and Dibates Mellitus, RSCM Hospital • Social cardiology of Harapan Kita hospital. • Social Oncology of Dharmais Cancer hospital • Dit. General of Community MOH-RI • Health insurance safetiness(JPKM) • Healthy heart association • (Persadia, LM3) • Center of Occupational health, MOH-RI • Center of Health Promotion, MOHRI • NIHRD-MOH-RI • City forum of healthy Depok • Depok health office

36

Action

Reorienting services

other public places. Free distribution of guidance book, which has title of “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, to community. Improve and facilitate the function of the gathering activities in community to become ‘Posbindu PTM’ as integrated health post for monitoring, early detection and control of risk factors NCD regularly

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

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

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

“Posbindu PTM” in Abadijaya village

• NIHRD • City forum of healthy Depok • Depok health office • Intervention team

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

Abadijaya PHC

• Center of Lipid and Dibates Mellitus, RSCM Hospital • Depok health office

Publication Posbindu PTM to Motivate other districts or villages other villages. to develop ‘Posbindu PTM’

37

Matriks 4 : Indicator of Intervention Activities Monitoring Activities

Indikator Input

Impak/Output

Monitoring Method OutCome

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

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

Respon rate of NCD RF surveillance

Prevalence/proporti on and mean value of NCD RF

Training of NCD RF surveillance for local health workers


Capacity of District Health Office in implementing the NCD RF Surveillance


Implementation of NCD RF surveillance


Availability of evidence based of NCD and its risk factors.


Dissemination of NCD RF surveillance to the related stakeholders and community

Results if NCD RF surveillance PTM

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


Number of meeting per year Number of social action per year Number of advocacy activity per year Proportion of stake holder member involved in the activity • Policy of NCD’s risk factors control program available. • Support from other sectors


Report Documentation

Prevalence/proporti on and mean value

Report Documentatio

Implementation of dissemination Presentation method

Establishment of Healthy Depok City Forum

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

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

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

WHO STEPS wise approach for surveillance risk factors of NCD


38

• Appropriate structure for NCD’s programs • Availability of coordinator for NCD’s program. • Appropriate infra structure of NCD’s program. • Appropriate of medication facilities at local health center • Availability of budget • Facilitation Round table discussion of the Time, Place Discussion process implementation of NCD health Proportion of target audience service (“Yankes PTM”) in the Adequate facility public health center and integrated Quality of moderator/facilitator health post of NCD (“Posbindu PTM”) in the community. Round Table Discussion of building Agreement on type and quantity commitment to PT ASKES (health of medicine of NCD patients insurance) in Depok covered by health insurance of ASKES Conducting forum of communication Time, Place Discussion process and coordination of stakeholders and Proportion of target audience health workers in NCD control Adequate facility programs in Depok. Quality of moderator/facilitator Workshop to develop of programs/ activities for PC of NCD and risk factors in Depok

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

Time, Place Discussion process Proportion of target audience Adequate facility

• Amount of local government budget for NCD’s programs. • Number of policy regarding NCD’s control programs. • Agreement of strategy, program, and activities and its intervention targets • Number of applied NCD’s programs • Number of planning program of NCD’s PC programs

of NCD RF

n, planning



To



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


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


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


,planning, report of institution survey

•

39

cancer (secondary prevention), for physician, nurse, and dietitian. Training in management of “PosBindu PTM” and “Yandu PTM” for the health workers Training in management of “PosBindu PTM” and for potential and active volunteer. Training for potential health volunteers, with the topics of

Quality of facilitator Material • Community knowledge concerning management of “PosBindu PTM & YanduPTM. Increasing knowledge of NCD among industries and private sectors. Increasing of community knowledge about NCD’s risk factors and its control program.

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

Prevalence/proporti on and mean value of NCD RF Prevalence/proporti on and mean value of NCD RF Prevalence/proporti on and mean value of NCD RF

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

Increasing health worker’s skill in Prevalence/proporti controlling risk factors of on and mean value cardiovascular diseases, diabetes of NCD RF mellitus, and cancer.

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

Volunteer’s skill in promoting Prevalence/proporti healthy diet, gaining physical on and mean value activity, and stop smoking habbit. of NCD RF

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

•

•



40

major NCD’s risk factors Free distribution of poster to gain individual and community skill about NCD risk factors, Free distribution of guidance book, which has title of “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, to community. Improve and facilitate the function of the gathering activities in community to become ‘Posbindu PTM’ as integrated health post for monitoring, early detection and control of risk factors NCD in regular base Improve of health services function in PHC to providing clinical health service for controlling of risk factors of NCD in integrated approach.

• Material • Area of distribution

Increasing of alertness and knowledge


Observation

Implementation of “Posbindu PTM” activity in regular and periodic. Increasing of “posbindu PTM” ratio to number of RW (administrative unit) Implementation of NCD integrated health service in PHC. Sufficient facilities and medicine for NCD patient in PHC

Increasing coverage of who participated in NCD risk factor monitoring periodically


Increasing number of NCD case who were followed up by PHC


Publication of Posbindu PTM to others villages

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

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


Rekapitulasi “Posbindu” Record, phone communication Field visit Survey Recapitulation of results Recording and reporting of NCD case in PHC Report documentation

41

Matrix 5 : Activities Schedule in 2003-2006 Activities

2003-2004 1

2

3

4

5

6

7

8

9

2004-2005 1 0

1 1

1 2

1 3

1 4

1 5

1 6

1 7

1 8

1 9

2 0

2 1

2 2

2005-2006 2 3

2 4

1 5

2 6

2 7

2 8

2 9

3 0

3 1

3 2

3 3

3 4

3 5

3 6

3 7

3 8

Socialization of goals and benefits of NCD risk factors surveillance to stakeholders and community Training of NCD RF surveillance for local health workers Implementation of NCD RF surveillance Dissemination of NCD RF surveillance to the related stakeholders and community Establishment of Healthy Depok City Forum Advocacy NCD and its risk factors as public health problem in Depok Workshop to develop of programs/ activities for PC of NCD and risk factors in Depok Training for potential health volunteers, with the topics of Healthy diet, Exercise for healthy heart and Diabetes mellitus., Stop smoking program

42

3 9

4 0

Training program of controlling risk factors (primary prevention) and clinical therapy for cardiovascular diseases, diabetes mellitus, and cancer (secondary prevention), for physician, nurse, and dietitian. Workshop in controlling NCD for industries and potential private sectors and discussion of partnership program development in controlling major NCD’s risk factors Free distribution of poster to gain individual and community skill about NCD risk factors, “CERDIK”

Improve and facilitate the function of the gathering activities in community to become ‘Posbindu PTM’ as integrated health post for monitoring, early detection and control of risk factors NCD regulary Improve of health services function in PHC to providing clinical health service for risk factors of NCD integratedly. Publication of Posbindu PTM to other villages

43

5. EVALUATION 5.1 Result of process evaluation All the programs and activities had been accomplished as planed, however not all the activities could be done promptly as in the schedule. During the last Depok Government Office, especially Depok Health Office has plenty of programs and activities. Parliament election and Indonesian President Election occurred in 2004, while Depok Major Election was on 2005. Those important agenda took lots of energy and time of most people in Depok, particularly the government employee. The next few sections will present the results of process evaluation of each program. 5.1.1 NCD RF Surveillance in 2003 5.1.1.1 Sampling and Response Proportions of surveillance Data was collected by inviting respondents to the two places, Abadijaya Public Health Cervices (PHC) and Abadijaya village office. Particularly for respondents who were living quite far from the PHC, the data collection was conducted in the local administrative unit (RW). Respondent who was not able to attend were not replaced, but they got second invitation to attend on the following week. Home visit was performed when the respondent could not attend after the third invitation. Although this strategy requires more time, funds and human effort, but it leads to greater response rate. Out of 2200 respondents, who were stratified randomly selected by sex and age group in the Abadijaya village using two stage cluster random sampling, there were 847 men respondents (77%) and 959 women respondents (86.9%) had been interviewed for Step 1 and Step 2 approach. Meanwhile, 686 men respondents (62.36%) and 934 women respondents (84.9%) participated for Step 3 approach (measurement of fasting blood glucose and two hours pp blood glucose, and total blood cholesterol) and 161 men and 25 women were not eligible for the blood examination because they didn’t complete the fasting requirement. The lowest respondent’s response was among man age 25 – 34 years old, while the highest was among women age 55 – 64 years old. (See attachment 13 Data Book 2003 table 1.1 up to 1.3). Results of the survey showed that older age group and females had higher response rate than younger age and males. Higher response rate among older age and women is most likely because of older respondents tend to give higher concern on health, and usually, women have more self-aware on health. Generally, man respondents feel more apathetic to check their health due to economical aspect. They think that it would be useless if they found their sickness but they can not afford to cure it. Besides, due to man natural typical, man mostly ‘feels’ more strong and healthy than

44

women, which make them deny their health problems. In the mean time, respondent’s response proportion that above the targeted respondents, might due to sampling error. Because, sampling frame was performed based on the data from the previous year (year 2002), which lead to age group alteration. Approximately 30 respondents (1.6%) had categorized into older age group. As it mentioned above, the respondent distribution were mainly women and older age group. However, the different in age and sex was not proportionally significant, which was 1 – 8.6 % (< 10 %).Therefore; the data was representative to describe risk factors based on age and sex. Prevalence of NCD (diabetes and hypertension) in Depok was generally higher than the national figures, in which mostly found among males.15, 31 Those described that Depok society especially males had bigger chance to have higher NCD prevalence. In the case of diabetes mellitus and hypertension, it was known that it was not the number one cause of death diseases in Indonesia, but the acute complication of diabetes mellitus and hypertension may lead to higher mortality rate, while the chronic complication can lead to other diseases such as stroke, blindness, coronary heart diseases, chronic kidney diseases, gangrene, and impotent, which those would lead to great issue on survival, disability, and less productivity, as well as costly health expenditure for the community. The health problems not only had negative impact to individual or community, but also for the government, as it would influenced economy status, especially when diabetes occurred among those who still economically productive.31 Because of that, we concern more to those diseases in prevention and control program. 5.1.1.2 Risk Factors of NCD in 2003 More detail figures of NCD risk factors surveillance results on 2003 can also be seen on Data Book 2003, which attached and in fact sheet 2003 at attachment 11. Data of tobacco use can be seen on table 2.1 up to table 2.8. In general, the prevalence of daily smokers was 32.9% among men and 3,8% among women. Women mostly started smoking at older age than men (mean age were approximately18.4 years old in men and 22.9 years old in women). Table 3.1 describes alcohol consumption in last 12 months, it shows that the prevalence of current consumers was higher (6.1%) in men than in women (0.2%). The average number serving per day of fruit intake was about 1.8 serving among men and 1.8 among women. Then, the average number serving per day of vegetables intake was about 1.7 serving among men and also women (Table 4.1). The prevalence of fruits and vegetables consumption > 5 servings per day was 11% for men, and 14.5% for women, while prevalence of not consume fruits and vegetable everyday was higher for men (19.5%) than women (9.8%) (see table 4.2). Regarding type of oil consumption, it shows that most of respondents consume palm oil. Table 5.1 to table 5.7on Data Book 2003, was illustrate physical activity status at work, during transportation, and during leisure time, by age and sex. The prevalence of low level activity was 19.5% in men and 12.3% in women (see Table 5.1), while the median time

45

of total physical activity per day was 94.3 minutes among men and 138.3 minutes among women (see Table 5.2). Other physical activity descriptions can be seen in several other tables 5.3 up to 5.7 in Data Book 2003). Raised blood pressure and diabetes history is described on table 6.1 to table 6.5 on Data Book 2003, and also fact sheet. Regarding the time elapsed since most recent blood pressure measurement of less than 12 month among men were 72.7%, and 15.8% for time elapsed of 1 to 5 years, and 11.5% for time elapsed of more than 5 years. While among women were 73.5% for time elapsed of less than 12 months, 16.4% for time elapsed of 1 to 5 years, and 10.1% for time elapsed of more than 5 years. While confirmed diagnosis of raised blood pressure by health workers during past 12 months was slightly higher among men (16.4%) than women (15.6%) and confirmed diagnosis was 3.6 % among men and 2.3% among women. Other description of raised blood pressure history and diabetes can be seen on several other tables. As can be seen on data book on table 7.2 the mean value of Body Mass Index was slightly higher in women (24.8) than in men (23.6). The prevalence of obesity was also higher among women than men. The prevalence of high waist-hip ratio (WHR > 1) was 0.8 % in men and 17.7 % in women (WHR > 0.85). Table 7.6 shows that average systolic blood pressure was 122.5 mmHg for men and 117.6 mmHg for women. Prevalence of raised blood pressure (SBP >= 140 and/or DBP >= 90 mmHg) was 9.2 % among men and 7.9 % among women. While the prevalence of raised blood pressure (SBP >= 170 and/or DBP >= 100 mmHg) was 4.5 % among men and 2.9 % among women. Table 8.1 to table 8.6 illustrate the result of biochemical measurement, including blood glucose, blood cholesterol and triglyceride measurement. As can be seen on table 8.1 the mean value of fasting blood glucose among men was 4.9 mmol/L and women 4.8 mmol/L, similarly, the prevalence of high blood glucose (≥ 7 mmol/L) for fasting blood glucose was 5.3 % for men and 5.2% for women. The mean value of 2 hours of blood glucose after glucose load was 7.8 mmol/L in men and 7.7 mmol/L in women, while the highest blood glucose level was 11.7 mmol/L. The prevalence was rather higher among men (11.7 %) than women (8.8%). Based on diabetes mellitus diagnosis criteria (fasting blood glucose >= 7 mmol/L and or 2 hours of blood glucose after glucose load >=11.7), the prevalence of diabetes in Depok was 9.8% for men and 10.1% for women. Concerning the fasting blood cholesterol, the figures show that the mean value and the prevalence were slightly greater among women than men. Table 8.4 and 8.5 explain that mean value of blood cholesterol was 4.6 mmol/L among men and 4.8 among women, while the prevalence of high blood cholesterol ( ≥ 5.2 mmol/L) was 28.8% in men and 31.3% in women. Similarly, the prevalence of high blood cholesterol ( ≥ 6.5 mmol/L) was 5.6% in men and 5.5% in women.

46

5.1.1.3 Utilization of surveillance risk factors NCD information Community based surveillance of NCD risk factors had been applied in Depok. The data collection method in the surveillance was interview, physical measurement, and blood measurement. Personnel in data collection activity was health workers who had education background at least one year diploma, and member of Healthy Depok City Forum who had education background at least three years diploma. Coordinator of Health Service Unit Depok Health Office, was involved the activity. Technically, capacity of Depok Health Office in conducting the NCD risk factors surveillance was inadequate. That was because of the limited capacity of the human resources. Not all the trained personnel got involved in the surveillance activity. There was lack of commitment consistency among the health workers who had been trained as data collection personnel in the NCD risk factor surveillance. The health workers who had been trained sometime had to move to other unit and could not participate in the date collection activity. In the future, selection of surveillance personnel should involve more health workers at all unit in Depok Health Office. Strong commitment from local government, parliament, and from other related sectors such as health insurance company are necessary to make sustainable program on NCD prevention and control. The commitments include policy on program implementation, financial support; provide adequate diagnostic facilities and other technical medical necessity, legitimating the community based program, district government regulation on health services, and district government policy on healthy life style environment that enable community to get more access on health living, such as giving free tax for fitness center or sport club, restriction on smoking advertisement, or use the cigarette tax for health promotion program. The commitment and policies mentioned above could not be achieved without accurate and representative information as evidence based for advocacy to the policy makers in Government Office.14,18,26,29 As it was occurred in Depok, the decision makers gave more concern on morbidity data of certain NCD such as diabetes mellitus, heart diseases, and hypertension by rather than the information of NCD risk factors. Therefore, additional information such as diseases severity and further complicated diseases, disability, and mortality, in association with human development index, were effective to get more attention to prioritize the NCD prevention and control program. Adequate information as evidence based was obtained by the NCD risk factors surveillance and mortality surveillance. Information from the surveillance was substantially necessary in NCD prevention and control program. In the planning stage, the information was used to determine the program strategy and target, while in the implementation stage the information was utilized as monitoring instrument of program benefits. In the evaluation stage, results of the surveillance were used to assess program effectiveness. Community based surveillance was more effective to identify community

47

NCD problems than the hospital based surveillance.11 Hospital based surveillance was more effective only to assess the working performance of health institution, because not all cases of NCD were hospitalized or visited hospital. 5.1.2 Policy Development and Coordination Several programs that related to policy development had been performed step by step. Forum of healthy city of Depok (FKDS) had been established and facilitated by health official. It is an integrated and coordinated forum involving local community organizations, NGO, other related non-health sectors, and related private sector which potentially support the promotion of healthy life style. Networking had been developed and it was an advanced collaboration between local health government and FKDS, in planning and managing public health program. The FKDS had motivated the community and local government officials to develop local and regional government policy by creating social environment that conducive for NCD risk factors prevention and control program. High prevalence of diabetes mellitus had taken into account by the Depok Health Office and already put it as input in policy and program advocacy. Evidence based information, frequent advocacy activities such as hearing, round table discussion, and public seminars resulted good progress. Workshop of PC of NCD Program in Depok City and audiences about NCD problem in Depok City were agreed that for controlling NCD risk factors in Depok city government needed some programs and structure. A comprehensive of strategies for NCD control programs had been developed, and will be integrated through routine activities. Previously, Depok Health Office didn’t have specific program structure for NCD. Funding of the NCD risk factors control program in Depok were mostly supported by World Health Organization (WHO). After one-year intervention program that is in 2004, it had some progress on several aspects below: 1) The local government would contributed funding for small programs such as seminars, routine meeting for every 3 months 2) The local government could give of the facility (funding, policy, and office room) for ‘FKDS’ as a working group for co-coordinating and communicating activities to perform healthy Depok 2006, which included NCD risk factors control programs in community. 3) Structure and working mechanism of different unit and coordinator for NCD program had been determined by Depok Health Office. 4) The policy support and programs plan for NCD from the local government, which were previously not available, have been initially developed. The information below is policy support, activities that had been done and programs plan for NCD and its risk factors control program in Depok, up to December

48

2004. The activities are focused on three main programs for NCD in Indonesia, which are Surveillance, Health Promotion, and Health Service Management. 5.1.2.1 Policy and program in surveillance • • •

• •

Information of NCD risk factors surveillance in 2003 had been used by the local government in planning health development strategy for Depok municipality. Information of NCD risk factors surveillance in 2003 had been utilized by the local health office to improve drugs availability the local community health centre. Funding for surveillance activities in 2003 was from WHO. Endocrine unit of Ciptomangunkusumo Hospital had given additional funding specifically for implementation of Step 3 approach. Coordinator for surveillance program at Depok health office has made plan to conduct training of NCD surveillance implementation for health worker. Plan of action of surveillance risk factors NCD for the next term have not been developed yet by the surveillance program coordinator at the Depok health office.

5.1.2.2 Policy and program in health promotion • •

•

Implementation of health promotion activities were partly facilitated by personnel form central health office (Ministry of Health) Coordinator for health promotion program had planed to conduct baseline survey for health behavior within family and review all the community health program which had been conducted NCD control program in the community, as well as to develop regulation for ‘no smoking area’ program in public places, monitoring the activities of integrated health post of NCD, and built strong adequate collaboration with the health service program division/unit. Coordinator of health promotion program at the health office and half of the health promotion personnel at the public health centre had been successfully carried out their function as facilitator of ‘Posbindu PTM’ activities in other village in Depok.

5.1.2.3 Policy and program in health service management • •

•

Head of the local health office agreed to decide that the coordinator for NCD control program is the head of health service division in the Depok health office. Depok health office has applied policy to develop integrated health service for NCD (‘Yandu PTM’) at the community health centre in which patients have to pay the services which is determined by the community and affordable for most of the community. This has been supported by a decree from the head of the local government. Depok health office has developed new policy concerning the number of days of medicine supply to patients with NCD at the public health centre. The medicine is given for two weeks period, while previously it was only given for 3 days.

49

•

•

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

5.1.2.4 Policy and program in industry sector A workshop Involving industries in controlling NCD risk factors programs among workers was attended by representative from 28 industries in Depok, most of them has a minimum of 1000 employees. The chairman of industries association (Apindo) in Depok, supported future collaboration with local health office in managing NCD control program, especially for workers. This workshop resulted in several agreements, as follows: • Establishment of working group for occupational health and safety among workers in Depok, under co-ordination of Depok health office. • Commitment to conduct health education particularly for controlling NCD risk factor in working environment • Promotion on occupational health will be socialized in work places and will be one of the substantial health programs. Occupational health programs that relate to NCD, are: implementation of physical activities at least 10 minutes in every 4 hours at work for all workers; no smoking area; and provide health food in the cafeteria. • Developing plans to carry out NCD risk factors surveillance periodically in the work places. However, a coordinator at Health Office was substantially needed to create a sustainable NCD prevention and control program. The coordinator was expected to manage planning, implementation, and evaluation, of three main strategies of NCD prevention and control program determined by Ministry of Health, which includes surveillance, health promotion, and health service management. Coordinator, who specifically for NCD, was not available yet in Depok Health Office, and the three main strategies were under three different unit in Depok Health Office, which were: 1) Surveillance activities were under responsibility of Diseases Prevention and Control unit, which was usually working for communicable diseases. 2) Health promotion was under responsibility of Family Health unit, which given more work on maternal and child health. 3) Health service management was under responsibility of Primary Health Service Unit.

50

The experience learn from Depok, showed that basically coordination between related unit had been done, however, the coordination was not sufficiently taken due to responsibility to complete other task than NCD. The NCD prevention and control program need to be under responsibility of one section to make the program implementation more effective and well improved. 5.1.3 Strengthening individual skill All the training activities were conducted by Depok health office, and the intervention team played as facilitators (steering committee). This activities were taken in both 2004 and 2005. The participants were health workers (general practitioners, nurse, dietician), health volunteers, and other community member. Almost all the targeted activities were accomplished, except the clinical training for general practitioners (GP) of the community health centre. The percentage of GP who participated was only about 50% of the targeted number of GP. That was because miss information about participant criterion and subjects of the training. After the training, GPs who did not attend were enthusiastic to suggest that there will be similar training in the near future. Almost all training activities were beneficial for the participants. They expect that those activities will be followed and supported by concrete NCD control programs. The activities increased knowledge among health workers and health volunteers, specifically about NCD and its risk factors control program, as well as about how to develop health services as required. The topic given in the training can be seen on attachment10. Table 1 and Table 2 describe result of knowledge test among the participants before and after the training. 5.1.4 Enhancing social environment and enabling community actions Some of NCD risk factors like sport, diet (cholesterol, blood glucose and salt) and smoking was intervened by integrated program on “Healthy Lifestyle Promotion”. Intervention activity was done by giving priority to community and private empowerment and by “community based development.” As a health extension material to arise community knowledge about integrated NCD risk factors control, “CERDIK” poster (The meaning is SMART behavior which contain message for controlling risk factors of NCD)” and guidance book “Towards Healthy Youth and Pleasant Old Age, Without Coronary Heart Disease – DM and Cancer”, were created. “CERDIK” poster stands for : “C” is Ciptakan lingkungan yang aman nyaman indah dan sehat (Create a safe, comfortable, beautiful and healthy environment) ”E” is Enyahkan asan rokok dan polusi udara lainnya (Evade cigarette smoke and other smoke pollution) ”R” is Rangsang aktifitas dengan gerakolah raga dan seni

51

( Stimulate activities by sports, work and art) “D” is Diet yang sehat dengan gizi yang cukup dan seimbang ( Have a healthy and balanced diet ) “I” is Istirahat yang cukup ( Have adequate rest) “K” is Kuatkan iman dalam menghadapi stress (Strengthen your spiritual life for managing stress) Campaign activities had been held by local health office in collaboration with “Health Depok City Forum” (FKDS) and facilitated by Ministry of Health, such as: •

• •

•

•

•

•

• •

• •

•

•

Organized “NCD in Depok City” seminar, that was attended by deputy Mayor of Depok; head of local health government, head of E commission of DPRD (assembly at municipal level), delegation of other sectors, government organizations and NGOs in health sectors Disseminated “CERDIK (Smart)” poster and guidance book freely to community. Organized interactive dialogue of health lifestyle and controlling integrated NCD by activity groups (regular social gathering, Islamic gathering, DM’s patient gathering, etc). Arranged interactive dialogue of health lifestyle on controlling NCD by local electronic mass media (FM “Ria” Radio) Campaign for health lifestyle (assembling street banner and dissemination poster/sticker) Seminar ‘Protect Depok Community of DM Threat” that was attended by head of local health government, Secretary of Mayor of Depok , Head of E commission of DPRD, some of government organizations and NGOs in health sector, DM’s patient and public community (about 250 persons) Activates ‘Healthy and Clean Friday’ activity, which is a routine activity of cleaning the workplace environment among the government institutions on every Friday Reward the community organization that held control activity on NCD risk factors Give awards to the model of cadres who has proactively in health promotion activity Give awards to the healthy elderly who have healthy lifestyles Give reward the good of restaurants that always prepare healthy menu and healthy food processing Give award to fitness centre which have a large amount of members and have no smoking area. Facilitated and motivated the implementation of “Posbindu PTM” by established communication forum of “Posbindu PTM” at village level. The communication forum had function to develop coordination which was performed every three month. This forum also used for sharing experience in conducting “Posbindu PTM” between coordinators and health volunteers.

52

NCD prevention and control program definitely required an integrated and comprehensive policy support., especially in regard to improve the human development index (Education index, purchasing power, life expectancy). Integrated policy was more feasible to develop rather than exclusive policy. Therefore, it will need a forum for communication and coordination of all the related stakeholders at District level. The forum will also important for the planning an evaluation program. Depok was fortunate to have such forum, a Healthy Depok City Forum, which was very potential to integrated the NCD prevention and control program. One of the missions of Healthy Depok City Forum was to create a healthy city which means support healthy life style environment. 5.1.5 Reorienting Health Services 5.1.5.1 Posbindu PTM Posbindu PTM is activities of NCD monitoring and controlling program, include activities of counseling, sharing experience and knowledge, and early detection which is organized by community and develop for the community. Although the initiative of establishing ‘Posbindu PTM’ originally will be implemented in Abadijaya, it is expected that ‘Posbindu PTM’ will be available in every administrative block (RW). There were 30 ‘Posbindu PTM’ representing 6 villages in Depok participated in the training activities. ‘Posbindu PTM’ have been established in 6 villages out of 6 subdistricts, that already have trained health volunteers to conduct ‘Posbindu PTM’ . It is expected that the ratio of number of “Posbindu PTM” and number of block village (RW) is 100%. Ratio of number of ‘Posbindu PTM’ in each village compare to number of administrative block (RW) in each village are presented on table 3 , it shows that the ratio of ‘Posbindu PTM’ and RW at the each village, the highest is at the village of Abadijaya, the second highest was village of Tugu, followed by village of Beji. The highest ratio in village of Abadijaya most probably because this village was the study area of surveillance and intervention program, that made the community and the health workers more well prepared and more eager to develop ‘Posbindu PTM. For village of Beji, the high ratio might be caused by involvement of active and professionalism of health workers from the public health centre in developing ‘Posbindu PTM’. Meanwhile, high ratio in village of Tugu is related to the participation of substantially active public figures in applying ‘Posbindu PTM’. In Abadijaya village there are several potential resources in the development of integrated health post for NCD or ‘Posbindu PTM’ among the 30 “Posbindu PTM’, as regards of financial and human resources, facilities, and community group. All of the 30 posts have already involved Family Welfare Organization and “Arisan Warga” (a neighborhood social gathering group). Meanwhile, 25 integrated health posts have involved Moslem Community Groups, 14 posts in collaborated with Healthy Heart

53

Club, and only 1 post has involved Diabetes Community Association. There were 6 posts had financial contribution from ‘Dana Sehat’ (community health insurance for low income community). Among the 30 posts, 22 posts have already had particular place for the activities and have provided Waist Hip Ratio measurement, while 20 posts have conducted body weight measurement. Several forms and recording-reporting tools to assess the target achievement, capacity and benefits of “Posbindu PTM” in community, had been developed. The achievement of each activity was categorized into 4 grades (Pratama, Madya, Purnama, and Mandiri). Detail forms and recording-reporting procedure of ‘Posbindu PTM’ as well as definition of each grade and activity indicators can be seen on form Posbindu PTM monitoring in attachment 8‘Pratama’ is the lowest level of Posbindu, it means the most basic or newly developed Posbindu, the second level was ‘Madya’, which means ‘Posbindu’ that had more activities, coverage and resources than the previous level (Pratama), and the next level was ‘Purnama’, which was at moderate level in implementing the Posbindu, and the highest level was ‘Mandiri’, which had the most complete activities, coverage, and resources. Results on “Posbindu PTM” monitoring activity (questionnaire attached on attachment 9) showed that the progress achievement of “Posbindu PTM” in Abadijaya village was increasing in every year. In 2003, Pratama level has been reached by 96.7% Posbindu PTM and only 3.3% reached “Madya” (see Table 8). In 2004, development level of ‘Posbindu PTM’ was 46.7%” for Pratama level, 30% for Madya, 16.7% for Purnama, and 6.7% of “Posbindu PTM was on level Mandiri (Table 9). In 2005, ‘Pratama’ level of ‘Posbindu PTM’ decreased to 40%”, for Madya, 20% for Purnama, and 20%, and for ‘Mandiri’ level was 20%. (Table10). Recent data in 2006 (see table 11) described more better figure of “Posbindu PTM”, there were only 13.3% in Pratama and Madya level, 33.3% reached Purnama, and 40% had reached Mandiri. Although the evaluation of the training showed an impressive result in knowledge, however, progress evaluation taken during 2004, 2005 and 2006 by field visits, communication by phone, and evaluation on report documentation of communication meeting which was done every three month, found that there were few limitations in the of ‘Posbindu PTM’, which are: 1) Lack of skill of NCD risk factors and its prevention among the health volunteers, which make them feel less confident to run the activities. 2) Lack of skill in recording and reporting system. 3) Lack of supporting facilities for the activity 4) Limited number of medics/paramedics in the residential area who were willing to participate in the activity. . 5) Low awareness of NCD risk factors prevention among the community.

54

Those information mentioned above, was found from the quantitative study which was done in 2005. Results of the study presented that there was significant different of target achievement of “Posbindu PTM” development level, between skilled health volunteer in blood pressure measurement with “Posbindu PTM” development level. There was 86.4% of “Posbindu PTM” who had better skill in blood pressure measurement had increased the progress become Purnama and Mandiri. (p < 0.05). The same of result also was found that there was significant different of target achievement of “Posbindu PTM” development level, between skilled health volunteer in diet maintenance. Meanwhile, health volunteer knowledge and limited facility had not significantly relate to the “Posbindu PTM” progress. (see Table 7 ). Limited number and quality of human resources showed significant association to the “Posbindu PTM” progress (p = 0.01). Particular amount of money that agreed by the community tend to show higher progress of “Posbindu PTM” (Purnama-Mandiri). It was found 88.2 % of ”Posbindu PTM” had managed the budget by fix amount of money that agreed by community (p 0.01). Oppositely, “Posbindu PTM” that managed the budget by voluntary donation significantly mostly was on Pratama and Madya level. (see Table 5). Limited number of human resources had significantly related to “posbindu PTM” progress development (p =0.01), but the facility resources had not significantly associated to the progress development (p 0.08). The implementation of ‘Posbindu PTM’ still needs to be supported by health workers from the local public health centre. In the point of partnership indicator and community health safety insurance, which in general still under the level of ‘Pratama’ and ‘Madya’, it is important to increase health volunteers and health worker’s capability as well as to increase partnership. Those two indicators (partnership and community health safety insurance) are substantially important for sustainability of the community based health programs. Health workers from the community health centre suggested that the training can be conducted at the community health centre, therefore it is necessary to provide adequate medicine and health diagnostic facilities to support the activity. In general, the health centers only have limited health facilities. Recording and reporting activities for ‘Posbindu’ were still confusing for the health volunteers and health workers. However, method in recording and reporting system is useful for the monitoring and evaluation activities of ‘Posbindu PTM’ in the community. It is suggested to conduct training and practice directly for monitoring and evaluation activities of ‘Posbindu PTM’ in the community Recording and reporting activities for ‘Posbindu’ were still confusing for the health volunteers and health workers. However, method in recording and reporting system is useful for the monitoring and evaluation activities of ‘Posbindu PTM’ in the community. It is suggested to conduct training and practice for monitoring and evaluation activities of ‘Posbindu PTM’ in the community. This condition shows that

55

training and technical assistant for health volunteer, in particular for reporting-recording and counseling of cases, are substantially important and need to conducted in the near future for better performance of “Posbindu PTM” implementation. The implementation of ‘Posbindu PTM’ still needs to be supported by health professional. This was because the community preferred of getting more health information or educated by health professional rather than getting it from health volunteer. Value of health volunteer was not sufficiently change the community awareness on healthy life style. Referring to the ‘health believe model’ in the behavior study, it was obvious that community tend to trust their health condition to the health professional or health experts.21,26 Series of meeting had been carried out to encounter this problem. Limited number of health professional from PHC made it less possible for them to guide or assist in every “Posbindu PTM” activity. More possible way to address this issue was trying to motivate any health professionals living in the working area of “posbindu PTM” or health professional who worked in private hospital or health clinic to participate in the activity. This approach had been applied in Depok, and in fact not all “Posbindu PTM” coordinator could manage this approach due to personal communication point of view. Therefore, increasing health volunteers and health worker’s capability and partnership are still intensely needed. The evaluation showed that medical aspect and partnership with health professional were significantly related to the ‘Posbindu PTM’ progress development (see Table 6 and Table 7). Experiences gained by investigator team when they directly involved in building the partnership, it was found that detail and clear explanation that the benefits were not only community health, but also give benefits to the private health clinics. Firstly, the activity could be used to promote their clinics to the community. Secondly, ‘Posbindu PTM’ might found some people who had NCD risk factors, in which there would be more chance for them to visit the private health clinics they knew from the “Posbindu PTM” activity. The concept of ‘supply creating demand approach’ and ‘demand creating supply approach’ could naturally developed in this partnership approach. This approach resulted positive results in sustainability of “Posbindu PTM”. There were nine “Posbindu PTM” (30%) that could performed actively every month with supports from health professional of local private health clinic in their area. Supports that had been given included medical tools such as blood pressure measurement tool, weighing scale, and sometimes they also brought vitamin and medicine Partnership with pharmaceutical industry also had been developed. As a result of the partnership with PT Merck and PT Roche digital blood test company, some “Posbindu PTM” got free digital blood test tools for blood glucose and cholesterol. This supports enabled ‘Posbindu PTM’ to provide blood test to monitor hiperglicemia and hypercholesterol. Similar partnership had also developed with the health insurance company, but it didn’t give significant results yet. Two indicators (partnership and

56

community health safety insurance) are substantially important for sustainability of the community based health program. Therefore, it is important to develop the two indicators for more effective partnership strategy. Socialization and publications of the positive impact of Posbindu PTM was sufficiently achieved. A local middle up well known magazine March 2006 edition in Jakarta had covered success story of “posbindu PTM” activity, in six full pages. Also, a FM radio (RIA FM) had broadcasted interactive dialog about ‘Posbindu PTM’ and other NCD risk factors issues. This local radio could reach Depok area as well other areas including Jakarta. As a result, supports from Depok Health Office had dramatically increased. The budget allocation for NCD from the Depok Government Office was sharply increased from Rp.200,000,000,- in 2004-2005 to Rp.500,000,000,in 2005-2006, although the amount was not sufficient compare to other programs. Most of budget was used for ‘Posbindu PTM’ and other related programs, such as training for health volunteers, medical doctors, and paramedics, was well as providing measurement equipment such as stethoscope and spigmomanometer. Currently, there were 360 health volunteer working for ‘Posbindu PTM’, 50 medical doctors and paramedics had been trained for PC of NCD and it risk factors program in Depok. 5.1.5.2 Integrated ’Yandu PTM’ in PHC Public Health Center (PHC) is the technical unit of District Health Office, that responsible to manage health development for sub district area. One of the Health Office missions is achieving healthy sub district/healthy village to support Healthy Indonesia with considering the local community need and resources as well as working area. Basically, the concept of healthy sub district or healthy village is to create healthy life style among the community that supported by healthy environment, and more qualified and adequate health access that equal for all community member to improve community health status optimally. Functions of PHC are as initiator or motivator for health development in PHC working area; center of family and community empowerment and in health aspect; and provide primary health services focusing on individual health program as well as on public health program.26, 31-33 Function of PHC

Initiator for health developme nt in PHC working area

Centre of family and community empowerment

Center of health services in level 1

Health service

Medical service

57

The structure of PHC in Health System is stated on the following: 1. On the National Health System, as a primary health service facility at the first level of health system. 2. On the District/City Health System, as technical operational unit of District Health Office. 3. On the District Health System, as a structural unit of District Government on health aspect for the sub district level. 4. First level of health facility, in which PHC plays as a partner for various first level health care facilities, as well as educator or facilitator of community based health program. In the management of PHC, some important aspects below are needed to be considered 1) Aspect of responsibility for health status of community in the working area of PHC (district or village) 2) Aspect of community empowerment that covers community in PHC working area. 3) Aspect of integrated approach. 4) Aspect of referral health services (particularly for further health treatment) There were 18 basic health care programs in PHC. Generally, the programs include: individual health care (private Good), and public health care (public goods). Government has tried to reduce the programs into 6 obligatory programs, which will added with local needs which will be varied depend on local PHC capacity. The 6 obligatory programs are as a health promotion, environmental health, maternal and child health including birth control, nutrition, communicable diseases control, basic medication Several possible additional program development are as adolescent health, mental health, over nutrition, injury, non-communicable diseases (degenerative diseases), and improving services, such as 24 hours service, appointment service for better service quality, etc. Several additional roles and functions have been applied in PHC to implement the NCD prevention and control program through community based program. The additional roles and function are as follow: 1) Organize NCD risk factors surveillance in PHC working area. 2) Referral facility of NCD risk factor case which was referred from the NCD risk factor monitoring activity in “Posbindu PTM”. 3) Educate or improve community based program, such as “Posbindu PTM”, NCD club, exercise or sport club, etc. 4) Planning and Conducting NCD prevention and control program, with strengthening promotion and prevention aspects and also concerning the curative and rehabilitative aspects, fulfilling the community need and adjusted to PHC capacity.

58

5) Develop adequate partnership with related institutions and stakeholders in the PHC working area, such as make collaboration with local general hospital for capacity building on NCD case management and referral system, as well as develop partnership with private sectors of non-government organizations, to improve community based health program. Revitalization is very important to enable PHC successfully running its roles and functions, particularly in implementing NCD prevention and control program. The revitalization programs are as the following: 1) Improve PHC concept direct to recent district autonomy policy. , 2) Obtain policy support and regulations to enable the operational of “Yandu PTM” (integrated health services for NCD) in PHC. 3) Enhance health workers capacity in PHC to provide qualified NCD case management as well as NCD prevention and control in integrated approach. 4) Provide PHC with facilities (required laboratory or measurement equipments) for NCD case management and prevention program. 5) Provide PHC with sufficient medicines required for NCD case treatment, 6) Improve reporting and recording system in PHC, particularly for NCD cases. 7) Develop referral system of NCD case from “Pobsindu PTM” to local PHC and vise versa. At present, the activity of ‘Yandu PTM’ could only be performed in a public health centre of village of Abadijaya. The operation of ‘Yandu PTM’ has been supported by a decree from the City Mayor and local Health Office. The activities were carried out once a week, on every Monday. The average number of patient was 10-20 patients. The number of patient was still limited, because the visiting hour was only from 8 am to 12 am. When we tried to apply longer office hour the total number of patient reached 20 in maximum. This implies there is a greater patient’s need regarding NCD medication and care. The community proposed that the frequency of service should be added become twice a week (Saturday and Monday) instead of once a week. It is important to be considered that most of the people work on Monday to Friday, and Saturday is the best time for them to visit ‘Yandu PTM’. Public Health Center coverage for NCD case was still relatively low, which was approximately 10% compare to prevalence of NCD case in Depok. The implementation of ‘Yandu PTM’ had several limitations, as follow : 1) 2) 3)

Limited number of medical doctors and paramedics as well as limited skill of NCD case management Patient who had NCD preferred to go to general hospital, because they could not used insurance for medicine and laboratory test in PHC. Reporting and recording system had not sufficiently applied.

59

4)

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

This condition shows that training of NCD clinical management and technical assistant for reporting-recording, required to be gained. This issues had been discussed in the coordination meeting between PHC, Depok Health Office, and other stakeholders. Health workers from the community health centre suggested that the programs can be conducted at the community health centre; therefore it is necessary to provide adequate medicine and health diagnostic facilities to support the activity. In general, the health centers only have limited health facilities. It had been agreed that the integrated health service of NCD would not only provided by local PHC, but also would applied in other private health clinics. Obviously, the health service provided by private health clinics was better than in PHC, even though it would be more costly. Therefore, in the future the training will involve health professionals from private sectors as well. PHC could not optimally support ‘posbindu PTM’ in community due to limited capacity and resources. This evaluation showed that good progress or performance of this community based approach required stronger personal awareness and commitment among the health professionals involved in the program, both from PHC and Health Office. Monitoring and technical guidance from Depok Health Office addressed to PHC were very vital. The Health Office should give more attention to PHC that didn’t show qualified performance or progress on NCD prevention and control program. However, working mechanism and system showed that PHC was under the Government Office not Health Office, which made Health office had less authority to supervise or monitor the PHC. Inputs or community response might significantly effective to the health service policy when community felt unsatisfied with the health service. Nevertheless, culturally and traditionally criticizing health services still assumed as impolite manner because some of the community still believed that medical professionals, especially doctors, was their life saver that made them felt inappropriate to show non-satisfaction of the services. Coordination meeting was expected to encounter this situation. However, the Government Office had given huge financial support to the intervened PHC, more than one billion rupiah for improving the PHC facilities only not for improving the service performance quality. This issue will be discussed and managed at the coordination meeting of Healthy Depok City Forum at the end of year 2006. . 5.1.6 Constraints in NCD control program implementation In general, Community base intervention on prevention and control NCD program implementation had been performed successfully. However, several conditions

60

in the local government office and recent health care system brought some constraints for NCD control program implementation. Those are: 1) NCD is still low priority despite the growing interest of the local government and community. This is reflected by low allocation of funding from the local government. Meanwhile, NCD control program is kind of new programs which require additional budget allocation and it has not been used as an indicator of minimum health care standard. 2) Basically, Depok health office showed positive response to NCD control program, however, some administrative function, in regard of decentralization system, took more working time of the health workers, who was supposed to run NCD control program. As a result, co-ordination and intervention of NCD control program were a little bit slow up. 3) Collaboration of NCD control program between Province level and District level was not established yet thus caused less support from the Depok health office to conduct NCD control program. 4) Limited human resources and drugs facilities in the community health centre, as well as limited knowledge of NCD control program among health workers. 5) Non-conducive social environment condition for NCD risk factors control program. Promotion of unhealthy products, such as tobacco advertisements, fast food, soft drinks, is extremely assertive. 6) Decision-makers in the local health office still not given priority for Non Communicable Diseases. One significant reason is because there is no sufficient information regarding mortality data of NCD as cause of death in Depok.

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

61

2) The surveillance activity or data collection activity was done in one post which was located close to the respondent’s residential area. 3) The activities always involved local community leader or member. The community was treated as subject of the surveillance instead of the object. 4) The activities were prepared at least one month prior to the data collection, and respondent had invited at least one week before the health examination. 5) Respondents had been adequately informed to fast for the blood test. 6) Local health volunteers reminded respondent to come to the post and compulsory to fast for the blood test, one day before the data collection. 7) Results of health examination were distributed immediately in one week time after the data collection date. 8) Referral mechanism or follow up for the NCD case found during the data collection activities had been prepared in collaboration with local PHC or health clinic. Detail figures of prevalence and mean value of NCD risk factors can be seen on book 2006 (Attachment 14), while the brief description of NCD RF can be seen on fact sheet 2006 on attachment 13. The NCD risk factors prevalence and mean value significantly decreased, especially hypertension, compare to 2003 survey, except for smoking, alcohol consumption, and physical activity. Data on 2003 and 2006 could not be directly compared as there were some changes in population distribution and size. Therefore, intervention effect evaluation had done based on standard population size, which was taken from Depok population data on the middle years of intervention time period it was on 2004. Depok population distribution by sex and age group (25-34, 3544,45-54, 55-64) in 2004 was used in weighting data analysis. Level of Confidence Interval 95% was used to estimate the significance of deference of the intervention result. Table 12 up to Table 43 showed prevalence and adjusted mean of NCD risk factors in 2003 and 2006. 5.2.1 Behavior Risk Factors Prevalence of daily smokers had not significantly decreased (26% ; 95% CI 22.8%– 29% for men and 3.9%;95% CI 2.5%–5.2% for women) in comparison to 2003 data (32.5 % ; 95% CI 28.1 % – 36.8% for men, and 4.2%;95% CI 2.7%–5.7% for women ), both in men and women. The detail figure of smoking prevalence can be seen on Table 12 up to Table 17. Data on average age when started smoking, smoking duration, and average number of cigarette per day, as well as alcohol consumption during last 12 months (Table 18), were not significantly decreased. Significant lower prevalence of daily smoking in Depok had not yet achieved. This is most probably because of anti smoking promotion was not as huge as smoking prevention in Depok. Obviously, the cigarette advertising was shown in every famous and crowded public places in Depok. There were plenty of sport events and entertainments were sponsored

62

by the tobacco industry. These unhealthy advertising and sponsorship were quite common in other parts or districts in Indonesia. Meanwhile, regulation on smoking restriction and tobacco advertising ban were not yet developed in Depok. Several intervention activities, coordinated by Healthy Depok City Forum, had been undertaken. The activities included anti smoking campaign, promote non smoker City Major on the election campaign, who finally won the election on 2006. Previous Major in 2005 had not yet made any changes on smoking issues. A round table discussion with related sectors resulted agreement on cigarette advertising restriction. In fact, unavailability of national policy on tobacco control in Indonesia, give significant influence on unsuccessful to reduce smoking prevalence in Depok. Anti smoking activities that have been done until recently are develop smoking control program by promoting ‘rooms without astray’ in the house and public places, changing the tradition of using words ‘cigarette money’ for tip, into the word ‘fruits or milk money’, put note or announcement of ‘no smoking area’ in public places, and make smokers feel inconvenient to smoke by get away from them when they smoke. The future plan has emphasized more intensive on tobacco control policy development. Definitely, community will raise the selected new Major for his promise and commitment to support tobacco control program in Depok. The fruits consumption was slightly increase, but not significant, between 2003 data and 2006 data. The average fruits consumption was ranging from 1.8 to 1.9 serving per day, which increased in 2006 (1.9 to 2.1 serving per day). Similar trend was occurred for vegetable consumption. Percentage of those who consumed vegetables 5 servings or more had significantly increased from 14% to 17.5% for both men and women, from 13% to 18.2% for men, and from 15.3% to 16.4% for women. Detail figure of fruits and vegetables consumption can be seen on Table 19 up to Table 21. Information gained from in depth interview and focus group discussion of dietary behavior found that Availability of fruits and vegetable in the local market in Depok is relatively sufficient in variety as well as in quantity. People consume less fruits and vegetable consumption due to some reasons, such as low knowledge on the health benefits of fruits and vegetables, some myths on negative effects of particular fruits, and low skill in serving vegetable among the housewives. Beside, it is also important to gain local fruit production by encourage community to use the backyard to grow fruit and vegetable plant. Government and related sectors also need to consider to control the fruits and vegetable price adjusting the community purchasing power. Therefore, several activities have to be done are increase knowledge on health impact of fruits and vegetable consumption, improve skill among housewives to prepare vegetable in healthy way, fast, and interesting. Also it will need improvement in local fruits production by utilizing home yard and control fruits and vegetable price to be more affordable.

63

Data of physical activity, showed that the percentage of sedentary physical activity significantly decrease in both sexes from 33% in 2003 to 22.4% in 2006. A sharp decreased was found among women, which decreased from 33.5% to 14.3%, but the percentage was not significantly decreasing among men (from 32.6% to 28.7%). Median time spent in work increased not significantly from 25.7 minutes per day in 2003 to 60 minutes per day in 2006. Similar trend occurred for median time spent during transportation and leisure time. More detail figures can be seen on Table 22 up to Table 25). In fact, in regard to physical activity, community had high motivation and spirit to take exercise and physical activity, especially walking. Most of the people are aware of the health benefits of physical activity. Inadequate physical activity is mostly because of non conducive environment, such as lack of sport and physical activity facility provided by the local government, traffic jam, and unavailability of pedestrian path. Results of in depth interview and focus group discussion showed that community need on physical activity, there are sufficient support of availability and maintaining the sport facilities for public in each RW (administrative unit) from local Government Office, repairing and providing safe and convenient pedestrian path, increase motivation to exercise. Regular physical activity which could be done by almost all people was walking. All groups stated that walking was the most convenient physical activity. This can be seen from community greater enthusiasm to walk in the open areas (in the area of University of Indonesia campus) or new road (real estate area) during the week end or holiday. Particularly for less than 1 kilometer distance, walking is still convenient among the community; however there were some constraints. There was assumption among the community that walking in the daily activity for travel from one place to other places considered as ‘broke’ (‘bokek’) or doesn’t have enough money to pay for transportation. And the walking facilities or pedestrian area in public areas was limited or not constructed specifically for pedestrian, and not suitable for walking (dirty, smell, mud-covered, etc). Several activities and programs of community based intervention had been undertaken to work out the issues mentioned above. Depok Government Office had tried to encounter community need regarding health environment. Pedestrian path had been provided to enable community to walk safely. However, the pedestrian path areas were mostly occupied by the street vendor. Therefore people have to walk on the road, which is actually unsafe and lead to greater risk of traffic accident. Plans for the future to promote physical activity in community include: 1) Motivate government to provide adequate pedestrian path which is safe, healthy and comfortable.

64

2) Government should be able to provide ‘city garden’ in each the village which is also suitable for walking activity. 3) A big event of walking together for all Depok citizens is allocated at least once a year, to motivate and gain walking tradition among the community Physical Risk Factors Mean value of BMI significantly decreased for both men and women. The mean value declined from 24,3 in 2003 to 23.4 in 2006. The mean value of BMI declined from 23.9 in 2003 to 23.0 in 2006 among men, and from 24.9 in 2003 to 23.9 in 2006 among women. Similar trend also found on prevalence of overweight (BMI >= 25 kg/m2) and obesity (BMI >= 30 kg/m2). The detail of BMI showed on Table 26 up to Table 28 . The intervention program for diet was focused on promoting healthy diet by balance calorie intake. The program was targeted for health volunteer so that can be socialized to the community, particularly housewives. Although the fruits and vegetables consumption were not significantly improved, the community had more skills on dietary management for more balance and healthy diet. Further analysis will be needed to assess the relationship of community skill and awareness in diet and BMI. Table 30 up to Table 33 were disseminate the prevalence and mean of systolic and diastolic blood pressure decreased significantly after the intervention. The prevalence of raised blood pressure (SBP >= 140 and/or DBP >=90) considerably decreased from 9% in 2003 to 4.5% in 2006, specifically, from 9.2% in 2003 to 5% in 2006 for men and from 8.6% to 4.9% for women. Similarly, grade 2 raised blood pressure (SBP >= 170 and/or DBP >=100 mm/Hg) significantly declined from 3.8% in 2003 to 1.2% in 2006; from 4.3% to 1.4% among men, and from 3.1% to 1% among women. This quite good improvement on blood pressure related to improvement in community awareness to monitor their blood pressure regularly and to follow it up immediately when the blood pressure got higher, as it was suggested in ‘Posbindu PTM’. Information from PHC report showed that number of hypertension case increased in the last few years. In addition, more sufficient availability of medicine in PHC leads to adequate treatment for hypertension patients. Improvement on community knowledge and awareness of NCD issues and its related diseases might contribute to the decreasing figures. This assumption can not be analyzed as the questions on individual knowledge were not available in STEPS instrument but we can add optional questions on that aspect for the next STEPS survey in the future. Biochemical Risk Factors Mean of fasting blood glucose decreased considerably from 4.9 mmol/L in 2003 to 4.6 mmol/L in 2006. Specifically, the mean value declined from 5 mmol/L to 4.6 mmol/L in men and from 4.9 mmol/L to 4.6 mmol/L in women. Meanwhile, prevalence

65

of raised blood glucose (>=7 mmol/L ) also declined from 5.8% to 3.2% for both sexes, from 5% to 3.7% for men and 6.1% to 2.6% for women. The significant decline also occurred for two hours blood glucose load as well as diabetes prevalence. More clear figure can be seen on Table 34 up to Table 38. Mean blood cholesterol also showed significant improvement after the intervention, except for men (Table 39). The prevalence of raised total cholesterol (>=5.2mmo/L) reduced considerably from 31.6% in 2003 to 19.6% in 2006 for both sexes; and it declined from 29.7% to 20.9% for men, and from 34% to 18.9% for women (Table 40). The prevalence of raised total cholesterol (>=6.5 mmol/L) also decreased from 5.9% in 2003 to 3.9% in 2006 for both sexes; and it reduced from 5.3% to 3.1% for men and from 6.7% to 3.6% for women (Table 41). The decrease was likely related to more adequate services and medication treatment from PHC, early detection in the community, knowledge and awareness to reduce high cholesterol food intake, as well as routine monitoring in ‘Posbindu PTM’. This study found that combined risk factors or those who had high risk (having three of more risk factors) decreased significantly by age group and sex after the intervention (Table 43). The percentage of those who had lower risk was increase significantly. Detail percentage can be seen on Table 42. This significant improvement of NCD risk factors after the intervention concluded that the community based intervention of NCD prevention and control program has achieved the main goal. In general, ‘Posbindu PTM’ gave vital contribution to reduce the NCD risk factors prevalence and mean value. As showed on Table 44 the higher risk group mostly who stayed in area where the ‘Posbindu PTM’ development level was on Pratama and Madya, while for those who had lower risk factors mostly stay in the area where the ‘Posbindu PTM’ level was Purnama-Mandiri. (p< 0.05).

6. CONCLUSION 1) The community based intervention of NCD prevention and control program that had been conducted for three years had significantly reduced the prevalence of several common risk factors, such as obesity, hypertension, hyperglycemia, hyper cholesterol, and high risk or combined risk factors (having three or more risk factors) and also considerably reduced the prevalence of diabetes mellitus. Meanwhile, smoking, less physical activity, and fruits and vegetable consumption also decreased but not significantly. 2) Three main effective strategies of CBI on PC of NCD and its risk factors program, are surveillance of risk factors of NCD, development policy and coordinating, strengthening individual skill, enabling strong community action, enhancing social environment, and re-orienting health service, which are essentially need to be conducted in coordinated approach and integrated (not in systematic or sequence

66

way). Implementation at district level requires structural policy support which can stimulate the implementation of NCD prevention control program. In this case, it is vital to provide program coordinator for province level and district level to monitor and to integrate program achievement. Other contribution to ineffective support from the Depok Health Office was employee mutation which occurred frequently and unpredictable. This leads to ineffective working performance among the coordinators. The mutation should be done after specific working time period, so that enable the employee to complete the task, and prepared adequate time for hand over so that the program can still be taken optimally and sustain. 3) Health City Forum of Depok (“FKDS”) as a partnership coordinating institution in Depok Municipality, which consists of people from local government, Health NGO, industry, private business and community figures. FKDS is an effective forum for co-ordination and advocacy to policy makers. The activity on controlling risk factors of NCD by a combination of the two approaches (‘supply creating demand approach’ and ‘demand creating supply approach’) had been conducting through ‘Health City Forum of Depok’ by synergistic and integrated. 4) Information of diseases which was obtained from the NCD risk factors surveillance activity can motivate the policy makers to develop policy for NCD control program. Information dissemination of NCD risk factors issues in related to human development index during the advocacy process was more effective to motivate the policy makers rather than the information of NCD risk factors only. 5) Activities in ‘Posbindu PTM’ have been well developed and run in the community, although some of educators still are not confidence enough to give counseling. Community organizations that can be potentially developed are integrated health post for elderly (‘Posyandu Usila’), healthy heart exercise group, and community group (‘Arisan’). Activities in ‘Posbindu PTM’ are not necessarily only monitoring and counselling of NCD risk factors in community. If the activities are conducting in routine period, it can be as a partnership media and knowledge transfer media in NCD risk factors control program in primary level. NCD risk factors was considerably reduced among the community that had ‘Posbindu PTM’ at Purnama and Mandiri level. 6) Coverage of ‘Yandu PTM’ (integrated health service for NCD) in PHC was relatively still low. Participation of private health clinic, partnership with pharmaceutical industries and media, gave substantial contribution to accelerate progress level of Posbindu PTM, as well as for its sustainability.

67

7. RECOMMENDATION 1) Surveillance activity for NCD risk factors and/or mortality surveillance is important to be linked on community base intervention strategy for evidence base line and evaluation programs/activities. Policy development for further specific programs and sustainability on NCD control program are considerably required to be done. 2) To gain awareness of NCD issues among the policy makers as well as to obtain policy support for sustainable NCD prevention and control programs, it is very substantial to associate the outcome of the NCD program with the increasing human development index (HDI), such as life expectancy illiteracy rate, average school years, and purchasing power index. NCD problem identification and its relation to human development index were used during the advocacy to the policy makers. 3) To supportive social environment, it will be beneficial to develop similar concept of NCD control program in different setting, such as workplaces and schools. Motivation and facilitation through encouraging health system and networking, as well as flexible operational guideline, are substantially important for NCD control program. Activities of ‘FKDS’ need to be done with more intensive technical support especially for administrative activity, as well as build partnership with pharmaceutical industry and media. 4) Activities of ‘Posbindu PTM’ ideally should be performed by established community health organisation; such as integrated health post for elderly and healthy heart exercise group. The health promoter should be carried out by family welfare association. Support and active participation of the health professional still important for ‘Posbindu PTM’ until they are completely independent, while partnership with private health clinic also have to be maintained. 5) Depok still need to develop programs to improve capability of health workers and health volunteer in NCD control program, in particular capacity to promote physical activity, diet, and stop smoking. It is also substantially necessary to perform appropriate training or courses specifically for recording and reporting system of ‘Posbindu PTM’ for health workers as well as for health volunteer. 6) Routine meeting (once every 3 months) among health workers and among health volunteers concerning NCD control activities require to be performed in minimum at the sub-district level. Therefore, it is expected that health workers can share experiences and develop co-ordination for the activities. 7) Community base intervention approach on PC of NCD and its risk factors are necessary to be applied in other district or village area in Indonesia to control and reduce the NCD risk factors in different setting of community. Process evaluation need to be undertaken annually, while the outcome evaluation should be done in at least every 5 years. 8) ‘Posbindu PTM’ as operational activity of community based intervention at the lowest community setting as part of integrated NCD prevention and control program requires further analysis and study using quasi experimental design to accessing its effectiveness and cost effectiveness.

68

Table 1 : Difference of mean score of knowledge test in pre and post training 2004 4.3 Topic of training

n

Means of Post Test 84.6

t value

p

35

Means of Pre Test 56.7

Controlling NCD risk factors and clinical therapy for physician, nurse, dietician. Improving community participation in developing ‘Posbindu PTM’ and ‘Yandu PTM’ , for the health workers Healthy diet, exercise and stop smoking program for community. Management of ‘Posbindu PTM’ for potential and active volunteer Method of healthy diet, exercise and stop smoking program for selected cadre

-15.07

0.00

30

62.17

85

-11.57

0.00

44

62.39

84.43

-13.54

0.00

30

56.5

83.6

-13.57

0.00

30

66.75

87.5

-8.69

0.00

Table 2 : Difference of mean score of knowledge test in pre and post training 2005 4.4 Topic of training

n

Means of Post Test 88.60

t value

p

30

Means of Pre Test 70.68

Controlling NCD risk factors and clinical therapy for physician, nurse, dietician. Improving community participation in developing ‘Posbindu PTM’ and ‘Yandu PTM’ , for the health workers Healthy diet, exercise and stop smoking program for community. Management of ‘Posbindu PTM’ for potential and active volunteer Method of healthy diet, exercise and stop smoking program for selected cadre

-17.02

0.00

30

75.71

88.82

-13.09

0.00

30

68.35

85.21

-16.86

0.00

60

77.50

87.53

-10.04

0.00

30

70.15

87.24

-17.09

0.00

69

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

Number of RW

Number of ‘Posbindu PTM’

Ratio

Abadijaya

27

15

0.55

Cinangka

15

3

0.20

Cinere

10

2

0.20

Beji

9

4

0.44

Ratujaya

10

2

0.20

Tugu

10

4

0.40

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

Variables Routine fixed donation Yes No Pearson 8.123 df 1

No

11.8 61.5

15 5

88.2 38.5

4 6

66.7 25.0

2 18

33.3 75.0

0 10

0 40.0

5 15

100.0 60.0

4 6

23.5 46.2

13 7

76.5 53.8

p 0.08

From Posbindu Service Fee Yes No Pearson 1.697 df 1

2 8

p 0.05

Sponsor Yes No Pearson 3.000 df 1

Purnama- Mandiri Number %

p 0.00

Voluntary donation Yes Pearson 3.750 df 1

Pratama-Madya Number %

p 0.19

70

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

Variables Limited number of human resources Yes No Pearson 6.429 df 1 p 0.01 Limited quality of human resources Yes No Pearson 6.429 df 1 p 0.01 Limited facility Yes No Pearson 3.000 df1 p 0.08 Unwilling to pay Yes No Pearson 7.500 df1 p 0.00



10 0

47.6 0

11 9

52.4 100.0

10 0

47.6 0

11 9

52.4 100.0

10 0

40.0 0

15 5

60.0 100.0

10 0

50.0 0

10 10

50.0 100.0

Table 6. Target achievement of Posbindu PTM by Constraints which found in counseling activity Variables No opportunity Yes No Pearson 0.085 df 1 p 0.77 Less self confident Yes No Pearson 10.000 df 1 p 0.00 Less skills Yes No Pearson 10.000 df 1 p 0.00 Less facility Yes No Pearson 10.000 df 1 p 0.00 Not trusted Yes No Pearson 10.000 df 1 p 0.00



3 7

37.5 31.8

5 15

62.5 68.2

10 0

55.6 0

8 12

44.4 100.0

10 0

55.6 0

8 12

44.4 100.0

10 0

55.6 0

8 12

44.4 100.0

10 0

55.6 0

8 12

44.4 100.0

71

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

Variables Knowledge of NCD Sufficient Less sufficient Pearson 0.714 df 1 p 0.39 Knowledge of ‘Posbindu’ Sufficient Less sufficient Pearson 0.714 df 1

61.9 77.8

8 2

38.1 22.2

13 7

61.9 77.8

8 2

38.1 22.2

13 7

61.9 77.8

8 2

33.3 33.3

16 4

66.7 66.7

2 8

11.8 61.5

15 5

88.2 38.5

8 2

44.4 16.7

10 10

55.6 83.3

3 7

13.6 87.5

19 1

86.4 12.5

p 0.10

Skill in diet maintenance Sufficient Less sufficient Pearson 2.500 df 1

13 7

p 0.00

Skill to measure anthropometry Sufficient Less sufficient Pearson 14.403 df 1

38.1 22.2

p 1.00

Skill to measure blood pressure Sufficient Less sufficient Pearson 1.667 df 1

8 2

p 0.39

Knowledge of NCD Prevention Sufficient Less sufficient Pearson 0.000 df 1


p 0.39

Skill in motivate community Sufficient Less sufficient Pearson 0.714 df 1


p 0.00

72

Table 8. Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2003 No

Indicator

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

‘Pratama’ n

%

n

%

1

Activities implementation

27

90

2

6.7

2

Obesity monitoring coverage Blood pressure monitoring coverage Blood glucose monitoring coverage Blood cholesterol monitoring coverage

27

90

2

6.7

27

90

2

6.7

28

93.3

1

3.3

28

93.3

1

3.3

3 4 5 6

NCD education

28

93.3

1

3.3

7

Counseling

28

93.3

1

3.3

8*

Exercise coverage/ Physical Activity once in a week

10

33.3

13

43.3

9

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

3 3 22 27

10 10 73.3 90

27 27 8 0

90 90 26.7

10

Activities personnel

25

83.3

5

16.7

11

Health safety insurance

27

90

3

10

12

Independent participant

29

96.7

1

3.3

13

Partnership

29

96.7

1

3.3

29

96.7

1

3.3

All Indicator

n

%

‘Mandiri’ n

%

73


Indicator


‘Pratama’

‘Mandiri’

n

%

n

%

n

%

n

%

1


17

56.7

7

23.3

4

13.3

2

6.7

2


17

56.7

7

23.3

4

13.3

2

6.7

17

56.7

7

23.3

4

13.3

2

6.7

17

56.7

7

23.3

4

13.3

2

6.7

20

66.7

5

16.7

4

13.3

1

3.3

3

10

2

6.7

3 4 5 6

NCD education

27

90

2

6.7

7

Counseling

27

90

2

6.7

8


10

33.3

13

43.3

4

13.3

9


3 3 5 20

10 10 16.7 66.7

15 15 15 5

50 50 50 16.7

12 12 10 5

40 40 33.3 16.7

10


10

33.3

5

16.7

15

50

11


27

90

3

10

12


15

50

5

16.7

10

33.3

13

Partnership

20

66.7

7

23.3

3

10

14

46.7

9

30

5

16.7

All Indicator

74


Indicator


‘Pratama’

‘Mandiri’

n

%

n

%

n

%

n

%

1


7

23.3

10

33.3

8

26.7

5

16.7

2


7

23.3

10

33.3

8

26.7

5

16.7

7

23.3

10

33.3

8

26.7

5

16.7

7

23.3

10

33.3

8

26.7

5

16.7

7

23.3

10

33.3

8

26.7

5

16.7

3 4 5 6

NCD education

10

33.3

12

40

4

13.3

4

13.3

7

Counseling

10

33.3

12

40

4

13.3

4

13.3

8


8

26.7

8

26.7

5

16.7

9

30

9


3 3 5 13

10 10 16.7 43.3

7 7 7 8

23.3 23.3 23.3 26.7

12 12 10 5

40 40 33.3 16.7

8 8 8 4

26.7 26.7 26.7 13.3

10


10

33.3

5

16.7

10

33.3

5

16.7

11


23

76.7

4

13.3

3

10

12


12

40

5

16.7

8

26.7

5

16.7

13

Partnership

18

60

7

23.3

3

10

2

6.7

12

40

6

20

6

20

6

20

All Indicator

75

Table 11 . Achievement of Development Level of Integrated Health Post for NCD (‘Posbindu PTM’) by Indicator in Abadijaya in 2006 No

Indicator


‘Pratama’

‘Mandiri’

n

%

n

%

n

%

n

%

1


-

-

2

6.7

8

26.7

20

66.7

2


3

10

3

10

15

50

9

30

3

10

3

10

15

50

9

30

3

10

3

10

15

50

9

30

3

10

3

10

15

50

9

30

3 4 5 6

NCD education

3

10

3

10

15

50

9

30

7

Counseling

3

10

3

10

17

56.7

7

23.3

8


-

2

6.7

8

26.7

20

66.7

9


3 6 4 5

10 20 13.3 16.7

15 12 12 9

50 40 40 30

9 9 9 6

30 30 30 20

10


11


12


13

Partnership

All Indicator

3 3 5 10

10 10 16.7 33.3

30 3

10

3

10

19

63.3

5

16.7

8

26.7

22

73.3

12

40

6

20

4

13.3

8

26.7

4

13.3

4

13.3

10

33.3

12

40

76

Table 12. Percentage who currently smoke tobacco daily Both Sexes Results for adults aged 25-64 years (adjusted *)

25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

Males

Females

2003 (N=1806)

2006 (N=1806)

2003 (N=847)

2006 (N=909)

2003 (N=959)

2006 (N=897)

% (95 CI %) 19.9 (15.0-24.8) 24.9 (18.1-31.7) 21.5 (16.6-26.5) 18.0 (14.5-21.5) 21.0 (18.3-23.6)

% (95 CI %) 15.5 (11.9-19.1) 18.1 (14.5-21.8)) 16.7 (13.5-19.9) 14.5 (10.2-18.8) 16.3 (14.4-18.3)

% (95 CI %) 32.5 (24.3-40.8) 35.8 (26.4-45.2) 32.1 (23.3-40.9) 29.0 (24.1-33.9) 32.5 (28.1-36.8)

% (95 CI %) 26.1 (20.0-32.2) 27.4 (21.4-33.4) 31.2 (25.4-37.1) 19.4 (13.7-25.1) 26.0 (22.8-29.0)

% (95 CI %) 4.3 (1.2-7.4) 2.1 (0.2-4.0) 5.7 (2.8-8.6) 2.8 (0.6-5.0) 4.2 (2.7-5.7)

% (95 CI %) 2.4 (0.5-4.3) 6.9 (3.8-10.0) 3.9 (1.7-6.2) 0 3.9 (2.5-5.2)

Table 13. Average age started smoking (years) for those who smoke tobacco daily Both Sexes Results for adults aged 25-64 years (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

2003 (N=308)

2006 (N=308)

Males 2003 (N=272)

Females

2006 (N=239)

2003 (N=36)

2006 (N=35)

mean

mean

mean

mean

mean

mean

(95 CI %) 18.2 (17.0-19.5) 17.9 (16.5-19.4) 20.0 (18.6-21.4) 19.9 (18.6-21.7) 19.0 (18.3-19.7)

(95 CI %) 16.3 (15.7-17.0) 17.6 (16.4-18.9) 20.9 (19.0-22.9) 21.1 (18.5-23.7) 18.2 (17.5-18.9)

(95 CI %) 18.0 (16.7-19.3) 17.7 (16.3-19.2) 19.4 (18.0-20.9) 19.6 (18.3-20.9) 18.6 (17.9-19.4)

(95 CI %) 16.3 (15.7-13.6) 16.6 (15.3-17.8) 20.2 (18.3-22.1) 21.1 (18.5-23.7) 17.8 (17.1-18.5)

(95 CI %) 20.1 (16.5-23.7) 25.2 (17.4-33.0) 24.9 (20.3-29.5) 24.6 (17.5-31.6) 23.0 (20.6-25.5)

(95 CI %) 16.1 22.8 26.2 0 21.9

77

Table 14. Average years of smoking Both Sexes Results for adults 2003 2006 aged 25-64 years (N=308) (N=308) (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

Males 2003 (N=272)

25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

2006 (N=239)

2003 (N=36)

2006 (N=35)

mean

mean

mean

mean

mean

mean

(95 CI %) 12.5 (11.0-13.9) 22.7 (21.2-24.1) 28.8 (27.1-30.6) 39.7 (38.1-41.2) 23.8 (22.5-25.2)

(95 CI %) 12.8 (11.8-13.7) 21.9 (20.5- 23.3) 28.3 (26.4- 30.2) 36.9 (34.3- 39.7) 21.7 (20.3- 23.1)

(95 CI %) 12.8 (11.4-14.3) 22.9 (21.5-24.4) 29.5 (27.6-31.4) 40.0 (38.4-41.5) 24.3 (22.9-25.8)

(95 CI %) 12.6 (11.6-13.6) 22.8 (21.4-24.4) 29.2 (27.3-31.0) 37.0 (34.3-39.7) 22.1 (20.6-23.6)

(95 CI %) 8.9 (5.4-12.4) 13.6 (6.4-20.8) 22.9 (18.5-27.3) 35.0 (26.3-43.7) 18.3 (14.8-21.7)

(95 CI %) 15.6

Table 15. Percentage smoking manufactured cigarettes Both Sexes Results for adults aged 25-64 years (adjusted *)

Females

Males

17.3 22.3 0 18.0

Females

2003 (N=308)

2006 (N=274)

2003 (N=272)

2006 (N=239)

2003 (N=36)

2006 (N=35)

% (95%CI) 67.7 (52.6-82.9) 82.3 (72.7-92.0) 79.7 (71.9-87.4) 92.2 (86.5-97.9) 78.1 (72.1-84.2)

% (95%CI) 14.9 (5.6-24.1) 21.0 (11.7-30.3) 21.6 (12.1-31.0) 26.2 (10.5-41.9) 19.5 (14.0-25.1)

% (95%CI) 69.6 (53.4-85.9) 83.6 (73.7-93.5) 85.7 (77.6-93.8) 91.7 (85.5-97.8) 81.0 (74.6-87.5)

% (95%CI) 14.7 (5.0-24.3) 24.4 (13.3-35.5) 23.5 (13.1-33.9) 26.2 (10.5-41.9) 20.8 (14.8-26.8)

% (95%CI) 50.0 (2.8-97.2) 40.0 (-10.4-90.4) 28.5 (-0.8-57.9) 100

% (95%CI) 17.8 (-16.2-51.7) 4.5 (-5.2-14.3) 7.9 (-8.3-24.2) 0

45.7 (23.3-68.1)

8.5 (-2.5-19.5)

78

Table 16. Mean number of Cloves manufactured cigarettes smoked per day Both Sexes Males Results for adults 2003 2006 2003 2006 aged 25-64 years (N=245) (N=55) (N=227) (N=52) (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

Females 2003 (N=18)

2006 (N=)

mean

mean

mean

mean

mean

mean

(95 CI %) 11.0 (9.1- 12.9) 12.3 (9.9- 14.7) 12.5 (9.9- 15.0) 9.4 (8.1- 10.7) 11.5 (10.4- 12.7)

(95 CI %) 13.1 (11.5-14.7) 12.7 (11.9-13.5) 12.4 (1.8-13.0) 12.0

(95 CI %) 11.1 (9.2-13.1) 12.4 (10.0-14.8) 12.6 (10.0-15.3) 9.7 (8.2-11.1) 11.7 (10.5-12.9)

(95 CI %) 13.3 (11.6-15.0) 12.6 (11.7-13.4) 12.4 (11.8-13.1) 12.0

(95 CI %) 9.0 (6.2-11.8) 8.0 (-0.9-16.9) 9.0 (3.1-14.9) 6.1 (3.8-8.4) 8.2 (6.2-10.3)

(95 CI %) 0

12.6 (12.1-13.2)

12.6 (12.1-13.2)

0 0 0 0

Table 17. Mean number of Non-Cloves manufactured cigarettes smoked per day Both Sexes Males Females Results for adults 2003 2006 2003 2006 2003 2006 aged 25-64 years (N=65) (N=219) (N=47) (N=187) (N=18) (N=32) (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

mean

mean

mean

mean

mean

mean

(95 CI %) 12.5 (9.2-15.7) 10.4 (8.0-12.7) 9.4 (6.3-12.6) 8.2 (4.6-11.7) 11.0 (9.0-13.0)

(95 CI %) 8.5 (6.7-10.2) 9.2 (7.7-10.8) 10.5 (8.5-12.6) 11.0 (7.1-15.0) 9.4 (8.4-10.4)

(95 CI %) 12.8 (9.0-16.5) 11.0 (8.4-13.6) 10.0 (6.0-14.0) 8.2 (4.6-11.8) 11.5 (9.2-13.8)

(95 CI %) 8.7 (6.9-10.6) 10.1 (8.4-11.8) 11.3 (8.9-13.7) 11.0 (7.1-15.0) 9.9 (8.8-11.0)

(95 CI %) 10.6 (5.7-15.5) 4.0 (1.5-6.5) 8.5 (2.8-14.2) 0

(95 CI %) 4.8

8.9 (5.1-12.7)

5.7

6.0 6.1 0

79

Table 18. Percentage of Abstainers (who did not drink alcohol in the last year) Both Sexes Males Females Results for adults 2003 2006 2003 2006 2003 2006 aged 25-64 years (N=1806) (N=1806) (N=847) (N=909) (N=959) (N=897) (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

% (95%CI) 94.5 (91.6-97.5) 97.5 (95.1-99.8) 96.2 (03.8-98.5) 99.2 (98.3-100.3) 96.3 (95.0-97.7)

% (95%CI) 97.6 (96.2-99.1) 98.2 (97.0-99.5) 99.1 (98.2-100) 99.4 (98.3-100.5) 98.3 (97.6-99.0)

% (95%CI) 90.1 (85.3-94.9) 96.2 (92.8-99.7) 94.2 (90.1-98.2) 98.8 (97.0-100.6) 94.0 (91.7-96.3)

% (95%CI) 95.8 (93.2-98.4) 96.8 (94.5-99.1) 98.0 (96.0-100) 99.2 (97.7-100.7) 97.1 (95.8-98.3)

Table 19. Mean number of servings 0f fruit consumed per day Both Sexes Males Results for adults 2003 2006 2003 2006 aged 25-64 years (N=755) (N=748) (N=304) (N=349) (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

% (95%CI) 100

% (95%CI) 100

100

100

99.2 (98.0-100.3) 100

100

99.7 (99.4-100.1)

100

100

Females 2003 (N=451)

2006 (N=399)

mean

mean

mean

mean

mean

mean

(95 CI %) 1.9 (1.7-2.0) 1.9 (1.7-2.0) 1.9 (1.8-2.0) 1.9 (1.8-2.1) 1.9 (1.8-2.0)

(95 CI %) 2.0 (1.8-2.2) 2.1 (1.9-2.2) 2.0 (1.8-2.1) 2.0 (1.8-2.2) 2.0 (1.9-2.1)

(95 CI %) 1.7 (1.4-2.0) 1.8 (1.6-2.0) 1.9 (1.8-2.1) 1.9 (1.7-2.1) 1.8 (1.7-2.0)

(95 CI %) 2.2 (1.8-2.5) 2.1 (1.9-2.4) 1.9 (1.7-2.1) 2.1 (1.9-2.4) 2.1 (1.9-2.3)

(95 CI %) 2.0 (1.8-2.2) 1.9 (1.8-2.1) 1.8 (1.7-1.9) 1.9 (1.7-2.2) 1.9 (1.8-2.0)

(95 CI %) 1.9 (1.6-2.1) 2.0 (1.8-2.2) 2.1 (1.9-2.3) 1.6 (1.4-1.9) 1.9 (1.8-2.0)

80

Table 20. Mean number of servings of vegetable consumed per day Both Sexes Males Results for adults 2003 2006 2003 2006 aged 25-64 years (N=1223) (N=1242) (N=500) (N=579) (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

Females 2003 (N=723)

2006 (N=663)

mean

mean

mean

mean

mean

mean

(95 CI %) 1.7 (1.7-1.8) 1.6 (1.5-1.8) 1.8 (1.7-1.9) 1.8 (1.7-1.8) 1.7 (1.7-1.8)

(95 CI %) 1.7 (1.6-1.8) 1.7 (1.6-1.7) 1.7 (1.6-1.7) 1.7 (1.6-1.8) 1.7 (1.6-1.7)

(95 CI %) 1.7 (1.5-1.8) 1.6 (1.5-1.8) 1.8 (1.6-1.9) 1.8 (1.7-1.9) 1.7 (1.6-1.8)

(95 CI %) 1.7 (1.6-1.9) 1.6 (1.6-1.8) 1.6 (1.5-1.7) 1.7 (1.6-1.8) 1.7 (1.6-1.8)

(95 CI %) 1.7 (1.6-1.8) 1.7 (1.6-1.8) 1.8 (1.7-1.9) 1.7 (1.6-1.8) 1.7 (1.7-1.8)

(95 CI %) 1.7 (1.6-1.8) 1.7 (1.5-1.8) 1.7 (1.6-1.8) 1.6 (1.4-1.8) 1.7 (1.6-1.8)

Table 21. Percentage who ate 5 or more combined servings of fruit & vegetables per day Both Sexes Males Females Results for adults 2003 2006 2003 2006 2003 2006 aged 25-64 years (N=1751) (N=1806) (N=808) (N=909) (N=943) (N=897) (adjusted *) 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years

% (95%CI) 12.5 (9.1-15.9) 9.4 (5.8-13.0) 16.4 (12.8-20.0) 16.7 (13.4-20.0) 14.0 (12.0-15.9)

% (95%CI) 17.7 (14.1-21.3) 17.4 (13.9-20.9) 17.8 (14.0-21.5) 16.6 (11.9-21.4) 17.5 (15.3-19.6)

% (95%CI) 7.9 (3.5-12.3) 8.5 (3.5-13.5) 19.0 14.3-23.8) 16.1 (12.1-20.1) 13.0 (10.3-15.7)

% (95%CI) 20.6 (15.1-26.1) 16.7 (11.5-22.0) 15.4 (10.7-20.1) 18.0 (12.1-23.9) 18.2 (15.2-21.2)

% (95%CI) 18.1 (13.0-23.1) 11.3 (6.8-15.8) 12.5 (7.5-17.4) 17.5 (11.8-23.1) 15.3 (12.5-18.0)

% (95%CI) 14.0 (9.8-18.3) 18.2 (13.4-22.9) 19.9 (14.7-25.0) 12.5 (6.1-18.9) 16.4 (13.9-19.0)

81

Table 22. Percentage with low levels of activity (defined as 50 % of target

≤ 25 % of target

> 25 % - 40 % of target

> 40 % - 50 % of target

> 50 % of target

≤ 25 % of target

> 25 % - 40 % of target

> 40 % - 50 % of target

> 50 % of target

≤ 25 % of target

> 25 % - 40 % of target

> 40 % - 50 % of target

> 50 % of target

6

NCD education

≤ 3 times per year

3-4 times per year

4-6 times per year

> 6 times per year

7

Counselling

none

Available for diet only

Diet and Stop smoking

Diet, stop smoking, and others

8

Exercise coverage/ Physical Activity once in a week Participant Coverage : Age > =55 y old Age 45 – 54 y old Age 35 – 44 y old Age 25 – 34 y old

≤ 25 % of target

> 25 % - 40 % of target

> 40 % - 50% of target

> 50 % of target

≤ 25 % of target ≤ 25 % of target ≤ 25 % of target ≤ 10 % of target

25– 40 % of target 25– 40 % of target 25– 40 % of target 11 - 25 % of target

>40%-50 % of target >40%-50 % of target >40%-50 % of target >25%-40 % of target

> 50 % of target > 50% of target > 50 % of target > 40 % of target

10


50 % is community

75 % is community

90 % is community

100% is community

11


≤ 25 % of target

> 25 % - 40 % of target

> 40 % - 50 % of target

> 50 % of target

12


75 % of member

13

Partnership

none

< 2 times

3 – 4 times

> 4 times

14

All Indicator

≤ 25 % of indicator

> 25 % - 40 % of indicator

> 40 % - 50 % of indicator

> 50 % of indicator

3 4 5

9

46

47

Attachment 6 Questionnaire ACTIVITY EVALUATION OF “POSBINDU PTM” ID number :

RW:

Village :

Sub District :

(administrative unit)

A. General Identification of ‘Posbindu’/ Organization / Club 1.a Name of ‘Posbindu’/ Organization / Club : 1.b Address : .............................................. Telephone : ......................................... 1.c Major activities of the ‘Posbindu’/ Organization / Club prior to conducting “Posbindu PTM” a. b. c. d. e. f. g.

Sport/exercise Housewife gathering Religious activity Family Welfare Education Integrated health post for under five children Integrated health post for elderly Other, specify....................

1. 1. 1. 1. 1. 1. 1.

Yes Yes Yes Yes Yes Yes Yes

2. No 2. No 2. No 2. No 2. No 2. No 2. No

1.d Have this organization/ club already implemented “Posbindu PTM” activity? 1. Yes we have 2. No we haven’t not 2.a Name of Coordinator/ Organization leader/Club leader : 2.b Coordinator status/ position in his/her residential neighborhood : 1. Position in RT (neighborhood block) /RW(administrative unit)/Village office 2. Public figure 3. Community activist 4. no position 5. others, specify ............... 2.c Education background of Coordinator/leader : 1. Incomplete high school or lower 2. High school 3. Higher than high school 2.d What kind of courses/training that have been taken by Coordinator/Leader ? (any kind of courses/training, including non- health or not NCD) .................................................................................. .................................................................................. .................................................................................. 2.e What is the main occupation of Coordinator/Leader : 1. Unemployee/no full time job 2. Working as ( specify ..........) 2. Retired from government employee (specify ..................) 3. Retired from private company (specify ...................) 4. Retired from military (specify ................. ) 5. Small business (sales) 6. Big business 7. Self employee/family company 8. Other, specify ........................................

1

Attachment 6

2.f Economy status of Coordinator/leader : 1. Below average income in the surrounding residential area 2. Equal to average income in the surrounding residential area 3. Above average income in the surrounding residential area 3.a Name of health educator/health volunteer of NCD prevention activity/other volunteer: 1. .................................... 2. ..................................... 3. ...................................... 4....................................... 5..................................... 3.b Health educator/health volunteer of NCD prevention activity/other volunteer status/ position in his/her residential neighborhood : 1. Position in RT (neighborhood block) /RW(administrative unit)/Village office 2. Public figure 3. Community activist 4. no position 5. others, specify ...............

1 2 3 4 5

3.c Education background of health educator/health volunteer of NCD prevention activity/other volunteer: 1. Incomplete high school or lower 2. High school 3. Higher than high school

1 2 3 4 5

3.d What kind of courses/training that have been taken by health educator/health volunteer of NCD prevention activity/other volunteer ? (any kind of courses/training, including non- health or not NCD) .................................................................................. .................................................................................. .................................................................................. ................................................................................... .................................................................................. 3.e What is the main occupation of health educator/health volunteer of NCD prevention activity/other volunteer 1. Unemployee/no full time job 2. Working as ( specify ..........) 2. Retired from government employee (specify ..................) 3. Retired from private company (specify ...................) 4. Retired from military (specify ................. ) 5. Small business (sales) 6. Big business 7. Self employee/family company 8. Other, specify………………….

1 2 3 4 5

2

Attachment 6

3.f Education background of health educator/health volunteer of NCD prevention activity/other volunteer: 1. Incomplete high school or lower 2. High school 3. Higher than high school

1 2 3 4 5

B. Progress of “Posbindu PTM” (For those who have implemented “Posbindu PTM”) 1. During year 2005, how many times have you conducted the “Posbindu PTM” activity? ............time 1.a Have the activities conducted in routine? 1. Yes, every month (go to 1.b) 2. Yes but every month routine

3. No, it is not

1.b What are the constraints of unable to run the activities in routine time? a. b. c. d. e. f.

The community doesn’t agree to have routine activity The personnel/health volunteer unable to conduct routine activity The facility is not available for routine activity Financial problem Time arrangement difficulty Others, specify ...........................................................

1.c How do you usually determine the activity schedule ? 1. 2. 3. 4.

Determined by coordinator Determined by PHC Determined by community agreement Others, specify ...................

2.a How much are the percentage of BMI and WHR monitoring coverage? 2.b Is there any problem or constraint that make the community unable to monitor their body weight? 1. Yes there is a problem 2. No, there is no problem 2.c If there is a problem/constraint, what is the main problem/constraint? a. b. c. d. e. f.

Limited number of human resources Limited quality of human resources Limited facility Limited budget Community member afraid to know their body weight Other, specify............................................

2.d What are the supporting aspects (if available) in regard of monitoring the body weight? 1. yes

2. no

a. Adequate human resources b. Adequate facility c. Free of charge services

3

Attachment 6 d. Community willingness to pay e. Community awareness on body weight monitoring benefits f. Other, specify .................................... 3.a How much the percentage of blood pressure monitoring coverage? 3.b Is there any constrain/problem in blood pressure monitoring activity? 1. Yes there is a problem

2. No, there is no problem

3.c If there is a problem/constraint, what is the main problem/constraint? a. b. c. d. e. f.


3.d What are the supporting aspects (if available) in regard of blood pressure monitoring? 1. yes

2. no a. b. c. d. e. f.

Adequate human resources Adequate facility Free of charge services Community willingness to pay Community awareness on body weight monitoring benefits Other, specify ....................................

4.a How much the percentage of blood glucose monitoring coverage? 4.b Is there any constrain/problem in blood glucose monitoring activity? 1. Yes there is a problem 2. No, there is no problem 4.c If there is a problem/constraint, what is the main problem/constraint? a. b. c. d. e. f.


4.d What are the supporting aspects (if available) in regard of blood glucose monitoring? 1. yes

2. no a. b. c. d. e.

Adequate human resources Adequate facility Free of charge services Community willingness to pay Community awareness on body weight monitoring benefits

4

Attachment 6 f. Other, specify .................................... 5.a How much the percentage of blood cholesterol monitoring coverage? 5.b Is there any constrain/problem in blood cholesterol monitoring activity?

1. Yes there is a problem

2. No, there is no problem

5.c If there is a problem/constraint, what is the main problem/constraint?

a. b. c. d. e.

Limited number of human resources Limited quality of human resources Limited facility Limited budget Community member afraid to know their body weight f. Other, specify............................................ 5.d What are the supporting aspects (if available) in regard of blood cholesterol monitoring? 1. yes

2. no

a. Adequate human resources b. Adequate facility c. Free of charge services d. Community willingness to pay e. Community awareness on body weight monitoring benefits f. Other, specify .................................... 6.a During year 2005 how much time have you conducted counseling activity for NCD prevention ? ........... time 6.b What are the problems/constraints found in conducting counseling activity for NCD prevention ? 1. Yes a. b. c. d. e.

2. no

Lack of time or opportunity Lack of self confident Lack of capability Lack of facility Other, specify .........................

6.c What is the supporting aspect found in the counseling activity? 1. Yes

2. No

a. Community interest on NCD issues b. Skill on giving counseling c. Adequate time availability d. Adequate facility e. Other, specify......................... 7.a Did counseling always conducted in every “Posbindu PTM” activity? 1. Yes 2. No 7.b What were the risk factor issues that had been raised in counseling activity? 1. Yes

2. No

a. Diet

5

Attachment 6 b. c. d. e. f.

Smoking Stress Weight management Sport/exercise Other, specify.................................................

7.c What is the main constrain/problem found in counseling activity? 1. Yes 2. No a. Lack of community trust b. Lack of opportunity c. Lack of self confident among the health volunteer d. Lack of knowledge or capability e. Lack of facility f. Other, specify .........................

Supervisor

(.........................................)

6

Attachment 10

Courses Topics for Health Volunteer and Health Workers Topic of material in brief regarding clinical course or training of NCD controlling strategy and community development in health service are as follow : a. For health worker in Public Health Centre 1) Strategy of Controlling Risk Factors of NCD in Depok 2) Classifications, Diagnosis, Prevention, and Initial Treatment of Coronary Heart Diseases 3) Classifications, Diagnosis, Prevention, and Initial Treatment of Hypertension 4) Electrocardiogram examination and assessment 5) Classifications, Diagnosis, Prevention, and Initial Treatment of Diabetes Mellitus 6) Management Diabetes Mellitus and Its Complication 7) Diagnosis, Prevention, and Management of Obesity 8) Diet for NCD, and calorie calculation 9) Strategy of Stop Smoking 10) Stop smoking technique and coping for smoking cessation 11) The benefit of Exercise and Physical Activity in controlling major NCD 12) Strategy of motivation for Exercise 13) Training of community participation on developing

‘Integrated Health Post

(Posbindu) of NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD’ for health workers 14) Ministry of Health Fundamental Policy on Community Health Care 15) The role of ‘Integrated Health Post (Posbindu) of NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD to reduce risk factors NCD 16) Management strategy of developing ‘Integrated Health Post (Posbindu) of NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD

17) Developing Partnership and Networking on ‘Integrated Health Post (Posbindu) of NCD’ and ‘Integrated Health Care’ (Yandu) of NCD at municipality stage 18) Health Promotion in Work places (Centre of Occupational Health) 19) Role of businessman on NCD management and risk factor to the labour (Centre of Occupational Health) 20) Major NCD problems in Worker at Depok city 21) Occupational Health Care on controlling NCD to the labour b. For potential health cadre in community 1) Implementation of

‘Integrated Health Post (Posbindu) of NCD’ and ‘Integrated

Health Care’ (Yandu) of NCD’ 2) Roles of Health Volunteer in Development and Sustainability of ‘Integrated Health Post (Posbindu) of NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD’ 3) Management Strategy of ‘Integrated Health Post (Posbindu) of NCD’

and

‘Integrated Health Care’ (Yandu) of NCD’ 4) Developing Partnership and Networking on ‘Integrated Health Post (Posbindu) of NCD’ and ‘ Integrated Health Care’ (Yandu) of NCD’ at village stage 5) Coronary Heart Diseases and its prevention 6) Hypertension and its prevention 7) Diabetes Mellitus and its prevention 8) Obesity and its prevention 9) Diet for NCD, and calorie calculation 10) Stop smoking technique and coping for smoking cessation 11) The benefit of Exercise and Physical Activity in controlling major NCD