202012-V15N2 The Indonesia Journal of Public Health

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 351 facilities that support health measures and Given that the majority of the respodnents had health problems, this study health diagnosis. The health diagnosis reveals that 68 people did not go for medical check by doctors. It means the students tend identifies health problems and involves to be less aware of their health issues. doctor’s advice. Table 6. Frequency Distribution of Table 9. Doctors’ Recommendations of Respondents by Health Problems. Sports for Respondents. The existence of health Total Sports Total problems recommendation by Yes 44 people 1 people No 76 people doctors 21 people 1 people This study does not find any health Basketball 5 people issues in most of the repsondents (76 people). Swimming 7 people There were 44 respondents who were required Yoga 11 people to do exercises. Jogging/walking 11 people Cardio 1 people Table 7. Types of Health Problems Occuring Treadmill 10 people to Respondents. Weight loss 68 people Light exercise Types of health problems Total No recommendation Allergy 1 people Not seeing a doctor Anemia 10 people Asthma 3 people This study shows that the majority of Hypertention 1 people the respondents who had health issues were Indigestion 17 people advised to do swimming (21 people). Eleven Acne 2 people respondents were advised to exercise on a Overweight 42 people treadmill, and the remaining were advised to Obesity 9 people do exercises for weight loss. Wasting 11 people Irregular menstrual cycle 2 people The role of health diagnosis on gymnasium Bone abnormalities 1 people needs Tiredness 2 people Sprain 1 people Table 11 presents that out of 120 Constipation 1 people respondents, as many as 97.50% of the No problems and noanswer 17 people respondents required a gymnasium at Universitas Airlangga. The respondents were mostly overweight (42 people). Table 8. History of Respodents’ Health Table 10. Gymnasium Needs of Checks by Doctors Respondents. History of health Total Gymnasium needs Total checks Yes 117 people Yes 53 people No 4 people No 68 people

352 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:348-355 Table 11. Types of Gymnasium Facilities which only can be accessed by the society of Required. academicians at Universitas Airlangga. Gymnasium Total Table 14. Seperation of Gymnasium Rooms facilities 91 people by Gender. 67 people Swimming pool 33 people Gymnasium rooms Total Cafeteria 32 people by gender Jacuzzi Yes 91 people Sauna 9 people No 21 people Lifting Weights, Gym Equipment, 6 people Table 15. Preference on Gymnasium Users. Fitness Equipment Jogging Track, 3 people Gymnasium users Total Tennis, Badminton, 1 people Society of academicians 73 people Volleyball, Society of academicians Basketball, Treadmill and public 47 people Yoga, Pilates, Zumba Changing room DISCUSSION Regarding desired gymnasium Needs assessment is the process of facilities, the majority of the respondents determining priority needs. Seel and Glasgow required pool (75.83%). explain that needs are discrepancies between what is available and what is available with Table 12. Required Gymnasium Concept. what is expected. Need assessment is the process of gathering information about gaps Gymnasium Total and determining gap priorities to be solved Concept \"(Rinawiyanti et al. 2014). 41 people Indoor 3 people Kaufman and English define needs Outdoor 76 people analysis as a formal process to determine a Indoor and Outdoor gap between actual outputs and impacts with the desired outputs and impacts, place these This study informs that 63.35% of gaps in priority scales, and then choose respondents preferred indoor and outdoor prioritized gaps to be resolved (Makmur and gymnasium. Widagdo 2017). Need analysis can be useful for identifying problem solutions. Table 13. Need For Sports Coach. Predisposing factors are factors that Need for sports Total make them possibly determine what is needed coach (Samudin and Sasmito 2017). In other words, Yes 56 people needs are the basis and direct stimulus for No 64 people using health services. Needs are divided into two categories: perceived needs or perceived As many as 64 people did not need a (subject assessment) and evaluated needs personal trainer to assist them to exercise. (health diagnosis). These variables are This study finds that 82.50% of the measured from various symptoms, disturbed respondents preferred to slip gym rooms for functions, and perceptions of health (Liam et men and women. As many as 60.83% of al. 2017). respondents preferred private gymnasium

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 353 Perceived needs (Subject assessment) Role of health diagnosis on gymnasium needs Green (1980) proposes two behavioral variables that may influence priority needs. There are several steps in analyzing These include predisposing factor andoutside Gosslow's needs (Makmur and Widagdo behavior (enabling factor and reinforcing 2017): The first step is gathering information, factor). The predisposing factors include such as activities offered, who understands knowledge, attitudes, beliefs in health, values, what, who will learn, obstacles, and the perceptions, and demographic factors that influence of certain circumstances. The will influence individual and community information will be useful in determining motivation to take action. goals to be achieved and priority problems to The respondents need indoor and outdoor be resolved. gymnasium concepts, seperate gymnasium rooms for men and women, and private The second step is identifying gaps gymnasium which only can be access by the through the Organizational Elements Model society of acedemicians at Campus C, (OEM). The model explains five elements Universitas Airlangga. Most of those who (Suryana Hasim 2013). The first two elements required gymnasium facilities were female involve input and process in the utilization of students aged 21-30 years. They favored every potential and existing sources, and the sports because they wanted to keep the body other three include products, outputs and healthy and mantain ideal weight. outcomes as the final result of a process. Input components include the present conditions, Evaluated needs (Health diagnosis) for example, finance, time, buildings, teachers, students, needs, problems, goals, Despite perceived needs, enabling and curriculum materials. Additionally, factors include personal skills, group process components involve staff formation, resources, and community resources, education according to competencies, including the availability of health service planning, methods, individual learning, and facilities, health workers, costs, distance, and applicable curriculum. access to transportation. Besides, reinforcing factors support the emergence of health Product components include completion measures and include family factors, friends, of education, skills, knowledge, and attitudes, teachers, regulations, and legislation in the as well as successful competency test. health sector, attitudes, and behavior of health Further, output components involve workers, as well as other factors related to graduation certificates, prerequisite skills, and health providers. licenses. The outcome components are related to the adequacy and contribution of Almost all students had health individuals or groups at present and in the problems. Overweight was the most common future. Using these component analyses, health issue experienced by the students, and gymnasium architects can determine the some also experienced digestive disorders extent to which a gymnasium is useful for the (gastritis). Less than 50% of the students users. These analyses essentially determine checked their health problems to doctors, and gaps between expectations and reality. most of them were recommended to do swimming. The next step is analyzing performance. In the third stage, after the architects understand various information and identifies gaps, they can analyze performance. They learn from formulating new management policies and a better organizational structure,

354 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:348-355 or developing materials and tools. that provides a swimming pool. The Performance analysis includes identification determination of students’ dymnasium needs of teachers, suggestions, school policies, was considered through doctors’ advice for social climate and psychological climate, as well as complete student learning support. swimming activities based on the health The fourth is identifying obstacles. diagnosis. This study summarizes a health Various obstacles may occur due to facility diagnosis playes a role on gymnasium needs time, materials, grouping and composition, philosophy, personnel and organization. of the students at Universitas Airlangga. Besides, constraints also may arise from a Considering high demands on the learning program, for example, teachers, principals, and students themselves. establishment of gymnasium and lots of its Addtionally, philosophy of work, work health benefits, the campus is expected to motivation, and competence may be other build a gymnasium with its required facilities. constraints too.Moreover, other constraints Moreover, further research should study more may occue due to the existing facilities, deeply about factors that affect motivation for including the availability, completeness, and condition of the facilities, and the amount of exercises or sports so that the university may funding and its allocation. consider gymnasium facilities that can facilitate the students’ most favorite sports. Then, the last step is identifying objectives (Makmur and Widagdo 2017). REFERENCE Need assessment is a process of identifying, documenting, and justifying gaps between the Kotler, Armstrong. 2010. Principles current situation and later outcomes based on the priority scale of each need Kaufman Marketing. 17th ed. ed. Marc Oliver (1983). Not all needs are instructionally designed objectives. An architect needs to Opresnik. Northwestern: Global Edition. determine urgents needs more on the top of Liam, Wil et al. 2017. “Perancangan Gym the others. Center Dengan Fasilitas Penunjang Bagi This study reports that nearly half of Pengguna Di Surabaya.” Intra 5(2): the students had a desire to do swimming as 524–30. their doctors recommended to do so. Therefore, the students preferred swimming Makmur, Harbet, and Herry Widagdo. 2017. pool which becomes one of the gymnasium facilities. Most of them required mixed “HEALTHY GYM FAMILY concepts of an indoor and outdoor gymnasium. In carrying out execercises, the (Perencanaan Pendirian Usaha Jasa majority of the students did not need a Fitness Center).” Jurnal Manajemen personal trainer. Finally, more than 80% of STIE Multi Data Palembang: 1–15. the students preferred separate gym rooms for male and female. Muttaqin, Andi, Ifwandi, and Muhammad Jafar. 2016. “Motivasi Member Fitness CONCLUSION Center Dalam Melakukan Latihan It can be concluded that the students at Universitas Airlangga require a gymnasium Kebugaran Jasmani (Studi Kasus Pada Member Wana Gym Banda Aceh Tahun 2015).” Jurnal Ilmiah Mahasiswa Pendidikan Jasmani, Kesehatan dan Rekreasi 2: 100–113. Rinawiyanti, Esti Dwi, Rosita Meitha, Jeremia Januar, and Pratama Putra. 2014. “Studi Segmentasi Berorientasikan Psikografis Dan Behavioral Pada Konsumen Fitness Center Di Surabaya.” International Management di Fachhochschule Nuertingen University 7(1): 25–38.

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 355 Samudin, Esti Yulitriani T, and Adi Sasmito. Suryana Hasim. 2013. Analisis Strategi 2017. “Semarang Sport Centre (Dengan Pemasaran Gym Dan Swimming Pool Pendekatan Konsep Penekanan Hi-Tech Architecture).” Universitas Pandanaran YHI Whellness Hotel Melia Purosani (1): 1–20. Saqurin. 2013. “Tingkat Kebugaran Pada Yogyakarta. Yogyakarta: Universitas Mahasiswa Dengan Olah Raga Negeri Yogyakarta. Taekwondo Di Universitas Airlangga.” Takdir D., Mahmudin, Sudirman. 2008. 1 Fakultas Keperawatan Universitas Kewirausahaan. Wijaya Muhadi Karya : Airlangga: 7. Yogyakarta. Sugiyono. 2011. “Statistik Untuk Penelitian.” Trudeau. 2008. “Kumpulan Makalah : 1–370. Disampaikan Pada Konvensi Nasional Pendidikan Universitas Pendidikan Indonesia.” Jurnal Keolahragaan

RECOMMENDATION OF DIPHTHERIA ANTITOXIN TO DIFFERENT SUSPECTS DURING THE DIPHTHERIA OUTBREAKS,LUMAJANG DISTRICT IN 2018 Munif Arifin Lumajang District Health Office Jalan Jend. S. Parman Number 13 Tel. (0334) 881066, Lumajang, East Java, Indonesia Correspondence Address: Munif Arifin Email: [email protected] ABSTRACT The number of diphtheria suspects in Lumajang district was the second highest in East Java province during the diphtheria outbreaks in 2018. The number of diphtheria cases was more than 500% in 2018 compared to 2017. To give diphtheria antitoxin (DAT), the provincial diphtheria expert team consider various suspects’ characteristics for DAT recommendation as DAT supplies are limited. This case report aimed to explore and describe the relationship between diphtheria suspects’ characteristics, including age, gender, symptoms, immunization status, duration of disease, and contact status with other suspects according to the DAT recommendations from the expert team. This case report was descriptive and used a cross-sectional approach. It was conductedduring the diphtheria outbreaks and involved total samples of all suspects. Based on age, the majority of the suspects (92%)were under 19 years old. Suspects at this age were the target of an outbreak response immunization (ORI) program. Those who were not targetted to receive ORI (aged over 19 years) began to appear in November and mostly in December. The trend of non-ORI targetted age increased after the third round of ORI implementation. According to the report form parents, most suspects (46.7%) had complete immunization status, and only 6.7% of their immunization records were reported on growth chart cards. All suspects with positive diphtheria never had and know routine immunization records. The laboratory tests show only 5% were suspected with positive diphtheria with a cultural type of mitis toxigenic. As many as 32% of the total suspects were recommended for DAT treatment. The use of controlled DAT could save 1,640,000 iU. Keywords: Diphtheria, outbreak response immunization, diphtheria antitoxin. ABSTRAK Jumlah suspek penyakit difteri di Kabupaten Lumajang tertinggi ke dua di Jawa Timur saat Kejadian Luar Biasa (KLB) difteri tahun 2018. Terjadi peningkatan kasus pada tahun 2018 mencapai lebih 500% dibandingkan tahun 2017. Untuk memberikan serum antidifteri pada suspek, Tim Ahli Difteri Provinsi mempertimbangkan berbagai karakteristik suspek untuk rekomendasi serum antidifteri. Rekomendasi ini dilakukan karena keterbatasan persediaan serum antidifteri. Case report bertujuan untuk mengeksplorasi dan mendiskripsikan hubungan karakteristik suspek difteri, meliputi umur, jenis kelamin, gejala, status imunisasi, lama sakit, dan status kontak dengan suspek lain dengan rekomendasi serum antidifteri dari tim ahli. Case report ini menggunakan rancangan diskriptif dan pendekatan potong lintang. Case report ini dilakukan selama KLB difteri dan melibatkan total sampel seluruh suspek. Berdasarkan usia, mayoritas suspek (92%) berusia di bawah 19 tahun. Usia ini merupakan sasaran program imunisasi tanggap kejadian luar biasa. Suspek yang bukan sasaran program imunisasi ini (berumur lebih dari 19 tahun) mulai muncul pada bulan Nopember dan sebagian besar pada bulan Desember. Tren usia suspek yang bukan sasaran ORI meningkat setelah pelaksanaan ORI putaran ke tiga. Sebagian besar suspek (46.7%) mempunyai status imunisasi lengkap berdasarkan informasi dari orang tua, dan hanya 6.7% mempunyai catatan imunisasi pada Kartu Menuju Sehat (KMS). Seluruh suspek dengan positif difteri tidak pernah melakukan dan tidak mengetahui catatan imunisasi rutin tersebut. Uji laboratorium menunjukkan hanya terdapat 5% suspek dengan hasil uji laboratorium positif mitis toksigenik. Jumlah suspek yang direkomendasikan mendapatkan terapi serum antidifteri sebanyak 32%. Penggunaan serum antidifteri yang “terkendali” dapat menghemat 1.640.000 iu serum antidifteri. Kata Kunci: Difteri, imunisasi tanggap kejadian luar biasa, serum antidifteri. INTRODUCTION immunization to suspects. This disease is caused by the gram-positive bacterium Diphtheria is a highly contagious Corynebacterium diphtheria strain of the disease that can be prevented by giving toxin and characterized by inflammation on ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.356-368 Received 1 July 2019, received in revised form 10 July 2019, Accepted 17 September 2019, Published online: December 2020

the infected parts, especially the mucous Munif Arifin, Recommendation Aspect of... 357 membranes of the pharynx, larynx, tonsils, quickly. Some signs and symptoms of diphtheria were still unclear, but some nose, and skin. Severe diphtheria can be people who had such obscure symptoms such as painful swallowing, characterized by difficulty in swallowing, pseudomembrane, epistaxis, bull neck, and stridor had been reported as suspects. Fast shortness of breath, stridor, and neck case tracking could give fast prevention measures for the disease transmission, swelling that looks like a bull neck. Death leaving aside the possibility of overdiagnosis (Lumajang District Health usually occurs due to obstruction or Office, 2018). blockage of the airway, damage on the heart According to the standard operating procedure (SOP), suspects found in less muscle, and abnormalities in the central than 24 hours must be reported to the East Java Provincial Health Office in Form Dip nervous system and kidney (Indonesian 1, which contains various suspects’ data, including name, age, address, immunization Ministry of Health, 2017). status, signs and symptoms, and others. This report is used not only as an outbreak The Circular Letter of the Governor epidemiological update but also as considerations for the Diphtheria Expert of East Java Number 460/69/012.4/2018 Team of East Java Province to recommend DAT treatment for the suspects. The expert concerning determination of diphtheria team come from Dr. Soetomo District General Hospital and Universitas Airlangga outbreaks in East Java and the Decree of the The team sent the recommendation along with the suspects’ pseudomembrane photos Regent of Lumajang district Number through WhatsApp chats. 188.45/16/427.12/2018 concerning Not all suspects receive DAT treatment due to the limitations of DAT at diphtheria outbreaks announced that the provincial level. Hence, DAT was distributed by recommendationtreatment diphtheria outbreaks occurred in Lumajang that applied to diphtheria suspects in Lumajang district. Treatment district, as well as other East Java regions. METHODS Outbreaks of infectious diseases, especially This case report used a those that can be prevented by quantitative-descriptive design and a cross-sectional approach during the 2018 immunization become public health diphtheria outbreaks. It sampled all diphtheria suspects in Lumajang district problems because they result in greater and focused on the analysis of DAT treatment recommendations of the risks of morbidity and deaths. The disease provincial diphtheria expert team. The mechanism of DAT recommendation was transmission should be anticipated and done at some stages. First, every diphtheria suspect found in a health prevented quickly and accordingly. During the diphtheria outbreaks, an outbreak response immunization (ORI) program was carried out through the distribution of 3 doses of diphtheria immunization to people aged 1-19 years. This program has also been carried out in regions where such outbreaks occur as stipulated in the Regulation of Indonesian Ministry of Health No. 1501 of 2010 concerning certain types of communicable diseases that need plague and mitigation measures. The number of diphtheria suspects in Lumajang district in 2018 was ranked the second highest in East Java province. In 2017, there were 11 diphtheria suspects and 60 suspects in 2018. The increase between the years was more than 500%. Such increase occurred possibly as the primary healthcare center and hospital surveillance officers did track and report the suspects

358 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 service facility (primary healthcare Letter of Director-General of P2P Number UM.01.05/1/3274/2017 on 21st December center, clinic, or hospital) was reported 2017 concerning about the prevention of diphtheria outbreaks. online through WhatsApp to the East Java Moreover, the East Java Provincial Provincial Health Office. The report Government issued the Letter of East Java consisted of suspects’ pseudomembrane Governor to the Regent/Mayor on 8th January 2017 Number: 460/69/012.4/2018, photos, immunization status, age, gender, regarding determination of diphtheria outbreaks, anticipation of surges and age, symptoms (pseudomembrane, disease transmission, and the implementation of an outbreak response epistaxis, bull neck, and stridor), date of immunization (ORI) program. disease, history of contact with other The immunization program was carried out in regions where the outbreaks suspects, treatment given, or bleeding occurred based on the Regulation of Indonesian Ministry of Health No. 1501 of status during a throat or nasal swab. 2010 concerning certain types of communicable diseases that need plague Second, the provincial diphtheria expert and mitigation measures. This program aims to break the chain of transmission and team provided several possible immediately end the outbreaks and high immunity gaps in infants. Few infants in recommendations based on the report: 1) Lumajang have received complete basic immunization, and this immunization has Negative diphtheria, 2) Erythromycin not equally been distributed. Ideally, further immunization should be given to children at antibiotic treatment, PPC, or mouth rinse, school ages to future outbreaks. and 3) DAT treatment (with its dosage). In the third stage, the epidemiological surveillance officers tracked the suspects and people in close contact with them and collected a specimen collection of the throat and nasal swabs, as well as prophylaxis. Furthermore, the swab results were tested for further diagnosis in the Central Laboratory of Health Laboratory of Surabaya . This case report basically identified the relationship between DAT recommendationtreatmentas an independent variable and dependent The number of diphtheri suspects in Lumajang district in 2018 variables including immunization status, The number of diphtheria suspects in age, gender, symptoms 2018 was 60 suspects spread in 22 primary healthcare centers, except Ranuyoso, (pseudomembranous, epistaxis, bull Pronojiwo, and Penanggal Primary Healthcare Centers. neck, stridor), date of disease, and history Suspects’ characteristics based on of contact with other suspects. domicileThe suspects’ domiciles are presented in Table 1. Meanwhile, to see the significance and degree of the relationship, this case report utilized the bivariate test. Further, multivariate logistic regression was carried out to analyze statistically significant risk factors for DAT Table 1. Frequency Distribution of the Diphtheria Suspects based on recommendation. Domiciles in Lumajang District in 2018. RESULTS During the diphtheria outbreaks, the Puskesmas Total % suspects aged 1-19 years were given 3 doses of diphtheria immunization in February, Rogotrunan 17 27.87 July, and November 2018. This Pasirian 6 9.84 immunization program was according to the Kedungjajang 5 8.20 Sukodono 5 8.20

Munif Arifin, Recommendation Aspect of... 359 Puskesmas Total % Table 2. Distribution of Suspects’ Characteristics based on Age and Candipuro 3 4.92 Gender in Lumajang District in 2018. Jatiroto 3 4.92 Padang 2 3.28 Randuagung 2 3.28 Suspects’ n% Characteristics Tempursari 2 3.28 Age 1 1.7 5 8.3 Tunjung 2 3.28 < 1 year 46 76.7 >1 s/d 2 year 8 13.3 Yosowilangun 2 3.28 >2 s/d 8 year > 8 year 37 60.7 Bades 1 1.64 23 37.7 Gender Gesang 1 1.64 Male Female Bades 1 1.64 Gesang 1 1.64 Gucialit 1 1.64 Klakah 1 1.64 Kunir 1 1.64 Labruk 1 1.64 Pasrujambe 1 1.64 Senduro 1 1.64 The majority of the suspects (76.7%) were aged 2-8 years old. The Sumbersari 1 1.64 lowest age of suspicion is 1 year, the highest is 39 years. Based on gender, most of the Tekung 1 1.64 suspects were male (60.7%), while women were 37.7%. Tempeh 1 1.64 Suspects’ characteristics based on risk Total 60 100 factors for immunization status and history of contact Most of the suspects (28%) lived in This case report presents risk factors the working area of the Rogotrunan for immunization status and history of contact in Table 3. Primary Healthcare Center, but the suspects spread in almost all working areas (88%). Based on monthly trends, diphtheria suspect fluctuations are presented in Graph 1. Table 3. Frequency Distribution of Risk Factors for Immunization Status and History of Contacts with Other Diphtheria Suspects in Lumajang District in 2018. Graph 1. Trends of Diphtheria Suspects in Variables n % Lumajang District in 2018. Immunization 4 6.7 Status 2 46.7 At the beginning of the year from 8 11.7 January to July, the trend of suspects tended to - Complete fall, then rose in July to September, and Growth Chart significantly increased again in December. Cards Table 2 illustrates - Information from parents - Incomplete records

360 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Variables n % Further symptoms were presented in Table - Do not know 7 15.0 4. 20.0 the cards 9 - Never 1 Table 4. Frequency Distribution of 2 Suspects’ Diphtheria Symptoms complete the cards in Lumajang District in 2018. History of contact - Never Suspect n% - Ever Characteristics Pseudomembranous 5 91.7 - Negative 5 8.3 5 - Positive 00 60 100 Based on immunization status, most Epistaxis 58 96.7 of the suspects (46.7%) had complete - Negative 2 3.3 immunization as their parentas told. Only - Positive 6.7% had complete immunization reported in their growth chart cards.Regarding a Bull neck 41 68.3 history of contact, 55 suspects (91.7%) had - Negative 19 31.7 never been in contact with other suspects, - Positive while 5 others (8.3%) had. Stridor 38 63.3 Suspects’ characteristics based on - Negative 22 36.7 symptoms - Positive Table 4 explains that all suspects Suspect characteristics based on the (100%) were positive pseudomembranous, duration of disease 58 suspects (96.7%) were negative epistaxis, 41 suspects (68.3%) had no Table 5 presents how long the symptoms of bull neck, and 38 suspects suspects suffered from diphtheria before being (63.3%) had no symptoms of stridor. treated in health service facilities. Table 5. Frequency Distribution of the Duration of Disease Experienced by the Diphtheria Suspects in Lumajang District in 2018. Duration of Not Recommended DAT Status Total Disease 30 (77%) treatmentRecommended 39 1-3 days 8 (45%) 9 (23%) 18 4-6 days 3 (100%) 10 (56%) 3 >7 days 41 (68%) 0 (0%) 60 Total 19 (32%) Based on Table 5, most suspects possibility for DAT experienced the disease for 1-3 days and some of them received DAT recommendations. treatmentrecommendations. While suspects with the duration of 4-6 days were given DAT recommendations. The Suspects’ characteristics based on sooner the duration of disease, the less treatment status

Munif Arifin, Recommendation Aspect of... 361 Besides, this case report shows that treatment, while 19 (31.7%) others were 55 suspects (91.7%) were hospitalized, and given DAT treatment. Regarding DAT 5 other suspects (8.3%) received outpatient dose, of 19 suspects given DAT treatment, care. Before being hospitalized, 39 suspects 12 suspects (20%) received a DAT dose of (65%) had been sick for 1-3 days, 18 40,000 Iu, 4 suspects received a DAT dose suspects had suffered from the disease for of 20,000 Iu, 2 suspects had a DAT dose of 4-6 days (30.0%), and 3 suspects had been 60,000 Iu, and 1 suspect received a DAT sick for 7 days (5 %). dose of 80,000 Iu. Table 6. Frequency Distribution of Table 7. Frequency Distribution of DAT Treatment Status of Diphtheria Status in Diphtheria Suspects in Suspects in Lumajang District in Lumajang District in 2018. 2018. Variables n% Variables n% Diphtheria Antitoxin Treatment status 55 91.7 (DAT) - Inpatient 5 8.3 - Outpatient - Not Duration of Disease - 1-3 days recommended 41 68.331.7 - 4-6 days - >7 days - Recommended 19 DAT dose Not recommended 20.OOO IU 41 68.33 39 65.0 40.OOO IU 4 6.67 18 30.0 3 5.0 60.000 IU 12 20.00 80.000 IU 2 3.33 Total 1 1.67 Suspects’ characteristics based on DAT 60 100.00 status DAT given to suspects was In Table 7, this study finds 41 associated with duration of disease prior to suspects (68.3%) were not given DAT health treatment at health service facilities. Table 8. Frequency Distribution of DAT Recommendation and Duration of Disease in Diphtheria Suspects in Lumajang District in 2018. Duration of Not Recommended DAT Status Total Disease treatmentRecommended 1-3 30 9 39 days Count 77% 23% 100% 50% 15% 65% % within % of Total 8 10 18 4-6 44% 56% 100% days Count 13% 17% 30% % within % of Total 3 03 >7 days Count

362 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Duration of Not Recommended DAT Status Total Disease 100% treatmentRecommended 100% Total % within 5% 5% % of Total 41 0% 60 Count 68% 0% % within 68% 19 100% % of Total 32% 100% 32% Table 9. Frequency Distribution of Laboratory Test Results of Diphtheria Suspects in Lumajang District in 2018. DAT Status Results of laboratory specimen examination Negative Positive Total Graph 2. Percentage of Suspects’ Not 40 1 (2%) 41 Age and DAT Recommendation in Recommended (98%) 2 (10%) (100%) Lumajang District 2018. Recommended 3 (5%) treatment 17 19 Graph 2 shows that the majority of (90%) (100%) DAT recommendations were given to Total suspects aged 2-8 years. However, most 57 60 suspects aged 1-2 years were not (95%) (100%) recommended for DAT. treatment The implementation of outbreak Suspects’ characteristics based on response immunization (ORI) program laboratory test results in 2018 Based on Table 9, there were 3 The outbreak response suspects (5%) with the positive of toxigenic immunization (ORI) in Lumajang district mythic. was conducted in 3 rounds, between February-March, June-July, and November-December 2018. Table 10 shows the recapitulation of ORI coverage in Lumajang district in 2018. Table 10. Coverage of ORI in Lumajang District 2018. Total coverage of 1 to <19 years Age Total target Round 1 Round 2 Round 3 Range Proy Riil Pro Rii Pro Riil Pro Riil Abs y l Abs y (%) Abs yi (%) (% (%) (%) ) (%) 1 S/D < 57.71 59.841 58.47 101 98 58.47 101 98 56.56 98.0 95 5 Years 7 40.771 1 1 30 ≥5-<7 30.09 40.87 136 10 39.80 132 98 39.95 132. 98 Years 9 1 0 5 1 73

Munif Arifin, Recommendation Aspect of... 363 Total target Total coverage of 1 to <19 years Proy Riil Age Round 1 Round 2 Round 3 Range Pro Rii Pro Riil Pro Riil Abs y l Abs y (%) Abs yi (%) (% (%) (%) ) (%) ≥7-<19 185.6 160.91 158.0 85 98 157.6 85 96 156.7 84.4 97 Years 60 9 14 28 34 2 Total 273.4 261.53 256.7 94 98 255.9 94 98 253.2 92.6 97 1-<19 76 1 55 04 48 0 Years Overall, the ORI coverage had reached the especially of the target age of 1 to <5 years. minimum target of 90%. The trends show a The coverage corresponds to the number of decrease in ORI coverage in the third round. diphtheria suspects in Lumajang district as seen in Graph 4. The number of diphtheria suspects decreased while the ORI coverage increased. Meanwhile, Graph 5 shows the coverage of the target age of ORI program. Graph 3. ORI Coverage in Lumajang District in 2018. Graph 5. The Target Age of Diphtheria Suspects for ORI Program in Lumajang District in 2018. The number of non-targetted age for ORI program began to emerge in November, and the highest one was found in December. The calculation of the association between routine immunization and suspects’ characteristics is available in Graph 6. Graph 4. ORI Coverage and the Number of Diphtheria Suspects in Lumajang District in 2018. Graph 3 illustrates the trend in round 3 was the most decreasing ORI coverage,

364 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Graph 6. Association between Diphtheria there were no deaths as 100% suspects were Suspects and Routine treated less than 24 hours according to the Immunization Coverage in standard. Lumajang District in 2018. Epidemiological aspects of diphtheria Graph 6 illustrates only Rogotrunan suspicion Primary Healthcare Center had below 95% of routine immunization coverage, but it Most of the suspects (28%) lived in had the highest number of suspects. the working areas of Rogotrunan Primary Whereas Tekung Primary Healthcare Healthcare Center. While there were eight Center had lower coverage and a low suspects from the Pasirian Primary Healthcare number of suspects. Center, five others from Kedungjajang Primary Healthcare Center, five others from DISCUSSION Sukodono Primary Healthcare Center, 3 suspects from Candipuro Primary Healthcare This study reports an increase in Center, and 3 suspects from Jatiroto Primary sdiphtheria suspects occurred during the Healthcare Center. While there was only one diphtheria outbreaks in Lumajang district. suspect in each of other primary healthcare In 2017, there were 11 diphtheria suspects, centers. The other three primary healthcare while in 2018 there were 60 suspects. Based centers (Pronojiwo, Penanggal, and on the results of laboratory tests, 3 suspects Ranuyoso) had no diphtheria suspects in were positive toxigenic mythic. The 2018. number of diphtheria suspects in 2018 was higher than in 2017. In 2018, the suspects Some primary healthcare centers with were found in almost all regions (88% the high number of diphtheria suspects were working areas of primary healthcare located in urban areas (Rogotrunan, centers). Sukodono, and Kedungjajang Primary Healthcare Centers), or in areas with high According to the standard operating population density (Pasirian and Jatiroto procedure (SOP) and diphtheria prevention Primary Healthcare Centers). Whereas no technical guidelines, diphtheria situation diphtheria suspects wre found in highland would be considered an outbreak if one areas (Pronojiwo, Penanggal, and Ranuyoso). suspect was found without waiting for Further study is required to examine the laboratory test results. Immediate relationship between topographic and countermeasures were done, such as taking environmental aspects and diphtheria all specimens of the throat and nasal swabs. suspicion. The specimens were then investigated in the Central Laboratory of Health Laboratory Suspects’ characteristics based on age (BBLK) of Surabaya. During the and gender countermeasures, treatments were given and did have the success rate of 100%, and After the first ORI round and the second ORI round, the number of diphtheria suspects fluctuated. In 2018, only 5 suspected people were aged over 19 years (non-targetted age for ORI), 4 suspects were found in December, and 1 suspect was found in November. This shows that the shifting trend of non-targetted suspects occurred after the implementation of the third ORI round. From January to October 2018, there were no suspected people aged 19 years in the first and second ORI rounds. After these

roundsa, suspects aged over 19 years old were Munif Arifin, Recommendation Aspect of... 365 discovered in November (1 suspect) and December (4 suspects). It can be assumed that result in a negative Schick test result of after of the first and second ORI rounds, the 83.84% and 3 times immunizations showed suspects receiving ORI had stronger a perfect negative Schick test result. It immunity, and the non-targetted suspects’ age means the more complete the for ORI had replaced the targeted suspects’ immunization, the better the immunization age. The chi-square test shows a significant status. relationship between ORI and the shifting age of diphtheria suspects with a α value of 0.004. Moreover, this study reports 24% of the suspects had never been immunized, the Suspects’ characteristics based on risk majority of suspects (43%) had complete factors for immunization status and history immunization status according to of contact information from their parents (no documented evidence). Whereas the Regarding history of contact with percentage of suspects with complete other suspects, , 4 of 5 suspects (80%) who immunization status who had growth chart ever had contact with other suspects were cards was only 7%. This study further aged 5 years, and 1 suspect with similar reveals nearly half of the suspects without contant was 3 years old. It suggests that immunization records were aged >10 years. childhood or younger ages are the state of While all suspects who had immunization playtime which greatly leads children to records were less than 5 years old contract diphtheria. (toddlers). From these findings, immunization records and reporting system The majority of the suspects (75%) are required. were over 5 years old, and only 25% of them were under 5 years old. The trend of Furthermore, this study reports most diphtheria suspicion was increasing in of the suspects had problems with adulthood. Given the target age for ORI, the immunization due to incomplete majority (92%) were less than 19 years old immunization, undetected immunization and thus not targetted to receive ORI. Most status, and absence of immunization. These parents of the suspects did not know their findings are relevant with other studies child’s immunization status, while other which find the relationship between said their children had never been diphtheria and immunization status. immunized. Only 6.7% of the suspects had According to Utami (2010), incomplete documentary evidence such as growth chart immunization status could affect diphtheria cards. It suggests that most suspects had transmission and put people at 3.9 times incomplete immunization, thus increasing greater risks for contracting diphtheria the risk of susceptibility to diphtheria. The compared with complete immunization use of antibody titers tend to be higher status. Further, Widoyono (2011) explains because of better immunization intervals. the mortality rate in children without Children should be immunized with immunization is four times greater than diphtheria (in 0-12 months) and with children who are immunized. booster (in 18 to 24 months) and BIAS (at grade 1 and 2 of elementary schools). Suspects’ characteristics based on symptoms These results are consistent with Lubis's (2005) study, which states that According to its etiology, diphtheria is children who received DPT immunization a very contagious disease caused by once showed a negative Schick test result of Corynebacterium diphtheria. It causes 72.73%. Further, twice immunization could symptoms and signs such as fever at 38ºC, bleeding and painful swallowing due to grayish-white pseudomembranes or

366 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 membranes in the throat, enlargement of the sSuspects’ characteristics based on DAT neck lymph nodes, and swollen soft neck treatment and results of laboratory tests tissue so-called the bull neck. Some other symptoms also inclde shortness of breath and Based on the results of laboratory snoring sound. tests, of the 60 suspects, there were 3 suspects with positive mythic toxicity. One In 2018, the main reason for DAT of them was 16 years old, and two others treatmentwas made by the expert team’s were 22 years old. Two suspects (67%) recommendation due to pseudomembranous received DAT, and one suspect (33%) did symptoms. All suspects with these symptoms not receive DAT recommendation. received DAT treatment. While other KA, 16 years old, Pasirian, never symptoms included epistaxis (3.3%), bull immunized, received ORI in the first round; neck (31.7%), and stridor (36.7%). WK, 22 years old, Pasirian, never immunized, received ORI in the first round; Suspects’ characteristics based on DAT AN, 22 years old, Kunir, never immunized, status did not receive ORI. Doctors diagnosed diphtheria based This study reports most adult on symptoms and clinical condition. suspects were positive diphtheria. Diphtheria treatment begins by distributing Immunizationwere given to these suspects DAT and antibiotics to the suspects without by considering their body immune. Besides, laboratory results or swab results. DAT there were three suspects that had never had dose ranging between 20,000-100,000 IU routine immunization. Kartono's research was determined empirically based on (2007) finds that the main factor that causes disease severity and duration of disease, and diphtheria was incomplete DPT/DT suspects’ weight ( Indonesian Ministry of immunization which contributed to 46,403 Health, 2017). times greater risk of diphtheria in children. The number of suspects Two of three suspects were still recommended for DAT treatment was 19 students. This suggests that diphtheria people (32%), who received 760,000 IU of transmission was associated with DAT dose. The majority (63%) environmental aspects. recommended for DAT received 40,000 IU of DAT dose. The total number of DAT Outbreak response immunization during doses was 760,00 IU or on average 4 vials diphtheria outbreaks in Lumajang (@ 10,000 IU). The use of \"controlled\" district in 2018 DAT ould save 1,640,000 IU of DAT dose. If converted to 41 suspects, it would be The Letter of East Java Governor formulates as 41 suspects x 4 vials = 164 vials x Rp. 2,200,000 = IDR 360,800,000. assigned the Regent/Mayor on 8th January Based on response of actions, this 2017 Number: 460/69/012.4/2018 to study finds the faster the suspect was referred to a health service facility (a immedeiately announce diphtheria primary healthcare center and hospital), the less possible they would receive ADT outbreaks. Such immediate announcement treatment. There were 23% suspects with disease duration of 1-3 days (before being aimed to anticipate spikes and disease referred to a health service facility) who received DAT. Most suspects (56%) had transmission. During the outbreaks, an disease duration of 4-6 days. The success rate of treatment was 100% (no deaths), and outbreak response immunization (ORI) all suspects were treated in less than 24 hours according to the standard. program was carried out by referring to the Decree of the Regent of Lumajang Number: 188.45/16/427.12/2018 concerning diphtheria outbreaks and outbreak response immunization (ORI) program in Lumajang district. The district had achieved the minimum target of ORI coverage at 90%.

Munif Arifin, Recommendation Aspect of... 367 However, several primary healthcare Kabupaen Lumajang Tahun 2018, centers did not reach the minimum target. The lowest ORI coverage occurred to 12 Dinkes Lumajang primary healthcare cetners in the first ORI round. Regulation of the Minister of Health Nomor The ORI coverage was not directly 1501 tahun 2010 tentang Jenis proportional to the number of suspects in each working area. Penyakit Menular Tertentu yang Based on the findings, the number Dapat Menimbulkan Wabah dan of suspects would be more dominantly influenced by the population density Upaya Penanggulangan. compared to the ORI coverage. Diseases transmit easily through direct contact in Indonesian Ministry of Health, 2017. high population densities such as urban areas (Notoatmojo, 2007; Achmadi, 2005). Pedoman Pencegahan dan CONCLUSION Pengendalian Difteri, Direktorat The case report concludes during Surveilans dan Karantina Kesehatan the diphtheria outbreaks in 2018, there were 60 suspects who were mostly 19 years old Direktorat Pencegahan dan and became the target for ORI treatment. Only few suspected people had positive Pengendalian Penyakit toxic oxygenic categories. All positive suspects had no routine immunization Decree of the Regent of Lumajang Nomor records. The shift to non-targetted age for ORI treatment increased after the third 188.45/ 16/427.12 /2018 tentang round. Besides, the treatment success rate was perfect and resulted in zero deaths. keadaan kejadian luar biasa difteri There were 19 suspects (32%) who received DAT recommendation with 760,000 IU of (KLB difteri) DAT dose. Furthermore, the use of \"controlled\" DAT could save 1,640,000 IU. Decree of the Regent of Lumajang Nomor : Immunization records and report 188.45/ 17/427.12 /2018 Tentang must always be improved, for example through growth chart books, maternal and Pokja Out Break Response child health books, and infant and toddler cohorts. Besides, the provincial government Immunization (ORI) Difteri Kab. should supply more DAT stocks to reinfore response towards diphtheri treatment. Lumajang REFERENCE Kartono B, Purwana, dan Djaja. 2008. Lumajang District Health Office, 2018, Hubungan Lingkungan Rumah Laporan Kejadian Luar Biasa (KLB) Difteri dan Outbrek dengan Kejadian Luar Biasa (KLB) Response Immunization (ORI) difteri di Kabupaten Tasikmalaya (2005–2006) dan Garut Januari 2007 Jawa Barat. https://doi.org/10.21109/kesmas.v2 i5.250 Lubis, B. 2005. Penelitian Status Imunisasi Terhadap Penyakit Difteri Dengan Schick Test pada Murid Sekolah Taman Kanak-kanak di Kotamadya Medan. e-Journal USU Repository. SE Gubernur Jatim kepada Bupati/Walikota, Nomor 460/69/012.4/2018 tanggal 8 Januari 2018 tentang Penetapan Situasi KLB Difteri di Jatim Notoatmodjo, S. 2007. Promosi Kesehatan dan Ilmu Perilaku. Jakarta : Rineka Cipta Utami, A.W., (2010). Faktor yang mempengaruhi kejadian penularan difteri di Kota Blitar Propinsi Jawa Timur, tesis. Fakultas Kesehatan Masyarakat Universita

368 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Airlangga,Program Studi Ilmu Kesehatan Masyarakat.

THE RELATIONSHIP OF KNOWLEDGE, EXPOSURE TO SUNLIGHT, AND CALCIUM INTAKE WITH THE RISK OF OSTEOPOROSIS Erliza Anggraini Firdaus1 , Bambang Wirjatmadi2 1 Study Program of Public Health, Faculty of Public Health, Airlangga University, Surabaya, Indonesia 2 Department of Health Nutrition, Faculty of Public Health, Airlangga University, Surabaya, Indonesia Correspondence Address: Erliza Anggraini Firdaus Email: [email protected] Email: ABSTRACT Osteoporosis is a bone disease causing decreased bone density. It often occurs to elderly women. At the age of 50- 80 years, 23% Indonesian women were at risk of osteoporosis, and this number would increase to 53% at the age of 70-80 years. This study aimed to identify the relationship of knowledge, calcium intake and exposure to sunlight habits with the risk of osteoporosis. This study used a cross-sectional design involed 26 members of the osteoporosis gymnastic group who had a low and high risk of osteoporosis. Data of food consumption were retrieved from 24-hour food recall. The chi-square analysis shows knowledge level had a relationship with risk of osteoporosis (p=0.047). Exposure to sunlight (p=0.437) and calcium intake (p = 0.187) had a relationship with the risk of osteoporosis. It can be concluded that the level of knowledge had a significant relationship with risk of osteoporosis. Knowledge variable is important to show the community mindset about the dangers and risks of osteoporosis. Therefore, education about osteoporosis is required. Keywords: osteoporosis, knowledge, calcium intake, exposure to sunlight habits. ABSTRAK Osteoporosis merupakan penyakit pada tulang yang ditandai dengan penurunan kepadatan tulang. Osteoporosis sering kita jumpai pada wanita lanjut usia atau lansia. Di usia 50 – 80 tahun wanita Indonesia berisiko osteoporosis sebesar 23% dan akan meningkat menjadi 53% pada usia 70 – 80 tahun. Tujuan dari penelitian ini adalah mempelajari hubungan pengetahuan dengan asupan kalsium dan kegiatan berjemur pada risiko osteoporosis. Penelitian ini termasuk jenis penelitian yang menggunakan rancangan studi cross sectional. Sampel penelitian ini adalah anggota kelompok senam osteoporosis yang memiliki risiko rendah dan tinggi terkena osteoporosis dengan jumlah 26 orang. Data Konsumsi pangan diperoleh melalui food recall 24 jam. Hubungan antara variabel dengan analisis Chi Square Tingkat pengetahuan dengan risiko osteoporosis p = 0,047. Kebiasaan berjemur dengan risiko osteoporosis p = 0,437 dan asupan kalsium pada resiko osteoporosis p = 0,187. Sehingga dapat disimpulkan bahwa tingkat pengetahuan yang memiliki hubungan signifikan terhadap risiko osteoporosis. Faktor pengetahuan sangat penting untuk menunjukkan pola pikir masyarakat mengenai bahaya dan risiko osteoporosis. Dan pemberian edukasi tentang osteoporosis sangat di perlukan. Kata Kunci : osteoporosis, pengetahuan, asupan kalsium dan kegiatan berjemur INTRODUCTION and social, psychological, and physical problems that interfere someone’s health Osteoporosis is a bone disease status (Cembrowicz, 2007). which reduces bone density. Decreased bone density occurs due to lower calcium According to the World Health levels. Osteoporosis is often called a \"silent Organization (WHO), there have been 200 disease\" because it does not cause million people suffering from osteoporosis symptoms apparent to osteoporosis worldwide. This number will increase every sufferers (Sefrina, 2015). It often occurs to year. In Indonesia, the Indonesian Ministry people in middle ages and above, especially of Health stated that the proportion of women. Osteoporosis can cause disability Indonesians at risk of osteoporosis was 19.7% in 2016 and would continue ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.252-257 Received 29 May 2017, received in revised form 27 June 2017, Accepted 30 July 2017, Published online: December 2020

Erliza Anggraini Firdaus and Bambang Wirjatmadi, Relationship Between Knowledge...253 increasing each year. Further, it was stated METHODS that two out of five people in Indonesia were at risk of suffering from osteoporosis. This study was a comparative- At the age of 50-80 years, 23% Indonesian observational study using a cross-sectional women were at risk of osteoporosis, and the design. The study’s population was proportion would increase to 53% at the age members of the osteoporosis gymnastics of 70-80 years (Sefrina, 2015). According group at Dr. Soetomo District General to Pranoto (c2009) the Indonesian Hospital, Surabaya. The group was then population had a life expectancy of 64.71 divided into two sub-groups as the research years (1995-2000) and 67.68 years (2000- samples.Group I were the members of the 2005). With the increasing age, the risk of osteoporosis group with low risk of osteoporosis will increase. Five Indonesian osteoporosis, while Group II consisted of provinces, such as South Sumatra (27.7%), members with high risk of osteoporosis. Central Java (24.02%), Yogyakarta (23.5 This study employed a simple random %), North Sumara (22.82%), East Java sampling technique to collect 26 female (21.42%) and East Kalimantan (10.5%)had respondents. This study was conducted in a higher risk of osteoporosis. the parking lot of the Medical Rehabilitation Installation, Dr. Soetomo Muchtadi (2009) mentions the rate District General Hospital Surabaya from of bone formation may be normal, but there October 2016 – January 2017. will be an acceleration of bone resorption causing a decrease in bone mass. Bone To collect primary data, this study resorption can maintain calcium levels in used questionnaires given to the the blood. When people consumed foods respondents to identify their knowledge with low calcium levels, they are more about osteoporosis, calcium intake, and likely to suffer from osteoporosis. Some exposure to sunlight. Further, it utilized the risk factors that can increase the incidence data of monitored food consumption from a of osteoporosis include heredity, low intake 24-hour Food Recall. Meanwhile, this study of calcium and vitamin D3, smoking, lack obtained secondary data from the of sun exposure (Setiati, 2008). Further, description and profile of Dr. Soetomo these factors involve alcohol consumption, District General Hospital, Surabaya. fizzy and excessive caffeine consumption, lack of physical activity and exercise, The level of knowledge was menaoupose, chronic diseases and long- categorized into three:low (<60%), medium duration drug intake (Sefrina, 2015). (60% - 80%), and high (> 90%). Potassium consumption level was divided into two: Calcium and phosphate play an less (≤ 1200mg / day) and sufficient (≥1200 important role in bone formation. mg/day) (Andriani, 2012). While levels of Insufficient calcium intake will lead to exposure to sunlight were categorized into abnormal formation of bone and its tissue. two: enough (10-15 minutes per day) and Calcium can maintainbone tissue during less (<15 minutes per day) (Marmi, 2013). adulthood, especially for the elderly (Fatmah, 2010) and bone density. Other Data analysis were carried out in 2 nutrients that play a role in the bone ways: descriptive and analytical analyses. formation include vitamin D, vitamin C, Descriptive analysis presented the results in phosphorus, magnesium, and zinc (Sefrina, a frequency distribution table. Chi-square 2015). analysis was used to find out the relationship of knowledge, calcium intake, With the overview of osteoporosis and exposure to sunlight with the risk of incidence, this study aimed to identify the osteoporosis (α=0.05). relationship of knowledge, calcium intake and exposure to sunlight with the risk of osteoporosis.

254 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:252-257 RESULTS Table 2. Relationship between knowledge levels and risk of osteoporosis Table 1 shows 12 respondents at low among the respondents. risk of osteoporosis were aged 50-60 years (92.3%) and 6 of them with high risk of Level Low Risk High Risk osteoporosis (46.2%) were at the age of 61- Knowledge n% n% 70 years. Eight respondents with low risk -- 2 15.3 group had a high school education, and five Low 6 46.2 10 77 respondents with high risk had a junior high Medium 7 53.8 1 7.7 school education. Mostly, the respondents High 13 100 13 100 were housewives (53.8%). Total P 0.047 Education may affect calcium intake. It lies on the argument that says The analysis informs us that most of highly educated elderly will plan a healthy the respondents had high school and junior and nutritious diet for himself and his high school education. They mostly had family to meet his family’s nutritional moderate knowledge about osteoporosis. needs. According to Notoatmodjo (2011), The community knowledge and education knowledge is the result of knowing that level may suggest mindset about the occurs after people sense a certain object. dangers and symptoms of osteoporosis, and the state of work that might make them Table 1. Characteristics of respondents of overlook their health problems. The result osteoporosis gymnastics group at shows half of the respondents with low risk dr. soetomo district general had a moderate level of knowledge (53.8%). hospital in 2016. While, 10 respondents with high risk had a high level of knowledge (77%). Characteristics Low High Risk Risk n% Patterns of food consumption from Age n% one person to another can be different due 50 – 60 Years 5 38.5 to different levels of knowledge. Likewise, 61 – 70 Years 12 92.3 6 46.2 the elderly who have osteoporosis factors 1 7.7 2 15.3 tend to have different food consumption > 70 Years -- 13 100 patterns following their level of knowledge. Total 13 100 Someone who is knowledgable tend to Education 1 7.7 choose better quality foods. 1 7.7 5 38.5 Elementary -- 4 30.8 Generally, calcium is necessary for Junior High 8 61.5 1 7.7 the bone development. Osteoblasts add and High school 4 30.8 2 15.3 store calcium in bones, while osteoclasts Diploma -- 13 100 break down and excrete calcium in bones In Bachelors 13 100 particular cases, when the body lacks 7 53.8 calcium, calcium in the bones will be Total 4 30.8 6 46.2 released to meet the body's needs, thus Job 5 38.5 -- causing porous bones (Tandra, 2009). Old Housewife 2 15.3 people generally lack calcium which should Retiree -- at 1000 mg among people aged 19-50 years. Civil servant 1 7.7 -- People more than 51 years old even need Private 1 7.7 13 100 higher calcium intakes at 1200 mg employee 13 100 (Andriani, 2012). Someone’s physical Entrepreneur health will decrease in older ages. As a Total result, it may cause psychological and

Erliza Anggraini Firdaus and Bambang Wirjatmadi, Relationship Between Knowledge...255 social physical function disorders which eight respondents with low risk (61.5%) had can further lead to dependency on others sufficient exposure to sunlight, while 7 (Andriani, 2012). respondents with high risk (53.8%) had inadequate exposure to sunlight. Table 3. Relationship between calcium intake and risk of osteoporosis DISCUSSION among the respondents. The members of osteoporosis Calcium Intake Low Risk High gymnastics group at Dr. Soetomo District n% Risk General Hospital Surabaya mostly had a Less n% junior high school, high school, and <1200 mg 8 61.5 diploma education. Besides, they had Enough >1200 6 46.2 moderate knowledge about osteoporosis. mg 5 38.5 Total 13 100 7 53.8 Furthermore, food consumption that P 13 100 varies among people may be due to different 0.187 levels of knowledge. Likewise, the elderly could have different food consumption In the low risk group, 8 respondents patterns since exposure to information they (61.5%) had less than 1200 mg calcium obtained might be different too. intake per day. Seven respondents (53.8%) with high risk had a sufficient calcium People aged 19-50 years ideally intake at > 1200 mg per day. need 1000 mg calcium, while those more than 51 years old should have 1200 mg Table 4. Relationship between level of calcium intake (Andriani, 2012). Another exposure to sunlight and risk of mineral that plays an important role in osteoporosis among the bones is phosphorus. Consuming less or respondents. excessive food is also not good for the body. Food consumption discussed in this study Level of Low Risk High Risk explains about types and amount of daily Exposure to food consumption, as well as characteristics n %n% of the food consumers (Andriani, 2012). Sunlight 8 61.5 6 46.2 Enough 5 38.5 7 53.8 This study reveals that the level of Not enough 13 100 13 100 knowledge had a significant relationship with the risk of osteoporosis. Knowledge Total 0.431 can lead to an action, activity or behavior P (Kusumawati 2014). Elderly with good knowledge tend to maintain health Moreover, osteoporosis can be condition every day. According to prevented if people receive enough vitamin Notoatmodjo (2011), before adopting new D which comes from sunlight. People need behaviors, someone will experience a about ten-to-fifteen-minute sunlight sequential process starting from awareness exposure every day (Marmi, 2013). The (awareness), in which they realize a intensity of UVB (short ultraviolet waves) stimulus (object). In other words, sunlight is low at 07.00 AM and increases knowledge is necessary for investing in the following hours. At 11.00 AM, this healthy behavior. Some vulnerable groups intensity is relatively stable and high until with high risks of osteoporosis were those 14.00 PM. At 16.00 PM, it reaches the same who were menopause and , smokers. Also, intensity as at 07.00 AM. Exposure to low those were aged 30 to 40 years who had intensity of sunlight can facilitate vitamin D heredity, lack of exercise, history of certain intake (Setiati, 2008). The result explains drug consumption, and low intake of calcium and vitamin D. To prevent

256 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:252-257 osteoporosis, knowledge is the key factor the analysis shows there was no relationship that might trigger someone to consume between knowledge and exposure to healthy foods for bones, regulate a healthy sunlight. It may be due to the fact that lifestyle, and exercise regularly and support vitamin D can be absorbed from not only bone health. sunlight, but also foods and other supplements such as milk. The result has a Calcium intake in the elderly is very relevance with the fact that most of the important for bone strength to avoid respondents were retirees who maybe do osteoporosis. If calcium intake in bone not work outside and take a moment for decreases, bone density will decrease faster being exposed to sunlight in the morning. thereby leading to greater osteoporosis risks. Furthermore, vitamin D plays an This study also reveals that 53.8% important role in the process of calcium of the respondents had sufficient exposure absorption in the body (Sefrina, 2015). to sunlight. Most of them already knew the Older people who have more calcium and importance of exposure to sunlight since more exposure to sunlight will be less at risk vitamin D generated form sunlight of osteoporosis. contributes to the bone mineralization process in which the absorption of calcium Every day the respondents consumed occurs in the body (Tandra, 2009). A carbohydrates derived from whole grains previous meta-analysis study recommends (rice). Elderly are recommended to to give high doses of calcium intake (1200 consume less simple sugars and replace mg or more) and vitamin D intake (800 mg them with complex carbohydrates or more) to prevent osteoporosis contained in nuts and seeds as a source of (Witjaksono, 2012). energy and a source of fiber (Marmi, 2013). This result explains that most respondents The body needs calcium for consumed carbohydrates derived from metabolic processes. When the body lacks noodles once a month calcium, it will take calcium reserves in the (sometimes).Vegetable and animal protein bones. Apart from consuming high-calcium is required to fulfill 10% of the total calorie foods, people need to be concerned about needs per day (Andriani, 2012). However, vitamin D deficiency which will impact the repsondents rarely consumed animal bone metabolism seriously. protein. This study shows the respondents consumed meat, eggs, and other animal CONCLUSION protein food twice a week. Daily consumption of vegetables and fruits with The study’s respondents were high fiber was good enough. However, mostly aged 50-60 years, had high school excessive consumption of fiber may cause education, a moderate level of knowledge minerals and other nutrients to be absorbed about osteoporosis, worked as a housewife by the fibers, not by the body itself. or retiree, and had enough exposure to sunlight and good food intake. Knowledge Also, milk is important because of its had a significant relationship with risk of high calcium level is good for bones. This osteoporosis. Therefore, the hospital needs type of food can be an alternative for people to further educate the gymnastics group aged more than 51 years and requiring 1200 about the risks and dangers of osteoporosis mg calcium intake. to make them more alert about the issues. The group also needs to be more open to The analysis shows that there was a parties or management and willing to significant relationship between knowledge express complaints or problems related to and exposure to sunlight. Knowledge can be their health. manifested into actions or attitudes towards health and risk of osteoporosis. Early It is also highly recommended that prevention and treatment can be done further research could use a larger number through knowledge investment. However,

Erliza Anggraini Firdaus and Bambang Wirjatmadi, Relationship Between Knowledge...257 of samples and more variables to give more mengenal, mengatasi, dan representative findings. mencegah tulang keropos. Jakarta : REFERENCE PT. Gramedia Pustaka Utama. Andriani, M., Wirajarmadi, B., 2012. Witjaksono, F., 2012. Nutrisi pada Osteoporosis. Jakarta : RSCM Departemen Gizi FKUI. Peranan Gizi dalam Siklus Kehupan. Jakarta : Kencana Prenada Media Grup. Cembrowicz, 2007. Osteoporosis. 2th ed. London : Class publising. Fatmah, 2010. Gizi usia lanjut. Jakarta : Erlangga. Kusumawati, D., 2014. Gambaran Tingkat Pengetahuan Lansia Tentang Osteoporosis di Panti Wedha Dharma Bakti Surakarta. Karya Tulis Ilmiah. STIKES PKU Muhammadiyah Surakarta. Marmi, 2013. Gizi dalam Kesehatan Reproduksi. Yogyakarta : Pustaka Belajar. Muchtadi, D., 2009. Gizi anti penuaan dini. Bandung : Alfabeta, CV. Notoatmodjo, S., 2011. Kesehatan Masyarakat. Jakarta : Rineka cipta. Notoatmodjo, S., 2012. Metodelogi penelitian kesehatan. Jakarta : Rineka cipta. Pranoto, A., 2009. Osteoporosis secara umum. Diabetes and Nutrition Center, Dr Soetomo Hospital- Airlangga University Division of Endocrinology Metabolism, Department of Internal Medicine, Medical Faculty, Airlangga University. Sefrina, A., 2015. Osteoporosis the silent disease. Yogyakarta : rapha oitpada Publising. Setiati, S., 2008. Pengaruh Pajanan Sinar Ultraviolet B Bersumber di Sinar Matahari terhadap konsentrasi Vitamin D (25(OH)D) dan Hormon Paratiroit pada perempuan usia lanjut. Jurnal Kesehatan Masyarakat Nasional, 2(4), pp.147 – 15. Tandra, H., 2009. Segala sesutu yang anda ketahui tentanng osteoporosis

THE UTILIZATION OF GOLDEN PERIOD OF ISCHEMIC STROKE IN PATIENTS IN PRODUCTIVE AGES Vidya Tri Huttami1, Atik Choirul Hidajah1 1Epidemiology Department, Faculty of Public Health, Airlangga University, Surabaya, Indonesia Correspondence Address: Vidya Tri Huttami Email: [email protected] ABSTRACT The 2007 Basic Health Survey shows the highest number of deaths in Indonesia rural and urban areas was caused by stroke. In 2007-2013, the stroke prevalence in productive age increased up to 22‰. Stroke that attacks productive age can impair individual’s ability to do activities, and thus they might have family financial constraint. Disabilities can be prevented and minimized if patients utilize a golden period of an ischemic stroke. This study identified the utilization of golden period of ischemic stroke in patients and analyzed causes of delayed patient admission to the Neurology Clinic of Sidoarjo Hospital. This study was a descriptive study conducted to 39 post- stroke ischemic patients in productive ages under further therapy at the Neurology Clinic of Sidoarjo Hospital in 2016. The data were collected through interview from January-February 2017. The results present 62% of stroke ischemic patients utilized the golden period of a ischemic stroke. The average respondents' admission took 29.87±47.46 hours after patients experienced first stroke ischemic attacks (ranging from 1-168 hours). The respondents were admitted to the hospital late or >4.5 hours after the stroke attacks because most of them did not know stroke signs and symptoms. Therefore, hospitals or health care providers have to provide counseling service to patients and family members about stroke signs and symptoms, as well as the importance of early admission for treatment as soon as patient gets the first stroke attack. Keywords: utilization of the golden period, ischemic stroke, productive age. ABSTRAK Kematian tertinggi di wilayah pedesaan dan perkotaan Indonesia berdasarkan hasil Riskesdas Tahun 2007 disebabkan oleh stroke. Pada Tahun 2007-2013 prevalensi stroke usia produktif mengalami pengingkatan sebesar 22,2‰. Stroke yang menyerang usia produktif dapat menyebabkan terganggunya ekonomi keluarga dikarenakan kecacatan setelah terjadinya serangan stroke. Kecacatan dapat dicegah dan diminimalkan jika pasien memanfaatkan golden period stroke iskemik. Penelitian ini bertujuan untuk mengidentifikasi pemanfaatan golden period oleh pasien stroke iskemik dan untuk menganalisis penyebab terjadinya keterlambatan pasien datang ke rumah sakit. Penelitian ini merupakan penelitian deskriptif pada 39 pasien pasca stroke iskemik di usia produktif yang mendapatkan pemeriksaan lanjutan di Poli Syaraf RSUD Sidoarjo. Pengambilan data dilakukan dengan cara melakukan wawancara pada pasien pasca stroke iskemik di usia produktif pada bulan Januari-Februari Tahun 2017. Hasil dalam penelitian ini menunjukkan bahwa 62% memanfaatkan golden period penanganan stroke. Rata-rata kedatangan responden di rumah sakit pada 29,87±47,46 jam setelah terjadinya serangan stroke iskemik (range 1-168 jam). Responden yang datang ke rumah sakit terlambat atau >4,5 jam setelah serangan stroke dikarenakan sebagian besar responden tidak mengetahui tanda dan gejala penyakit stroke. Diharapkan rumah sakit atau tempat pelayanan kesehatan memberikan penyuluhan mengenai tanda gejala stroke pada pasien dan anggota keluarganya, serta pentingnya datang ke rumah sakit lebih awal setelah terjadi serangan stroke. Kata kunci: pemanfaatan golden period, stroke iskemik, usia produktif INTRODUCTION from permanent disabilities which possibly burden families and community. Whereas Stroke occurs because of damage in in developing countries, stroke cause at blood circulation in the brain, causing brain least nearly 6 million deaths each year tissue dead (Batticaca, 2008). Stroke (WHO, 2002). becomes the third deadliest disease in the world compared to heart disease and cancer. In Indonesia, stroke is the first cause Every year, 15 million people worldwide of most deaths in urban and rural areas. The suffer from a stroke. Among them, 5 million proportion of deaths due to stroke was people died, and another 5 million suffered 19.4% in urban areas and 16.1% in rural areas (MOH RI, 2008). The prevalence of ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.258-265 Received 12 May 2017, received in revised form 28 June 2017, Accepted 30 July 2017, Published online: December 2020

Vidya Tri Huttami and Atik Choirul Hidajah, Utilization Of Golden Period... 259 stroke in Indonesia had increased from 8.3 hours after patients experience stroke per 1,000 people in 2007 to 12.1 per 1,000 (Hacke, W., et.al 2008). people in 2013. East Java province had the fourth highest stroke prevalence among Surveys in sever,al Asian countries other Indonesian provinces as many as 16 show that most patients in Indonesia were per 1,000 people (MOH RI, 2013) admitted late to the hospital. They mostly spend six hours to a week for hospital Based on the 2012 Health Profile of admission as they try alternative medicine East Java, stroke was among the ten most (Sutrisno, 2010). Whereas approximately common disease in patients under one-third of respondents were admitted to a outpatient and inpatient care at type-B hospital more than 24 hours after patients hospitals. For example, Sidoarjo District got stroke. The respondents were unaware General Hospital reported stroke became of mild stroke signs and symptoms. the top 10 causes of deaths in 2014-2015. In 2014, ischemic stroke was the fourth major By pointing out the stroke cause of deaths at the hospital with the prevalence in Indonesian community, this prevalence of 10.10%. Then in 2015, it study aimed to identify to which extent increased to 14.9% of deaths. patients use the golden period of ischemic stroke and to analyze causes of hospital Strokes can occur in any ages from admission among stroke patients. newborns to elderly. The disease incidence increases as people get older (Anies, 2006). METHODS In the past, stroke only affected elderly, but now this disease tends to increase in This study was descriptive and productive ages, even under the age of 45 collected data from January to February at years. The 2013 Basic Health Research the Neurology Clinic of Sidoarjo Hospital shows the prevalence of stroke in District in 2017. These study’s samples productive ages (15-64 years) was 62.6 per were 39 ischemic stroke respondents in 1,000 people. As stroke attacks young productive age (15-64 years) who could people in productive ages, they can have communicate well. lower productivity and family financial distress (Yulianto, 2011). These study’s variables involved patients’ characteristics (gender, age, Early patient admission to a hospital education, current occupation, family for patients who experience stroke signs and income, use of health insurance, and type of the quality of the initial treatment are health insurance), the number of stroke detrimental to the number of disabilities attacks, time span between stroke warning patients will have later. The golden period sign and the time of hospital admission, or golden hour is a certain period patients utilization of golden period of ischemic with stroke can use to decide an appropriate stroke, and factors affecting the utilization treatment. Medications carried out during of the golden period. the golden period can increase the likelihood of a stroke recovery (Adiati, T., The respondents wre then Wahjoepramono, 2010). The earlier interviewed to give further information. patietns are admitted to a hospital for Data obtained from the interview were treatment, the better the prognosisis, processed, analyzed descriptively, and thereby lowering the possibility of presented in a tabular or figure form. disabilities suffered later (Nadesul, 2011). Based on the European Cooperative Acute RESULTS Stroke Study (ECASS III), the golden period of administration of intravenous Respondents’ Characteristics thrombolysis therapy is less than 3-4.5 Respondents’ characteristics include gender, age, education, occupation, family income, use of health insurance, and

260 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:258-265 types of health insurance. The results show Based on age, the respondents in the that the respondents were mostly male age range 55-64 years were more dominant (53.8%). The number of male respondents (61.6%). There was no respondent aged 15- was not much different from that of female 24 years. Only one respondent was aged 32 respondents (46.2%). years, and one oldest respondent was 64 years old. Most respondents had elementary Table 1. Characteristics of Respondents at and junior high education (46.1%), while the Neurology Clinic of Sidoarjo only a few respondents had higher Hospital in 2016. education(18.0%). Characteristics n% This study further describes the respondents’ current employment status. Gender 21 53.8 Most respondents did not work after they Male 18 46.2 experienced stroke (43.6%). The majority Female of the respondents were in the high-income status (IDR 2,500,000-3,500,000) (51.3%). Age Most of them used health insurance issued by the government to get treatment from the 15-24 Years 00 hospital (79.5%). 25-34 Years 1 2.6 35-44 Years 4 10.2 45-54 Years 10 25.6 55-64 Years 24 61.6 Table 2. Number of Stroke Attacks. Education Number of n % Stroke Attacks Low (Elementary-Junior 18 46.1 1 time 36 92.3 2 times 2 5.1 High School) 14 35.9 3 times 1 2.6 Total 39 100 Intermediate (High 7 18.0 school) Higher (Bachelors) Occupation Housewife 12 30.8 Explained in Table 2, almost all respondents (92.3%) experienced stroke Unemployed 17 43.6 once. Civil servant/ soldier/ 1 2.6 police 3 7.7 Private worker 2 5.1 Time span between stroke attack and the time of hospital admission Entrepreneur 4 10.2 Retiree Family Income Table 3. Time span between stroke attack with time of hospital admission. Low (<1.5 million) 1 2.6 Medium (1.5-2.5 million) 11 28.2 Time of hospital n % High (2.5-3.5 million) 20 51.3 admission Very High (> 3.5 million) 7 17.9 <4.5 Hours Use of Health Insurance 1 Hour 10 25.6 2 Hours 8 20.5 No 8 20.5 3 Hours 6 15.4 Yes 31 79.5 Types of >4.5-48 Hours 6 15.4 Insurance 31 100 Government Health 0 0 3-4 Days 4 10.2 Private 5-6 Days 4 10.2 7-8 Days 1 2.6 Total 39 100

Vidya Tri Huttami and Atik Choirul Hidajah, Utilization Of Golden Period... 261 Table 3 presents most respondents Factors Percentage were admitted to the hospital in the first 1 (6.6%) hour of stroke attack (25.6%). The average Patients are not admission duration was 29.87 ± 47.46 hours 1 (6.6%) after the onset of stroke (range 1-168 hours). willing to be The longest hospital admission took about 7 15 (100%) days after the onset of a stroke. admitted to Utilization of Golden Period hospitals The utilization of stroke golden Patients get period can be observed from the time span between the time of stroke attack and and misdiagnosis at the admission of hospital admission. Respondents were considered using the first-level golden period if they were admitted to the hospital at ≤ 4.5 hours after experiencing healthcare facility the first stroke attack. Total In Table 4, this study presents 15 respondents did not use the stroke golden period for seeking the first treatment (60.0%) mostly because they could not identify the signs and symptoms. Not Utilized DISCUSSION Utilizin Golden Period Respondents’ Characteristics g… 62% As seen in Table 1, post-stroke Figure 1. Utilization of Stroke Golden patients participating in this study were Period mostly males (53.8%). Some studies show that men were more at risk of stroke Figure 1 shows that more than half compared to women (Wahyu, 2009). A man of the respondents utilized the golden has a 25% higher risk of having a stroke at period to get the first treatment as soon as a young age than a woman (Stroke possible (62%). Association, 2016). Factors causing the utilization of golden In line with this finding, the 2013 period Basic Health Research finds in Indonesia the prevalence of stroke in men was higher Patient admission outside the golden but not much different from women. Based period (4.5 hours only after ischemic stroke on the diagnosis of medical practitioners, attacks) did not use the time because of men have stroke prevalence of 7.1 per 1,000, some factors explained in Table 4. while women have that of 6.8 per 1,000. Similarly, Adawiyah, R., Kariasa, (2014) Table 4. Factors of Admission at >4.5 have found at Fatmawati Poli Neurology Hours. Hospital in Jakarta, the number of stroke male patients was more than that of females. Factors Percentage The higher incidence of stroke in men can 9 (60.0%) be caused by a higher unhealthy lifestyle, Patients cannot such as hypertension, smoking, and 4 (26.8%) drinking alcohol. identify stroke One of the risk factors for stroke is signs age (Sari, et al., 2016). In this study, the respondents mostly suffered from stroke in Nobody can the age range of 55-64 years (61.6%). In Indonesia, most stroke sufferers are in the accompany patients productive age group (Lumbantobing., 2007). Similarly, the 2013 Basic Health to hospitals

262 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:258-265 Research discovers an increase in the difficult to receive information and vice versa. prevalence of stroke along with increasing The results also show most age. The highest prevalence of stroke respondents with low education (61.1%) did not use the golden period of stroke to seek occurs at the age of 55-64 years. Age of 15- for treatment. It poses as the result of insufficient knowledge about stroke signs 24 years has stroke prevalence of 2.6 per and symptoms. 1,000, and age of25-34 years has prevalence In addition to education, the incidence of stroke also affects occupation. This study of 3.9 per 1,000. Additionally, age of 35-44 shows that most of the respondents did not work after experiencing stroke (43.6%). years had stroke prevalence of 6.4 per 1,000, Although all respondents were in productive age, the majority did not work. while people in the age group of 45-54 years Before the stroke attacked them, they still could work normally. Before the have stroke prevalence of 16.7 per 1,000. respondents got stroke, the majority of them had worked in private companies (10 Finally, those in the age group of 55-64 year respondents) and worked as entrepreneurs (4 respondents). However, they decided not tend to have stroke prevalence of 33.0 per to continue working as their health condition was not as fit as before. 1,000 people. Supporting this finding, Mahendra, B., The Basic health Research also shows and Rachmawati (2005) clarify disability is the most common effect of stroke limit each increase in age will cause a greater risk patients to move. In particular, strict regulations of some companies do not allow of having stroke. When people in the people with stroke to take leave from work or some people come home to seek for productive age suffer from stroke, it is someone who can take care of them. As a result, patients with stroke have more likely to result in economic distress on limitation in doing activities. families. Yulianto (2011) mentions people Most respondents with low education (61.1%) did not make use of the golden with stroke may have a decline in period of stroke for seeking a treatment due to lack of knowledge about the disease productivity and financial difficulties after symptoms. Immediate action in the golden period may reduce the impact or all. This is consistent with the results which complications of stroke. indicate almost half of the respondents Analyzed from health insurance status, people can utilize health insurance to (43.6%) did not work due to disabilities monitor their health status regularly just in case stroke attacks will recur. This study such as a paralysis. If the mortality and points out some respondents had recurrent strokes. Adawiyah, R andc Kariasa (2014) disability can be overcome, they might get also find the majority of post-stroke patients who continued treatment at the hospital back to work. To cope this problem, the experienced the first stroke (69.4%). government should have good, fast, and People should be alerted about recurring stroke since the attack might more appropriate stroke management (Lumbantobing., 2007). Education absolutely can bridge solutions for stroke management. This study find the respondents with stroke mostly had a low level of education (elementary-junior high school) (46.1%). Brillianti (2016) in her study also find that most post-stroke patients had elementary education. The lack of education can affect people’s lifestyle. Notoatmodjo (2007) further elaborates that people with more knowledge can shape better mindset and attitude, as well as behavior of healthy lifestyle. Lack of information about signs and symptoms will lead to susceptibility to various diseases, including stroke. Wardhani, N. R., and Martini, (2014)supports the finding by saying the learning process is influenced by education. People with low education will be more

Vidya Tri Huttami and Atik Choirul Hidajah, Utilization Of Golden Period... 263 fatal than the first attack. According to consequences that come up later. Lutfie, Pinzon, R and Laksmi, (2010), repeated (2012) said that fast and precise handling strokes in the first year were found in 11.2% during the golden period can prevent the of cases. Therefore, it is important to fatal effects of stroke. The longer people mitiage risk factors which can be a major ignore stroke, the greater the brain damage cause of recurring stroke, such as can occur. Quick treatment for stroke may controlling hypertension, cholesterol, and reduce 30% disabilities. smoking habits. Utilization of Golden Period of Stroke Time span between stroke attack and the time of hospital admission The utilization of the golden period of stroke can only be seen in people with Keeping us warned about stroke signs ischemic stroke. Based on Table 1, more will ease more rapid patient admission to than half of the respondents (62%) with hospitals to seek for the first treatment. ischemic stroke utilized the golden period to Table 3 shows most of the respondents were manage stroke signs and symptoms. The admitted in the first hour of stroke European Cooperative Acute Stroke Study attacks(25.6%), with an average duration of (ECASS III) mentions ischemic stroke 29.87 ± 47.46 hours. Not much different handling in the golden period takes less than from the research conducted by Saver, et al., 3-4.5 hours (Hacke, et al., 2008). (2010), there were 27.1% of patients admitted within 60 minutes after the onset Even though more than half of the of symptoms, but more than 70% admitted respondents were admitted within ≤4.5 outside the golden period. Such long patient hours, many patient admissions exceeds the admission can affect duration of drug golden period. As a result, they probably administration and treatment patient will did not receive this antithrombotic receive. treatment. Saver, et al., (2010) states brain damage result in nearly 2 million nerve cells Treatment of R-tPA (recombinant die. Decline in disabilities due to stroke may tissue plasminogen activator) for patients occur if patients are admitted to hospitals in with ischemic stroke is more effective if the golden period. Early treatment in the given in the first hour of stroke symptoms golden period can stabilize the condition of (Ebinger, et al., 2015). These anti- patients and prevent morbidity and thrombolytic drugs can destroy thrombus- mortality rates due to stroke. thrombus that clogs in the blood vessels of the brain (Mahendra, B & Rachmawati Factors causing delay in patient 2005). Not all patients admitted during the admission golden period can receive R-tPA treatment since they need to meet several criteria. It is likely to delay patient admission Research at 905 hospitals that are members when patients are not aware of stroke signs of the GWTG-Stroke (the Get With the and symptoms. This matter might be Guidelines) shows 28.3% respondents associated with insufficient knowledge of admitted in ≤60 minutes after the first stroke patients or their families. Therefore, attack, while 31.7% came in 61-180 families should be more aware of acting to minutes. The rest were admitted in > 180 get immediate help. In another minutes. It means only 64.7% patients circumstance, late patient admission admitted in ≤60 minutes received TPA occurred because of misdiagnosis. As a injection more than the others (Saver, et al., result, the respondents could not be 2010). immediately referred to get better treatment in more advanced health facility. Such Fast patient admission will the patient misdiagnosis indicates that the healthcare will have a greater chance of receiving facility did not apply quality control or antithrombotic drugs for reducing

264 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:258-265 improve quality of their services. Some stroke. Skripsi. Fakultas Ilmu healthcare providers are not capable of Keperawatan. Universitas Indonesia. giving treatment to patients because they Adiati, T., Wahjoepramono, E., 2010. 171 have limited facilities, equipment, or Tanya Jawab tentang stroke. personnel, thereby referring the patients to Jakarta: PT Gramedia. more advanced health facility. Anies., 2006. Waspada Ancaman Penyakit Tidak Menular, Solusi Pencegahan The respondents already used health dari Aspek Perilaku Dan insurance for accessing promotive, Lingkungan. Jakarta: PT. Elex preventive, curative, and rehabilitative Media Komputindo. treatments. Similar to the results of Association., S., 2016. State Of The Nation Misbach's, (2001) research, patients with Stroke Statistic. little knowledge of stroke signs and Batticaca, F., 2008. Asuhan Keperawatan symptoms had delayed admission to pada Klien dengan Gangguan hospitals. Some others still tried to find Sistem Persyarafan. Jakarta: traditional treatment for curing their disease, Salemba Medika. and some had transportation difficulties. Brillianti, P., 2016. Hubungan Self- Management dengan Kualitas CONCLUSION Hidup Pasien Pascastroke di Wilayah Puskesmas Pisangan More than half of the respondents Ciputat. Skripsi. Fakultas took advantage of the golden period to get Kedokteran dan Ilmu Kesehatan. first treatment at hospital. The majority of Universitas Islam Negeri Syarif respondents who were admitted late had Hidayatullah. poor knowledge of stroke signs and Indonesian Ministry of Health, 2008. Riset symptoms. Besides, they had nobody to Kesehatan Dasar 2007,. Jakarta. help them visit the hospital. Some still had Indonesian Ministry of Health, 2013. Riset difficulty in finding transportation, were not Kesehatan Dasar 2013,. Jakarta. willing to be treated at the hospital, and Ebinger, M., Kunz, A., Wendt, M., Rozanki, others got misdiagnosis that prolong M., Winter, B., Waldschmidt, C., et referral to more advanced healthcare al., 2015. Effects of golden hour facilities. thrombolysis: a Prehospital Acute Neurological Treatment and InIt is important that all family Optimization of Medical Care in members are aware of stroke signs and Stroke (PHANTOM-S) substudy. symptoms to act out just in case patients JAMA Neurology, 72(1), pp.25–30. experience stroke attacks. It is expected that hospitals, especially nerve polyclinics can https://doi.org/10.1001/jamaneurol.2 provide counseling about stroke signs and 014.3188 symptoms, as well as the utilization of the golden period in handling ischemic stroke Hacke, W., Kaste, M., Erich, B., Miroslav, and improve. First-level healthcare B., Antoni, D., Donata, G., et al., facilities should improve the quality of 2008. Thrombolysis with alteplase 3 examinations, working together with health to 4,5 hours after acute iskemik insurance agency, and provide training stroke. The New England Journal of about stroke for staff. Medicine, 59(13), pp.1313–1329. REFERENCE Lumbantobing., 2007. Stroke bencana peredaran darah di otak. Jakarta: Adawiyah, R., Kariasa, I.M., 2014. Faktor Badan Penerbit FK-UI. faktor yang berhubungan dengan kualitas hidup pada pasien pasca Lutfie, S.H., 2012. Kembali aktif pasca stroke, panduan terapi mandiri penderita stroke di rumah. Solo:

Vidya Tri Huttami and Atik Choirul Hidajah, Utilization Of Golden Period... 265 Metagraf. pengetahuan tentang stroke pada pekerja institusi pendidikan tinggi. Mahendra, B., Rachmawati, E., 2005. Atasi Jurnal Berkala Epidemiologi., 2(1), pp.13–23. Stroke dengan tanaman obat. WHO, 2002. The atlas of heart disease and stroke. Jakarta: Penebar Swadaya. Yulianto, A., 2011. Mengapa Stroke Menyerang Usia Muda?. Jakarta: Margaret, J.S., Loria, G., 2013. Early PT. Buku Kita. management of acute ischemic stroke cases (Acute Stroke Protocols & Guidelines/Algorithms) @ Apollo Hospitals, Hyderabad. Apollo Medicine IO. https://doi.org/10.1016/j.apme.2013. 11.002 Misbach, J., 2001. Pattern of hospitalized- stroke patients in ASEAN countries an ASNA stroke epidemiological study. Med J Indones, 10(1), pp.48– 56. https://doi.org/10.13181/mji.v10i1.6 Nadesul, H., n.d. Menyayangi Otak, menjaga kebugaran, mencegah penyakit, memilih makanan. Jakarta: Kompas. Notoatmodjo, S., 2007. Pendidikan dan Perilaku Kesehatan. Jakarta: PT Rineka Cipta. Pinzon, R., Laksmi, A., 2010. Awas Stroke!Pengertian, Gejala, Tindakan, Perawatan dan Pencegahan. Yogyakarta: Andi Offset. Sari, W., Lili, I., Catur, S., 2016. Care Your Self, Stroke cegah dan Obati Sendiri. Jakarta: Penebar Plus. Saver, JL., Eric, ES., Greg, C., Fonarow., Mathew, JR., Xin, Z., et al., 2010. The “golden hour” and acute brain ischemia presenting features and lytic therapy in >30.000 patients arriving within 60 minitus of stroke onset. AHA Journals., 41, pp.1431- 1439. https://doi.org/10.1161/STROKEAHA .110.583815 Sutrisno, A., 2010. Stroke?You Must Know Before You Get It!. Jakarta: PT Buana Printing. Wahyu, G.G., 2009. Stroke hanya menyerang orang tua?. Yogyakarta: PT. Bentang Pustaka. Wardhani, N. R., Martini, S., 2014. Faktor yang berhubungan dengan

THE RELATIONSHIP BETWEEN MOTHER’S OCCUPATION, ADEQUACY LEVELS OF ENERGY AND PROTEIN WITH INFANT’S NUTRITIONAL STATUS Dian Anita Nilawati1, Lailatul Muniroh1 1Department of Public Nutrition, Faculty of Public Health , Airlangga University, Surabaya, Indonesia Correspondence Address: Dian Anita Nilawati Email: [email protected] ABSTRACT Infant is one of vulnerable groups that have nutritional problems. High prevalence of nutritional problems could affect nutritional status that become an important concern. The determining factor of nutritional status includes nutritional intake and maternal occupation. The purpose of this study was to determine the relationship between maternal occupation and nutritional intake, with nutritional status of infants aged 6-12 months. This study used cross-sectional design, with nutrional status of infants as dependent variable; intake of the food energy sufficiency level and protein sufficiency level. Subject was selected by simple random sampling technique. The interview was conducted on 88 mothers of infants aged 6-12 months, which used questionnaire, form food recall 2x24 hours (breastfeeding and complementary feeeding), and anthropometric measurements (W/L index). Data analyzed used Spearman-Rank test and Coefficient Contingency. The results of this study showed that most of the infants had normal nutritional status (76,1%). Maternal occupation (p=0,025) had correlation with nutritional status. The food energy sufficiency level (p=0,047) had correlation with nutritional status and protein sufficiency level (p=0,016) had correlation with nutritional status. The conclusion of this study is infant who get the sufficiency level of energy and protein sufficiency level adequate has normal nutritional status. Wasting infant tend to have inadequate energy and protein intake. This study suggest mothers to give complementary feeding appropriately the quantity and according to the stage of giving food to infant. Keywords: maternal occupation, nutritional status of infant, the sufficiency level of energy, protein sufficiency level ABSTRAK Bayi merupakan salah satu kelompok yang rentan mengalami masalah gizi. Masih tingginya prevalensi masalah gizi yang dapat berdampak pada status gizi menjadi hal penting untuk diperhatikan. Faktor yang menjadi penyebab dari status gizi adalah pekerjaan ibu dan asupan gizi. Tujuan dari penelitian ini adalah untuk menganalisis hubungan antara pekerjaan ibu, tingkat kecukupan energi dan tingkat kecukupan protein dengan status gizi bayi umur 6-12 bulan. Penelitian dilaksanakan dengan rancangan cross sectional. Tehnik sampling menggunakan simple random sampling. Penelitian dengan wawancara dilakukan menggunakan kuesioner, form food recall 2x24 hours (ASI dan MP-ASI), dan pengukuran antropometri (BB/PB). Data diolah dengan uji analisis Spearman Rank dan Coefisien Contingensi. Hasil penelitian menunjukkan sebagian besar bayi mempunyai status gizi normal (76,1%). Hasil uji statistik didapatkan adanya hubungan pekerjaan ibu (p=0,025) dengan status gizi bayi, hubungan tingkat kecukupan energi (p=0,047) dengan status gizi bayi dan tingkat kecukupan protein (p=0,016) dengan status gizi bayi. Kesimpulan dari penelitian adalah bayi yang tingkat kecukupan energi dan tingkat kecukupan protein adekuat maka mempunyai status gizi normal. Tingkat kecukupan energi dan protein semakin inadekuat maka bayi cenderung akan berstatus gizi kurus. Penelitian ini merekomendasikan kepada ibu untuk memberikan MP-ASI secara tepat kuantitasnya dan sesuai tahapan dalam pemberian makanan ke bayi. Kata Kunci: pekerjaan ibu, status gizi bayi, tingkat kecukupan energi, tingkat kecukupan protein INTRODUCTION stunting, and wasting. Data obtained from UNICEF (2014) show that Indonesia has A problem in achieving the 37% of children suffering from stunting, Sustainable Development Goals (SDGs) is 12% suffering from wasting, and 12% malnutrition. Nutrition problems in being overweight. developing countries include underweight, ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.266-275 Received 31 May 2017, received in revised form 11 June 2017, Accepted 15 July 2017, Published online: December 2020

Dian Anita Nilawati and Lailatul Muniroh, Relationship Of Mother Work... 267 Failed nutrition may lead to infant prevent obesity. Belfield and Kelly (2010) mortality. Paying attention to children’s explain that breastfeeding can increase the growth is one way to overcome this probability of healthy condition and problem. The pattern of infant feeding prevent obesity in infants. Giving should be concerned as their brain growth supplementary food too early results in reaches around 75%. In the first 1,000 days insufficient quality nutrients because of a child's life, exclusive breastfeeding for infants cannot get breastfeeding optimally. 6 months and providing quality and timely can also reduce the death rate of under two Nutritious food is the main capital million by 6% (National Development of growth for infants (Walyono, 2010). Planning Agency., 2010). Supplementary food should be given when an infant is 6 months old. Providing In Indonesia, infants usually suffer balanced nutritious supplementary food from undernutrition and over nutrition. supports optimal growth and development. Excess or lack of nutrient intake in infants If breastfeeding is insufficient or can affect the nutritional status and health supplementary food given do not meet the status. Nutritional problems can be nutritional needs of the body, infant will permanent and unrecoverable even though suffer from malnutrition (Kurniasih, et al.c, children meet their nutritional needs in the 2010). Insufficient nutritional intake that future (Adriani, 2012). causes malnutrition ultimately increases infant morbidity and mortality rate (Dietz, Nutritional status contributes to the 2008). quality of Human Resources (HR), especially in terms of intelligence, Infants are the most vulnerable to productivity, and creativity. Poor infant’s nutritional problems compared to other age nutritional status can inhibit physical, groups. They need food with high calories, mental, and cognitive growth. Factors that protein, various vitamins and minerals. cause nutritional problems in infants can be divided into two, namely direct and indirect Infancy is a part of the first two factors. Direct factors are related to food years of life known as the golden age in intake and infections, while indirect factors which infants experience very rapid growth are concerned about work, knowledge, care and development. Nutrition determines patterns, social condition, economic human health and well-being (Sari, 2010). condition, health services, etc. (Adriani, 2012). The 2013 Basic Health Research shows that 5.7% Indonesian toddlers suffer One of the indirect factors affecting from malnutrition, and 13.9%. Indonesian infant’s nutritional status is mother's toddlers suffer from malnutrition. The occupation. Working mothers do not have prevalence of malnutrition and enough time to pay attention to their undernourisment in children increased from infants’ adequacy level of food intake. If 2007 to 2013, while the prevalence of they do, infants can effectively improve underweight in toddlers was 6.8%. The their nutritional status (Kusumawati, 2014). prevalence of obesity in toddlers reached 11.9%. East Java province is one of the Moreover, inadequate breastfeeding provinces which has high nutritional is one of the direct factors for nutritional problems as indicated by the prevalence of problems in infants. The World Health underweight and obesity issues in 2015 at Organization (WHO) and the United 15.6% and 2.2%, respectively (Surabaya Nations International Children's District Health Office, 2015). Emergency Fund (UNICEF) have recommended that children get breastfed Surabaya city also has high for at least 6 months and Insiani Early prevalence of malnutrition. The prevalence Breastfeeding. In addition to improving of underweight and obesity in Surabaya city infants’ health, breastfeeding can also was 16.9% and 3.1%, respectively. Data collected in the working area of the

268 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:266-275 Tanjungsari Primary Healthcare Center in compared to those that followed the WHO- 2015 show according to Body Weight/Age MGRS standard. Data were collected index, 4.9%. toddlers were underweight. through questionnaire-based interview and While in Surabaya, 22.8% toddlers were 2x24 hour food recall form instead. underweight (Surabaya District Health Nutritional intake was calculated from the Office, 2015). The high prevalence of volume, energy, and protein of breast milk. underweight and obesity and other If infants drink breast milk for 15 minutes, malnutrition can be influenced by various they would get the volume as follows: factors including adequacy levels of energy and protein. Overviewing the nutritional ASI = 500 ml = y ml problems in infants, this study aimed to X analyze the relationship between mother’s employment, adequacy level of energy, and Breast milk energy = adequacy level of protein with the 500 ml/100ml x 67 Kkal= Z nutritional status of infants aged 6-12 months in the working area of Tanjungsari X Primary Healthcare Center, Surabaya. Breast milk protein = 500 ml/100ml x 1.2 g= t gram METHODS X This study used a cross-sectional Information : research design, in which data were collected at the same time and place X = the highest frequencies during the (Notoatmodjo, 2010). This research design study was done by identifying mother's work and measuring adequacy levels of energy and Furthermore, the volume, energy, protein that infants receivedTanjungsari and protein in the first day and so forth were Primary Healthcare Center. This study was totaled and averaged. The average conducted in the working area of consumption of energy and protein of Tanjungsari Primary Healthcare Center in breast milk was summed with energy and Surabaya from October 2016 to February protein intake of supplementary food. 2017. Then, the data of summed energy and protein intake were compared to the energy The research population was and protein adequacy standard. Data were mothers who had infants aged 6-12 months analyzed and presented in the forms of and lived in the working area of the frequency distribution, cross-tabulation, Tanjungsari Primary Healthcare Center in and percentages. To determine the Surabaya. The research sample was relationship between mother’s occupation selected using a simple random sampling and infant’s nutritional status, this study technique from the population that met the performed a contingency coefficient test. criteria. There were 88 mothers willing to Meanwhile, the Spearmen Rank test was beinvolved. Their infants should have no performed to find the relationship between LBW history and no birth defects. The adequacy levels of energy and protein with sampling frame was obtained from the baby infants’ nutritional status. This study has cohort book Tanjungsari Primary passed the ethical clearance with No: 13- Healthcare Centerprovided by the primary KEPK. healthcare center. RESULTS Measurement of infant’s nutrition status based on Body weight/body length Respondents’ Characteristics used a digital scale and length board. The results of the measurements were then Respondents in this study were 88 mothers who had infants aged 6-12 months and who lived in the working area of

Dian Anita Nilawati and Lailatul Muniroh, Relationship Of Mother Work... 269 Tanjungsari Primary Healthcare Center. Table 1 shows that most of the repsondents had female babies aged 12 months old. The rest had babied at least aged9 months old. Table 1. Frequency Distribution of Employed Infants’ Characteristics in the Unemployed 36% Working Area of Tanjungsari 64% Primary Healthcare Center, Surabaya, 2016. Independent Category n % Job Variable 6 months 10 11.4 Figure 1. Frequency Distribution of Mothers’ Characteristics by 7 months 10 11.4 Occupation. 8 months 10 11.4 Age 9 months 5 5.7 Table 2. Frequency Distribution of Mothers’ Characteristics in the 10 months 18 20.5 Working Area of the Tanjungsari 11 months 12 13.6 Primary Healthcare Center, 12 months 23 26.1 Gender Male 39 44.3 Independent Category n% Variable Female 49 55.7 79 83.3 Age 20-35 Mothers’ age was categorized into Years 9 10.2 age groups of <20 years, 20-35 years, and >35 Years 11 >35 years. Table 2 shows that most of the 78 99 mothers were in the age group of 20-35 Birth Distance Close 50 56.8 years (89.8%). These results indicate that they had been in early adulthood. The Sufficient 38 43.2 majority were 30 years old. This study categorized birth spacing into 2 groups: Infant feeding Breast close (<24 months) and enough birth Milk spacing (≥24 months or single/first child). No Breast Most of the mothers had spaced one birth Milk to another (98.9%); in other words, their infants had sufficient age difference. In Surabaya, 2016. terms of breastfeeding, most of the mosthers still breastfed infants during 6-12 Adequacy level of energy months. Adequacy level of energy was Mother's occupation categorized into two types. The infants were considered to have adequate energy Figure 1 shows that 63.6% of the intake if the adequacy level of energy was mothers did not work. In accordance with at ≥77% RDA. While inadequate level of the results of the interview, they worked as energy reached <77% RDA. private employees.

270 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:266-275 Table 3. Frequency Distribution of Table 4. Frequency Distribution of Adequacy Level of Energy in Adequacy Level of Protein in Infants Aged 6-12 Months in the Infants Aged 6-12 Months in the Working Area of the Tanjungsari Working Area of the Tanjungsari Primary Healthcare Center, Primary Healthcare Center, Surabaya, 2016. Surabaya, 2016. Nutritional status n % Nutritional status n % Very thin 0 0.0 69.3 Thin 7 8.0 Adequate 61 30.7 Normal 67 76.1 Fat 6 6.8 Inadequate 27 Very fat 3 3.4 Infant’s Nutritional Status Table 3 illustrates that the infants had adequate level of energy (69.3%). Infants’ nutritional status measurements were categorized into 5 Adequacy Level of Protein groups: very thin, thin, normal, fat, and very fat. Adequacy level of protein also used the same categories. Infants were Table 5. Distribution of Frequency of considered adequate protein if the adequacy Nutritional Status in Infants level of protein reached ≥ 77% RDA. Aged 6-12 Months based on Contrastly, those with the adequacy level of Body Weight/Body Leght protein at <77% RDA would be considered to have inadequate protein. Based on Table Nutritional status n % 4, this study explains most infants had 77.3 adequate levels of protein (77.3%). Adequate 7 22.7 Inadequate 67 This study presents that most of the infants had normal nutritional status (76.1%), but 8% of them were underweight Table 6. The relationship between Adequacy Levels of Energy and Protein Adequacy Levels with Nutritional Status of Infants Aged 6-12-Months in the Working Area of the Tanjungsari Primary Healthcare Center in Surabaya in 2016. Categorie Nutritional status s Variables Very thin Thin Normal Fat Very Fat Employed n% n% Mother's unemploy 5 12.6 n% n% n % 3 9.4 Accupation ed 2 3.6 6.3 2 3.6 Adequate 18 56.3 4 12.5 2 1.8 Adequacy 2 3.3 4 6.6 Level of Inadequate 49 87.5 2 3.6 1 Energy 5 18.5 1 3.7 47 77.0 5 8.2 3 4.9 20 74.1 1 3.7 0 0.0 Adequacy Adequate 3 4.4 52 76.5 6 8.8 3 4.4 4 5.9 20.0 15 75.0 0 0.0 0 0.0 1 5.0 Level of Inadequate 4 Protein

Dian Anita Nilawati and Lailatul Muniroh, Relationship Of Mother Work... 271 Table 7. The Relationship between Independent Variables and Nutritional Status of Infants Aged 6-12 Months in the Working Area of Tanjungsari Primary Healthcare Center, Surabaya in 2016. Variables p Notes r Mother's occupation 0.025 There is a 0.335 Adequacy level of energy 0.016 relationship 0.257 There is a relationship Adequacy level of protein There is a 0.247 relationship 0.020 Table 6 shows that infants with to not have much time to prepare food for adequate energy levels had a normal babies at the same time, and maternalhealth nutritional status (77%). Furthermore, those condition was not fully fit. Too close births, with adequate protein levels had a normal as a result, affect mothers’ psychological nutritional status as well (76.5%). However, condition which can hinder breast milk some babies had underweight status production (Soetjiningsih., 2016). although they had adequate energy levels. The results indicate that almost all In Table 7, the analysis shows there infants with normal nutritional status had was a weak relationship between adequacy adequate birth spacing (more than 24 level of energy and infant nutritional status months). The birth spacing is sufficient to (p= 0.016; r= 0.257). help parents formulate the optimal care for their children, for instance providing Moreover, adequacy level of proten nutritious food (Adriani, 2012). had a weak relationship with infants’ nutritional status (p= 0.02; r= 0.247). Hasnain, and Sophie, 2010) and (Umeta, et al., 2003) further support this DISCUSSION finding by stating that babies born more than 24 months after previous birth did not Respondents’ Characteristics experience nutritional problems. Research conducted by Candra (2013) also finds that Age is an indicator for determining babies with birth spacing of more than two individual’s productivity. Older people years were not at risk of nutritional compared to younger people have less problems because their parents took care of productivity due to the less fit physical them optimally and monitored their condition and health. Age will affect nutrition intake. parental roles in providing nutrition to infants. It can be seen from this study where Breast milk is a very important for most of the mothers were in the age of 20- infants because it provides infant’s 35 years. According to Mubarak (2012), nutritional needs and contains immune there will be physical and psychological substances that can enhance health. changes in older ages. Psychological or Breastfeeding for infants is highly mental aspects in older ages become more recommended because it can support the mature. The mothers had enough early stages of infant growth. knowledge and experience about giving nutrition for their infants. The results show that most infants were breastfed. Similarly, research by Too close births can interfere child's Ratnaningsih, (2011) explains there was a physical and mental growth. Mothers tend relationship between the period of breastfeeding and nutritional status of

272 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:266-275 infants aged 6-12 months in Demak babies minimum food intake until they are at the age of 6 months. When babies are regency. Giri, (2013) also discovers a older, they need more nutrients from supplementary food (MP-ASI). Baby’s relationship between exclusive digestive system requires an adaptation process to solid food unless they will be breastfeeding with nutritional status of prone to diarrhea due to imperfect digestion. So that breast milk must still be infants aged 6-24 months. given as an immune substance (Nur and Marissa, 2014). if babies are ready to digest The relationship between mother’s solid foods but not given supplementary occupation and infant’s nutritional food yet, they will delay the process of status development and growth (Barasi, 2007). Mother's occupation determines to The more adequate breastfeeding, the which extent mothers pay attention to their better the infant’s nutritional status. infants’ growth. Working mothers usually Supplementary food only adds more had little time to spendwith their infants, nutrients as a baby gets older. Nutrious food and thus they put less attention on their is required to produce energy, protein, and infant growth (Ariningsih, and Rachman, all nutrients that fit the baby's needs. As 2008). infancy physical and mental growth occurs very quickly, intelligence and agility are The results of this study indicate more visible. Failing to meet the needs will that most of the mothers were unemployed. affect poor nutritional status (Adriani, In fact, mother’s occupation had a 2012). relationship with infant’s nutritional status. This is in line with research conducted by The results show that most of the Sulistyorini and Rahayu (2009), who find a infants with adequate energy intake had relationship between mother’s occupation normal nutritional status. In other words, and infant’s nutritional status. In other adequacy level of energy had a relationship words, unemployed mothers had infants withinfant’s nutritional status (p= 0.016). with better nutritional status. Farhanah and Futher, Meipita, (2009) discovers a Naleena, (2012), also further elaborates that relationship between adequacy level of the occupational status of mothers could energy produced from supplementary food play an important role in determining child with the nutritional status of infants aged 6- feeding practices which can affect infant’s 12 months. health and nutritional status. It means unemployed mothers could feed children Afriyani's research (2016) also finds better according to the age of the baby. a significant relationship between nutrient Little time spent with babies will affect intake and wasting cases at Talang Betutu parental role. Poor parental role, therefore, Primary Healthcare Center in Palembang will affect nutrition intake for infants as city. Wasting is a type of malnutrition in babies still depend on their caregivers. which infant’s weight does not go right with the height or the z score of more than -2SD. The relationship between adequacy Wasting in children can disrupt child levels of energy and protein with infant’s growth and even lead to death. A child who nutrition status gets enough nutrient intake is less likely to experience wasting or nutritional problems. Giving supplementary food too early Ernawati's research (2009) finds a can increase allergic reactions as babies’ relationship between adequacy level of digestive tract is not perfect yet to process energy and child’s nutritional status as well. solid foods which result in an increased risk of infection and obesity (Barasi, 2007). The low energy intake may be due to several factors including the frequency of Good nutrition intake is inseparable from parental role in managing child feeding pattern. Breastmilk only gives

Dian Anita Nilawati and Lailatul Muniroh, Relationship Of Mother Work... 273 feeding and amount of foods, appetite, and Most of them breastfed their babies and had infectious diseases (Astari, 2005). It is also sufficient birth spacing. important to pay attention to the process of food preparation and food hygiene Their infants mostly had adequate (Soetjiningsih., 2016). energy and protein levels. This also was dealing with their nutritional status which Research by Meilyasari and this study finds normal. Isnawati, (2014) in Purwokerto shows that low energy and protein intake in infants was Mother's occupation had a related to nutritional problems. Lack of relationship with infants’ nutritional status. nutrition intake, especially energy and In the same way, adequacy levels of energy protein in the long term, can cause baby’s and protein were related to infants’ weight loss, susceptibility to infection, and nutritional status. growth and development problems (Dewey and Mayers, 2011). Mothers should give supplementary foos appropriate for infants’ age to support This finding is relevant to Ningrum's optimal growth and normal nutritional study (2004), which find that good status. It is recommended that working complementary feeding that fulfills babies’ mothers pay more attention to provide nutrient needs could reduce the occurrence nutritional supplementary food for their of less protein energy in infants in the babies Muktiharjo Kidul sub-district, Pedurungan district, Semarang city. Another previous REFERENCE study conducted by Setiani (2012) shows a relationship between the risk of infectious Adriani, M., 2012. Peranan Gizi dalam diseases and the nutritional status of infants Siklus Kehidupan. Jakarta : aged 6-12 months. Infants who had an infectious disease were twice more likely to Kencana. have poor nutritional status as the immune Afriyani, R., 2016. Faktor – Faktor Yang system did not defend children from infectious diseases. Mempengaruhi Kejadian Wasting Feeding style for children should be Pada Balita Usia 1-5 Tahun Di concerned to meet the nutrition intake, such as protein. Infants aged 6-12 months need Puskesmas Talang Betutu Kota not only breast milk but also supplementary food to fulfill higher nutrition needs Palembang. Jurnal Kesehatan., 7(1, (Istiany, A., 2014). April), pp.66–72. Like energy, protein with the right proportion is necessary in early https://doi.org/10.26630/jk.v7i1.120 growth. Insufficent nutrition intake will cause infection and even growth disorders Ariningsih, E., and Rachman, H.P.S., 2008. (Fitriana, 2013). Therefore, supplementary foods in addition to breast milk could Strategi Peningkatan Ketahanan provide protein intake for infants older than 6 months (Darmayanti, 2014). Pangan Rumah Tangga Rawan CONCLUSION Pangan. Analisis Kebijakan Pertanian., 6(3), pp.239–255. In summary, most of the mothers in the working area of Tanjungsari Primary Astari, L.D.A., Dwiriani, C.M., 2005. Healthcare Center in Surabaya were aged between 20-35 years and unemployed. Hubungan Karakteristik Keluarga, Pola Pengasuhan dan Kejadian Stunting Anak Usia 6-12 Bulan. Media Gizi dan Keluarga., 29(2), pp.40-46. National Development Planning Agency., 2010. Periode Emas pada 1000 Hari Pertama Kehidupan. Barasi, M.E., 2007. Ilmu Gizi. Jakarta : Erlangga. Belfield, C.R., Kelly, I.R., 2010. The Benefits of Breastfeeding Accros The Early Years of Childhood.

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THE RELATIONSHIP BETWEEN GENDER, HISTORY OF ANKLE SPRAIN, AND ANKLE STABILITY WITH ANKLE SPRAIN STATUS Zhafira Faruhasa Epidemiology Department, Faculty of Public Health, Airlangga University. Surabaya, Indonesia Correspondence Address: Zhafira Faruhasa Email: [email protected] ABSTRACT Injuries can occur as a result of various activities, which of them is a sport. In 2017, basketball was a sport that produced the highest prevalence of injury incidence in the United States at 15.77%. Athletes who have ankle sprain are 20-40% more likely to experience chronic ankle instability. This study analyzed the relationship between gender, history of ankle sprain, and ankle stability with ankle sprain status in basketball athletes of Universitas Airlangga Surabaya. This study was analytical-observational research using a cross-sectional design. The research population was basketball athletes who were members of the basketball club of Universitas Airlangga, and finally there were 23 respondents selected as the research samples. The sample selection used the accidental sampling technique. The results of chi-square test (α = 0.05) indicate that there was a relationship between the previous history of ankle sprain (p = 0.002; RR = 9.1) and ankle stability with ankle sprain status (p = 0.013; RR = 6.), but gender had no relationship with ankle sprain status (p = 0.435; RR = 1.6). It concludes that the history of ankle sprain injury and ankle stability were related to ankle sprain status, but gender was not related to it. Keywords: gender, history of ankle sprain, ankle stability, ankle sprain ABSTRAK Cedera dapat terjadi akibat dari berbagai aktivitas manusia, salah satunya adalah olahraga. Pada tahun 2017, Bola basket merupakan olahraga yang menghasilkan kejadian cedera tertinggi di Amerika Serikat dengan prevalensi sebesar 15,77%. Atlet yang mengalami pergelangan kaki terkilir memiliki kemungkinan sebesar 20- 40% untuk mengalami ketidakstabilan pergelangan kaki kronis. Penelitian ini bertujuan untuk mengetahui hubungan antara jenis kelamin, riwayat pergelangan kaki terkilir dan stabilitas pergelangan kaki dengan kejadian pergelangan kaki terkilir pada atlet bola basket Universitas Airlangga Surabaya. Jenis penelitian ini merupakan penelitian observasional analitik dengan desain potong lintang. Populasi penelitian adalah atlet bola basket yang tergabung dalam Unit Kegiatan Mahasiswa (UKM) Bola Basket Universitas Airlangga Surabaya, dan terdapat 23 responden terpilih sebagai sampel. Pemilihan sampel menggunakan teknik sampling aksidental. Hasil uji chi-square (α = 0,05) menunjukkan bahwa terdapat hubungan antara riwayat pergelangan kaki terkilir sebelumnya (p = 0,002; RR = 9,1) dan stabilitas pergelangan kaki (p = 0,013 dan RR = 6,4) dengan kejadian pergelangan kaki terkilir, sedangkan jenis kelamin tidak berhubungan dengan kejadian pergelangan kaki terkilir(p = 0,435; RR = 1,6). Dapat disimpulkan terdapat hubungan antara riwayat pergelangan kaki terkilir sebelumnya dan stabilitas pergelangan kaki terkilir dengan kejadian pergelangan kaki terkilir, sedangkan tidak terdapat hubungan antara jenis kelamin dengan kejadian pergelangan kaki terkilir. Kata kunci: jenis kelamin, riwayat pergelangan kaki, stabilitas pergelangan kaki, pergelangan kaki terkilir. INTRODUCTION The national proportion of injuries in sports was 3.5%. East Java province has Injury is an incident caused by the same high proportion of sport injuries various activities, one of which is sports. as the national proportion (Indonesian Sport is an activity performed with Ministry of Health, 2013). Sports injuries conscious regular movements to increase can be caused by two factors: intrinsic body functions. Human do sports because factors and extrinsic factors. Intrinsic of achievement, recreation, health, and factors include the athlete's condition, such education (Giriwijoyo, 2017). as tissue structure, tissue weakness, body posture, activity level, lack of physical and ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.276-285 Received 29 April 2019, received in revised form 28 May 2019, Accepted 5 July 2019, Published online: December 2020

Zhafira Faruhasa, Relationship Types Of Gelamin... 277 mental readiness, while extrinsic factors potential to cause injury. Ankle sprain can include sport activities, such as sports occur to atheletes when they are equipment, falls or exposure, and training practicing, competing, or after competing methods (Indonesian Ministy of Youth and (O’Connor et al., 2004). Sports, 2015). Further, Gordon et al., (2014) Sprains, strains, knee injuries, researched WNBA athletes (Women's Achilles tendon injuries, pain along the National Basketball Association) and shin, fractures, and dislocations are the NCAA (National Collegiate Athletic most common types of injuries in sports Association) in the United States. They (National Institute of Arthritis and have shown that 117 of 172 athletes Musculoskeletal and Skin Disease, 2004). (69.11%) reported having ankle sprain. Based on Fong et al., (2007), ankle sprain Another study conducted by Ito et al., was the most common type of injury in the (2015) shows that the most common Netherlands (73%), the United States injuries in Japanese basketball athletes (68.3%), and Hong Kong (33%). It is were legs and ankle sprain (24.8% in men estimated that about 3,140,132 ankle and 23.8% in women). This study finds the sprain injuries in the United States have highest proportion of ankle sprain occurred occurred to 1,461,379,599 people/year to the atheletes (58% in men and 64.4% in with an incidence rate of 2.15 per 1,000 women). In 2017, basketball resulted in people/year (Waterman et al., 2010). The the highest number of injuries in the sprain was the fourth-highest type of United States with the prevalence of injury in Indonesia in 2007 with a 15.77% (Consumer Product Safety prevalence of 20.9% (Indonesian Ministry Commission, 2017). of Health, 2007). In 2013, the incidence of sprain increased to become the second- According to Sarwack and Chyntia largest type of injury in Indonesia with a (2014), athletes who experience ankle proportion of 27.5% (Indonesian Ministry sprain have a 20-40% chance of of Health, 2013). experiencing chronic ankle instability. Ankle sprain can also cause a continuum The highest incidence of ankle of lifelong consequences such as disability sprain was found in team sports and field and decreased quality of life (Wikstrom, et matches, for example basketball (Fong et al., 2013). These long-term consequences al., 2007). About half of all ankle sprain include changes in gait, disability to incidents occurred due to athletic and withstand loads, and maintain a stable basketball activities (41.1%) (Waterman et support base (Hoch et al., 2016). al., 2010). To begin the research, this study The high prevalence of ankle aimed to determine the relationship sprain in basketball can largely be between gender, history of ankle sprain, attributed to the nature of the sport which and ankle stability with ankle sprain status involves rapid changes in direction, player in basketball athletes at Universitas contact, repetitive jumps, and landing Airlangga, Surabaya. activities. Research conducted by Tummala et al., (2018) shows that METHODS basketball players changed movements every 2.0 to 2.82 seconds and jumped up This study was an analytical- from 35 to 46 times per game. Basketball observational study using a cross-sectional is considered a limited-contact sport. research design. The population in this Running with explosive movements and study was basketball athletes who were changes in direction and fast speed is part members of the basketball club at of the basketball features. Extreme Universitas Airlangga Surabaya. Of the pressure on the body during play has the population, the sample was 23 respondents

278 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:276-285 selected using the accidental sampling and non-injury (FAAM score of less than technique. This study was conducted in 75%). March 2019 at GOR CAMPUS C Universitas Airlangga, Surabaya. The Data were analyzed using bivariate research dependent variable was ankle and multivariate analyses. Bivariate sprain status, while the independent analysis could determine the distribution variables were gender, history of ankle of variables in the form of cross-tabulation sprain, and ankle stability. using a computer application, while multivariate analysis could identify the The history of ankle sprain were relationship between the dependent injuries that the respondents experienced variable and the independent variables in the last 6 months since the study was using the chi-square test with a α-value of conducted. In the questionnaire, it asked 0.05. This study has obtained an ethical whether the respondents had ever or never approval from the Ethics Commission of the ankle sprain. Ankle stability was Faculty of Public Health Airlangga measured using a balance test so-callled a University No: 63/EA/KEPK/2019. single-leg stance test, where the respondents stood one foot with knees bent RESULTS at an angle of 90o forward, arms straight to the sides, and eyes open for 30 seconds. The distribution of respondents’ This test was carried out to both legs characteristics by gender alternately. The test results were considered positive if the athletes were The results show that the majority unable to test one or both legs (Trojian and of respondents were female as many as 14 McKeag, 2006). Ankle stability was people (51.9%), while there were only 9 categorized into 2 categories: good (if the male respondents (39.1%) (Table 1). test results were negative) and bad (if the test results were positive). Table 1. The Distribution of Respondents’s Characteristics Data on ankle sprain were obtained from the scale results of the Foot and by Gender. Ankle Measure (FAAM). The FAAM was an instrument that describes functional Gender Freque Pecentage limitations for ankle and foot disorders. ncy (%) The FAAM consisted of 29 questions Male 9 39.1 divided into 2 measurements: 21 questions Female 14 51.9 for daily activity measurement and 8 Total 23 100 questions for sports measurement. Sports measurement was used to investigate The distribution of respondents’ athletes or populations with high physical characteristics by history of ankle activities (Martin, 2003). Therefore, this sprain study only used the sport measurement. The total scores of this measurement Table 2. The Distribution of Respondents’ ranged from 0 to 32. The sum of the scores Characteristics by History of from all answers was then added up and Ankle Sprain. divided by the largest possible value. It was then multiplied by 100 to get a History of Freque Percentage percentage. The higher score obtained Ankle Sprain ncy (%) indicated better functional quality. Ankle Ever 10 43.5 sprain status was categorized into two: Never 13 56.5 injury (FAAM score of more than 75%) Total 23 100 The results indicate that 10 respondents who had suffered from ankle

Zhafira Faruhasa, Relationship Types Of Gelamin... 279 sprain (43.5%), while 13 respondents had Table 5 shows that the majority of no history of ankle sprain (56.5%) (Table respondents were women, but the 2). prevalence of ankle sprain status was greater in men (44.4%) than women The distribution of respondents’ (28.6%) despite the same number of characteristics by ankle stability people with injuries in both men and women. The chi-square test finds no This study finds that 12 relationship between gender and ankle respondents had good ankle stability sprain status with a p-value of 0.435 and (52.2%), while and 11 respondents had an RR value of 1.6, meaning male athletes poor ankle stability (47.8%) (Table 3). had a 1.6 times greater risk for ankle sprain than women. Table 3. The Distribution of Respondents’ Characteristics by Ankle The relationship between history of Stability. ankle sprain and ankle sprain Ankle Freque Percentage This study points out the most Stability ncy (%) respondents with ankle sprain status had Good 11 47.8 ever a history of ankle sprain beforehand Bad 12 52.2 (70%). It finds a relationship between a Total 23 100 history of injury and ankle sprain status with a p-value of 0.002 and a RR value of Ankle sprain status 9.1, meaning those with a history of ankle sprain had a 9 times greater risk for ankle The results show that only 8 sprain than those who never had such respondents had ankle sprain (34.8%), history. while the others did not suffer from ankle sprain (65.2%) (Table 4) The relationship between ankle stability and ankle sprain status Table 4. The Distribution of Ankle Sprain Status among Basketball In this study, most ankle sprain Athletes. occurred in basketball athletes who had poor ankle stability (58.3%). The chi- Ankle Sprain Freque Percentage square test reveals ankle stability had a Status ncy (%) relationship with ankle sprain status with a 8 34.8 p-value of 0.013 and an RR value of 6.4, Injury 15 65.2 indicating athletes with poor ankle stability Non-Injury 23 100 were 6 times more likely to suffer from Total ankle sprain injuries than those with good ankle stability. The relationship between gender and ankle sprain status Table 5. Analysis of the Relationship between Gender, History of Ankle Sprain and Ankle Stability with Ankle Sprain Status. Ankle Sprain Status Total n% Variable Yes No p RR 9 39.1 0.435 1.6 Gender n% n % 14 60.9 Male Female 4 44.4 5 55.6 4 28.6 10 71.4 Injury History