Objectives Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia. Design With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility. Setting In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered. Participants Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys. Primary and secondary outcome measures The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district. Results Overall, mothers’/families’ consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities. Conclusions The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.

The World Health Organization (WHO) developed the Safe Childbirth Checklist (SCC) to increase the application of essential birth practices to ultimately reduce perinatal and maternal deaths. We study the effects of the SCC on health workers safety culture, in the framework of a cluster-randomized controlled trial (16 treatment facilities/16 control facilities). We introduced the SCC in combination with a medium intensity coaching in health facilities which already offered at minimum basic emergency obstetric and newborn care (BEMonC). We assess the effects of using the SCC on 14 outcome variables measuring self-perceived information access, information transmission, frequency of errors, workload and access to resources at the facility level. We apply Ordinary Least Square regressions to identify an Intention to Treat Effect (ITT) and Instrumental Variable regressions to determine a Complier Average Causal Effect (CACE). The results suggest that the treatment significantly improved self-assessed attitudes regarding the probability of calling attention to problems with patient care (ITT 0.6945 standard deviations) and the frequency of errors in times of excessive workload (ITT -0.6318 standard deviations). Moreover, self-assessed resource access increased (ITT 0.6150 standard deviations). The other eleven outcomes were unaffected. The findings suggest that checklists can contribute to an improvement in some dimensions of safety culture among health workers. However, the complier analysis also highlights that achieving adherence remains a key challenge to make checklists effective.

Introduction: The COVID-19 pandemic has spread throughout the world, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that affects the respiratory system. The emergence and spread of the COVID-19 pandemic have caused confusion, anxiety and fear among the community, including university students. Anxiety to the COVID-19 pandemic causes various psychological manifestations, including fear of disease transmission, loss of loved ones, and decline in future socio-economic aspects. Anxiety can also lead to physical responses like gastrointestinal symptoms. This study aimed to determine the relationship between anxiety to COVID-19 pandemic and gastrointestinal symptoms complained by university students. Methods: This observational analytic study using cross-sectional approaches involved 311 university students of Universitas Syiah Kuala, Banda Aceh, Indonesia. Anxiety to COVID-19 pandemic was measured using the Depression, Anxiety, and Stress Scale questionnaire, while gastrointestinal symptoms were measured using the Gastrointestinal Symptom Rating Scale questionnaire. Result: Of the 311 respondents, 157 (50.5%) of them felt anxiety about the COVID-19 pandemic, with 28 (9%) and 13 (4.2%) students experienced severe and very severe anxiety, respectively. Besides, 264 (84.9%) university students complained of gastrointestinal symptoms, both upper and lower gastrointestinal tracts. There was a significant relationship between the level of anxiety to COVID-19 pandemic and gastrointestinal symptoms. Conclusion: In conclusion, anxiety about the COVID-19 pandemic can cause gastrointestinal symptoms amongst university students. Therefore psychological assistance is needed to reduce psychological and physical disorders during the pandemic.

The transmission of dengue and other medically important mosquito-borne viruses in the westernmost region of Indonesia is not well described. We assessed dengue and Zika virus seroprevalence in Aceh province, the westernmost area of the Indonesian archipelago. Serum samples collected from 199 randomly sampled healthy residents of Aceh Jaya in 2017 were analyzed for neutralizing antibodies by plaque reduction neutralization test (PRNT). Almost all study participants (198/199; 99.5%) presented with multitypic profiles of neutralizing antibodies to two or more DENV serotypes, indicating transmission of multiple DENV in the region prior to 2017. All residents were exposed to one or more DENV serotypes by the age of 30 years. The highest geometric mean titers were measured for DENV-4, followed by DENV-1, DENV-2 and DENV-3. Among a subset of 116 sera, 27 neutralized ZIKV with a high stringency (20 with PRNT₉₀ > 10 and 7 with PRNT₉₀ > 40). This study showed that DENV is hyperendemic in the westernmost region of the Indonesian archipelago and suggested that ZIKV may have circulated prior to 2017.