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RISK FACTORS OF LUNG ADENOCARCINOMA IN PATIENTS AT DR. SOETOMO DISTRICT GENERAL HOSPITAL SURABAYA IN 2018 Luluk Lady Laily1 *, Santi Martini2, Kurnia Dwi Artanti3, Sri Widati4 1 Faculty of Public Health, Airlangga University,Surabaya, Indonesia 2,3 Department of Epidemiology, Faculty of Public Health, Airlangga University, Surabaya, Indonesia 4Departemen of Health Promotion and Behavioral Science, Faculty of Public Health, Airlangga University,Surabaya, Indonesia Correspondence Address: Luluk Lady Laily Email: [email protected] ABSTRACT Lung adenocarcinoma is one type of lung cancers that increases in number every year globally. Smoking is one of the risk factors for lung adenocarcinoma. This study aimed to determine the distribution of the risk factors of lung adenocarcinoma in patients. The risk factors observed in this study included age, gender, smoking history, number of cigarettes, types of cigarettes, and smoking duration. This study was descriptive and performed a cross sectional design. The study’s population was all lung cancer patients who were treated at Dr. Soetomo District General Hospital Surabaya. The samples were drawn using the accidental sampling technique from the population that met the inclusion criteria. The inclusion criteria for this respondents were patients who were diagnosed with lung adenocarcinoma and were willing to be interviewed. While the exclusion criteria involved patients with incomplete medical record data and patients who were not willing to be interviewed. The results indicate that the majority of lung adenocarcinoma patients at Dr. Soetomo District General Hospital Surabaya were male who were light smokers, diagnosed at more than 50 years old. Most of them used filter cigarettes and had smoked for more than 30 years. Keywords: Lung adenocarcinoma, risk factors ABSTRAK Adenokarsinoma paru merupakan salah satu jenis kanker paru yang jumlahnya meningkat setiap tahunnya di seluruh dunia. Penggunaan rokok merupakan salah satu faktor risiko dari adenokarsinoma paru. Penelitian ini bertujuan untuk mengetahui distribusi faktor risiko adenokarsinoma paru pada pasien. Faktor risiko yang diteliti, yaitu usia saat diagnosis, jenis kelamin, riwayat merokok, jumlah batang rokok, jenis rokok, dan lama merokok. Penelitian ini adalah penelitian deskriptif observasional dengan desain potong lintang (cross sectional). Populasi pada penelitian ini adalah seluruh pasien kanker paru yang berobat di RSUD Dr. Soetomo Surabaya tahun 2018. Sampel penelitian berasal dari populasi yang dipilih menggunakan teknik sampling aksidental sesuai dengan kriteria inklusi. Kriteria inklusi penelitian ini adalah pasien yang didiagnosis kanker paru jenis adenokarsinoma dan bersedia diwawancarai. Sedangkan kriteria eksklusi penelitian ini adalah pasien yang data rekam mediknya tidak lengkap dan pasien yang tidak bersedia diwawancarai. Hasil menunjukkan bahwa pasien adenokarsinoma paru yang berobat di RSUD Dr. Soetomo Surabaya sebagian besar adalah laki-laki, didiagnosis kanker paru saat berusia 50 tahun atau lebih, dan perokok ringan. Kebanyakan menggunakan jenis rokok filter dan telah merokok selama 30 tahun atau lebih. Kata kunci: Adenokarsinoma paru, faktor risiko INTRODUCTION occur to 30% of male population and has caused 34.2% deaths worldwide. In female Lung cancer is a type of cancer that population, the lung cancer cases reach causes deaths in the world (Putra et al., 13.6% and has caused 11.2% deaths 2015). The highest new lung cancer cases (GLOBOCAN, 2012). ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.295-303 Received 23 May 2019, received in revised form 17 June 2019, Accepted 16 July 2019, Published online: December 2020

296 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:295-303 The incidence of lung cancer in men According to Mäkinen (2017), since in Indonesia reached 25,332 cases and caused 21.8% deaths of 103,100 people the 1960s, the increased incidence of with cancer. The incidence of lung cancer was three times less in women, amounting pulmonary adenocarcinoma has been to 9,374 cases with a mortality rate of 9.1% of 92,200 people with cancer (WHO, linked to three factors related to smoking. 2014). The first factor is a change in cigarette Carcinogen is a chemical which makes the growth of lung cells out of production with the appearance of filter control, thereby causing lung cancer. Based on its histology, lung cancer has two types: cigarettes, containing lower tar and nicotine small cell lung cancer (SCLC) and non- small cell lung cancer (NSCLC). Non-small and thus leading to deeper smoke inhalation cell lung cancer (NSCLC) is the most common type, and it is classified into three and the spread of tobacco smoke to the main subtypes: squamous cell carcinoma, adenocarcinoma, and large cell carcinoma lungs. It occurs due to the increase in (Clarke, 2017). tobacco-specific N-nitrosamines Recent lung cancer trends show an increased incidence of pulmonary transforming central tumors (including adenocarcinoma in men and women, as previously observed in the United States squamous cell carcinoma (SCC) and small (Paris, et al. 2010). Data from the Southeast Asia Tobacco Control Alliance (2017) cell lung cancer (SCLC)) to peripheral show that the incidence of pulmonary adenocarcinoma in Southeast Asia tend to tumors or lung adenocarcinoma (Travis, et increase in recent years compared to other types of lung cancer. Research conducted al. 2015). The second factor is the risk of by Wang, et al. (2014) at the Guangzhou Medical College Hospital shows that the SCC and SCLC increasing rapidly with proportion of pulmonary adenocarcinomas in 61 lung cancer patients (55.7%) was more increasing smoking duration than that higher than other types of non-small cell lung cancer. of pulmonary adenocarcinoma which Severe lung tumor is most likely to appears later (Lortet-Tieulent, et al. 2014). spread to the central nervous system (CNS). As many as 50% of patients diagnosed with The third factor is reduced risk of SCC and NSCLC or SCLC will experience metastases in the brain. Interestingly, SCLC after stopping smoking than that of different lung cancer subtypes spread to the CNS at different rates. CNS metastases adenocarcinoma (Kenfield, et al. 2008). mostly occur in patients with pulmonary adenocarcinoma compared to patients with Evidence shows that non-smoking other non-small cell lung cancers (6.6 - 43%). CNS metastases cause not only the factors also influence changes in the clinical burden of morbidity and mortality, but also acute neurological deficits, prevalence of pulmonary adenocarcinoma cognitive impairment, and seizures (Wang, et al. c2014). (Lee, et al. 2016). An estimated 10-15% of lung cancer deaths are caused by factors in spite of active smoking (Samet, et al. 2009). Improvements in imaging and detection of peripheral pulmonary nodules, as well as changes in the classification of lung tumor histology and pathology may have influenced the time trend in the ratio of pulmonary adenocarcinoma to SCC (Lee, et al. 2016). The prevalence pulmonary adenocarcinoma is always higher than that of SCC in women regardless of smoking status (Samet, et al. 2009). The incidence of lung cancer can be controlled by establishing a diagnosis as early as possible. Histopathological examination of the type of lung cancer is also important to do to help the doctor determine the therapy to be given. Much analysis is needed on the risk factors that influence types of lung cancer, especially those related to smoking behavior, such as smoking history, smoking duration, types of cigarettes, and the number of cigarettes.

Luluk Lady Laily, Santi Martini, Kurnia Dwi Artanti and Sri Widati, Description of Lung... 297 This study aimed to determine the RESULTS distribution of risk factors of pulmonary adenocarcinoma in patients at Dr. Soetomo This study presents the distribution District General Hospital Surabaya in 2018. of risk factors of pulmonary It is expected to increase knowledge about adenocarcinoma in Table 1. It shows that risk factors for pulmonary adenocarcinoma the number of male patients (55.6%) was as a basis for determining prevention and more than that of female patients (44.4%). control measures for lung cancer. The table also explains that most patients (66.7%) who were diagnosed with cancer METHODS were 50 years old or older. This study was an observational- Additionally, smoking history descriptive study with a cross-sectional variable is categorized into active smokers, study design. Data were collected in passive smokers, and nonsmokers. Active November 2018 at Dr. Soetomo District smokers are respondents who have smoked General Hospital Surabaya. The study’s at least 100 cigarettes during their lives, population was all lung cancer patients andpassive smokers are non-smokers who treated at the hospital in 2018. The research are exposed to cigarette smoke in the sample was selected using the accidental environment. While nonsmokers are sampling technique from the population respondents who have smoked less than that fits the inclusion criteria. They were 100 cigarettes or never smoked during their patients who were diagnosed with life. The results indicate that the number of adenocarcinoma lung cancer and were patients who were active smokers were willing to be interviewed. While patients more dominant (52.8%) than that of with incomplete medical records and those passive smokers (19.4%) and non-smokers who were not willing to be interviewed (27.8 %). were excluded from the sample. Of the 19 active smokers, 14 of This study used primary data and them (73.7%) had smoked for 30 years or secondary data. Primary data were more, and 5 patients (36.3%) had smoked questionnaire-based interviews with for less than 30 years. These data indicate patients, while secondary data were that the majority of pulmonary obtained by looking at the patients’ medical adenocarcinoma active smokers had record data. smoking duration of 30 years or more. Independent variables observed In terms of types of cigarettes, included age at diagnosis, sex, smoking patients were considered to smoke non- history, number of cigarettes, types of filter cigarettes if they consumed weekly cigarettes, and smoking duration. more than 50% of cigarettes which do not Furthermore, the study’s dependent have cork or synthetic fiber foam . While variable was the incidence of pulmonary some were considered to take filter adenocarcinoma. cigarettes if they smoked weekly more than 50% of cigarettes with cork or synthetic This study has obtained an ethical fibers foam. Out of 9 active smokers, there approval by the Ethics Committee of Dr. were 7 patients (36.8%) who smoked non- Soetomo District General Hospital filter cigarettes and 12 patients (63.2%) Surabaya on October 14th, 2018, with No. who smoked filter cigarettes. In other 0727 / KEPK / X / 2018. words, pulmonary adenocarcinoma patients who were active smokers mostly smoke filter cigarettes.

298 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:295-303 Table 1. Distribution of Lung Adenocarcinoma Risk Factors at Dr. Soetomo General District Hospital in 2018. Variable Category Frequency Percentage (n) (%) Female 16 44.4 Gender Male 20 55.6 Age at Diagnosis Total 36 100.0 ≥50 years 24 66.7 <50 years 12 33.3 Total 36 100.0 Smoking History Active smokers 19 52.8 Passive smokers 7 19.4 Non-smokers 10 27.8 Smoking Duration Total 36 100.0 ≥30 years 14 73.7 <30 years 5 26.3 Total 19 100.0 Types of Cigarettes Non-Filter 7 36.8 Filter 12 63.2 Total 19 100.0 Number of Cigarettes Light 19 52.8 Moderate 8 22.2 Weight 9 25.0 Total 36 100.0 This study also grouped the patients the incidence of pulmonary into light smokers, moderate smokers, and adenocarcinoma was increasing in both heavy smokers. Light smokers are patients men and women anand had no relationship who have a Brinkman index value of 0-199 betwith gender (OR = 1.13 [95 % CI: 0.78 - points, and moderate smokers are those with 1.63]) (Paris, et al, 2010). It is in contrast to a Brinkman index value of 200-599 points. Hernowo's research (2012) which shows Further, heavy smokers are patients who that the prevalence of pulmonary have a Brinkman index value of more than adenocarcinoma in men was 25%, which 600 points. Brinkman index is calculated by was lower than in women at 42%. Women multiplying the average number of are more at risk of suffering from cigarettes smoked everyday and smoking pulmonary adenocarcinoma as they are duration every year. The results show there vulnerable to carcinogens of tobacco were 19 light smokers (52.8%), 8 moderate smoke. The increased incidence of smokers (22.2%), and 9 heavy smokers pulmonary adenocarcinoma in women may (25.0%). It means the majority of be closely related to specific risk factors of pulmonary adenocarcinoma patients were lung cancer among women, such as light smokers. hormonal factors or gene susceptibility (Paris, et al, 2010). DISCUSSION According to Cooper, et al. (2013), Based on gender, the majority of almost all Epidermal Growth Factor pulmonary adenocarcinoma patients were Receptor (EGFR) mutations occur to male. A recent analysis of trends in lung pulmonary adenocarcinoma patients. EGFR cancer incidence in Europe has shown that gene mutations are more commonly found in female patients, young patients, and non-

Luluk Lady Laily, Santi Martini, Kurnia Dwi Artanti and Sri Widati, Description of Lung... 299 smoker patients. Oktaviyanti (2015) pathogenesis of pulmonary discovers female patients with lung adenocarcinoma (Hu and Chen, 2015). adenocarcinoma experienced EGFR mutations more. Also, EGFR mutations Cigarette smoke contains several occurred to nonsmokers (51%) than active classes of carcinogens such as polycyclic smokers (10%). aromatic hydrocarbons, benzo (a) pyrenes, and tobacco-specific nitrosamines. Most of Supporting this study finding about these compounds exert their genotoxic age of lung cancer patients, Roszkowski effects by forming DNA and reactive (2001) also discover the incidence of oxygen species that can cause mutations in pulmonary adenocarcinoma was higher in the K-RAS and p53 genes. Tobacco- patients diagnosed with lung cancer at less specific nitrosamines can also activate than or equal to 50 years (12.6%) than nicotinic acetylcholine receptors (nAChR) patients diagnosed at more than 50 years of and b-adrenergic receptors (b-AR) to some age (7.6%). The same results were obtained extent. The activation of these receptors can by Guntulu, et al. (2007) who find that cause cell proliferation. Furthermore, it has 23.5% pulmonary adenocarcinoma been proven that nicotine is a major incidence occurred to patients under 50 addictive component of cigarette smoke years old, while 17.8% were observed in that can trigger the development of cell patients aged 50 years or more. Some cycles, angiogenesis, and metastases of studies argue that differences in age where lung and pancreatic cancer (Schaal and patients are diagnosed with lung cance have Chellappan, 2014). something to do with smoking characteristics. There are unique patterns of gene expression, especially in lung cancer Furthermore, most of the patients patients with a history of smoking. These with pulmonary adenocarcinoma are active patterns include CDK1, CCNB1, STAT1, smokers. Wakelee, et al. (2007) further AURKA, and CDC20. All the elaborate the highest proportion of Differentially Expressed Genes (DEG) pulmonary adenocarcinoma incidence encode important regulators that determine occurs to non-smokers, while the medium the control and development of the cell proportion is discoverable in former cycle, which shows that smoking triggers smokers. Whereas the lowest proportion is cell hyperproliferation which contributes to observed among heavy smokers. Lung the pathogenesis of pulmonary adenocarcinoma is known a cancer type adenocarcinoma. Many previous studies discovered in non-smokers, but the have stated a strong relationship between proportion does not give overview about the smoking and cell proliferation in various risks of pulmonary adenocarcinoma types of malignancies, including lung between smokers and nonsmokers. cancer. Mitogenic effects are largely mediated by nicotine and its derivatives Biological pathways that include through a variety of different molecular extracellular matrix-receptor interaction, as mechanisms. For example, smoking well as migration and cell proliferation, induces radical oxygen production which affect the incidence of lung cancer, causes the formation of truncated regardless of smoking status. However, amphiregulin transmembrane, which is then smoking induces unique gene expression detected by EGFR and results in the patterns as seen in the increase in cell cycle proliferation of aberrant pulmonary regulators (CDK1, CCNB1, and CDC20). epithelial cells. Besides, by involving Biological pathway and p53 signaling nicotinic acetylcholine receptors (nAChR), pathway significantly influence biological nicotine provides pleiotropic cellular tissue as well. This finding provides a better functions for growth factor secretion (such understanding of how smoking causes the as VEGF and platelet-derived growth molecular changes that contribute to the

300 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:295-303 factor) and initiation of mitogen-activated the upward trend in pulmonary protein kinase signaling. Specifically, in adenocarcinoma is mainly due to the spread non-small cell lung cancer, nAChR of filter cigarettes. People inhaled filter activation induces the recruitment of β- cigarettes more deeply than non-filter arrestin to the receptor, which in turn cigarettes. The inhalation transports activates Src and increases the binding of tobacco-specific carcinogens further E2F1 and Raf-1 transcription activators to towards the bronchioalveolar junction, a the proliferative promoter. Consequently, place where pulmonary adenocarcinoma exposure to nicotine of cigarettes prompts often appears (Ombao, et al. 2010). abnormal mitogenesis through various mechanisms that contribute synergistically Concerning types of smokers, the to the initiation and development of majority of pulmonary adenocarcinoma pulmonary adenocarcinoma (Hu and Chen, patients observed in this study were light 2015). smokers who had consumed 0-199 cigarettes during their lifetime. To further With smoking duration of more than explain this finding, Seki, et al. (2013) or equal to 30 years among patients in this explain that the risk of pulmonary study, it indicates that smoking causes adenocarcinoma would increase 2.82 times addiction. Ji, et al. (2015) assert smoking in men who smoked 21 cigarettes per day or duration is associated with the dose- more (95% CI: 2.00 - 3.98). In men who response to nicotine that affects body parts smoked 11-20 stems per day, the risk would prone to lung cancer risk, including increase by 2.06 times (95% CI: 1.51 - chromosome 15q25 which contains several 2.81). genes that play a role in cell growth, signaling, and metabolism. Chromosome CONCLUSION 15q25 contains the nicotinic acetic acid receptor (CHRNA5-CHRNA3-CHRNB4) This study concludes that lung involved in the process of nicotine adenocarcinoma patients at Dr. Soetomo addiction. It mediates the synthesis and Surabaya were predominantly male, release of growth factorss and signals the diagnosed with cancer at the age of 50 years growth of tumors and metastasis. or older. Most of them were light smokers Additionally, chromosome 15q25 is also who smoked 0-199 cigarettes during their associated with peripheral arterial disease lifetime for 30 years or more, and the and chronic obstructive pulmonary disease majority smoked filter cigarettes. (COPD) (Koifman, et al., 2009). This study recommends smoker to In this study, most of the patients educate the community about the dangers of with pulmonary adenocarcinoma smoked smoking, especially emits effects on non- filter cigarettes. In similar way, Marugame, smokers.Also, the provision of smoking at al. (2004) have found that the risk of cessation service integrated with disease pulmonary adenocarcinoma was higher in control in health facilities is important for filter smokers compared to non-filter stopping people to smoke. It is expected to smokers, regardless of gender. Supporting reduce the risk factors of lung cancer as this finding, Ombao, et al. (2010) further most lung cancer patients are smokers. describe filter cigarettes were more likely to contribute to the increased incidence of REFERENCE pulmonary adenocarcinoma. Cooper, W. A., Lam, D. C., Toole, S. A., Filter cigarettes produce deep and Minna, J. D., 2013. Molecular intense tobacco smoke inhalation and Biology of the Lung Cancer, transmit larger carcinogens such as nitrogen Radiology and Oncology, 39(3), p. oxides and nitro salty compounds to the 197. lung edges. It has been hypothesized that

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DESCRIPTION OF DEPRESSION SYMPTOMS IN HEMODIALYSIS PATIENTS AT JEMURSARI HOSPITAL, SURABAYA Yuyun Tri Wulansari1, Chatarina U. W.1 1Epidemiology Department, Faculty of Public Health, Airlangga University, Surabaya, Indonesia Correspondence Address: Yuyun Tri Wulansari Email: [email protected] ABSTRACT Chronic kidney disease is decreasing glomerular filtration rate of less than 15mL/minute which causes someone to undergo a hemodialysis therapy that replaces kidney function. The course of chronic kidney disease is progressive and irreversible and may cause psychological problems in hemodialysis patients such as depression. This study aimed to describe to what extent patients under hemodialysis treatment at Jemursari Hospital, Surabaya experience depression symptoms in patients. This study was descriptive research with a cross-sectional approach. The simple random sampling technique was performed to select 72 patients who had scheduled hemodialysis treatment and been qualified for the inclusion criteria. Data were then analyed using a univariate analysis in variable frequency distribution. The results show that patients with depression symptoms were mostly men as many as 31 people (43.1%), and the majority were aged 46-65 years as many as 24 people (49%). The latest formal education in most respondents was high school (23.6%). There were 38 respondents (77.5%) who got married, and most respondents were unemployed (77.5%) and had undergone hemodialysis for more than 12 months (77.5%). This study concludes that the patients under hemodialysis treatment at the hospital experienced mild depression symptoms. Keyword: hemodialysis, depression, Beck Depression Inventory. ABSTRAK Penyakit ginjal kronik merupakan kondisi penurunan laju filtrasi glomerulus kurang dari 15mL/menit yang menyebabkan ginjal membutuhkan terapi hemodialisis sebagai pengganti fungsi ginjal. Perjalanan penyakit ginjal kronis bersifat progresif dan ireversibel yang berisiko menimbulkan masalah psikologis pada pasien hemodialisis seperti depresi. Penelitian ini bertujuan untuk mengetahui gambaran tingkat gejala depresi pada pasien hemodialisis di RSI Jemursari Surabaya. Desain yang digunakan dalam penelitian ini adalah penelitian deskriptif dengan pendekatan potong lintang. Penelitian ini menggunakan teknik sampling acak sederhana untuk memilih 72 pasien yang menjalani perawatan hemodialisis reguler (terjadwal) dan yang memenuhi kriteria inklusi. Teknik analisis data yang digunakan adalah analisis univariat dengan melihat distribusi frekuensi variabel. Hasil menunjukkan sebagian besar pasien yang mengalami gejala depresi adalah laki-laki sebanyak 31 orang (43,1%), dan mayoritas berusia 46- 65 tahun sebanyak 24 orang (49%). Jenjang pendidikan formal terakhir yang ditempuh adalah SMA (23,6%). Mayoritas responden berstatus menikah (77,5%), dan tidak bekerja (77,5%) dan telah menjalani hemodialisis lebih dari 12 bulan (77,5%). Kesimpulan dari penelitian ini adalah sebagian besar pasien di rumah sakit tersebut mengalami gejala depresi ringan. Kata kunci: hemodialisis, gejala depresi, Beck Depression Inventory. INTRODUCTION / 1.73 m2 (Category GFR G3a - G5) (KDIGO, 2012). Chronic Kidney Disease (CKD) is kidney damage that occurs for more than Based on the 2013 Basic Health three months or a decrease in Glomerular Research, the prevalence of chronic kidney Filtration Rate (GFR) of less than 60mL / min disease in Indonesia was diagnosed by doctors at 2%. The highest prevalence of ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.304-314 Received 18 June 2019, received in revised form 21 June 2019, Accepted 26 July 2019, Published online: December 2020

Yuyun Tri Wulansari and Chatarina U. W, Description of Depression Symptoms... 305 chronic kidney disease occurred in Central esteem, pessimism about the future, Sulawesi at 0.5%, while the prevalence in decreased libido, sleep disturbance, and East Java was at 0.3% (Ministry of Basic limited appetite (Gerogianni and Babatsikou, Health Research, 2013). In 2015, the national 2014). health insurance burden of Rp 16.9 trillion was allocated to fund treatment cost of According to WHO, depression is a catastrophic diseases such as heart disease, mental disorder characterized by sadness, kidney failure, and stroke (Social Health loss of interest or pleasure, feelings of guilt or Insurance Administration Agency (BPJS), low self-esteem, sleep or appetite disorders, 2016). feelings of fatigue, and poor concentration. Depression can be long-lasting, repetitive, According to the Indonesian Renal and can disrupt individuals in their normal Registry (IRR), the number of hemodialysis daily activities. Severe depression can cause patients, both new and active patients, individuals to commit suicide (WHO, 2017). continues to increase every year. In 2016, there were 52,835 active patients and 25,446 There was a relationship between new patients. In 2017, the number of active depression and high mortality in patients and new patients increased up to hemodialysis patients in the long run. In 77,892 and 30,831, respectively. In 2018, general population, the prevalence of major East Java was ranked the second province depression was 1.1%-15% in males and 1.8% with the largest number of new patients after -23% in females. However, in hemodialysis West Java province with 4828 new patients patients, the prevalence was much higher at (Indonesian Renal Registry, 2018). around 20% -30% and can even reach a prevalence of 47% (Chen et al., 2010). Hemodialysis therapy is needed for a person who experiences a decrease in A study shows that patients with End- glomerular filtration rate of less than 15 Stage Renal Disease (ESRD) had a 4 times mL/min, or it can be said that someone has higher risk of depression than general kidney failure (National Kidney Foundation, population (Hedayati et al., 2008a). In the 2013). The Regulation of Indonesian United States, the incidence of suicide in Ministry of Health No. 812 of 2010 describes hemodialysis patients was 500 times more hemodialysis as a substitute therapy for than in general population. However, refusal kidney function which aims to excrete uremic to do hemodialysis can be considered as a toxins and regulate body fluid and electrolyte subtle attempt to suicide (Chen et al., 2010). balance. One study has reported that Hemodialysis patients are in an depression contributed tothe highest annual uncomfortable condition because their mortality of hemodialysis patients in survival depends on hemodialysis therapy Pakistan, compared with patients in Western during their lifetime. The progressive and countries (Hedayati et al., 2008b). During the irreversible course of the risk causes period of the hemodialysis therapy, one in psychological problems in hemodialysis 500 patients attempted suicide or violated patients. dietary rules (Gerogianni and Babatsikou, 2014). Depression is the most common psychological complication that has a serious In the first 1-3 weeks, patients with impact on the quality of life of hemodialysis acute renal impairment will be relatively patients and their social, economic, and easier to accept the process of hemodialysis. psychological well-being (Anees et al., Opposing this feeling, patients with chronic 2011). Depression manifests primarily with kidney failure experience strong fear and sadness, anxiety, depressed mood, poor self- anxiety for disability or death, as well as fears of social and financial problems as they have

306 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:304-314 to accept the fact that they have to undergo extent hemodialysis patients at Jemursari hemodialysis for life. During this period, Hospital in Surabaya experienced depressive patients experience sleep disorders, symptoms . depressive symptoms, and strong concerns about the loss of self-autonomy, work, family METHODS roles, and sexual function (Gerogianni and Babatsikou, 2014). This study was a descriptive study Although the incidence of depression in with a cross-sectional approach. It was hemodialysis patients is quite high, the diagnosis is often overlooked. Existing health conducted in May 2019 in the Hemodialysis services only focus on the physical aspects of the disease, and thus they need also to Room of the Jemursari Islamic Hospital in emphasize on considering psychological aspects, including depression due to chronic Surabaya. medical diseases linked to suicidal tendencies and affects survival rates (Saeed et al., 2012. The research population was all Jemursari Islamic Hospital is one of the regular (scheduled) hemodialysis patients at hospitals providin a hemodialysis center facility in Surabaya. Based on the Main the hospital in May 2019. The study sample Branch Office Social Security Administering Bodies Surabaya, Jemursari Islamic Hospital was 72 regular (scheduled) hemodialysis has become the second hospital with the highest number of hemodialysis procedure patients who met the inclusion criteria.The services after Dr. Soetomo since 2016. In 2016, the hospital served 13,002 patients should have regular hemodialysis hemodialysis actions. Further, it provided 14,410 hemodialysis actions in 2017 and treatment, be able to communicate, have 15,750 actions in 2018. The number of hemodialysis patients continues to increase, consciousness, and agree to participate by and so does the psychological burden . signing informed consent forms. While this Although the hemodialysis procedure is used to maintain patient survival, patient’s study applies exclusion criteria to life expectancy remains a problem. Based on the research conducted by Yulianto and hemodialysis patients with stroke, patients or Basuki (2018), the survival of patients with CKD who underwent hemodialysis was on their families who refused to participate, average 67.84 months. The survival of CKD patients who underwent hemodialysis was those in unfit condition andimpossibly unable lower in female patients, in the age group of 46-65 years, in those with the frequency of for interview until the data collection was hemodialysis of more than 3 times and a history of disease and complications. complete. Life which depends on a dialysis The respondents were selected using machine and is in uncertainty can be a powerful stressor for psychological problems probability sampling, in which the such as symptoms of depression. Therefore, this study highlighted to identify to what researchers took the same opportunity for members of the population to be selected as samples. Specifically, simple random sampling was done through a random draw on the roster of regular hemodialysis patients. This study only used one variable, depressive symptoms. Data collection was done through interview when the patients were queuing for hemodialysis therapy or while patients were in the hemodialysis process by taking into account the patient's state of consciousness and fitness. Measurement of depressive symptoms was done using the Beck Depression Inventory instrument developed by Aaron T. Beck in 1961. Depression symptoms were observed from respondents' self-assessement (self-report inventory).

Yuyun Tri Wulansari and Chatarina U. W, Description of Depression Symptoms... 307 To analyze the data, this study punishment, and 19 patients (25.4%) felt self- performed a univariate analysis by looking at loathing. As many as 17 patients (23.6%) the frequency distribution of depression criticized themselves more, but none of the symptoms. The results of the study were respondents thought about suicide. Some presented in the form of frequency and patients (36.1%) cried more, 26 patients narrative tables and compared with other (36.1%) experienced agitation, 18 patients similar studies. This study has obtained (25%) lost interest, and 23 patients (31.9%) ethical clearance from the Ethics had difficulty in making decisions. Further, Commission of Commission on Research 22 patients (30.6%) felt worthless, 40 patients Ethics Jemursari Islamic Hospital Surabaya (55.6%) lost energy, 50 patients (69.4%) (No: 005 / KEPK-RSI JS / V / 2019). experienced sleep disorders, and 47 patients (65.3%) got angry easily. Additionally, there RESULTS were 25 patients (34.7%) experiencing changes in diet, 27 patients (37.5%) had Overview of Depression Symptoms in difficulty in concentrating, 48 patients Hemodialysis Patients (66.7%) felt fatigued, and 56 patients (77.8%) lost interest towards sex. Table 1. Description of Depression Symptoms in Hemodialysis Overview of Depression Symptoms in Patients. Hemodialysis Patients by Gender Depression Regarding gender distribution, out of 49 patients who had depression symptoms, 31 Symptom Frequency (n) % patients (63.3%) were male, and 18 patients (36.7%) were female. There were 17 male Levels 31.9 respondents who experienced mild 41.7 depression symptoms (24.5%), and 2 male Normal 23 22.2 respondents had severe depression symptoms 4.2 (4.1%). While female respondents mosly Mild 30 100 experienced mild depression symptoms (56.5%). Moderate 16 Heavy 3 Total 72 Based on the results, of 72 Table 2. Description of Depression respondents, 49 respondents (68.1%) Symptoms in Hemodialysis experienced depression symptoms. The Patients by Gender. majority of respondents had experienced mild depressive symptoms (41.7%). A total of 16 Depression respondents (22.2%) experienced moderate depression symptoms, and 3 respondents Gender SymptomLevels Total (4.2%) experienced severe depression symptoms. Norm Mild Moder Heav al ate y This study also indicates that of 72 respondents, 20 respondents (27.8%) claimed Male 18 17 12 2 49 to feel sad, 22 respondents (30.6%) felt 36.7% 34.7% 24.5% 4.1% 100% pessimistic, 23 patients (31.9%) thought their disease was a failure, and 34 patients (47.2%) Female 5 13 4 1 23 lost their pleasure. Moreover, nearly half of 21.7% 56.5% 17.4% 4.4% 100% the respondents (48.6%) felt guilty, 40 patients (55.6%) considered the disease as a Total 23 30 16 3 72 31.9% 41.7% 22.2% 4.2% 100%

308 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:304-314 Overview of Depression Symptoms in Table 4. Description of Depression Hemodialysis Patients by Age Symptoms in Hemodialysis Patients by Education Based on age, of 49 respondents who experienced depression symptoms, 24 of Depression Symptom them (49%) were in the age group of 46-65 years. In the same age group, 12 patients Education Norm Levels Total (36.4%) had mild depression symptoms. al Whereas 10 patients (30.3%) experienced Mild Moder moderate depression symptoms, and 2 ate patients (6%) experienced severe depression symptoms. Not 0 1 1 1 3 Table 3. Description of Depression completed 0% 33.3% 33.3% 33.4 100% Symptoms in Hemodialysis Patients by Age. elementary % school Elementary 1 3 2 1 7 school 14.3% 42.8% 28.6% 14.3 100% % Junior high 4 65 1 16 school 25% 37.5% 31.25 6.25 100% % Depression Symptom % Age Levels Total High 9 12 5 0 26 Norm Moder Heav school 34.6% 46.2% 19.2% 0% 100% al ate y Mild Bachelors 9 8 3 0 20 45% 40% 15% 0% 100% 8 15 4 1 28 < 45 28.6% 53.6% 14.3% 3.5% 100% Total 23 30 16 3 72 31.9% 41.7% 22.2% 4.2% 100% 9 12 10 2 33 46 – 65 27.3% 36.4 30.3% 6% 100% Overview of Depression Symptoms in Hemodialysis Patients by Marital Status 6 3 2 0 11 >65 54.5% 27.3% 18.2% 0% 100% Table 5. Description of Depression Symptoms in Hemodialysis 23 30 16 3 72 Patients by Marital Status. Total 31.9% 41.7% 22.2% 4.2% 100% Depression Symptoms Overview of Depression Symptoms in Marital Levels Total Hemodialysis Patients by Education status Norm Mild Moder Heav The results of cross-tabulation Not al ate y presents the respondents’ education levels. Married / Table 4 shows that of 49 respondents who Divorced 4 6 4 1 15 experienced depression symptoms, 17 Married patients (34.7%) had completed high 26.7% 40% 26.7% 6.6% 100% schoolTwelve respondents (46.2%) who Total completed high school experienced mild 19 24 12 2 57 depression symptoms, and 5 respondents 33.3% 42.2% 21% 3.5% 100% (19.2%) experienced moderate depression symptoms. 23 30 16 3 72 31.9% 41.7% 22.2% 4.2% 100% Thirty-eight patients out of 49 respondents (77.5%) were married. Nearly half of the married patients experienced mild depression symptoms (42.2%), 12 of them

Yuyun Tri Wulansari and Chatarina U. W, Description of Depression Symptoms... 309 (21%) experienced moderate depression depression symptoms, and 1 person (2.1% ) symptoms, and 2 patients (3.5%) experienced had severe depression symptoms. severe depression symptoms. Table 7. Description of Depression Symptoms in Hemodialysis Overview of Depression Symptoms in Patients by Hemodialysis Hemodialysis Patients by Employement Treatment Duration. Status Hemodialysi Depression Symptom The results of cross-tabulation between employement status and depression s Treatment Levels Total symptoms present the majority of Duration Norm respondents who had depression symptoms al Light Moder Weig did not work. Based on the employment ate ht status, 38 patients with depression symptoms (77.5%) did not work. Of these patients, 25 < 12 months 7 9 5 2 23 patients (51%) had mild depression 30.5% 39.1% 21.7% 8.7% 100% symptoms, 12 patients (24.5%) had moderate depressive symptoms, and only one patient ≥ 12 months 16 21 11 1 49 (2%) had severe depression symptoms. 32.6% 42.8% 22.5% 2.1% 100% Total 23 30 16 3 72 31.9% 41.7% 22.2% 4.2% 100% DISCUSSION Table 6. Description of Depression Overview of Depression Symptoms in Symptoms in Hemodialysis Hemodialysis Patients Patients by Employement Status. This study reports the prevalence of depression symptoms in hemodialysis Depression Symptom patients was by 68.1%. It is relevant with the AlDukhayel's study (2015) which shows high Levels Total prevalence of depression symptoms in hemodialysis patients. Research conducted Job-status Norm Mild Moder Heav by Ambarsari (2017) at Wates Hospital al ate y Yogyakarta also reports that 89.2% depression symptoms occurred to No Labor 11 25 12 1 49 hemodialysis patients. 22.5% 51% 24.5% 2% 100% Hemodialysis patients at Jemursari Labor 12 5 4 2 23 Hospital in Surabaya mostly experienced 52.2% 21.7% 17.4% 8.7% 100% mild depression symptoms (41.7%). TSimilarly, Amalia (2015) reports that the Total 23 30 16 3 72 majority of respondents (37.5%) had mild 31.9% 41.7% 22.2% 4.2% 100% depression symptoms. Further, Alukukayel's research (2015) indicates 39.1% of Overview of Depression Symptoms in hemodialysis patients experienced mild Hemodialysis Patients by Hemodialysis depression symptoms using the Beck Treatment Duration Depression Inventory (BDI) instrument. This study finds the majority of The analysis of 21 items in depression people with depression symptoms had symptom variable shows 77.8% of patients undergone hemodialysis for more than 12 lost interest in sex, 66.7% experienced months(67.3%). In the group who underwent fatigue, 69.4% had sleep disorders, and 65.3 hemodialysis treatment, 21 patients (42.8%) experienced mild depression symptoms, 11 patients (22.5%) experienced moderate

310 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:304-314 % got angry easily. In with these findings, This contradicts the finding of Ruli’s Ritland (1996) also find that 43.5% of research (2008) which states that men were patients lost interest in sex, 81.5% more susceptible to chronic kidney failure experienced fatigue, 62.5% experienced sleep than women. However, in terms of disorder, and 43% claimed to be more depression, women developed depression offended. more easily than men. Women generally can acknowledge depression more compared to Someone undergoing a hemodialysis men, and thus doctors can handle depression therapy can lose self-freedom and social better in women. relations (Thong et al., 2007). Many factors trigger depression in hemodialysis patients Overview of Depression Symptoms in such as family support, age, education level, Hemodialysis Patients by Age and marital status (Theofilou, 2011). Besides, stressors originate from the lives of the This study informs us that the age hemodialysis patients themselves. These group of 46-65 years (elderly) (49%) were stressors include dietary restrictions and time more susceptible to depression symptoms. In problems, body function limitations, job loss, this age group, 12 respondents (36.4%) who changes in self-perception, changes in experienced mild depression symptoms. IIn reproductive function, perceived effects of the same way, Rustina (2012) discovers that the disease, drug use, costs, and worries the majority of respondents with depression related to care, uncertainty and anxiety, and symptoms were in the age group of 51-56 fear of death (Kimmel, 2001). years or in the category of early elderly. Further, Ambarsari (2017) elaborates that the Preventing and overcoming majority of respondents with depression depression symptoms in hemodialysis symptoms were aged between 46-55 years, patients is vital because it is also associated and 38.4% of them had mild depression with other adverse effects, including poor symptom rate of 24.6%. nutritional status and patient compliance with treatment (Watnick et al., 2003). According to Nevid et al. (2003), the incidence of depression mostly occurs to Overview of Depression Symptoms in elderly. Health condition in old age is less fit Hemodialysis Patients by Gender compared to young age. Several other physical ailments in elderly may cause The results of this study show most complications of diseases that trigger male patients experienced mild depression depression. symptoms (34.7%). This study indicates men had more depression symptoms than women. Overview of Depression Symptoms in It is supported by the result of research Hemodialysis Patients by Education conducted by Alukukayel (2015) 56 male patients mostly experienced depression Education is one of the factors that symptoms (84.8%). Further, Endris, can influence somone’s knowledge, attitudes, Fikreyesusand Amare (2019) also discover and actions. Good knowledge is the basis to that among 257 hemodialysis patients with determine attitude and actions, for example symptoms, 158 patients (61.5%) were male. adjusting to changes in health status. This study informs us that most respondents with According to Saeed et al. (2012), depression symptoms completed high school stress during treatment and the burden of (34.7%). This result is in line with Rustina's treatment cost affect the whole family and study (2012) which states that the majority of patients who are the heads of the household. respondents (17.9%) who experienced

Yuyun Tri Wulansari and Chatarina U. W, Description of Depression Symptoms... 311 depression symptoms completed high school. no fertility problems begin to experience Also, research from Amalia (2015) points out 57.14% of respondents with depression weaker conditions such as loss of sex drive. symptoms had high school education, and 42.87% of these respondents had mild A previous study at Zainoel Abidin depression symptoms. Regional Hospital in Banda Aceh, the Contrastly, Mukadder et al. (2004) discover that the lower the level of patient respondents experienced some education, the higher the Beck Depression Inventory score. Besides, Binbay et al. (2015) psyschological problems, such as fatigue, also state that the prevalence of depression was high in hemodialysis patients with low energy loss, and loss of interest in sex levels of education and socioeconomic status. (Yokha, 2012). Fatigue was the most Overview of Depression Symptoms in Hemodialysis Patients by Marital Status common complaint that hemodialysis Most of the respondents who suffered patients had at the hospital. The high risk of from depression symptoms (77.5%) were fatigue could limit patients’ activity, married. Most of them experienced mild depression symptoms (42.2%). This is in line including sexual activity. with Rustina's research (2012) which shows 34.33% of the research respondents had been Overview of Depression Symptoms in married, and 26.87% of them experienced Hemodialysis Patients by Employement mild depressive symptoms. Endris, Status Fikreyesus and Amare (2019) reveal that out of 257 hemodialysis patients with depression This study reports the majority of the symptoms, 137 people (53.3%) were married. respondents were unemployed. This is Saeed et al. (2012) report that the incidence consistent with research by Saeed et al. of depression was higher among (2012) who find 81% of hemodialysis hemodialysis and peritoneal dialysis patients patients did not work and felt depressed. who were married. According to Armaly et al. (2012), the tendency for depression will increase in Married people who do not work people with lower living standards and socio- could be at risk of experiencing moderate to economic status. severe depression. Marriage has given people great responsibility to maintain family’s Changes in physical abilities due to economic and social support (Saeed et al. chronic kidney disease limit patients to keep 2012). Moreover, hemodialysis patients have working. As a result, those who serve as the more difficulty in adapting to their partners heads of their family would feel depressed as than healthy people, and such difficulty leads they cannot fulfill their roles. A study in Iraq them to experience depression and anxiety further points out that the main factors for (Tavallaii et al., 2009). depression in hemodialysis patients were the unemployement and marriage (Hamody et Chronic kidney disease may cause al., 2013). disorganized roles in a marital relationship. Sexual dysfunction also causes problems in a Overview of Depression Symptoms in marital relationship (Palmer, 2003). Patients Hemodialysis Patients by Hemodialysis who were previously sexually active and had Treatment Duration This study discloses most of the respondents (67.3%) had undergone hemodialysis therapy for more than 12 months. It is consistent with Ambarsari's research (2017) which shows that the majority of respondents with depression symptoms (64.6%) had undergone hemodialysis therapy for 1-5 years. Duration

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FACTORS ASSOCIATED WITH NUTRITIONAL STATUS OF CHILDREN UNDER FIVE YEARS OF AGE IN GUNUNGSITOLI IDANOI PRIMARY HEALTHCARE CENTER Novrin Senselia Putri Ziliwu1, Lina Dewi Anggraeni1, Rosa Nora Lina2 1Sint Carolus School of Health Science, Jakarta, Indonesia 2Eijkman-Oxford Clinical Research Unit, Sint Carolus School of Health Science, Jakarta, Indonesia Correspondence Adress : Novrin Senselia Putri Ziliwu Email : [email protected] ABSTRACT The number of children under five years of age suffering from underweight was 28.0% in Gunungsitoli district. Out of six primary Healthcare centers in the district, Gunungsitoli Idanoi Primary Healthcare Center Healthcarewas one of the six primary healthcare centers with the highest malnutrition prevalence. Sixty-four children under five years of age there Healthcaresuffered from malnutrition. This study aimed to identify factors associated with the nutritional status of children under five in Gunungsitoli Idanoi Primary Healthcare Center, Gunungsitoli district. It was an analytical survey with a cross-sectional approach conducted in Gunungsitoli Idanoi Primary Healthcare Center in February 2019. Data were collected using a questionnaire. This study had samples as many as 246 mothers of children under five years of age selected using a purposive random sampling technique. The bivariate analysis indicates the nutritional status of children under five was significantly associated with mother’s employment status (p=0.043) and family size (p=0.015). While the nutritional status of children under five had no significant association with mother’s knowledge of nutrition (p=0.485), mother’s education (p=0.616), family income (p=0.511), infectious disease (p=0.913), and history of breastfeeding (p=0.847). Mother’s employment status and family size affected the nutritional status of children under five. The primary Healthcare center should cooperate with stakeholders across sectors, especially conduct training for improving economic business skills of the people in the village, and promote family planning program for couples of childbearing age. Keywords: Breastfeeding, children under five years of age, underweight, mother’s knowledge, mother’s employment. ABSTRAK Sebanyak 28,0% balita yang mengalami masalah kekurangan gizi di Kota Gunungsitoli. Puskesmas Gunungsitoli Idanoi memiliki masalah kekurangan gizi yang paling tinggi dari enam puskesmas yang ada di Kota Gunungsitoli. Sebanyak 64 balita mengalami masalah kekurangan gizi. Penelitian ini bertujuan untuk mengetahui faktor-faktor yang berhubungan dengan status gizi anak balita di Puskesmas Gunungsitoli Idanoi, Kota Gunungsitoli. Penelitian merupakan survey analitik yang menggunakan pendekatan potong lintang. Penelitian ini dilakukan di Puskesmas Gunungsitoli Idanoi pada bulan Februari 2019. Data penelitian diperoleh menggunakan kuesioner. Jumlah sampel pada penelitian ini sebanyak 246 ibu yang memiliki balita usia di bawah lima tahun yang dipilih dengan teknik purposive sampling acak. Analisis bivariat menampilkan adanya hubungan pekerjaan ibu (p=0,043) dan jumlah anak dalam keluarga (p=0,015) dengan status gizi anak balita. Faktor yang tidak berhubungan adalah pengetahuan ibu (p=0,485), pendidikan ibu (p=0,616), pendapatan keluarga (p=0,511), riwayat penyakit infeksi (p=0,913), dan riwayat pemberian ASI eksklusif (p=0,847). Pekerjaan ibu dan jumlah anak dapat mempengaruhi status gizi balita. Puskesmas tersebut perlu bekerja sama dengan pihak di berbagai lintas sektor terutama mengadakan pelatihan untuk meningkatkan keterampilan usaha ekonomi masyarakat di desa tersebut dan juga lebih menggalakkan program KB pada pasangan usia subur. Kata Kunci: ASI eksklusif, balita, gizi kurang, pekerjaan ibu, pengetahuan ibu. INTRODUCTION malnutrition include apathy, speech disorder, low intelligence quotient (IQ) Children under five years of age are levels, and decreased sensory integration groups prone to nutrition and disease (Pawenrusi, 2016). Severe malnutrition in (Salmah, 2018). Inadequate nutritional children under five years of age can affect status in the first 1000 days of life can cause brain development. irreversible effects. The effects of ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.315-324 Received 18 July 2019, received in revised form 9 August 2019, Accepted 14 November 2019, Published online: December 2020

316 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:315-324 The World Bank (2018) reports that Globally, 5.6 million children under the percentage of children under five five years of age died in 2016 (WHO, suffering from underweight was 13.5% 2017). The WHO explains that children worldwide (The World Bank, 2018). suffering from malnutrition are mostly Nutritional problems in these children are under five years old, and they have a higher most commonly found in Africa and Asia risk of death than older children. (UNICEF, 2018). The nutritional status Malnutrition caused around half of deaths monitoring or Pemantauan Status Gizi among children under five years of age. It (PSG) reported the prevalence of nutritional causes children under five years of age problems in Indonesia in 2017 was still the more prone to common infectious disease, same as in 2016 where 3.8% children under increases the frequency and severity of five years of age suffered from severe infection, and slows recovery (UNICEF, underweight, while 14.0% of them had 2018). moderate underweight, and 1.8% of them were obese (Indonesian Ministry of Health, Deaths of children (aged 0-4 years) 2018). The Regional Midterm could be minimized by ending malnutrition Development Plan for 2015-2019 states in all forms (WHO, 2017). The United improving the health and nutritional status Nations Development Programme (UNDP) of the community is one of the main targets. asserts that this way is one of the The effort could reduce the percentage of Sustainable Development Goals (SDGs) malnutrition in children under five years of which aim to end all forms of hunger in the age to 17.0% in 2019 (Indonesian Ministry world (UNDP, 2018). It targets a decrease of Health, 2015). in deaths of children (aged 0-4 years) by 10 million between 2017-2030 (UNICEF, Indonesia provinces with the 2018).The mortality rate targeted was at highest malnutrition prevalence in 2017 least 25 per 1,000 live births in each country were East Nusa Tenggara (28.3%), Central (WHO, 2017). Sulawesi (26.1%), West Kalimantan (25.9%), West Sulawesi (24.8%), and Aceh Many factors contribute to (24.8%). North Sumatera was ranked 19th achieving good nutritional status in out of 34 provinces for the highest children under five years of age. Lack of malnutrition prevalence (Indonesian food consumption is not only a major cause Ministry of Health, 2018). In 2017, it of nutritional problems. In several increased to 18.4% compared to the developing and underdeveloped countries, previous year. As much as 5.3% diarrhea is a major factor for malnutrition malnutrition was severe underweight, and (Hockenberry & Wilson, 2015). Other 13.1% malnutrition was moderate factors include poor environmental underweight (Indonesian Ministry of sanitation, inadequate knowledge of child Health, 2018). care, illiterate parents, economic and political factors, climate, types of food The malnutrition prevalence in consumed based on culture and religion, Gunungsitoli district was at 28.0% in 2017 and lack of adequate food (Hockenberry Indonesian Ministry of Health, 2018). and Wilson, 2015). Mother’s knowledge, HealthcareOut of six primary healthcare mother’s education, family income, centers in Gunungsitoli district, mother’s employment status, family size, Gunungsitoli Idanoi Primary Healthcare mother’s attitude, parenting, and infectious Centre has the highest malnutrition disease are other factors affecting prevalence in children under five years of nutritional status of children under five age. There were 64 years of age (Handayani, 2017). Healthcaremalnourished children reported there. The nutrition program coordinator in Gunungsitoli Idanoi Primary Healthcare Center explained that low income of

Novrin Senselia Putri Ziliwu, Lina Dewi Anggraeni and Rosa Nora Lina, Factors Associated With... 317 parents and lack of knowledge of nutrition malaria) and refused to participate were including exclusive breastfeeding and types excluded from the study. of MP-ASI may impact children’s nutritional status. Besides, more children in This study employed a modified a family may cause parents not aware of questionnaire that consisted of 21 questions food consumption patterns for their regarding mother’s knowledge of nutrition children. needs for children under five years of age, mother’s education, mother’s employment, Putri, et al. (2015) have conducted family size, family income, history of similar research in the working area of the infectious disease, and history of exclusive Nanggalo Padang Primary Healthcare breastfeeding. Previously, the validity and Center. They note that mother’s education, reliability of this questionnaire were tested family income, mother’s occupation, on people with similar inclusion criteria parenting, and family size affected the outside the research samples. using the nutritional status of children under five Cronbach's alpha of 0.802, that indicated a years of age. However, another previous perfect validity level. This study has passed study shows different results. It points out the ethical review by the Ethics that infectious diseases have an association Commission from Faculty of Medicine, with the nutritional status of under-five University of Indonesia with the letter children. Birth spacing, maternal education, number of 1276/UN2.F1/ETIK/2018 and nutrition care patterns, and maternal research permit from Gunungsitoli District occupation do not influence the nutritional Health Office with the permit number of status of under-five children. 440/494/PSDK-SDMK/I/2019. This study performed chi-square tests for analyzing the These different findings of other variables (mother’s education, mother’s previous studies have inspired this recent employment, family size, history of study , to identify factors associated with infectious diseases, and history of exclusive the nutritional status of children under five breastfeeding) and Fisher test for analyzing years of age in Gunungsitoli Idanoi Primary other variables (mother’s knowledge and Healthcare Center. family income). METHODS RESULTS Baseline Characteristics This study was conducted in Gunungsitoli Idanoi Primary Healthcare Table 1 presents characteristics of Center in February 2019. This study was 246 respondents participating in this study. quantitative research with a cross-sectional There were 169 respondents (68.7%) with approach. The research population involved good knowledge about nutrition needs of mothers of children under five years of age children under five years of age, and 184 in the working area of Gunungsitoli Idanoi respondents (74.8%) had primary Primary Healthcare Center. Finally, 246 education. Regarding employment and mothers as samples were selected using a family size, 205 respondents (83.3%) did purposive random sampling technique by not work, and 172 respondents (69.9%) had considering the inclusion and exclusion more than 2 children. This study also finds criteria. To be selected as the samples, 243 respondents (98.8%) had less than IDR mothers should be 20-35 years old, have the 2,132,188/month, and 207 mothers (84.1%) last children aged 1-4 years live in the had children with a history of infectious working area of Gunungsitoli Idanoi disease in the last three months. Further, Primary Healthcare Center, and be willing 133 mothers (54.1%) did not give to participate in this study. Mothers who exclusive breastfeeding, and 194 mothers suffered from diseases (URI, diarrhea, and (78.9%) had children with good nutrition status.

318 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:315-324 Table 1 Frequency Distribution of Respondents’ Characteristics Baseline Characteristics Frequency (n) Percentage (%) Mother’s Knowledge 22 8.9 Poor 169 68.7 55 22.4 Moderate GoodMother’s Education 184 74.8 Primary education 62 25.2 (Elementary School and Middle School) 205 83.3 41 16.7 Higher education 172 69.9 (High School and College) 74 30.1 Mother’s Employment 243 98.8 Unemployed 3 1.2 Employed 207 84.1 39 15.9 Family Size ˃2 133 54.1 ≤2 113 45.9 Family Income 4 1.6 < IDR 2,132,188/months 48 19.5 ≥ IDR 2,132,188/months 194 78.9 History of Infectious Disease Yes No History of exclusive breastfeeding No Yes Nutritional Status Severe underweight Moderate Underweight Good Mother’s Knowledge 37 mothers (20.1%) had children with severe underweight and moderate Table 2 shows that of 22 mothers underweight, and 147 mowthers (79.9%) who had poor knowledge, 4 mothers had children with good nutritional status. (18.2%) had children suffering from severe While among 62 mothers with higher underweight and moderate underweight, education, 15 mothers (24.2%) had children and 18 mothers (81.8%) had children with with severe underweight and moderate good nutritional status. While of 224 underweight, and 47 mothers (75.8%) had mothers who were well-informed about children with good nutritional status. nutrition needs for children under five years of age, 48 mothers (21.4%) had children Mother’s Employment with severe underweight and moderate underweight, and 176 mothers (78.6%) had Table 2 illustrates that of 205 children with good nutritional status. unemployed mothers, 38 mothers (18.5%) had children who experienced severe Mother’s Education underweight and moderate underweight, and 167 mothers (81.5%) had children with of the results show out of 184 good nutritional status. Further, this study mothers who completed primary education, finds among 41 working mothers, 14

Novrin Senselia Putri Ziliwu, Lina Dewi Anggraeni and Rosa Nora Lina, Factors Associated With... 319 mothers (34.1%) had children with severe History of Exclusive Breastfeeding underweight and moderate underweight, and 27 mothers (65.9%) had children with Regarding the history of exclusive good nutritional status. breastfeeding practice, among 133 mothers who did not breastfeed their children, and Family Size 27 mothers (20.3%) had children with severe underweight and moderate The results show among 172 underweight, and 106 mothers (79.7%) had mothers who had more than two children, children with good nutritional status. 44 mothers (25.6%) had children with Whereas, of 113 respondents who breastfed severe underweight and moderate their children, 25 mothers (22.1%) had underweight, and 128 mothers (74.4%) had children with severe underweight and children with good nutritional status. While moderate underweight, and 88 mothers of 74 mothers bearing ≤ 2 children, 8 (77.9%) had children with good nutritional mothers (10.8%) had children with severe status. underweight and moderate underweight, and 66 mothers (89.2%) had children with DISCUSSION good nutritional status. Relationship between mother’s Family Income knowledhe and nutritional status of children under five years of age In Table 2, the results show of 243 mothers with family income of less than The results indicate that nutritional IDR 2,132,188/month, 51 mothers (21.0%) status of children under five years old had had children suffering from severe no relationship with mother’s knowledge. underweight and moderate underweight, Malnutrition roccured not only to mothers and 192 mothers (79.0%) took care of who lacked knowledge but also to those children with good nutritional status. While with enough knowledge. Mothers with poor 3 mothers with family income of more than knowledge were 0.815 times more likely to or equal to IDR 2,132,188/month, only 1 have malnourished children than those with mother (33.3%) had a child with severe adequate knowledge. It is in line with the underweight and moderate underweight, research conducted by Apriliana and and two others (66.7%) had children with Rakhma (2017); Lestari, Sarbini, and good nutritional status. Rakhma (2015) which indicate that mother’s knowledge was not associated History of Infectious Disease with the nutritional status of children under five years of age. These studies find well- This study also suggests among 207 informed mothers turned out to have mothers whose children had a history of underweight children under five years old. infectious diseases, 43 mothers (20.8%) had However, these results are contradictory to children with severe underweight and other two studies which conclude that the moderate underweight, and 164 mothers nutritional status of children under five (79.2%) had children with good nutritional years of age could be affected by the level status. Whereas, among 39 mothers whose of mother’s knowledge (Pawenrusi, 2016; children had no history of infectious Suryani, 2017). disease, 9 mothers (23.1%) had children Knowledge about nutrition needs for with severe underweight and moderate children under five years of age will greatly underweight, and 30 mothers (76.9%) had affect actions that mothers will take children with good nutritional status. (Pawenrusi, 2016). Better knowledge will improve the ability of mothers to choose and serve nutritious food for their children.

320 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:315-324 Lack of mother’s knowledge and action for child's growth and development, but they nutritious food serving will cause sometimes did not apply it in actions. For malnutrition in children under five years of example, mothers know snacks are not age (Khotimah and Kuswandi, 2014). Good good for children's health, but they knowledge without actions will not be sometimes forget to limit snacking time and effective to end malnutrition in all forms. follow children’s snacking habit. It cause Most mothers said that they knew the children lose appetite of nutritious food. importance of adequate nutrition for their Table 2. Analysis of Relationship between Respondents’ Characteristics and the Nutritional Status of Children Under Five Years of Age Baseline Characteristics Severe Good Total P-value OR (CI underweight Nutritional 95%) Mother’s Knowledge + Poor Moderate N% n% Moderate + Good underweight 18 81.8 22 100 1.000 0.815 Mother’s Education n% 176 78.6 224 100 0.616 (0.263- Primary education 0.043 2.521) Higher education 4 18.2 147 79.9 184 100 0.015 0.789 48 21.4 47 75.8 62 100 0.511 (0.398- Mother’s Employment 1.563) Unemployed 37 20.1 167 81.5 205 100 0.913 0.439 Employed 15 24.2 27 65.9 41 100 (0.210- 0.847 0.916) Family Size 38 18.5 128 74.4 172 100 2.836 ˃2 14 34.1 66 89.2 74 100 (1.262- ≤2 6.372) 44 25.6 192 79.0 243 100 0.531 Family Income 8 10.8 2 66.7 3 100 (0.047- < IDR 2,132,188/month 5.976) ≥ IDR 2,132,188/month 51 21.0 164 79.2 207 100 1 33.3 30 76.9 39 100 0.874 History of Infectious (0.386- Disease 43 20.8 106 79.7 133 100 1.979) 9 23.1 88 77.9 113 100 Yes 0.897 No 27 20.3 (0.486- History of Exclusive 25 22.1 1.655) Breastfeeding No Yes Relationship between mother’s Munawaroh (2015) strengthen the education and nutritional status of children under five years of age nutritional status of children under five years old was not affected by mother’s This study reports no significant relationship between nutritional status of education. The result differs from the children under five years of age and mother’s education. Mothers with primary research conducted by Putri, et al. (2015); education were 0.789 times more likely to Suryani (2017). They discover mother’s have malnourished children than those with higher education. Sholikah et al. (2017); education did not have a meaningful relationship with the nutritional status of children under five years of age.

Novrin Senselia Putri Ziliwu, Lina Dewi Anggraeni and Rosa Nora Lina, Factors Associated With... 321 Mothers who completed higher education Types of parents’ work would levels have better abilities to increase generate different amount of income to knowledge, attitude, and behavior (Suryani, meet family’s needs, such as nutritious food 2017). Education significantly contributes (Adriani & Wirjatmadi, 2014). Working to the ability of individuals to interpret mothers are more likely to afford for the knowledge acquired. Good information and adequate nutritional intake of their children knowledge are not only available in formal (Supariasa, et al., 2016). education but also mass media, integrated service post, midwives, health cadres, the Relationship between family size and environment such as family and colleagues nutritional status of children under five (Pratiwi, et al., 2015). years of age This study suggests most highly The analysis provides an association educated mothers did not always have good between family size and nutritional status of knowledge of nutrition. It was proven by the children aged 0-4 years. This present study fact that mothers with primary education explains mothers who had more than 2 could get higher scores than mothers with children were 2.836 times more likely to higher education. It shows that all mothers have malnourished children than mothers who completed one of education levels still who had less than or equal to 2 children. had good knowledge of nutrition which Studies conducted by Putri, et al. (2015); would affect the nutritional status of Suryani (2017) elaborate by stating that children under five years of age. family size had a relationship with nutritional status of children under five Moreover, mothers with higher years old. Families with a large number of education had children with better nutrition family members tend to have malnourished status. As they had more agility to utilize children (Adriani and Wirjatmadi, 2014). technology and counseling services in However, studies done by Karundeng, et al. healthcare centers, they could access and (2015); Mahmood, et al. (2016) who understand information easily related to discover no significant relationship between balanced nutrition for pregnancy. family size and nutritional status of children under five years of age. Relationship between mother’s employment and nutritional status of A large number of children in a children under five years of age family can affect the quantity of food served, and family have to have enough This study discovers a relationship income to meet this need. Families with between mother’s employment and nutritious food consumption commonly nutritional status of children under five have fewer or equal numbers of 2 children. years old. It indicates that unemployed Families with fewer members will be able mothers had0.439 times more possibility of to provide nutritious food better for their having malnourished children than working family members. The capability of mothers. Other studies also find similar nutritious food serving depends a lot on results (Putri et al., 2015;Khotimah and family income. Kuswandi, 2014). Relationship between family income and Meanwhile, studies by Sholikah et nutritional status of children under five al. (2017); Rumende, et al. (2018) show years of age slightly different results. They explain that the nutritional status of children under five This study reports that there was no years old was not related to mother’s work. significant relationship between family Further, they report working mothers were income and nutritional status of children more likely to have children with poor under five years of age. Mothers who nutritional status.

322 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:315-324 earned less than IDR 2,132,188/month were possibly experience malnutrition if they do 0.531 times more likely to have not receive adequate nutritious food intake. malnourished children than those earning more than or equal to IDR Relationship between history of exclusive 2,132,188/month. Other research discover breastfeeding and nutritional status of the same findings (Ratufelan, et al. 2018). children under five years of age Meanwhile, some other studies find Additionally, there was no a relationship between family income and significant association between history of nutritional status of children aged 0-4 years exclusive breastfeeding and nutritional (Putri et al., 2015; Pawenrusi, 2016). Low status of children under five years old. family income cause parents not afford to Children who did not receive exclusive provide nutritious food as required in the breastfeeding were 0.897 times more likely family. While richer family income are to malnourished compared to those who more able to provide good quality food in received exclusive breastfeeding. good quantity (Adriani and Wirjatmadi, 2014). This present study indicates that Other studies point out similar families earning less or equal to IDR findings as this study does (Mahmood et al., 2,132,188/month had children with good 2016; Kowureng, et al. 2018). However, nutritional status that is also determined by different results were found in some studies dietary patterns. For example, mothers who which show history of exclusive are unable to buy chicken usually cook eggs breastfeeding had no relationship to which also contain protein. nutritional status of children under five (Andriani, et al. 2015; Pratiwi et al., 2015). Relationship between history of infectious disease and nutritional status Exclusive breastfeeding should be of children under five years of age done in the first 6 months of baby’s life without additional food and drink (Asih and This study reveals that history of Risneni, 2016). Exclusive breastfeeding for infectious disease had no relationship with babies can affect their nutritional status nutritional status of children under five (Ningrum, 2014). However, this present years of age. It further elaborates children study proves contrast findings which state who had a history of infectious disease had most children who received exclusive 0.874 times more possibilities of breastfeeding were also malnourished. It malnutrition. needs to highlight the fact that the quality and quantity of breast milk depend on This finding accords with that of mother’s food consumption. Nursing other studies which find similar results mothers need more calories around 200 to (Rohimah, et al., 2015; Arum, et al. 2017). 500 calories per day, intakes of calcium, In contrast, Handayani finds a relationship minerals, and fat-soluble vitamins. When between history of infectious disease and mothers cannot meet these nutrient needs, nutritional status of children aged 0-4 years they will not perform breastfeeding well. (Handayani, 2017). It is also in line with other research that shows similar results Mothers have to breastfeed their (Ratufelan et al., 2018). babies for 8-12 times during 24 hours with a duration of 3-4 hours. The average time to Decreased appetite tends to occur in breastfeed is 30-40 minutes. Some children under five years old who ever had respondents said that they breastfed their infectious diseases, and this can lead to children only when they are crying. Then malnutrition (Par’i, 2014). Those with they would stop breastfeeding when the history of infectious disease tend to have children stopped crying. Such breastfeeding good nutritional status as their dietary needs practice is not the ideal one as children do should be fulfilled for recovery. Children not receive optimal duration of with no history of infectious diseases breastfeeding.

Novrin Senselia Putri Ziliwu, Lina Dewi Anggraeni and Rosa Nora Lina, Factors Associated With... 323 CONCLUSION Faktor-faktor yang berhubungan This study concludes that the dengan Status Gizi Balita yang majority of mothersw in the working area of Gunungsitoli Idanoi Primary Healthcare mengikuti TFC di Kabupaten Center had good knowledge about nutrition for babies, completed primary education, Sukoharjo. Media Publikasi but they were mostly unemployed and had Penelitian, 15(1), 1–8. more than 2 children, earned less than IDR 2,132,188/month. The majority of their Arum, R., Rahfiludin, M. Z., & Nugraheni, babies had a history of infectious disease in the last three months, did not receive S. A. (2017). Faktor-faktor yang exclusive breastfeeding, but had good nutrition status. berhubungan dengan terjadinya Gizi Primary healthcare centers should Kurang pada Anak Balita Usia 24-59 always maintain and enhance cooperation with stakeholders across sectors to improve Bulan (Studi di Wilayah Kerja the community economic status. Empowering mothers to create job Puskesmas Halmahera Kota Semarang opportunities may contribute to increasing their family income which allow them to Tahun 2017. Jurnal Kesehatan afford nutritious food. Besides, it is Masyarakat, 5(3), 175–185. required to promote family planning programs for couples of childbearing age to Asih, Y., & Risneni. (2016). Asuhan reduce birth rates in the working area of Gunungsitoli Idanoi Primary Healthcare kebidanan Nifas dan Menyusui. Center. Primary healthcare centers could provide counseling services related to Jakarta: CV. Trans Info Media. family planning to increase mother’s awareness of family planning. Additionally, Handayani, R. (2017). Faktor-faktor yang villages should adopt family planning village goals to achieve contraceptive berhubungan dengan Status Gizi pada prevalence (CPR) targets set by the government. The establishment of family Anak Balita. Journal Endurence, 2(2), planning village is expected to reduce 217–224. population rates which could burden family’s economic condition https://doi.org/10.22216/jen.v2i2.174 REFERENCES 2 Adriani, M., & Wirjatmadi, B. (2014). Gizi Hockenberry, M. J., & Wilson, D. (2015). dan Kesehatan Balita. Jakarta: Wong’s Nursing Care of Infants and PRENAMEDIA GROUP. Children (10th ed.). St. Louis: Andriani, R., Wismaningsih, E. R., & Indrasari, O. R. (2015). Hubungan Elsevier. Pemberian ASI Eksklusif dengan Kejadian Status Gizi Kurang pada Karundeng, L. R., Ismanto, A. Y., & Balita Umur 1-5 Tahun. Jurnal Wiyata, 2(1), 44–47. Kundre, R. (2015). Hubungan Jarak Apriliana, W. F., & Rakhma, L. R. (2017). Kelahiran dan Jumlah Anak dengan Status Gizi Balita di Puskesmas Kao Kecamatan Kao Kabupaten Halmahera Utara. EJournal Keperawatan (e-Kep), 3(1), 1–9. Indonesian Ministry of Health. (2015). Rencana Strategis Kementrian Kesehatan Tahun 2015-2019. Jakarta: Kementrian Kesehatan RI. Indonesian Ministry of Health. (2018). Buku Saku Pemantauan Status Gizi Tahun 2017. Jakarta: Kementrian Kesehatan RI. Khotimah, H., & Kuswandi, K. (2014). Hubungan Karakteristik Ibu dengan Status Gizi Balita di Desa Sumur Bandung Kecamatan Cikulur Kabupaten Lebah Tahun 2013. Jurnal Obstretika Scientia, 2(1), 146–162. Kowureng, F. C., Kapantow, N. H., & Punuh, M. I. (2018). Hubungan antara Riwayat Pemberian ASI dengan Status

324 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:315-324 Gizi pada Anak Usia 24-59 Bulan di Infeksi dengan Kejadian Gizi Kurang pada Balita di wilayah kerja Wilayah Kerja Puskesmas Touluaan Puskesmas Benu-benua Tahun 2018. Jurnal Ilmiah Mahasiswa Kesehatan Kabupaten Minahasa Tenggara. Jurnal Masyarakat, 3(2), 1–13. Rohimah, E., Kustiyah, L., & Hernawati, N. Kesmas, 7(4). (2015). Pola Konsumsi, Status Kesehatan dan hubungannya dengan Lestari, P., Sarbini, D., & Rakhma, L. R. Status Gizi dan Perkembangan Balita. J. Gizi Pangan, 10(2), 93–100. (2015). Hubungan Pengetahuan dan https://doi.org/10.25182/jgp.2015.10. 2.%25p Sikap Ibu tentang Makanan Balita di Rumende, M., Kapantow, N. H., & Punuh, M. I. (2018). Hubungan antara Status Desa Malangjiwan, Kecamatan Sosial Ekonomi di Kecamatan Tombatu Utara Kabupaten Minahasa Colomadu, Kabupaten Karanganyar. Tenggara. Jurnal Kesmas, 7(4). Salmah, S. (2018). Pengantar Ilmu Mahmood, S., Nadeem, S., Saif, T., Kesehatan Masyarakat. Jakarta: CV. Trans Info Media. Mannan, M., & Arshad, U. (2016). Sholikah, A., Rustiana, E. R., & Yuniastuti, A. (2017). Faktor-faktor yang Nutritional Status and Associated berhubungan dengan Status Gizi Anak Balita di Pedesaan dan Perkotaan. Factors in Under-five Children of Public Health Perspective Journal, 2(1), 9–18. Rawalpindi. J Ayub Med Coll Supariasa, I. D. N., Bakri, B., & Fajar, I. Abbottabad, 28(1), 67–71. (2016). Penilaian Status Gizi (Edisi 2). Jakarta: EGC. Munawaroh, S. (2015). Pola Asuh Suryani, L. (2017). Faktor yang mempengaruhi Status Gizi Balita di mempengaruhi Status Gizi Balita. wilayah kerja Puskesmas Payung Jurnal Keperawatan, 6(1), 44–50. Sekaki Pekanbaru. Journal of Midwifery Science, 1(2), 47–53. https://doi.org/10.22219/jk.v6i1.2851 The World Bank. (2018). Prevalence of Underweight, Weight for Age. The Ningrum, A. S. (2014). Hubungan World Bank Group. UNDP. (2018). The Sustainable Pemberian ASI Eksklusif dengan Development Goals. UNICEF. (2018). Malnutrition rates Status Gizi Balita Usia 12-59 Bulan di remain alarming: stunting is declining too slowly while wasting still impacts Posyandu Dewi Sartika Candran the lives of far too many young children. Sidoarum Sleman. WHO. (2017). Children: reducing Par’i, H. M. (2014). Penilaian Status Gizi. mortality. Jakarta: EGC. Pawenrusi, E. P. (2016). Factors Related to the Nutritional Status of Children in Area Served by the Pattingalloang Health Center, Makassar. Pakistan Journal of Nutrition, 15(4), 333–336. https://doi.org/10.3923/pjn.2016.333. 336 Pratiwi, R. H., Suyatno, & Aruben, R. (2015). Faktor-faktor yang berhubungan dengan berat-kurang (Underweight) pada Balita di Perkotaan dan Perdesaan Indonesia berdasarkan Data Riskesdas Tahun 2013. Jurnal Kesehatan Masyarakat3, 3(2), 127–137. Putri, F. R., Sulastri, D., & Lestari, Y. (2015). Faktor-faktor yang berhubungan dengan Status Gizi Anak Balita di wilayah kerja Puskesmas Nanggalo Padang. Jurnal Kesehatan Andalas, 4(1), 254–261. Ratufelan, E., Zainuddin, A., & Junaid. (2018). Hubungan Pola Makan, Ekonomi Keluarga dan Riwayat

PREVALENCE AND FACTORS ASSOCIATED WITH HYPERTENSION AMONG HEALTH WORKERS OF CENTRAL HOSPITALS IN NEPAL Prakash Ghimire1,2*, Alisha Khadka3, Amornrat Anuwatnonthakate1, Supaporn Trongsakul1 1Department of Public Health, School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand 2Department of Health Services, Ministry of Health and Population, Nepal 3College of Nursing, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal *Corresponding Author: Prakash Ghimire Email: [email protected] ABSTRACT Hypertension is a significant public health issue considered as the world's biggest killer among the working-age group. Health workers are one of the working groups who are facing several factors in their lives that could induce hypertension among them. Nevertheless, there is a lack of information about hypertension among Nepalese health workers. Therefore, this cross-sectional study aimed to determine the prevalence and factors associated with hypertension among health workers of central hospitals in Nepal. A total of 422 health workers aged ≥30 years from seven central hospitals of Nepal were selected using a proportionate stratified systematic random sampling method. Information regarding characteristics (socio-demographic, clinical, behavioral, occupational, and perceived stress) of participants were obtained by face to face interviews using a questionnaire after getting informed written consent. Participant's blood pressure and body mass index were measured based on the World Health Organization STEP Surveillance Manual. Binary logistic regression model was used to identify the associated factors of hypertension. The prevalence of hypertension was 35.31% (95% CI: 30.70%-40.10%). After controlling potential confounding factors through multivariate analysis, seven factors (increasing age, low educational level, being married, low fruit & vegetable consumption, low physical activity, alcohol use, and increased perceived stress) were found as significant independent predictors of hypertension. In conclusion, hypertension is highly prevalent among Nepalese health workers. Effective behavioral change interventions and routine health screening programs focusing on hypertension should be implemented to control hypertension among this neglected group, Nepalese health workers. Keywords: Health Workers, Hypertension, Perceived stress, Physical activity, Prevalence, Nepal INTRODUCTION Asian Region (SEAR), hypertension accounted for 1.5 million deaths each year Hypertension is a growing global and found that one in three adults has high public health concern responsible for blood pressure (World Health Organization, substantial morbidity and mortality, 2013). A meta-analysis revealed the high primarily affecting the working-age prevalence of hypertension (33.80%) in population of low and middle-income Nepal as compared to other SAARC (South countries (World Health Organization, Asian Association for Regional 2018). Hypertension is the topmost Cooperation) countries (Neupane et al., preventable non-communicable disease 2014). Nepal is a landlocked, least (NCD), as well as a risk factor of NCDs that developed country situated in the SEAR embraced 9.4 million deaths, more than the currently facing a triple burden of disease, deaths from infectious illnesses combined including overwhelming consequences of (International Federation of Pharmaceutical NCD, significantly hypertension. Manufacturers and Associations, 2016; World Health Organization, 2018).The Based on the Nepal Step Survey worldwide prevalence of hypertension 2013, the hypertension rate in the Nepalese among adult people aged ≥ 18 years was adult people was 25.70% (Aryal et al., around 22% in 2015 (World Health 2014). Furthermore, the pooled analysis of Organization, 2018). In the South-East hypertension prevalence rate among the adult population of diverse geographical ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.325-338 Received 5 May 2020, received in revised form 11 May 2020, Accepted 28 May 2020, Published online: December 2020

326 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:325-338 locations in Nepal was ranged from 15.1% workers in Nepal. Therefore, a study is to 38.9% (Dhungana et al., 2016; Khanal necessary to uncover the concealed et al., 2017; Neupane et al., 2017). The situation of hypertension among Nepalese working-age adult population was the health workers. victim of 12.2 million premature deaths from NCD, mainly hypertension worldwide Health workers are the pillar of the (World Health Organization, 2017). Health health system in Nepal. The majority of the workers are an essential cohort of the nation Nepalese health workers (23.00%) with that belongs to the working-age group. As diverse job cadre are working in the central health guardians, health workers are health level hospitals (Ministry of Health and role models for their patients, families, and Population, 2013). These hospitals have a communities. high burden of workload, sedentary work style, deprived sleep, and shift work as The health of health workers is of compared to other levels of health great significance because they must be organizations in Nepal (Thapa, Malla and healthy for their better job performance. KC, 2018). To date, there is no provision of Unfortunately, the working conditions of health screening programs focusing on health workers expose them to long hypertension for Nepalese health workers, working duration, shift duties, unhealthy due to which the Nepalese government is dietary habits, sedentary lifestyle, and unaware of their health situation and stress, which are the significant inducers of thought that their health is not of priority hypertension (Taylor and Bithoney, 2012; concern. Manyisa and Aswegen, 2017; World Health Organization, 2017; Muzzi, Pawlina and Thus, this study aimed to estimate Schnorr, 2018). Hypertension is not only the prevalence and determine the factors responsible for deaths among health associated with hypertension among health workers but also accountable for their workers of central hospitals in Nepal, disability, poor mental health and quality of which could facilitate the formulation of life, an increased burden in health effective health intervention to control the expenditure of the nation, altered health foreseeable burden of hypertension in a system and its effects on patients, low neglected group, Nepalese health workers. workplace productivity from their absence (Taylor and Bithoney, 2012; World Health METHODS Organization, 2013; Kretchy, Owusu-daaku and Danquah, 2014; Asay et al., 2016; An analytical cross-sectional study International Federation of Pharmaceutical was conducted among health workers in Manufacturers and Associations, 2016). seven central hospitals located in Lalitpur Several studies evident the momentous and Kathmandu districts of Bagmati upsurge of hypertension and further Province, Nepal, from September to cardiovascular disease risk factors in health November 2019. Central hospitals are the workers in comparison to other working tertiary level health organization under the groups (Sumaila et al., 2016). Few studies health system of Nepal. In 2019, there were show the prevalence of hypertension eleven central hospitals, according to the among health workers at 9.20% in India, ministry of health and population, Nepal. 8.60% in Iran, and 35.27% in Thailand, Out of them, seven central hospitals were respectively (Sahebi, Vahidi and Mousavi, included as the study settings in this study 2010; Ahmed, Jadhav and Sobagaiah, 2018; as they consist of a large number of Sirinara, Hanprathet and Jiamjarasrangsi, varieties of health workers working and 2019). Nonetheless, until now, no studies dealing with the high flow of patients and have been conducted, which shows the workload (Ministry of Health and direct figure of hypertension among health Population, 2013). Based on the reports from

Prakash Ghimire, Alisha Khadka, Amornrat Anuwatnonthakate and Supaporn Trongsakul, Prevalence... 327 respective central hospitals, there was a sample size was estimated at 422. The appropriate sample was chosen using a 1,942 study population working in the proportionate stratified systematic random sampling method where strata refer to the study settings on the date of study in 2019. types of health workers (doctors, nursing staff, paramedic staff, and other health All the health workers aged ≥30 years staff). Firstly, the proportion of the required sample size (21.73%) inside the stratum of working in central hospitals for at least one each central hospital was determined. Then, inside each stratum, the first sample was year were inclusion criteria of this study. taken randomly, followed by the consecutive sample at each 5th interval until Whereas, pregnant, who were unable to getting the required number of samples from respective hospitals (Figure 1). respond, and on leave or training were the exclusion criteria. After using Cochran formula (n= Z2pq/e2); Z(desired confidence interval)=1.96, p(assumed prevalence)=0.5 (Naing, Winn and Rusli, 2006), q=0.5, e(allowable error)=0.05 and adding 10% to account any errors, the total required Seven Central Hospitals 1942 Doctors Nursing Staff Paramedics Staff Others Health Staff 512 818 294 318 Required Sample Required Sample Required Sample Required Sample Size Size Size Size 111 178 64 69 Figure 1. Flowchart of sample selection A questionnaire was developed hypertension, history of known NCDs) based on the WHO STEP Survey behavioral characteristics (amount of salt Questionnaire, Cohen's Perceived Stress intake, added salt intake, fruits & vegetable Scale-10, and literature review. consumption, physical activity level, Questionnaire's internal validity was alcohol use, tobacco use), occupational evaluated by three Nepalese experts based characteristics (work duration, shift work, on IOC method and found each item of sleep duration), and perceived stress of the questionnaire as congruent (IOC score participants were obtained by face-face- >0.5). A translated Nepali version interviews using a questionnaire. The questionnaire was piloted in 30 randomly physical measurement tools (digital BP selected health workers of tertiary hospital; machine, digital weighing machine, and other than study settings, to check its face portable standard stature) were identified, validity and reliability. The internal calibrated, and used to measure blood consistency of the perceived stress-related pressure, height, and weight of the questions was tested and found Cronbach's participants based on the WHO STEP alpha value at 0.746. Then, the information Surveillance Manual (Aryal et al., 2014). about socio-demographic characteristics (age, sex, educational level, marital status, Three readings of blood pressure monthly family income, type of health were taken from participants and workers, employment status), clinical categorized as hypertensive if the mean of characteristics (family history of last two readings has ≥140 mmHg systolic blood pressure or/and ≥ 90 mmHg diastolic

328 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:325-338 blood pressure or had a self-reported Nepal Health Research Council (Reg. no. history of hypertension (Chobanian et al., 696/2019) approved this study based on the 2003; Aryal et al., 2014). Helsinki Declaration 2002. The written permission for data collection was obtained Body mass index was calculated from the study settings. The informed using the formula, BMI=weight (kg)/height written consent was taken from the (m2) and classified as underweight (<18.50), participants prior to the data collection and normal (18.50-24.99), and Obese (≥30). confidentially was maintained thoroughly. Physical activity level was assessed by self- reported duration and intensity of physical RESULTS activity per week, later converted into Metabolic Equivalent Task (MET)- A total of 422 health workers were minute/week. METs-value for moderate- enrolled with a 100% response rate in the intensity activity and vigorous-intensity study. The mean (±standard deviation) age activity was 4 MET/minute and 8 of the participants was 36.50 (± 5.77) years MET/minute. The normal physical activity old. Majority of the participants were aged level was adopted as ≥600 MET- 30-39 years (59.70%), female (58.80%), minute/week. The consumption of fruits graduate (36.00%), married (82.50%), and and vegetables less than five servings per nursing staff (42.20%). 16.40% were other day termed as Low consumption. health staff (pharmacy staff, laboratory staff, Individuals who used alcohol products (at radiological staff, anesthesia staff, dietetics least 50 grams) and tobacco products in staff, ophthalmic staff, and dental staff). their lifetime were referred as alcohol users Similarly, 38.60% of participants had a and tobacco users, respectively. Regarding monthly family income of 51000-80000 perceived stress, participants were asked NRs, and 75.80% had permanent ten questions (four positive and six negative) employment. and labelled the score (0-4) of responses to each question. Then, the total score was Half of the participants (50.90%) categorized as (0-13)=low perceived stress, had a family history of hypertension, (14-26)=moderate perceived stress, and whereas only 13.27% of participants found (27-40)=high perceived stress (Cohen and to have a history of diabetes. 11.37% of the Williamson, 1988; NH Department of participants had history of other NCDs Administrative Services, 2014). (kidney disease, hypothyroidism, hyperthyroidism, arthritis, asthma, gout, Data were compiled, coded, entered, hemorrhoids, hyperlipidemia, and cleaned, and analyzed in SPSS V.20.0. migraine). More than half of the Descriptive statistics were used to describe participants were overweight (52.80%). the characteristics of the participants. All 66.80% of participants had a habit of low the categorical data were presented as fruits and vegetable consumption (<5 frequency and percentage, while servings/day). The minority of the continuous data as mean with standard participants (31.80%) deviation. Hypertension prevalence was consumed the recommended amount of salt illustrated in percentage with 95% (<5 grams/day). Furthermore, only 37.70% Confidence Interval (CI). The associated of participants used added salt before and factors from univariate analysis at p-value during eating food. 62.80% of participants 0.2 were entered into the multiple logistic found to be less physically active (<600 regression model to detect the significant MET-minute/week). Majority of the independent factors of hypertension with participants (59.20%) consumed at least Adjusted Odds Ratio (AOR) at 95% CI and one standard drink of alcohol in their p-value < 0.05. lifetime, while only 27.50% of participants found to use tobacco products. Most of the The ethical review board of Mae Fah Luang University (REH-62164) and

Prakash Ghimire, Alisha Khadka, Amornrat Anuwatnonthakate and Supaporn Trongsakul, Prevalence... 329 participants were working on a rotating higher among participants with age 40-49 shift basis (53.60%) and had a work years, female, post-graduate or higher duration of 1-9 years (55.70%). 85.10% of education, married, nursing staff, family participants had normal sleep duration (≥6 history of hypertension, overweight, low hours/day). Regarding the perceived stress, fruits & vegetable consumption, high salt more than 3/5th of the participants (62.60%) intake (5-10 grams/day), low physical perceived a moderate level of stress (Table activity, alcohol use and a moderate level of 1). The proportion of hypertension was perceived stress (Table 1). Table 1. Characteristics of hypertensive and non-hypertensive participants Characteristics Total n (%) Yes Hypertension n (%) No Total 422 (100.00) 149 (35.31) n (%) 273 (64.69) Socio-demographic characteristics Age (years) 30-39 252 (59.70) 44 (29.53) 208 (76.19) 81 (54.36) 56 (20.51) 40-49 137 (32.50) 24 (16.11) 9 (3.30) 50-59 33 (7.80) mean±SD = 36.50 ± 5.77 Sex Male 174 (41.20) 74 (49.66) 100 (36.63) 75 (50.34) 173 (63.37) Female 248 (58.80) 14 (9.39) 27 (9.89) Level of education Technical School 41 (9.70) Leaving Certificate (TSLC) Proficiency 108 (25.60) 36 (24.16) 73 (26.74) Certificate Level (PCL) Graduate 152 (36.00) 49 (32.88) 102 (37.36) 50 (33.57) 71 (26.01) Post-graduate or 121 (28.70) higher Marital status Unmarried 52 (12.30) 4 (2.68) 48 (17.58) 134 (89.93) 214 (78.39) Married 348 (82.50) 11 (7.39) 9 (4.03) Separated/ 12 (5.20) Divorced and Widowed Monthly family income (NRs) 20000-50000 103 (24.40) 29 (19.46) 74 (27.11) 50 (33.56) 113 (41.39) 51000-80000 163 (38.60) 30 (20.13) 51 (18.68) 40 (26.85) 35 (12.82) 81000-110000 81 (19.20) 41 (27.52) 71 (26.01) >110000 75 (17.80) 59 (39.60) 119 (43.59) 22 (14.76) 41 (15.02) Type of health worker 27 (18.12) 42 (15.38) Doctors 112 (26.50) Nursing staff 178 (42.20) Paramedic staff 63 (14.90) Other health staff 69 (16.40)

330 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:325-338 Characteristics Total n (%) Yes Hypertension No n (%) n (%) Employment status 192 (70.33) Permanent 320 (75.80) 128 (85.91) 56 (20.51) 25 (9.16) Contract 70 (16.60) 14 (9.39) 117 (42.86) Temporary 32 (7.60) 7 (4.70) 143 (52.38) 13 (4.76) Clinical characteristics 20 (7.33) Family history of hypertension 253 (92.67) Yes 215 (50.90) 98 (65.77) 30 (10.99) 248 (89.01) No 186 (44.10) 43 (28.86) 154 (56.41) Unknown 21 (5.00) 8 (5.37) 114 (41.76) 5 (1.83) History of diabetes 153 (56.04) Yes 56 (13.27) 36 (24.16) 120 (43.96) No 366 (86.73) 113 (75.84) 108 (39.56) 140 (51.28) History of other NCD 25 (9.16) Yes 48 (11.37) 18 (12.08) 89 (32.60) 184 (67.40) No 374 (88.63) 131 (87.92) 142 (52.01) Body Mass Index 131 (47.99) Normal 184 (43.60) 30 (20.13) 47 (17.22) 226 (82.78) Overweight 223 (52.80) 109 (73.15) 118 (43.22) Obesity 15 (3.60) 10 (6.72) 155 (56.78) Behavioral characteristics 90 (32.96) 22 (8.06) Fruit and vegetable consumption (servings/day) 161 (58.98) <5 282 (66.80) 129 (86.58) 188 (68.87) 61 (22.34) ≥5 140 (33.20) 20 (13.42) Amount of salt intake (grams/day) <5 134 (31.80) 26 (17.45) 5-10 228 (54.00) 88 (59.06) >10 60 (14.20) 35 (23.49) Added salt intake Yes 159 (37.70) 70 (46.98) No 263 (62.30) 79 (53.02) Level of physical activity (MET-minutes/week) <600 265 (62.80) 123 (82.55) ≥600 157 (37.20) 26 (17.45) Tobacco use Yes 116 (27.50) 69 (46.31) No 306 (72.50) 80 (53.69) Alcohol use Yes 250 (59.20) 132 (88.59) No 172 (40.80) 17 (11.41) Occupational characteristics Shift work Day (non-shift) 155 (36.70) 65 (43.62) Morning shift 41 (9.70) 19 (12.76) Rotating shift 226 (53.60) 65 (43.62) Work duration (years) 1-9 235 (55.70) 47 (31.54) 10-19 123 (29.10) 62 (41.61)

Prakash Ghimire, Alisha Khadka, Amornrat Anuwatnonthakate and Supaporn Trongsakul, Prevalence... 331 Characteristics Total n (%) Yes Hypertension ≥ 20 64 (15.20) n (%) No 40 (26.85) n (%) 24 (8.79) Sleep duration (hours/day) <6 63 (14.90) 49 (32.89) 14 (5.13) 100 (67.11) 259 (94.87) ≥6 359 (85.10) Level of perceived stress (score) Low (0-13) 144 (34.10) 20 (13.43) 124 (45.42) 118 (79.19) 146 (53.48) Moderate (14-26) 264 (62.60) 11 (7.38) 3 (1.10) High (27-40) 14 (3.30) The prevalence of hypertension who had a post-graduate or higher level of among health workers was 35.31% (95% education. The chance of having CI: 30.70-40.10). Out of those with hypertension in married health workers was hypertension, 79 (53.02%) participants had 4.34 times (AOR:4.34, 95% CI:1.85-15.90) diagnosed hypertension, whereas as compared to unmarried health workers. 70(46.98%) participants had undiagnosed Health workers who consumed <5 servings hypertension. Furthermore, almost half of of fruits and vegetable per day were 2.27 the participants 39 (49.40%) with times (AOR:2.27, 95% CI:1.06-4.88), more diagnosed hypertension, were not able to likely to get hypertension than those who control their hypertension. consumed ≥five servings of fruits and vegetable per day. Similarly, health workers In multivariate analysis, the with low physical activity (<600 MET- significantly associated factors of minutes/week) were 2.49 times (AOR:2.49, hypertension were age, educational level, 95% CI:1.12-5.14), more likely to be marital status, fruits & vegetable hypertensive as compared to those with consumption, physical activity, alcohol use, normal physical activity (≥600 MET- and perceived stress. The results showed minutes/week). Moreover, among alcohol that health workers who fell under age users, the odds of having hypertension had group 40-49 years and age group 50-59 increased by 4.57 times (AOR:4.57, 95% years were 3.11 times (AOR:3.11, 95% CI:2.11-9.92) than non-alcohol drinkers at CI:1.38-6.97), and 6.18 times (AOR:6.18, all. Additionally, health workers who had 95% CI:1.51-25.30) more likely to get moderate perceived stress and high hypertension respectively as compared to perceived stress were 2.64 times health workers aged 30-39 years. The (AOR:2.64, 95% CI:1.26-5.54) and 15.09 health workers who had the Technical times (AOR:15.09, 95% CI:2.27-100.22) School Leaving Certificate (TSLC) level of more likely to have hypertension education were 4.58 times (AOR:4.58, 95% respectively than health workers who had CI:1.44-14.62), more likely to have low perceived stress (Table 2). hypertension as compared to participants Table 2. Univariate and multivariate analysis of factors associated with hypertension Factors Crude OR p-value Adjusted OR p-value (95% CI) (95%CI) Age (in years) 30-39 Reference Reference 40-49 6.84 (4.27-10.95) <0.001 3.11 (1.38-6.97) 0.006 50-59 12.61 (5.48-28.97) <0.001 6.18 (1.51-25.30) 0.011 Sex Male 1.71 (1.14-2.56) 0.010 1.05 (0.49-2.26) 0.897

332 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:325-338 Factors Crude OR p-value Adjusted OR p-value (95%CI) (95% CI) Reference 0.010 0.061 Female Reference 4.58 (1.44-14.62) 0.134 2.37 (0.96-5.85) Education level 1.87 (0.82-4.25) 0.027 0.293 TSLC 0.74 (0.35-1.54) 0.417 Reference 0.251 PCL 0.71 (0.41-1.22) 0.213 Reference 0.757 4.34 (1.85-15.90) 0.665 Graduate 0.68 (0.41-1.11) 0.122 2.59 (0.44-15.28) 0.840 Post-graduate Reference Reference 0.050 0.61 (0.26-1.41) 0.211 or higher 0.85 (0.31-2.31) 0.604 1.26 (0.45-3.67) 0.589 Marital status Reference 0.176 Unmarried Reference 0.91 (0.35-2.35) 0.051 3.40 (0.99-11.58) Married 7.14 (2.65-21.31) <0.001 1.49 (0.80-2.79) 1.43 (0.37-5.57) Separated/ 12.00 (3.21-44.86) <0.001 Reference divorced and 1.26 (0.54-2.95) widowed Reference Monthly family income (NRs) Reference 1.58 (0.81-3.05) 20000-50000 Reference 4.49 (0.99-20.36) 51000-80000 1.13 (0.66-1.94) 0.661 81000-110000 1.50 (0.80-2.80) 0.201 >110000 2.92 (1.56-5.45) 0.001 Type of health worker Nursing staff Reference Doctors 1.16 (0.71-1.91) 0.546 Paramedic staff 1.08 (0.59-1.98) 0.798 Other health 1.29 (0.73-2.30) 0.376 staff Type of employment Permanent Reference Contract 0.37 (0.20-0.70) 0.002 Temporary 0.42 (0.18-1.00) 0.050 Family history of hypertension Yes 2.79 (1.80-4.30) <0.001 Unknown 2.05 (0.80-5.26) 0.137 No Reference Known diabetes Yes 4.03 (2.23-7.27) <0.001 No Reference Known kidney disease Yes 1.10 (0.26-4.67) 0.896 No Reference Other known NCD Yes 1.11 (0.57-2.18) 0.761 No Reference Body mass index Normal Reference Overweight 4.91 (3.06-7.86) <0.001 Obesity 10.27 (3.27-32.18) <0.001 Fruits and vegetable consumption (servings/day)

Prakash Ghimire, Alisha Khadka, Amornrat Anuwatnonthakate and Supaporn Trongsakul, Prevalence... 333 Factors Crude OR p-value Adjusted OR p-value <0.001 (95%CI) 0.035 (95% CI) <0.001 2.27 (1.06-4.88) 0.376 < 5 5.06 (2.98-8.58) <0.001 Reference 0.178 0.004 0.549 ≥5 Reference Reference <0.001 1.40 (0.67-2.93) 0.013 Amount of salt intake (gram/day) 2.02 (0.73-5.63) <0.001 0.585 < 5 Reference 0.82 (0.43-1.57) <0.001 Reference <0.001 5-10 2.61 (1.58-4.32) <0.001 2.49 (1.12-5.14) 0.346 > 10 5.81 (2.98-11.35) <0.001 Reference 0.726 Added salt intake 0.612 1.23 (0.57-2.68) 0.442 0.008 Reference 0.236 Yes 1.82 (1.22-2.76) <0.001 0.168 4.57 (2.11-9.92) No Reference <0.001 Reference 0.010 <0.001 0.005 Physical activity (METminutes/week) Reference 1.46 (0.66-3.23) < 600 4.36 (2.69-7.09) 1.22 (0.40-3.77) ≥ 600 Reference Reference 1.46 (0.55-3.88) Tobacco use 0.66 (0.34-1.31) Yes 4.15 (2.64-6.50) 1.85 (0.77-4.43) Reference No Reference Reference Alcohol use 2.64 (1.26-5.54) Yes 10.20 (5.83-17.84) 15.09 (2.27-100.22) No Reference Work duration (years) 0-9 Reference 10-19 4.06 (2.52-6.55) ≥20 6.66 (3.66-12.13) Shift work Day work Reference Morning shift 1.19 (0.60-2.39) Rotating shift 0.56 (0.36-0.86) Sleep duration (hours per day) <6 9.06 (4.79-17.14) ≥6 Reference Level of perceived stress (score) Low (0-13) Reference Moderate 5.01 (2.94-8.52) (14-26) High (27-40) 22.73 (5.83-88.68) DISCUSSION Mousavi, 2010; Ahmed, Jadhav and Sobagaiah, 2018; Osei-yeboah et al., 2018). It is the first epidemiological study It could be possible due to that previous that demonstrates the prevalence of studies has included individual aged <30 hypertension with its associated factors years, excluded the individual with among Nepalese health workers. The hypertension and diabetes, and different prevalence of hypertension among health study settings; primary care center of rural workers in the current study was 35.31%. areas (Sahebi, Vahidi and Mousavi, 2010; This prevalence is higher than the previous Ahmed, Jadhav and Sobagaiah, 2018; Osei- studies in India (9.20%), Iran (8.60%), and yeboah et al., 2018). Besides, one study had Ghana (16.07%) (Sahebi, Vahidi and an annual health screening program for