202012-V15N2 The Indonesia Journal of Public Health

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

334 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:325-338 health workers, which could promote physically active, use alcohol, consume less awareness among health care workers and fruits and vegetables, and had increased led to a low prevalence of hypertension perceived stress, i.e., known inducers of when comparing to this study (Osei-yeboah hypertension. Similarly, low education was et al., 2018). The study from Thailand significantly associated with hypertension demonstrates prevalence (35.27%) among Iranian health workers and Nepalese consistent with the current finding, where adults (Sahebi, Vahidi and Mousavi, 2010; the analogous working environment of Chataut, Adhikari and Sinha, 2011). A participants (in tertiary hospitals of urban consistent result was indicated in the past areas) might be a reason behind it (Sirinara, research (Schwenk, 2017). Hanprathet and Jiamjarasrangsi, 2019). Aryal et al (2014) reported 36.60% of The current study showed that being hypertension prevalence among Nepalese married was significantly associated with adult population aged ≥30 years, which is hypertension among health workers. A slightly higher than the current result. similar finding was noted from previous Comparing to the general population, it studies in Nepalese adult population and could be possible that health workers may health workers (Sahebi, Vahidi and have higher profound health knowledge, Mousavi, 2010; Dhungana et al., 2016). which leads to better health behaviours and Nepalese married people, especially disease prevention. females in urban areas, have busy and complicated life boost them to acquire In this study, increasing age was stressful life, low physical activity, and significantly associated with hypertension. unhealthy eating behaviours such as junk A similar result was reported by previous foods rather than fruits and vegetables (Ban, studies among health workers in Nigeria, 2018). A research evidence back-up the Thailand, and Ghana (Sumaila et al., 2016; current result by describing that the Osei-yeboah et al., 2018; Sirinara, transition from single to married life Hanprathet and Jiamjarasrangsi, 2019). possesses lifestyle modification such as Nepal demographic health survey 2016 sedentary lifestyle, which adversely revealed the same finding that increasing impacts their blood pressure resulting in age was significantly associated with hypertension (Wood, Goesling and Avellar, hypertension among Nepalese adults 2007). (Kibria et al., 2018). It was physiologically evident that older people are inevitable to Low fruits and vegetable get hypertension, a result of gradual consumption was found to be a significant changes in the cardiovascular system; predictor of hypertension among health vascular remodelling, arterial stiffness, and workers in this study. Fruits and vegetable endothelial dysfunction (Alghatrif et al., are a great source of potassium, which helps 2013). to prevent hypertension by maintaining renal homeostatic function (Wu and Wolley, A current study found that health 2019). A meta-analysis reported a similar workers having TSLC level of education association of low fruits and vegetable were at high risk of hypertension than consumption with hypertension among the health workers with post-graduate or higher Asian population (Li et al., 2016). Previous education. Health workers with TSLC studies in the Nepalese adult population education tended to have limited health found no association of fruits and vegetable knowledge as they learned only 18 months consumption with hypertension (Dhungana of basic health courses (Council For et al., 2016; Khanal et al., 2017; Neupane Technical Education and Vocational et al., 2017). The unhealthy working Training, 2020). Furthermore, analysis of environment (shift work, stress, high current findings revealed that health workload, unavailability of fruit and workers with TSLC education were less vegetable in the workplace) of the health

Prakash Ghimire, Alisha Khadka, Amornrat Anuwatnonthakate and Supaporn Trongsakul, Prevalence... 335 workers force them to consume less fruit consume more alcohol. and vegetable than general people. The Regarding perceived stress, the study setting of this study was in Kathmandu valley, Nepal, where unhealthy current study found a significant eating behaviours are in increasing trend, association between increased perceived i.e., people prefer to eat easily available stress and hypertension. Research junk foods instead of fruits and vegetables supported this association by stating that (Resource Centre for Primary Health Care, stress causes abnormal activation of the 2016). sympathetic nervous system alters hormonal cascades, which increases blood This study found the association pressure, cholesterol levels, fibrinogen, and between low physical activity and blood fluidity leads to cardiovascular hypertension in health workers. Ibrahim events, including hypertension (Mucci et stated that inadequate physical activity al., 2016). Previous studies among the alters blood pressure homeostasis resulting general population demonstrated similar in hypertension (Ibrahim, 2018). A findings that the increased perceived stress consistent result was observed in the studies was a significant factor of hypertension among the Nepalese population and (Redmond et al., 2013; Bhelkar et al., Nigerian health workers (Chataut, Adhikari 2018). The past studies in Indian health and Sinha, 2011; Dhungana et al., 2016; workers and Brazilian health workers Sumaila et al., 2016). Biddle found that less observed consistent finding with the current physically active individuals experience research (Owolabi et al., 2012; Leonelli et more stress in their life, which is also a al., 2017). Health workers have dual crucial inducer of hypertension (Biddle, responsibility towards their work setting, 2016). Health workers of central hospitals and home laid them prone to get high in this study mainly use vehicles for perceived stress. The health workers in this transportation and deal with high workload study deal with the high flow of patients in with less or no physical movement makes hospitals and family issues, which lodged them less physically active the whole day. them to experience more stress. The current study found the This study is equipped with several association of alcohol use with strengths. Firstly, it is a novel study that hypertension among health workers. It was uncovered the hidden burden of theoretically evident that alcohol use causes hypertension in Nepalese health workers. vasoconstriction action and alteration in the Secondly, health workers were benefited renin-angiotensin-aldosterone system, from this study as they had a chance to which ultimately leads to alcohol-induced know their hypertensive status and take hypertension (Crestani et al., 2014). With preventive measures on time. Lastly, study several reasons such as culturally findings added up the health data of health acceptable in ethnic groups, peer pressure, workers that would help different scholars stressful married life, family history of for further studies. Nevertheless, this study alcohol use, and smoking status, alcohol has a limitation on its study design. This use is aggressively prevalent among the study applied the cross-sectional study Nepalese population, especially in urban design, which cannot prove the real causal areas like Kathmandu. The percentage of relationship of disease, but appropriate to alcohol use was found to be higher among determine the prevalence. the health workers (59.20%) in this study than the national figure among Nepalese CONCLUSION adult population (26.5%) (Aryal et al., 2014). Based on the current findings, it was High prevalence of hypertension found that increased perceived stress with its modifiable factors (educational among health workers direct them to level, fruits and vegetable consumption,

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AN OVERVIEW OF DEPRESSION TENDENCIES IN PATIENTS WITH TYPE 2 DIABETES MELLITUS IN KEBONSARI PRIMARY HEALTHCARE CENTER, SURABAYA CITY Iftitah Shofiyati Departement of Epidemiology,Faculty of Public Health, Airlangga University, Surabaya, Indonesia Corresponden Address: Iftitah Shofiyati Email: [email protected] ABSTRACT Type 2 diabetes mellitus (DM) occurs due to insufficient insulin production or insulin resistance in the human body. Type 2 DM also causes physical weakness, vision problems, risk of death, and depression. This study aimed to describe depression tendencies in patients with type 2 DM under treatment in Kebonsari Primary Healthcare Center, Surabaya city. This study was a descriptive study with a cross-sectional approach. The research samples were 74 people with type 2 DM in the Kebonsari Primary Healthcare Center, Surabaya city. These respondents selected using simple random sampling had met the inclusion criteria. These repsondents were aged more than 25 years old, did not experience psychological disorders, and had suffered from type 2 diabetes mellitus for 5 years. The data analysis was done using a univariate analysis by looking at the frequency distribution of variables. The results indicate that the prevalence of patients with type 2 DM who tended to experience depression was at 50%. The majority of patients with type 2 DM who experienced depression were women (47.4%) and elderly (aged 46-65 years) (41.9%). Most of them had low education levels (62.2%), and some respondents had complications (37.8%) and poor family support (62.2%). Support from closest people such as family support can improve the adaptation of patients with the disease and can prevent psychological disorders, especially depression in patients with type 2 DM. Keyword: type 2 diabetes mellitus, family support, depression tendencies. ABSTRAK Penyakit diabetes mellitus tipe 2 adalah sebuah kondisi karena insulin yang diproduksi tubuh tidak cukup atau tubuh mengalami resistensi insulin. Diabetes mellitus tipe 2 dapat menyebabkan timbulnya kelemahan pada fisik, gangguan pengelihatan, risiko kematian dan depresi. Penelitian ini bertujuan untuk mengetahui gambaran tingkat kecenderungan depresi pada penderita diabetes mellitus tipe 2 di Puskesmas Kebonsari Surabaya. Penelitian ini adalah penelitian deskriptif dengan pendekatan cross sectional. Sampel berjumlah 74 penderita diabetes mellitus tipe 2 di Puskesmas Kebonsari dan termasuk dalam kriteria inklusi yang telah ditentukan, yaitu berusia lebih dari 25 tahun, tidak mengalami kelainan jiwa dan menderita diabetes mellitus tipe 2 selama lima tahun. Pengambilan sampel dilakukan dengan teknik simple random sampling. Teknik analisis data yang digunakan adalah analisis univariat dengan melihat distribusi frekuensi variabel. Hasil menunjukkan bahwa prevalensi penderita diabetes mellitus tipe 2 yang mengalami kecenderungan depresi sebesar 50%. Responden yang mengalami kecenderungan depresi sebagian besar adalah perempuan (47,4%), merupakan kelompok usia lansia (46-65 tahun) (41,9%), memiliki tingkat pendidikan yang rendah (62,2%), memiliki komplikasi (37,8%) dan mendapat dukungan keluarga yang rendah (62,2%). Dukungan dari orang terdekat salah satunya dari keluarga dapat meningkatkan adaptasi penderita dengan penyakitnya serta dapat mencegah timbulnya gangguan psikologis utamanya depresi pada penderita diabetes melitus tipe 2. Kata kunci: diabetes mellitus tipe 2, dukungan keluarga, kecenderungan depresi. INTRODUCTION organ to produce insulin to fulfill the body's needs or due to the disability of the body to Diabetes mellitus (DM) causes effectively use the insulin produced metabolism disorders that lasts years and (Indonesian Minsitry of Health, 2014). occurs due to the disability of the pancreatic ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.339-347 Received 16 July 2019, received in revised form 5 September 2019, Accepted 18 October 2019, Published online: December 2020

340 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:339-347 According to the Centers for Disease diabetes. For example, they may not follow Control and Prevention (2017), diabetes is the dietary advice, do physical activity, stop divided into three types, namely type 1 smoking, and comply with the treatment diabetes, type 2 diabetes, and gestational schedule (Riley, et al. 2009). diabetes. In 2003, 194 million people suffered from DM , and the number increased Additionally, DM can worsen to 200 million people in 2005 and 210 million depression symptoms. Stress due to concerns people in 2010. The International Diabetes in controlling diabetes and the effects of Federation (2013) report 5.6 million people in diabetes on the brain can contribute to Indonesia suffered from diabetes in 2000, and depression. In the United States, a person who the number reached 8.5 million people in has diabetes mellitus is twice as likely to 2013. It is predicted to rise to 14.1 million suffer from depression than general people. people in 2035. Further, the Indonesian At the same time, the depression symptoms Ministry of Health (2013) shows that the DM may reduce physical and mental health. For prevalence that mostly occurs to people at the example, overeating causes an increase in age of >15 years in Indonesia was at 1.5 body weight which is one of the risk factors percent. Specifically, in East Java province, for diabetes. Exhaustion and worthlessness the DM prevalence exceeded the national may cause a person to ignore the special diet prevalence at 2.1 percent. or medication needed to control diabetes. A study shows that people with diabetes and The number of DM incidents in depression have more severe diabetes Surabaya city steadily kept rising from 2016 symptoms compared to people with only to September 2018. The data from Surabaya diabetes (National Institute of Mental Health, District Health Office (2018) show that in 2011). 2016 the number of DM incidents was 105,208 incidents, which decreased to Diabetes and depression correspond 102,599 cases in 2017, while in September to each other. Depression may contribute to 2018 it bounced back to 115,460 incidents. the low control of diabetes, its complications, The highest number of patients with DM and inadequate management of depression. (4,060 incidents) in Surabaya received Irregular control of diabetes will cause the treatment n from January to September 2018 blood glucose level to exceed its normal in Kebonsari Primary Healthcare Center. limits and finally result in various complications (Fatimah, 2015). Ceaseless According to Handayani and Dewi DM complications may lead to prolonged (2009), people diagnosed with DM may depression. Chronic complications and experience physical and psychological difficulty of recovery in people with DM can disorders. These psychological disorders lead to depression. Complications will limit include depression, anxiety, irritability, one's activities in daily life and cause irritability, and loss of will or interest to live. prolonged depression. As stated by the WHO, depression is a mental disorder that causes several symptoms such A study by Ramdani (2016) shows as the feeling of depression, loss of joy and that patients with type 2 DM experienced a interest, guilty feeling for things, low self- certain degree of depression. As many as esteem, horrible eating and sleep habits, 82.3% patients had no depression symptoms, difficulty in concentrating, and loss of 15.2% experienced mild depression, and energy. The effects of depression start to 2.5% were moderately depressed. Research at trigger when someone has been diagnosed Ambarawa Regional Hospital by with diabetes mellitus. Patients will behave Kuminingsih (2013) showed 37.7% patients contrary to prohibitions to control their with DM experienced mild depression,

35.8% had moderate depression, and 26.4% Iftitah Shofiyati, An Overview On Depression... 341 had severe depression. with type 2 DM. To be selected as the Essentially, several factors such as repsondents, patients were over 25 years old, physical, psychological, and social factors had no history of mental illness, suffered related to DM and its therapy may also trigger from type 2 DM for over five years or more, depression. Patients with DM who are and were willing to participate in this study. depressed due to their chronic disease may While patients who were unwilling to experience depression (Supriati, et al. 2016). participate were excluded from the list. The The lack of social support and feeling of inclusive respondents were selected using a denial towards their conditions may distress simple random sampling method. people with type 2 DM (Semenkovich et al., 2015). This study utilized demographic and family support as independent variables and Involving social support is one of the depression tendencies as a dependent care management of depression associated variable. This study collected data through with DM. Patient interactions with their questionnaire-based interviews by visiting social environment play a role in increasing patients’ hourse from doors to doors. their adaptation in accepting and controlling their disease. One of the social support forms The demographic variables consisted is sfamily support (Isworo and Saryono, of age, gender, education level, and 2010). complications. The age variable were then divided into two groups, namely adult age A patient whose family is involved in group (26-45 years old) and elderly group the diabetes care will feel supported and (46-65 years old). The gender variable was motivated to cope with their condition. divided into male and female. The education Patients with DM may feel physical and level variable was categorized into low psychological comfort when receiving family education (not attending school, elementary support. It also helps them increase school, and junior high school graduates) and confidence to survive. Family is expected to higher education (high school and university always provide motivation, facilities and graduates). companionship to patients with DM, and thus they will feel loved and cared for doing The family support variable was activities independently (Supriati, et al. measured using the Hensarling Diabetes 2016). Family Support Scale (HDFSS). This instrument was developed by Hensarling in Based on the issue above, this study 2009. It can measure patient’s perceptions of identified depression tendencies that people family support they received so far. The with type 2 DM experienced. family support variable consisted of some dimensions, such as emotion, appreciation, METHOD instrument, and information dimensions. It was poured into questions consisting of 29 This study applied a descriptive items with alternative answers worth t 1-4 research design with a cross-sectional points. Family support was considered low if approach. It was conducted within 2 months the score obtained was smaller than the mean starting from May to June 2019 in Kebonsari (score of <76.9). While it was considered Primary Healthcare Center in Surabaya city. high if the score was the same or more than The research population included patients the mean (score of ≥76.9) with type 2 DM who underwent treatment in Kebonsari Primary Healthcare Center. The Furthermore, the depression tendency research samples involved were 74 people variable was measured using the Beck Depression Inventory (BDI) instrument created by Aaron T. Beck. This questionnaire

342 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:339-347 was applied to measure how severe one’s depressed, and 4.1% experienced a severe depression was, but it was not a diagnosis depression tendency. tool. The BDI questionnaire evaluated 21 depression symptoms which 15 symptoms Table 1. Depression Tendencies among described emotions, 4 symptoms described Patients with Type 2 DM in attitude change, and 6 symptoms were Kebonsari Primary Healthcare somatic symptoms. Each symptom was Center. ranked on a 4-point scale, and its value was summed to give a total score of 0-63. The Depression Tendencies assessment of depression tendencies wasbased on the scores obtained. A value or Variables Severe Moderat Mild Normal score of <10 indicated no depression e tendencies (normal), 10-18 suggested a mild depression tendency, 19-29 indicated a n% n % n % n % moderate depression tendency, and >30 showed major depression tendency.The data Gender analysis technique applied was the univariate analysis which presented the results in in -Male 0 0 0 0 2 2.7 21 28.4 frequency distribution tables narratively. This study has obtained an ethical proval from the -Female 3 4.1 7 9.5 25 33.8 16 21.6 Ethics Commission of Faculty of Public Health Airlangga University (No. Age 2 2.7 1 1.4 3 4.1 5 6.8 139/EA/KEPK/2019). -26-45 yo 1 1.4 6 8.1 24 32.4 32 43.2 -46-65 yo RESULTS Education Depression tendencies based on gender -Low 2 2.7 4 5.4 22 29.7 18 24.3 From gender perspective, depression tendencies mostly occurred to female -High 1 1.4 3 4.1 5 6.8 19 25.7 respondents (47.4%). Most female respondents (33.8%) experienced a mild Complicati depression tendency, 9.5% felt a moderate depression tendency, and 4.1% tended to on 2 2.7 4 5.4 22 29.7 9 12.2 have severe depression. While of 23 male -Yes 1 1.4 3 4.1 5 6.8 28 37.8 respondents, most of them did not experience -No depression tendencies. Only 2.7% of the male respondents experienced mild depression. Family The results of depression tendencies Support are summarized in Table 1. The measurement of depression tendencies experienced by - 3 4.1 6 8.1 22 29.7 15 20.3 patients with type 2 DM using the BDI questionnaire show that 50% of the Inadequate respondents tended to experience depression. - Adequate 0 0 1 1.4 5 6.8 22 29.7 Most respondents (36.5%) experienced a mild depression tendency, Total 3 4.1 7 9.5 27 36.5 37 50 9.5% of them tended to feel moderately Depression tendencies based on age According to age groups, most respondents who experienced depression tendencies were in the age group of 46-65 years old (the elderly age group). Of 63 respondents in the elderly group, 41.9% of them experienced depression tendencies. As many as 32.4% of them experienced a mild depression tendency, 8.1% experienced a moderate depression tendency, and 1.4% experienced a severe depression tendency.

Depression tendencies based on education Iftitah Shofiyati, An Overview On Depression... 343 level 21% of the respondents experienced mild The results show that the majority of depression, 12% experienced moderate respondents had low education (62.2%). This depression, and 18% felt severe depression. study reveals 29.7% of them experienced a mild depression tendency, 5.4% of In contrast, Ramdani (2016), who respondents experienced a moderate examined the level of depression of people depression tendency, and 2,7% others had a with type 2 DM at the Kardinah District severe depression tendency. General Hospital of Tegal district, shows mild depression occurred to 15.2% of the Depression tendencies based on patients, 2.5% of the patients experienced complications moderate depression, and none (0%) had major depression. Another variable discussed was complications. This study shows that the People who experience depression majority of the respondents who experienced tendencies often feel upset and worried about depression tendencies previously had the future due to their diseaseThey also complications (50%). In details, 29.7% of experience sleeping disorders as they need to them experienced a mild depression wake up to urinate at night for more than 3 tendency, 5.4% experienced a moderate times due to the high blood sugar levels. They depression tendency, and 2.7% others had a also sometimes feel tired and less energetic. severe depression tendency. Diabetes and depression correspond Depression tendencies based on family to each other. Depression can contribute to support the inadequate control of diabetes. Diabetes and its complications also contribute to poor Family support consisted of four management of depression. Depressive dimensions, namely emotion, appreciation, events may have the risk of depression instrument, and information dimensions. symptoms to appear again. A study shows a Based on Table 1, 62.2% of the respondents person with DM and depression is more received less family support. Among the prone to recurrent depression when being respondents who received lower family observed for five years (Lutsman, et al. support, 29.7% of them experienced a mild 2000). depression tendency, 8.1% experienced a moderate depression tendency, and 4.1% had Distribution of depression tendencies by a severe depression tendency. gender perspective DISCUSSION The results show that most depression Overview of depression tendencies in tendencies occurred to female respondents patients with type 2 diabetes mellitus (47.4%). Ramdani (2016) shows similar results by mentioning that the percentage of In Table 1, this study presents the depression tendencies in females was 53,2% prevalence of depression tendency in people higher than in males at 46.8%. Research with type 2 DM was 50%. It is in line with conducted by Ramanda (2014) also proves research conducted by Anderson et al., (2001) that the highest depression prevalence who find 48% of the respondents experienced occured to females (20%). Another study depression due to DM. Further, research further finds depression prevalence was conducted by Mufidah (2018) shows that higher in female patients (33.9%) than male patients (29.9%) (Rajender, et al. 2016). A meta-analysis study conducted by Anderson, et al. (2001) discovers that diabetes increased

344 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:339-347 the risk of depression twice higher in females Distribution of depression tendencies (28.2%) than males (18%). based on education level Depression is a psychological Reagrding education levels, this study disorder related to long-term stressors such as chronic diseases, including diabetes mellitus. indicates the majority of respondents had a Men and women performa different attitudes to dealing with the stressors. as men tend not low education level (62.2%). This is to be emotional in coping with a problem, they will prefer to solve a problem directly. consistent with research conducted by Whereas women outweigh emotion, and thus it can make women more difficult to deal with Ramanda (2014) stating that the majority of stress (Mujabi, 2017). respondents with low education experienced Distribution of Depression Tendencies from Age Perspective depression (20%). However, it differs from Based on the results, most research done by Sari (2016) pointing out the respondents in the elderly group (aged 46-65 years) mostly experienced depression fact that the majority of respondents tendencies (41.9%). In similar way, research by Ramanda (2014) states that a quarter of the experiencing depression were highly respondents at the age group of 46-65 years experienced depression. Research conducted educated (59%). by Mufidah (2018) also indicates the highest depression tendencies occurred to patients According to Sativa (2015), there was with type 2 DM under 60 years old. High depression rates in this age group might be a negative relationship between education caused by a decrease in health and a sense of worry about the future. Depression may level and depression tendencies in people reduce patient motivation to seek for treatment and to practice self-care and cause with type 2 DM. The higher education level, their blood sugar to be uncontrolled and (Egede and Ellis, 2009).Female elderly have the lower the degree of depression. Adequate more possibilities to experience depression tendencies due to hormonal changes that education levels can help patients understand cause menopause (Vamos, et al. 2009). Elderly patients with DM usually experience their condition, disease, and risks related to various health problems and undergo various kinds of health treatment. They generally feel DM (Mufidah, 2018). alienated (isolated), worried about their future, declining health, and disability due to Research conducted by Rajender et al. age (Rihmer and Angst, 2005). It is difficult to distinguish deterioration in elderly’s (2016) shows that education level was physical condition due to the progression of the complications or old age. associated with depression in people with type 2 DM. Low education level, especially illiteracy, may lead to lack of awareness of disease severity, routine medication, and dietary consumption which contribute to complications (Rajender, et al. 2016). Depression often occurs in low-educated people with DM (Vamos, et al. 2009). Low education can correspond to low economy, indecent living place, unemployment, and difficulties to get a permanent job, which may encourage depression (National Collaborating Centre for Mental Health, 2010). Low education level was a risk factor for depression in people with chronic diseases, including diabetes mellitus. Lack of knowledge about the disease and its management, as well as insufficient exposure to information about coping mechanism may also cause depression (Supriati, Nasution and Ilmansyah, 2016).

Distribution of Depression Tendencies Iftitah Shofiyati, An Overview On Depression... 345 Based on Complication families can change and improve the There were 37.8% of the respondents perception of the patients towards the disease who had complications and experienced more positively (Sari, 2016). depression tendencies. These complications varied, such as high blood pressure, vision Family support also help DM patients problems, leg injuries, and stomach disorders. more disciplined in maintaining the Mufidah (2018) finds that the prevalence of healthcare management (Mufidah, 2018). depression and complications at the same Lack of family support can cause time occurred to 51 patients (52%). Anxiety incompliance with dietary restrictions; hence, and lack of knowledge may pressure a person the disease can be controlled (Susanti, 2013). to deny the changes that occur. As a result, a denial can worsen one's blood sugar control, Family support and care will provide thereby increasing the risk of complications DM patients a sense of comfort, attention, and depression. Diabetes complications will compassion, and will foster patient to recover cause nerve damage, increase blood by accepting their condition. Another study viscosity, and impair the metabolism of fat conducted by Yusra (2011) finds that based (Mufidah, 2018). on interviews with five people with type 2 DM, two of them had been exhausted with Purwanti (2013) mentions when DM their condition for burdening their family, patients had wounds on feet, they would be at and three others had difficulty in practicing greater risk of experiencing depression than religious rituals and received less attention DM patients without wounds. Foot sores have from their family. Family support can caused unpleasant smell and often make encourage patients to take their medication patients feel inferior and ashamed. As a regularly according to the dose on doctor’s result, patients tend to isolate themselves and instruction (Meidikayanti and Umbul, 2017). have difficulties to get along with neighbors. Research conducted by Rehman and Kazmi CONCLUSION (2015) shows that there was high prevalence of depression, fear, and anxiety experienced A hald of total patients with type 2 by people with type 2 DM complications. DM in Kebonsari Primary Healthcare Center experienced depression tendencies. Most Distribution of depression tendencies respondents who experienced depression based on family support perspective tendencies were female and in the elderly age group (46-65 years old) and had low The results show that the majority of education levels and inadequate family the respondents received inadequate family support. support (62.2%), and nearly half of them experienced depression tendencies. Research Family as the closest people to conducted by Supriati, Nasution, and patients with DM should always provide Ilmansyah (2016) finds that although the adequate support by motivating, facilitating, majority of respondents received sufficient and accompanying them so that they could family support, nearly half of them still calm themselves for accepting their condition experienced mild depression. Garousi and and be encouragous to do their daily activities Garrusi (2013) state that supportive family independently and manage their health. behavior is a form of social support to avoid depression and anxiety to reduce stress. REFERENCES Interaction between patients and their Anderson, R. J. et al. (2001) ‘The Prevalence of Comorbid Depression in Adults with Diabetes: a meta-analysis’,

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THE ROLE OF HEALTH DIAGNOSIS ON GYMNASIUM NEEDS OF STUDENTS OF UNIVERSITAS AIRLANGGA, SURABAYA Ragilia Indah Lutfiana1, Sonny Marsetyo1, Pitasari Nastiti1, Ernawaty1 1Department of Health Administration and Policy, Faculty of Public Health, Airlangga University, Surabaya, Indonesia Correspondence Address: Ragilia Indah Lutfiana Email: [email protected] Email: [email protected] (082216009813) ABSTRACT Gymnastics is exercises in which physical activities and playing activities take place. At the same time, the nervous system works as a stimulant conductor in the form of coordination of muscle function. A gymnasium is prominent for university students as they need to be fit and healthy to do tasks given at the campus. This study aimed to identify gymnasium needs for students and the role of clinical diagnosis on the needs of students for a gymnasium at Universitas Airlangga, Surabaya. The research method was quantitative. The research population was all students of Universitas Airlangga, Surabaya. While the samples were chosen using nonprobability snowball sampling. This study utilized questionnaires as a primary data collection tool to understand gymnasium needs of the students of Universitas Airlangga. The results indicate the students equired private gymnasium facilities such as swimming pools and cafeterias which only could be accssed by the society of academicians at Universitas Airlangga. This study concluded that the students were advised by doctors to do swimming which was their desired sport. Keywords: need assessment, gymnasium, clinical diagnosis, swim. ABSTRAK Gimnastik merupakan senam di mana aktivitas gerak badan dan keterampilan bermain diterapkan. Pada saat yang sama, sistem syaraf bekerja sebagai penghantar rangsang dalam bentuk koordinasi fungsi otot. Gimnasium sangat penting bagi mahasiswa, dikarenakan mahasiswa harus ada dalam kondisi sehat untuk melaksanakan tugas yang diberikan di kampus. Penelitian ini bertujuan untuk mengetahui kebutuhan gimnasium dan pengaruh diagnosis klinis terhadap kebutuhan gimnasium mahasiswa di Universitas Airlangga, Surabaya. Metode penelitian yang digunakan merupakan metode kuantitatif . Populasi penelitian adalah seluruh mahasiswa di Universitas Airlangga, Surabaya. Sedangkan sampel dipilih menggunakan nonprobability snowball sampling. Kuisioner digunakan sebagai alat pengumpulan data utama untuk memahami kebutuhan gimnasium mahasiswa Universitas Airlangga. Hasil menunjukkan bahwa mahasiswa memerlukan fasilitas gimnasium privat seperti kolam renang dan kafetaria yang hanya diakses oleh civitas akademika saja. Penelitian ini menyimpulkan bahwa mahasiswa Universitas Airlangga Surabaya mengikuti saran yang diberikan dokter untuk melakukan olahraga berenang dan ini sesuai dengan kebutuhan olahraga mahasiswa. Kata kunci: penilaian kebutuhan, gimnasium, diagnosis klinis, renang. INTRODUCTION for concentration, memory, and intellectuality. Takdir D., Mahmudin (2008) Gymnastics is exercises in which mention four important effects of physical physical activities and playing skills take a activities in increasing knowledge and place. At the same time, the nervous system thinking processe. First, physical activities works as a stimulant conductor in the form of may increase the circulation of neurons that coordination of muscle function. In this make a person get more oxygen and nutrients regard, Trudeau (2008) emphasizes that in the brain. Second, these stimulate the activities also improve important functions production of neurotransmitters that can ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.348-355 Received 1 July 2019, received in revised form 10 July 2019, Accepted 17 September 2019, Published online: December 2020

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 349 improve mood and foster Brain-Derived Notoatmojo further explains that someone Neurotrophic Factor (BDNF) factors. Third, will do an action if he behaves towards an these facilitate a process of new brain cells so- object positively and believes that someone called neurogenesis, and the fourth effect of else wants him to take it. Theory of planned physical activities is to improve visual acuity. behavior explains beliefs influence attitude, Sunadi (2018) also states that fitness subjective norms, and perceived behavioral positively influences student achievement. control. These three components interact and become determinants of intentions for A fitness center or gymnasium is is someone to act (Azwar, 2007). It suggests that popular because it provides a variety of tools someone who receives health diagnosis will and facilities that have been designed probably decide on action they will take. properly for physical training (Muttaqin, Ifwandi, and Jafar 2016). Besides, a The establishment of a gymnasium in the gymnasium is also very easy to find because campus area is vital for students because it now many entrepreneurs invest in facilitates students with healthy activitiesat gymnasiums. Gymnasium businesses have campus. Saqurin (2013) ever found only 3 out been mushrooming, especially in big cities. It of 10 students on average at Universitas is not surprising that competition in gym Airlangga routinely did sportsThis study businesses arises quite fiercely. More and investigated students at Universitas Airlangga more gymnasiums are established, and thus to further know gymnasium needs of the the management must design certain students and identify whether health diagnosis strategies to offer gymnastic service products. could affect their gymnasium needs. From the research background above, this study aimed Moreover, the gym management must be to determine needs of gymnasium and the role able to sound marketing strategies to attract of health diagnosis on gymnasium needs of consumers as many as possible and to students at Universitas Airlangga, Surabaya. maintain the market share through th profit gain ((Makmur and Widagdo 2017). Various METHODS managerial efforts must be done, for example providing adequate facilities such as a This study employed a descriptive- comfortable, safe, and strategic room, quantitative method. It used questionnaires as complete weight training equipment for a primary data collection tool to understand training needs, and excellent customer gymnasium needs of students at Universitas service. Besides, a gymnasium must have an Airlangga. appropriate and accurate training program as well. The research population was all active students (undergraduate, graduate, and People will show positive or negative doctoral students) at Universitas Airlangga. behavior towards a new trend including the Population is all elements that have some mushrooming gymnasium businesses. common characteristics (Malholtra, 2004; Notoatmojo (2003) defines that behavior is Rinawiyanti et al. 2014). The samples were related tohow a person responds to pain and chosen using nonprobability snowball disease from himself and from external sampling. The selection of the smaples started factors. Kinds of responses include both from a small number, and those who agreed to passive responses (knowledge, perception, join recommended their colleagues to be the and attitude) and active responses (practice) next respondent. The sampling was towards pain and disease. A person's behavior conducted in seven days and finally found 121 towards pain and disease corresponds to the respondents consisting of 20 males and 101 levels of overall disease prevention measures. females.

350 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:348-355 RESULTS Besides, this study finds the majority of the respondents liked sports (88 people). Perceived Components (Subject assessment) Table 4. Distribution Frequency of This component discusses individual Respondents by Reasons on Sports subjective factors that can influence needs. Favoritism. This study includes individual characteristics such as gender, age, desires, attitudes, and Reasons Total beliefs stowards health. To have it as a hobby 10 To make body healthy 65 To maintain weight 13 Table 1. Distribution Frequency of To do it as a lifestyle 2 Respondents by Gender. To overcome stress 2 Gender Total To improve our sleep 5 Male 20 quality Female 101 Total 121 To do it as needs 1 Dislike sports 1 No answer 31 Explained that respondents were The results indicate most of the dominated by women as many as 101 people while men were only as many as 20 people. respondents liked sports because they wanted This shows that the majority of women who want a gymnasium. to maintain their body health (65 people). This study shows most of the Moreover, this study finds that the respondents were aged 21-30 years old (75 people), and the 17-20 age group was the most favored sports was swimming (58 second dominant respondents (38 people). It suggests that those who were interested in a people). gymnasium were the adult age group. Table 5. Frequency Distribution of Respondents by Favorite Sports. Table 2. Distribution Frequency of Sports Total Respondents by Age. Basketball 1 Total Self-defense 1 Age 38 Swimming 58 17-20 years 75 Cycling 2 21-30 years 6 Jogging/walking 3 31-40 years 2 Cardio 28 41-50 years Treadmill 35 Weight gain 16 Table 3. Distribution Frequency of Weight loss Respondents by Sport Favoritism. Yoga 33 people Volleyball 1 people 2 people Sports Favoritism Total Health diagnosis of students at Universitas Yes 88 Airlangga No 32 This study addresses external factors that can also influence needs. These referred to physical ability of individuals and resources including the availability of