Background: Stunting is still a major public health problem in low- and middle-income countries, including Indonesia. Previous studies have reported the complexities associated with understanding the determinants of stunting. This study aimed to examine the household-, subdistrict- and province-level determinants of stunting in Indonesia using a multilevel hierarchical mixed effects model. Methods: We analyzed data for 8045 children taken from the 2007 and 2014 waves of the Indonesian Family and Life Surveys (IFLS). We included individual-, family-/household- and community-level variables in the analyses. A multilevel mixed effects model was employed to take into account the hierarchical structure of the data. Moreover, the model captured the effect of unobserved household-, subdistrict- and province-level characteristics on the probability of children being stunted. Results: Our findings showed that the odds of childhood stunting vary significantly not only by individual child- and household-level characteristics but also by province- and subdistrict-level characteristics. Among the child-level covariates included in our model, dietary habits, neonatal weight, a history of infection, and sex significantly affected the risk of stunting. Household wealth status and parental education are significant household-level covariates associated with a higher risk of stunting. Finally, the risk of stunting is higher for children living in communities without access to water, sanitation and hygiene. Conclusions: Stunting is associated with not only child-level characteristics but also family- and community-level characteristics. Hence, interventions to reduce stunting should also take into account family and community characteristics to achieve effective outcomes.

RRH: Rural and Remote Health. Published article number: 7082 - Determinants of socioeconomic and rural–urban disparities in stunting: evidence from Indonesia

Objectives To assess the implementation and contextual barriers of POSBINDU, a community-based activity focusing on screening of non-communicable diseases (NCDs), mainly hypertension and diabetes, in Indonesia. Design This was a concurrent mixed-methods study, with a cross-sectional analysis of secondary data and focus group discussions (FGDs) on stakeholder of POSBINDU. Setting The study was conducted in seven districts in three provinces in Indonesia, with approximately 50% of the primary healthcare (PHC) were selected as areas for data collection (n PHC=100). Participants From 475 POSBINDU sites, we collected secondary data from 54 224 participants. For the qualitative approach, 21 FGDs and 2 in-depth interviews were held among a total of 223 informants. Primary outcomes and measures Proportion of POSBINDU visitors getting the hypertension screening and risk factors’ assessment, and barriers of POSBINDU implementation. Results Out of the 114 581 POSBINDU visits by 54 224 participants, most (80%) were women and adults over 50 years old (50%) showing a suboptimal coverage of men and younger adults. Approximately 95.1% of visitors got their blood pressure measured during their first visit; 35.3% of whom had elevated blood pressure. Less than 25% of the visitors reported to be interviewed for NCDs risk factors during their first visit, less than 80% had anthropometric measurements and less than 15% had blood cholesterol examinations. We revealed lack of resources and limited time to perform the complexities of activities and reporting as main barrier for effective hypertension screening in Indonesia. Conclusions This study showed missed opportunities in hypertension risk factors screening in Indonesia. The barriers include a lack of access and implementation barriers (capability, resources and protocols).

Introduction: Non-communicable diseases (NCDs) have surpassed infectious diseases as the leading global cause of death, with the Southeast Asian region experiencing a significant rise in NCD prevalence over the past decades. Despite the escalating burden, screening for NCDs remains at very low levels, resulting in undetected cases, premature mortality and high public healthcare costs. We investigate whether community-based NCD prevention and management programmes are an effective solution. Methods: In Indonesia, we compare participants in the community-based NCD screening and management programme Pos Pembinaan Terpadu-Penyakit Tidak Menular with matched non-participants with respect to their uptake of screening activities, health-related behaviour and knowledge and metabolic risk factors. We use statistical matching to redress a possible selection bias (n=1669). In Viet Nam, we compare members of Intergenerational Self-Help Clubs, which were offered similar NCD health services, with members of other community groups, where such services were not offered. We can rely on two waves of data and use a double-difference approach to redress a possible selection bias and to measure the impacts of participation (n=1710). We discuss strengths and weaknesses of the two approaches in Indonesia and Viet Nam. Results: In Indonesia, participants have significantly higher uptake of screening for hypertension and diabetes (+13% from a control mean of 88% (95% CI 9% to 17%); +93% from a control mean of 48% (95% CI 79% to 108%)). In both countries, participants show a higher knowledge about risk factors, symptoms and complications of NCDs (Indonesia: +0.29 SD (0.13–0.45), Viet Nam: +0.17 SD (0.03–0.30)). Yet, the improved knowledge is only partly reflected in improved health behaviour (Viet Nam: fruit consumption +0.33 SD (0.15–0.51), vegetable consumption +0.27 SD (0.04–0.50)), body mass index (BMI) (Viet Nam: BMI −0.07 SD (−0.13 to −0.00)) or metabolic risk factors (Indonesia: systolic blood pressure: −0.13 SD (−0.26 to −0.00)). Conclusion: Community-based NCD programmes are well suited to increase screening and to transmit health knowledge. Due to their extensive outreach within the community, they can serve as a valuable complement to the screening services provided at the primary healthcare level. Yet, limited coverage, insufficient resources and a high staff turnover remain a problem. Trial registration number: NCT05239572.

(1) Background: Mitral stenosis is the most common rheumatic heart disease (RHD). Inflammation and fibrosis are the primary pathophysiology, resulting in left atrial stress and dysfunction. Dapagliflozin is a new heart failure treatment with anti-inflammation and anti-fibrosis effects from previous studies. However, the specific role of dapagliflozin in RHD mitral stenosis is unknown. This study aims to investigate (i) the effect of dapagliflozin on biomarkers of fibrosis, NT-pro BNP levels and left atrial function; (ii) the relationship between the changes in fibrosis biomarkers with left atrial function and NT-pro BNP levels. (2) Methods: An open-label randomized study was conducted on 33 RHD mitral stenosis patients divided into a dapagliflozin group which received 10 mg dapagliflozin and standard therapy, and a control group which only received standard therapy. All patients were examined for levels of PICP, MMP-1/TIMP-1 ratio, TGF-β1, NT-proBNP, mitral valve mean pressure gradient (MPG), and net atrioventricular compliance (Cn) pre- and post-intervention. (3) Results: This study found a significant increase in PICP and TGF-β1 and a reduction in the MMP-1/TIMP-1 ratio in the dapagliflozin group and the control group (p < 0.05). In the dapagliflozin group, the levels of NT-pro BNP decreased significantly (p = 0.000), with a delta of decreased NT-pro BNP levels also significantly greater in the dapagliflozin group compared to the control (p = 0.034). There was a significant increase in Cn values in the dapagliflozin group (p = 0.017), whereas there was a decrease in the control group (p = 0.379). Delta of changes in Cn values between the dapagliflozin and control groups also showed a significant value (p = 0.049). The decreased MPG values of the mitral valve were found in both the dapagliflozin and control groups, with the decrease in MPG significantly greater in the dapagliflozin group (p = 0.031). There was no significant correlation between changes in the value of fibrosis biomarkers with Cn and NT-pro BNP (p > 0.05). (4) Conclusions: This study implies that the addition of dapagliflozin to standard therapy for RHD mitral stenosis patients provides benefits, as evidenced by an increase in net atrioventricular compliance and decreases in the MPG value of the mitral valve and NT-pro BNP levels (p < 0.05). This improvement was not directly related to changes in fibrosis biomarkers, as these biomarkers showed ongoing fibrosis even with dapagliflozin administration.

Background: Indonesia still faces challenges in maternal health. Specifically, the lack of information on community-level maternal morbidity. The relatively high maternal healthcare non-utilization in Indonesia intensifies this problem. Objective: To describe the burden of community-level maternal morbidity in Indonesia. Additionally, to evaluate the extent and determinants of missed opportunities in women with maternal morbidity. Methods: We used three cross-sectional surveys (Indonesian Demographic and Health Survey, IDHS 2002, 2007 and 2012). Crude and adjusted proportions of maternal morbidity burden were estimated from 43,782 women. We analyzed missed opportunities in women who experienced maternal morbidity during their last birth (n = 19,556). Multilevel mixed-effects logistic regressions were used to evaluate the determinants of non-utilization in IDHS 2012 (n = 6762). Results: There were significant increases in the crude and adjusted proportion of maternal morbidity from IDHS 2002 to IDHS 2012 (p < 0.05). In 2012, the crude proportion of maternal morbidity was 53.7%, with adjusted predicted probability of 51.4%. More than 90% of these morbidities happened during labor. There were significant decreases in non-utilization of maternal healthcare among women with morbidity. In 2012, 20.0% of these women did not receive World Health Organization (WHO) standard antenatal care. In addition, 7.1% did not have a skilled provider at birth, and 25.0% delivered outside of health facilities. Higher proportions of non-utilization happened in women who were younger, multiparous, of low socioeconomic status (SES), and living in less-developed areas. In multilevel analyses, missed opportunities in healthcare utilization were strongly related to low SES and low-resource areas in Indonesia. Conclusion: The prevalence of maternal morbidity in Indonesia is relatively high, especially during labor. This condition is amplified by the concerning missed opportunities in maternal healthcare. Efforts are needed to identify risk factors for maternal morbidity, as well as increasing healthcare coverage for the vulnerable population.