Health Needs Assessment for Health Promotion in an Indonesian

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聖路加看護学会誌 Vol.18 No.2 January 2015

原 著

Health Needs Assessment for Health Promotion in an Indonesian District of West Java Mayumi Mizutani1), Junko Tashiro2), Maftuhah3) 英文抄録  Purpose:To describe and assess the health needs in a district of West Java, as perceived by selected health professionals in the district in order to explore a strategy for strengthening community health and nursing of the district for health promotion.  Methods:Case study design was used. Data regarding health needs of the district were collected guided by the Precede−Proceed Model through interviews and documents and assessed. Seven participants from the district health office, a district hospital, a nursing school, and a health centre were interviewed. Documents on the websites of the Indonesian Ministry of Health, West Java provincial health office, a district office, and a district health office, and organizational records of the district health office and a nursing school were reviewed.  Results:District health needs were derived from multiple aspects:epidemiological, educational and ecological, and administrative and policy. Epidemiological aspects:remaining needs of maternal and child health;low access to sanitation;increasing noncommunicable diseases(NCDs) ;increasing HIV/AIDS and related environment factors were demographic changes due to increased life expectancy;economy supported by oil industry revenue;increased mobility of workers and weak sanitary systems. Educational and ecological aspects:insufficient functioning of referral system;limited human resources for health promotion;and limited health−sector budget. Administrative and policy aspects:majority of nurses had minimal level nursing education and minimal community nursing education;existing district health strategy for maternal and child health, sanitation, HIV/AIDS, and NCDs;and limited focus on NCDs for role description of community nurse.  Conclusion:Major health needs were identified in maternal and child health, sanitation, HIV/AIDS, and NCDs, insufficient referral system, limited human resources for health promotion, and limited health− sector budget. This study concludes that a local government should address these complicated health needs in order to promote health of people. It is also recommended that a local government should provide continuous education for community nurses to strengthen their collaborative skills with the community for promoting healthy−lifestyle behaviors, and capacity for surveillance of high−risk individuals and follow−up. Keywords:Health Promotion, Needs Assessment, Indonesia

Ⅰ.Introduction

increasing rapidly, even though Indonesia still has

 Indonesia is in a period of epidemiological transition.

burden of high communicable and increasing NCDs is

heavy burden of communicable diseases. This double placing additional pressures on the health system

The number of noncommunicable diseases(NCDs)is 受付日:2013年10月3日 受理日:2014年10月6日

(World Bank, 2008).  Due to the changes in demography and epidemiologi-

1)Doctoral Program in Nursing, St. Luke’s International Univer-

cal pattern of diseases, it is an opportune time for

sity Graduate School

Southeast Asian countries to revisit community health

2)St. Luke’s International University

with the focus on illness prevention and health promo-

3)Syarif Hidayatullah State Islamic University

− 3 −

tion(World Health Organization Regional Office for

the community health needs. However, there is limited

South−East Asia, 2011a) . The promotion of health

information on those needs from the perspective of

across the life span and prevention of disease are the

health promotion. Therefore, it is necessary to assess

most important components for reducing the burden of

the health needs of the community in order to develop

premature mortality and disability due to NCDs. (World

and strengthen community health.

Health Organization, 2008) . In addition to reducing the

Ⅱ.Purpose

level of exposure of individuals and populations to the common modifiable risk factors for NCDs−namely, tobacco use, unhealthy diet, physical inactivity, and the

 The purpose of this study was to assess and describe

harmful use of alcohol−it is important to strengthen the

the health needs in a district of West Java in order to

capacity of individuals and populations to make health-

recommend a strategy for strengthening basic nursing

ier choices and to follow lifestyle patterns that foster

education and health strategies in the district for health

good health.

promotion. The following four goals were set:1)

 The Indonesian Ministry of Health is in the process

describe and assess the health needs in the district

of revitalizing health centres that can address health

from an epidemiological aspect;2)describe and assess

policy direction that prioritizes health promotion and

the health needs from an educational and ecological

prevention without ignoring cure and rehabilitation

aspect;3)describe and assess the health needs from

(Kementerian Kesehatan Republik Indonesia, 2010) .

an administrative and policy aspect;and 4)synthesize

Indonesia’s health care is delivered through an exten-

the district health needs and recommend a strategy for

sive primary care system, which relies heavily on mid-

strengthening basic nursing education and health strat-

wives and nurses. However, the nurses’role in the

egies in the district.

community is limited to immunization services, antena-

Ⅲ.Definition

tal care, and communicable disease treatment(World Health Organization Regional Office for South−East Asia, 2011b). Moreover, the strategic objectives for

 Health needs:In this study, health needs were

health development in most of the Indonesian districts

defined as deficiencies to redress and assets to

focus on maternal and child health and curative ser-

strengthen in health including health professionals’per-

vices with little specific targeting for NCD prevention

ception of health sector’s measurements(health indica-

yet nursing is widely recognized as critical to illness

tors)and policy makers’perception of resources, feasi-

prevention and health promotion(Chiverton et al.,

bilities, and policy.

2003) . A district in West Java provides such an exam-

Ⅳ.Methods

ple and is the focus of this study.  Precede−Proceed Model is the most widely used

1.Study field

planning model for the development and evaluation of health promotion and policy programs in the world

 The study field was a district of West Java in Indo-

(Glasgow, 2011) . It was developed in the 1970s and

nesia. The district was located in the North coastal area

revised in 1991 and again in 2005. The new version is

of West Java and east from the capital city, Jakarta.

more streamlined, consisting of four planning phases,

The district had a population of 1.8 million in 2008 with

one implementation phase, and three evaluation phases.

the majority(90.6%)of Muslim(calculated from Resmi

The four assessment phases include: (1)social, (2)epi-

Pemerintah Provinsi Jawa Barat, 2012).The proportion

demiological, behavioral, and environmental assess-

of working−age population(15−64 years)was the major-

ment;(3)educational and ecological assessment and

ity(67.3%) , followed by younger population(0−14

(4)administrative and policy assessment. The newest

years) (27.5%),and elderly population(over 65 years)

version offers a more efficient planning model that

(5.2%) (Badan Pusat Statistik Kabupaten Indramayu,

merges two phases(that is, epidemiological assessment

2010).The vast plains make the district one of the sup-

and behavioral, and environmental assessment) (Gielen

pliers of the national rice production. Hundreds of arte-

et al., 2008). In order to strengthen the community

sian wells that produce oil and natural gas, which are

health and nursing(as an integral part of community

distributed for consumption in West Java and Jakarta,

health)within the district of West Java in collaboration

contributes to the wealth of the district (Pusat Data dan

with Indonesian researchers, it is crucial to understand

Analisa Pembangunan Jawa Barat, 2012).

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聖路加看護学会誌 Vol.18 No.2 January 2015

2.Participants and recruitment

gies and policy and administrative capabilities and

 The researchers purposively recruited participants from the district health office, a district hospital, a nursing school, and a health centre. These participants were recruited because they were uniquely positioned to

resources.

5.Data collection

 The data were collected in September 2012. Multiple

have field experience and an educated perspective

sources of evidence including documentation and inter-

based on their role in developing health strategies, edu-

views were used. The data regarding the epidemiologi-

cating health professionals, and providing health care

cal and the educational and ecological aspects were col-

services in the district.

lected through semi−structured interviews from participants and through reviewing documents. The data

3.Design

regarding the administrative and policy aspect were

 The design used in this study was a descriptive case

mainly collected through extant documents.

study using Yin’s, (2008)method because little is known

 Each interview was conducted in the official lan-

regarding the health needs in this district of West Java.

guage of Bahasa Indonesia by the bilingual Indonesian

Yin’s case study design provides for a complete sys-

researcher, and the Indonesian researcher translated

tematic description of a phenomenon within its context

participant’s responses into English for the Japanese

and relies on the triangulation of multiple sources of

researcher. Interviews lasted approximately 32 minutes

qualitative and quantitative evidence.

on average including the time for translation.  The researchers used an interview guide to help

4.Theoretical framework

keep the interview on track. The interview guide was

 This study was guided by the Precede−Proceed

based on the Precede−Proceed model. The key ques-

Model(Green et al., 2005) , which is the most widely

tions of the interview guide included the followings:

used planning model for the development of health pro-

What are health needs in the district?;What are envi-

motion and policy programs in the world(Glasgow,

ronmental needs?;Describe the district health system,

2011). The model provides a highly verified structure

how does it function?;What health services are pro-

for systematic and comprehensive data gathering and

vided?;What kind of human resources for health do

analyses. The model contains two components:Predis-

you have?;Describe your basic nursing education;

posing, Reinforcing and Enabling Constructs in Educa-

What is financial basis for health sector?;What is the

tional Diagnosis and Evaluation(PRECEDE)and Policy,

district health strategy to maintain or promote health of

Regulatory, and Organizational Constructs in Educa-

people?

tional and Environmental Development(PROCEED).

 The data was audio−recorded and written on field

The Precede consists of a series of planned assess-

notes with participants’consent, translated from Indo-

ments, and is followed by the Proceed, which is marked

nesian language to English, and transcribed. The third

by the strategic implementation of multiple actions

author(Indonesian)transcribed data and the first

based on the findings of the Precede. The Precede

author(Japanese)and third author arrived at a consen-

assessment process contains four phases:social assess-

sus for the name of the categories. The Indonesian

ment(Phase 1) , epidemiological assessment(Phase 2),

researcher was a lecturer at a university in Indonesia.

educational and ecological assessment(Phase 3) , and

She had 10 years of baccalaureate nursing education

administrative and policy assessment(Phase 4) .

experience in Indonesia and had been supporting stu-

 Social assessment (Phase 1) focuses on the community

dents to conduct research. The three authors were

and their perceptions of social conditions and quality of

involved in the study from the beginning. We continu-

life concerns. Since the study participants were health

ally collaborated about the study purpose, contents and

professionals, we omitted Phase 1 and focused on Phase

methods when we developed the research proposal, as

2, 3, and 4 to assess the health needs in the district.

well as when conducting the research.

Phase 2 includes health, health behavior, and an envi-

 Documents about the health needs in the district

ronmental assessment and Phase 3 includes causal fac-

were searched from the national, provincial, and district

tors such as predisposing, reinforcing and enabling fac-

government websites. Documents on the websites of

tors. Enabling factors are skills, resources, or barriers

the Indonesian Ministry of Health, West Java provincial

that can help or hinder the desired behavioral and envi-

health office, a district office, and a district health office

ronmental changes. Phase 4 includes educational strate-

were reviewed. Organizational records that the − 5 −

researchers obtained during the visit of the district

internal validity, external validity, and reliability. Yin

health office and nursing school in the district were also

noted that internal validity is only for explanatory

reviewed.

study and not for descriptive or explorative study and that external validity is for generalizability, which in

6.Data analysis

this case then would only apply to the health needs of

 Based on Yin(2008) , the data was analyzed to stipu-

this one area in the district. Therefore, we focused on

late a presumed set of causal links about it, or“how”or

the remaining two tests:(1)Construct validity, mean-

“why”something happened to“explain”a phenomenon.

ing identifying the correct operational measures for the concepts being studied. We defined the specific concept

The process was:

of“health needs” . Then, to describe perceived health

(1)Describe the health needs in the district from an

needs of health professionals, we used multiple sources

epidemiological aspect.

of evidence(interviews and documents)for data collec-

(2)Describe the health needs in the district from an

tion. Data taken only through interviews may indicate

educational and ecological aspect.

certain shortcomings in the measure. Therefore, docu-

(3)Describe the health needs in the district from an

ments were also reviewed in order to corroborate,

administrative and policy aspect. (4)Synthesize the district health needs and recom-

extend and enrich the data.(2)For reliability, the field

mend a strategy for strengthening basic nursing

notes were developed as a case study database so that

education and health strategies in the district.

the operation of the study could be repeated. Throughout the study procedure, the researcher received con-

7.Ethical consideration

sistent supervision from the second author, a professor

 This study was conducted following ethical consider-

who had more than 15−year experience of post−gradu-

ations including voluntary participation, privacy protec-

ate nursing education, practice, research and publica-

tion, and data security. The study was conducted

tions and developed the doctoral course in global health

together with a researcher from Syarif Hidayatullah

nursing.

State Islamic University, Jakarta. The permission for

Ⅴ.Results

conducting the study was granted by Kepala Dinas Kesehatan Kabupaten(the Director of the District Health Office)and Kepala Badan Kesatuan Bangsa,

 Seven health professionals participated in the inter-

Politik dan Perlindungan Masyarakat(the Director of

views. They were a director of the district health office,

the Agency for National Unity, Politics, and Community

a director of the district hospital, a group of three nurs-

Protection) . The researcher sought the organizations’

ing lecturers of a nursing school, and two staff of the

cooperation in the research in written format in

health centre.

advance about the research purpose, method, requests,

 H e a l t h n e e d s a s s e s s m e n t s o f t h e d i s t r i c t a r e

and ethical consideration. Participants were recruited

described next from three aspects: (1)epidemiological,

from the organizations that agreed to participate in the

(2)educational and ecological, and(3)administrative

research. Before beginning data collection, the Indone-

and policy. Each health needs assessment included data

sian researcher explained the purpose and the process

from the documents and the data from the interviews.

of the study to the participants and their written informed consent was obtained. The data that they provided were recorded only with the participants’ consent and were treated anonymously. Audio data and inter-

1.Epidemiological aspect of the health needs

 The phase of epidemiological assessment included

view transcripts were securely stored in a locked place.

two main areas. The first was the identification of the

All data will be destroyed three years after the study is

health needs and secondly the environment.

complete. The research ethics committee of St. Luke’s

1)Health needs. The following four health needs were

College of Nursing, Japan approved the study

derived:maternal and child health, sanitation, non-

(Approval number 11−029) .

communicable diseases, and HIV/AIDS.   (1)Remaining needs of maternal and child health.

8.Validity and reliability

Every participant reported about needs involving

 Yin(2008)recommended the following four tests to

maternal and child health. They pointed out the rela-

establish the quality of the study:construct validity,

tively high maternal mortality ratio and high infant

− 6 −

聖路加看護学会誌 Vol.18 No.2 January 2015 mortality rate. The district infant mortality rate(IMR)

reported HIV/AIDS as an increasing health issue in the

was 47 out of 1,000 live births, which was higher than

district because of the existence of people who work

the provincial average(39/1,000) . The district maternal

abroad. In the district, 47 HIV cases were found in

mortality ratio (MMR) was 108 out of 100,000 live births,

2007. The number of people living with HIV/AIDS

which was higher than the provincial average(95/

increased about 120% from 686 in February 2012 to

100,000) (Dinas Kesehatan Provinsi Jawa Barat, 2008).

825 in October 2012(Kompas, 2012).

Serving as a background about the high MMR and IMR,

  “HIV/AIDS now is increasing in the district. The

the antenatal visits and delivery of health care services

HIV/AIDS cases were high among returned female

in the district were derived. Pregnant women in the

workers who have been working in overseas. Around

district who received antenatal care four times were

70% cases related to unsafe sexual behavior and about

61.5%, which was lower than the rate in West Java

30% related to drug abuse. Strategy related this issue,

(79.7%). Women in the district who delivered sup-

the district hospital just opening a ward specific for

ported by skilled health personnel were 56.2%, which

integrative care management of HIV/AIDS cases.”

was lower than the rate in West Java(71.4%) (Dinas

2)Environment. There were four environmental factors. These were derived as a background of the

Kesehatan Provinsi Jawa Barat, 2008) .

aforementioned health needs.

 “MMR and IMR were focus of health effort in the area. Recently, MMR caused by eclampsia was higher

  (1)Demographic change due to increased life expec-

than postpartum hemorrhage, in which previous time

tancy. One participant reported that improvement in

postpartum hemorrhage was the major problem caused

life expectancy contributed to their aging society. The

MMR. The health district office is now investigating

life expectancy of the district was reported as

this unique trend.”

improved from 65.2 in 2006 to 66 years in 2008. The

 (2)Low accessibility to sanitation. Two participants

proportion of working−age population(15−64 years)was

reported sanitation as a health need. One participant

the majority(67.3%) , followed by younger population

thought that approximately 25% of the community

(0−14 years)(27.5%), and elderly population(over 65

lacked accessibility to latrines, which means they must

years) (5.2%) (Badan Pusat Statistik Kabupaten Indra-

use open fields or the river.

mayu, 2010).

  “Perilaku Hidup Bersih dan Sehat(PHBS)which

  “Health strategy in the district is purposed to

means behavior toward healthy lifestyle and sanitation

improve human development index. Life expectancy in

is a big problem in the district, for example, limited

this district is 66, which improved. Number of elderly is

access to sanitary water especially during dry season.

also tend to increase, thus we need to revitalize Posy-

Around 100,000 out of 400,000 houses do not have sani-

andu(health post)to provide services for children and

tary toilet.”

elderly as well.”

 (3)Increasing noncommunicable diseases. Two par-

  (2)Economy supported by revenue of oil industry.

ticipants reported NCDs like hypertension as an emerg-

The district is the fourth biggest contributor to the pro-

ing health issue due to an aging society. A participant

vincial budget, which accounts for 7.4% of the district

reported that hypertension was one of the main mor-

gross domestic products. The dominant sector contrib-

bidities in the health centre and was common in West

uting to the gross domestic product was oil and gas

Java. It was the third leading cause of morbidity for

(66.1%)in 2008(calculated from Resmi Pemerintah

outpatients aged 45−64 and the leading morbidity for

Provinsi Jawa Barat, 2012).

outpatients over aged 65 at health centres in West

 (3)Increased mobility of workers and HIV/AIDS.

Java. Three out of the top ten morbidities for outpa-

One participant reported that certain types of mobility

tients aged 45−64 and over 65 in hospitals in West Java

among workers contributed to the HIV epidemic. Of

were NCDs, including hypertension, cardiovascular dis-

the 10,358 people living with HIV/AIDS in West Java,

eases, and diabetes mellitus(Dinas Kesehatan Provinsi

about 30% reside in the Northern coastal region, which

Jawa Barat, 2008) .

includes the study district. The Northern coastal region

 “For NCDs, hypertension, diabetes, cardiac diseases

became vulnerable because of the unsafe sexual behav-

are common problems among elderly in the district.

ior commonly found among people employed for trans-

Posbindu is health center in village level specific for

portation such as:truck and bus drivers, bus ticket

promoting elderly health.”

sellers, parcel deliverer, and fishermen(Kompas, 2012) .

  (4)I n c r e a s i n g H I V/ A I D S . T w o p a r t i c i p a n t s

Out of the total 14,495 registered workers in the dis-

− 7 −

trict, 2,915 of them(20.1%)are working abroad(Pemer-

tors(specialist and generalist)per 100,000 people in the

intah Kabupaten Indramayu, 2012b) . A study con-

district was 6.0, which was lower than the provincial

ducted in Central Java found that the majority of Indo-

average of 7.0. The ratio of nurses was 52.3, and that of

nesian people suffering HIV/AIDS were Indonesians

the midwives was 25.4, which was higher compared to

working or ever had been working abroad (Sukesi et al.,

the provincial average, respectively 36.3 and 19.1(Dinas

2012) .

Kesehatan Provinsi Jawa Barat, 2008).

 “Working abroad is a highly expected by young peo-

 “Number of nursing and midwife personnel for Pusk-

ple in the district. Averagely 300 to 400 young workers

esmas(health center)and hospital were enough. How-

per village(number of village in the district is 316 vil-

ever, midwife for villages is still limited as well as num-

lages)work overseas such as Mideast, Korea, China,

ber of physician and dentist also need to be added.

Malaysia and Japan.”

There is a policy‘one midwife for every village.’ ”

 (4)Weak sanitary system infrastructure. As of 2009

 (3)Limited budget for health sector. A participant

of the total 492,549 households in the district, there

reported that only 1% of the district budget is allocated

were 337,100(68.4%)households having clean water

for the health sector. The total district health budget

facilities like taps and wells(Pemerintah Kabupaten

was 4.2% and the per capita health budget was 28,737

Indramayu, 2012a) . Latrine availability for households

Indonesian rupiah [approximately USD $3.0] , which was

was approximately 25%.

lower than for West Java, respectively 5.2% and 49,408

 “Limited access to sanitary water especially during

rupiah[approximately USD $5.1] (Dinas Kesehatan

dry season. Around 100,000 out of 400,000 houses do not

Provinsi Java Barat, 2008).

have sanitary toilet.”

 “The health budget in the district was about 1.125% from total budget of the district. The province budget

2.Educational and ecological aspect of the health needs

was 8.5%, we expected to have about 10% so we could

includes causal factors such as enabling factors.

3.Administrative and policy aspect of the health needs

do health promotion to improve healthy behavior.”

 This phase of educational and ecological assessment  Enabling factors. Participants reported three weak enabling factors:insufficient functioning of the referral

 Administrative and policy assessment entails the

system;limited human resources for health promo-

analysis of resources and political supports. These are

tion;and the district’s limited budget for the health

to enable the development of educational and environ-

sector.

mental supports for community action.

 (1)Inefficient functioning of the referral system. A

1)Educational strategies

participant reported that people go directly to the hos-

  (1)Majority of nurses had minimal level nursing

pital due to insufficient management ability at health

education. The majority of nurses(55.9%)in the district

center level. A participant reported that they provided

completed their education at SPK or Sekolah Perawat

delivery care, immunization and curative care for dis-

Kesehatan(equivalent to high school), followed by

eases at a health centre. The participant also mentioned

diploma(43.7%), and bachelor’s degree(0.4%) . The

that they referred patients to a hospital in case of

rates for West Java were, respectively 40.7%, 57.7%,

severe conditions like uncontrolled hypertension, car-

and 1.7%. The majority of midwives in the district

diac failure, and kidney failure.

completed their education at the diploma level(95.8%) ,

  “Many patients come to this hospital without referral

which was similar to the rate in West Java(94.0%)

from Puskesmas(health center)which mandated by

(Calculated from Dinas Kesehatan Provinsi Jawa Barat,

health insurance rules. When patients come directly to

2008.).

the hospital without referral, it is dilemmatic, in one

  (2)M i n i m a l c o m m u n i t y n u r s i n g e d u c a t i o n a t

side we cannot reject the patients but on the other

diploma level. Class credits for community nursing at

hand we cannot charge the expenses to government.

diploma level were about half the number credits at the

Thus, often the patients have to pay by themselves.”

bachelor’s level. According to the World Health Organi-

  (2)Limited human resources for health promotion.

zation Regional Office for South−East Asia(2011c),

A participant reported limited human resources for

there are about 15 class credits for community, family,

health promotion. Only 50% of the human resource tar-

and gerontology for the bachelor’s of nursing. Class

get was accomplished for the district. The ratio of doc-

credits for community, family, and gerontology nursing − 8 −

聖路加看護学会誌 Vol.18 No.2 January 2015

PRECEDE Administrative & policy assessment

Educational & ecological assessment

Minimal level of nursing education Minimal community nursing education at diploma level

Insufficient function of the referral system

Existing district health strategy for matemal and child health, sanitation, HIV/AIDS, and NCDs

Limited human resources for health promotion

Limited focus on NCDs for role description of community nurse

Limited budget for health sector

Epidemiological assessment Complicated health needs -Remaining needs of matemal and  child health -Low accessibility to sanitation -Increasing NCDs -Increasing HIV/AIDS Environment -Demographic change due to increased life  expectancy -Economy supported by revenue of oil  industry -Mobility of workers and HIV/AIDS -Weak sanitary system infrastructure

Figure 1 ‌‌Health‌Needs‌Assessment‌for‌Health‌Promotion‌in‌an‌Indonesian‌ District‌of‌West‌Java

in a diploma level nursing school in the district, were

AIDS. Based on the Ministry of Health’s decree on

seven credits. The total credits were 32 credits points:

community health nursing(No 279 year 2006) (Kemen-

five for medical surgical nursing, four for pediatric

terian Kesehatan Republik Indonesia, 2006), the follow-

nursing, four for maternal nursing, four for acute care

ing six services were described:health promotion;

nursing, four for nursing administration, four for psychi-

maternal and child health;nutrition;communicable

atric nursing, three for community nursing, two for

diseases;healthy environment;and treatment.

family nursing, and two for gerontology nursing.

Ⅵ.Discussion

  “Credits for community nursing in our school is three credits, divided into classroom and practicum. Community nursing practicum is around five weeks and

 A model of health needs assessment in a district of

becomes nine weeks if combined with geriatric and

West Java for health promotion was derived from a

family nursing.”

synthesis of the findings (Figure 1) and compared with

2)Policy, regulation, and organization

the national trends. The researchers then discussed the

 (1)Existing district health strategy for maternal

implications of the findings for basic nursing education

and child health, sanitation, HIV/AIDS, and NCDs. Four

and health strategies of the district and strengths and

main health needs, namely maternal and child health,

the limitations of the study.

sanitation, HIV/AIDS, and NCDs were articulated in the 2011−2015 strategic objectives for health development in the district(Dinas Kesehatan Kabupaten Indra-

1.Health needs in the district

 The district of West Java was suffering from compli-

mayu, 2012).The following six objectives were stated:

cated health and environmental needs. In addition to

1)improve community independence and empower-

maternal and child health and sanitation needs, NCDs

ment;2)improve healthy environments;3)improve

were an increasing health needs. As a background,

maternal and child health and nutritional status;4)

demographic changes due to improved life expectancy

improve access and quality of basic health services;

and economy supported by oil industry were reported.

5)improve prevention and control of diseases and 6)

The situation was similar to that of the nation as a

improve the management of government. Specific tar-

whole. While Indonesia still has the burden of communi-

gets on maternal and child health, sanitation, HIV/

cable diseases, the number of NCDs is increasing rap-

AIDS, and NCDs were described.

idly(World Bank, 2008) . In Indonesia, of all deaths,

 (2)Limited focus on NCDs for role description of

NCDs have increased from 52% in 2004(World Health

community nurse. The community nursing services

Organization, 2009)to 64% in 2008(World Health Orga-

were focused on maternal and child health and commu-

nization, 2011)representing a 12% increase in four

nicable disease but had little focus on NCDs and HIV/

years. The demographic changes are closely associated − 9 −

with changes in the cause of death(World Bank, 2008)

prevent new nurses from having enough competencies

ranging from communicable diseases to deaths from

for actual practice.

NCDs. The life expectancy of people in Indonesia has

 To address the complicated health issues, more

increased from 65 in 1990 to 68 in 2008(World Health

attention should be given to preventive and promotive

Organization, 2012b)and the proportion of working−age

health care by existing human resources for health.

population has increased from 59.5% in 1990 to 66.9%

The role of community nurses should be activated

in 2010(United Nations, 2010) . The nutritional transi-

because they are the front−line healthcare provider in

tion brings an epidemic of diet−related NCDs. Economic

the district.

growth has contributed to lifestyle changes like greater food consumption in Indonesia(Rada et al., 2010).  Moreover, HIV/AIDS was an increasing health issue in the district due to the mobility of people. Although HIV prevalence is still low, the increase of prevalence

2.Implications for strengthen basic nursing education and health strategies in the district  Implication for basic nursing education. In order to

is high, which will bring additional burdens to the dis-

meet the health needs of increasing NCDs and HIV/

trict. The trend is similar the nation as a whole.

AIDS in the district, basic education for nursing and

Although the aggregate national HIV prevalence is still

midwifery needs to be gradually strengthened at the

low (0.3%) (Jakarta Post, 2012) , the increase of reported

bachelor’s level. Indonesia is in the process of providing

cumulative AIDS cases in Indonesia is high, making it

higher education in nursing. Bachelor’s programs in

one of the fastest growing epidemics in Asia(World

nursing increased from one in 1985(Persatuan Perawat

Health Organization Regional Office for South−East

National Indonesia, 2013)to 318 in 2011(Asosiasi Insti-

Asia, 2007).

tusi Pendidikan Ners Indonesia et al., 2012). Moreover,

 As a background of complicated health and environ-

since most of the nurses working for health centres

mental needs, this study found needs related to ineffi-

complete their education at diploma or high school

cient functioning of the referral system at the health

level, emphasis on community nursing education at

centre with its limited human resources for health pro-

those levels is crucial. It is also necessary to promote

motion and limited district health sector budget. The

existing nurses’access to continuing education related

health service given in the health centre was prone

to NCDs prevention and health promotion.

toward curative treatment rather than health promo-

 Implications for district health strategy. In order to

tion and disease preventative treatment. To address

meet the district’s health needs, health systems need to

complicated health needs, it is important to promote

be strengthened with the support of health policy and

healthy lifestyles for all people throughout the health

strategy. More attention should be given to complex

care continuum(World Health Organization, 2012a) .

health needs of maternal and child health, sanitation,

For an effective health care continuum, disease preven-

HIV/AIDS, and NCDs. The guideline for the commu-

tion and health promotion at the health centre is neces-

nity nurses should include the complex health needs of

sary.

the district including NCDs in order to provide a frame-

 Although, the district health strategy for maternal

work for nursing interventions in the community.

and child health, sanitation, HIV/AIDS, and NCDs

 Preventative and promotive health care should be

existed, the assessment revealed a complex web of sys-

strengthened. For example, health education about

tem weaknesses:inefficient functioning of the referral

Perilaku Hidup Bersih dan Sehat(healthy and clean

system at the health centre with its limited human

lifestyle behavior)should be strengthened at the Posy-

resources for health promotion and limited district

andu(community health post for maternal and child

health−sector budget, minimal level nursing education,

health)and the Posbindu(community health post for

minimal community nursing education at diploma level,

elderly). Health education for healthy lifestyle behav-

limited focus on NCDs for the role description of com-

iors is necessary because some NCDs(e. g. cardiovas-

munity nurses. Furthermore, credits for community

cular diseases, diabetes)and some maternal health

nursing education are less at the diploma level than at

issues for example eclampsia have shared risk factors

the bachelor’s level. The majority of nurses working in

such as hypertension, raised blood glucose, and obesity.

health centres completed their education at a diploma

To compensate for the limited human resources for

or high school equivalent level. Limited focus on credits

health promotion, it is necessary for community nurses

for community nursing at the basic education level may

to collaborate with key community people such as the

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聖路加看護学会誌 Vol.18 No.2 January 2015 Kaders(health volunteers) , village chiefs, and imams (religious and community leaders) . Health centers and the health district need to educate community nurses in order to improve and maximize their capacity to collaborate with community people.  To address the insufficient functioning of the referral system, it is necessary to activate the role of community nurses. Their capacity for case−finding of high−risk people in the community, follow−up of high−risk people, and referring patients whenever necessary should be strengthened.  Even with the limited budget it should be allocated appropriately to support implementation of preventive and promotive health care. In order to do so, further studies are needed to support the study findings to encourage policy makers in recognizing the health needs in the district.

3.Strength and limitations

 The strength of this study was that it provided information from the perspectives of health professionals on the health needs of the community in a district of West Java in Indonesia from the perspective of health promotion.  However, the study was limited in that data were gathered only from health professionals. Further study is needed to include participants’perspectives from the people who receive healthcare in order to understand public’s perceived needs and priorities. In addition, there was the usual caution regarding researcher bias in interpreting the data due to the language barrier. The collaboration process with the Indonesian researcher served to minimize researcher bias. Acknowledgements  To each participant who was interviewed, thank you for sharing the fruitful information. This work was supported by JSPS KAKENHI Grant Number 23660114. References Asosiasi Institusi Pendidikan Ners Indonesia, Asosiasi Institusi Pendidikan Diploma Tiga Keperawatan Indonesia, Persatuan Perawat Nasional Indonesia[Indonesian Nurses Education Institute Association, Indonesian Diploma Nursing Education Institution Association, Indonesian National Nurses Association](2012):Standar Pendidikan Keperawatan Indonesia[Indonesian Nursing Education Standard]. http://hpeq.dikti.go.id/v2/images/Produk/19.3− Draf−Standar−Pendidikan−Keperawatan−19−Oktober− 2012.pdf(in Indonesian)(2013/7/22). Badan Pusat Statistik Kabupaten Indramayu[Indramayu

district statistics central agency] (2010) :Penduduk Kabupaten Indramayu Menurut Kelompok Umur Dan Jenis Kelamin Tahun 2010[Population by age classification and gender in 2010]. http://indramayukab.bps.go.id/images/ Data/IDA2010/3.8.4−2010.pdf(in Indonesian)(2012/10/ 29) . Chiverton PA, Votava KM, Tortoretti DM(2003):The future role of nursing in health promotion. American Journal of Health Promotion , 18(2) :192−194. http://www.ncbi. nlm.nih.gov/pubmed/14621418(Abstract) (2012/12/14) . Dinas Kesehatan Kabupaten Indramayu [Indramayu District Health Office] (2012) :Visi Misi Dinas Kesehatan Kabupaten Indramayu Tahun 2011−2015[Vision and mission of Indramayu health district office in the year 2011−2015]. http://dinkes.indramayukab.go.id/visi−misi.html(in Indonesian) (2012/11/16) . Dinas Kesehatan Provinsi Jawa Barat[West Java Province Health Office] (2008) :Tabel Profil Kesehatan Provinsi Jawa Barat Tahun 2007[Table of West Java provincial health profile in 2007]. http://www.depkes.go.id/down loads/profil/prov%20jabar%202007.pdf(in Indonesian) (2012/10/29) . Gielen AC, McDonald EM, Gary TL, et al. (2008) :Using the PRECEDE−PROCEED model to apply health behavior theories., Health behavior and health education;Theory, research, and practice (4th ed.), Glanz K, Rimer BK, Viswanath K(eds.) , 407−433, Jossey−Bass, San Francisco. Glasgow RE(2011) :Planning models and theories;Integrating components for addressing complex challenges. Journal of Public Health Dentistry , 71:S17. Green L, Kreuter M(2005) :Health program planning;An educational and ecological approach (4th ed.). McGraw− Hill, New York. Jakarta Post(2012) :Government focuses on prevention of HIV infection . http://www.thejakartapost.com/news/ 2012/03/03/government−focuses−prevention−hiv−infec tion.html(2012/12/8) . Kementerian Kesehatan Republik Indonesia[Ministry of Health Republic Indonesia] (2006) :Pedoman Penyelenggaraan Upaya Keperawatan Kesehatan Masyarakat di Puskesmas(NOMOR 279/MENKES /SK /IV /2006) [Guidelines for implementation of community health nursing efforts in health centers]. http://www.hukor.depkes.go. id/up_prod_kepmenkes/ (in Indonesian) (2012/10/29). Kementerian Kesehatan Republik Indonesia[Ministry of Health Republic Indonesia] (2010)Pembangunan Kesehatan Berbasis Preventif dan Promotif[Preventive and promotive based health development]. http://www. depkes.go.id/index.php/berita/press−release/849−pem bangunan−kesehatan−berbasis−preventif−dan−promotif. html(in Indonesian) (2012/10/29) . Kompas(2012) :Kasus HIV /AIDS di Pantura Tertinggi di Jawa Barat[HIV /AIDS cases in north coast is the highest in West Java]. http://health.kompas.com/read/2012/11/ 08/09374383/ (in Indonesian) (2012/11/16) .

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Pemerintah Kabupaten Indramayu[Indramayu district government](2012a):Kesehatan[Health]. http://www. indramayukab.go.id/statistik/100−kesehatan.html(in Indonesian)(2012/11/9). Pemerintah Kabupaten Indramayu[Indramayu district government] (2012b) :Sosial Tenaga Kerja dan Transmigrasi

[Social workforce and transmigration]. http://www.indra mayukab.go.id/statistik/96−sosial−tenaga−kerja−dan− transmigrasi.html(in Indonesian)(2012/11/9). Persatuan Perawat National Indonesia[Indonesian National Nurses Association](2013):Pendidikan keperawatan [Nursing Education]. http://www.inna−ppni.or.id/index. php/keperawatan−di−indonesia/pendidikan−keperawatan (in Indonesian)(2013/7/25). Pusat Data dan Analisa Pembangunan Jawa Barat[West Java development data and analysis centre](2012) :Sekilas Tentang Kabupaten Indramayu[Glance of Indramayu district]. fromhttp://bappeda.jabarprov.go.id/pusdalis bang/index.php?option=com_content&view=article&id =120:profil−daerah−kabupaten−indramayu&Itemid=75 (in Indonesian)(2012/10/29). Rada N, Regmi A(2010):Trade and food security implications from the Indonesian agricultural experience(United States Department of Agriculture). http://www.ers.usda. gov/Publications/WRS1001/WRS1001.pdf(2011/9/9) . Resmi Pemerintah Provinsi Jawa Barat[West Java Province Governmental Office](2012):Kinerja Perekonomian Kabupaten /Kota Di Jawa Barat[Economic performance of regencies /cities in West Java]. http://www.jabarprov. go.id/root/pdrb/BabVLapanganUsaha2006.pdf(in Indonesian)(2012/10/29). Sukesi K, Hany A, Putra KR(2012) :Survey of HIV(AIDS) and sexually transmitted disease in Indonesian migrant workers arrived at Juanda international airport Surabaya. Journal of Basic and Applied Scientific Research , 2(6): 5832−5835. United Nations(2010) :World population prospects . http:// esa.un.org/unpd/wpp/Excel−Data/population.htm(2012/ 11/25). World Bank(2008):Investing in Indonesia’s health:Challenges and opportunities for future public spending . World Bank, Washington DC.

World Health Organization(2008) :2008 −2013 action plan for the global strategy for the prevention and control of non-

communicable diseases . World Health Organization, Geneva. World Health Organization(2009) :Death and DALY estimates for 2004 by cause for WHO Member States . http:// w w w . w h o . i n t/ h e a l t h i n f o/ g l o b a l _ b u r d e n _ d i s e a s e/ gbddeathdalycountryestimates2004.xls(2012/10 29). World Health Organization(2011) :Death estimates for 2008 by cause for World Health Organization member states . http://www.who.int/gho/mortality_burden_disease/ global_burden_disease_death_estimates_sex_2008.xls (2012/10/29) World Health Organization. (2012a) :Strengthening the role of nursing and midwifery in noncommunicable diseases . http://www.who.int/hrh/nursing_midwifery/20MayFo rum_statement.pdf(2012/11/9) World Health Organization(2012b) :World health statistics 2012 . World Health Organization, Geneva. World Health Organization, Country Office for Indonesia (2008):WHO country cooperation strategy 2007−2012 − Indonesia . World Health Organization Regional Office for South−East Asia, New Delhi. World Health Organization Regional Office for South−East Asia(2007) :Review of the health sector response to HIV and AIDS in Indonesia:2007 . World Health Organization Regional Office for South−East Asia, New Delhi. World Health Organization Regional Office for South−East Asia(2011a) :Community health nursing outreach model in Indonesia . http://www.searo.who.int/en/Section1243/ Section2167/Section2168_15779.htm(2012/9/29) World Health Organization Regional Office for South−East Asia(2011b) :Community health nursing outreach model in Indonesia . http://www.searo.who.int/en/Section1243/ Section2167/Section2168_15779.htm(2012/9/29) World Health Organization Regional Office for South−East Asia(2011c) :Country paper on community health nurse / public health nurse in Indonesia . http://www.searo.who. int/en/Section1243/Section2167/Section2168_15779.htm (2012/9/29) Yin RK(2008) :Case study research:Design and methods (4th ed.) . Sage, Newbury Park CA.

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聖路加看護学会誌 Vol.18 No.2 January 2015

和文抄録

インドネシア西ジャワ州 A 県におけるヘルスプロモーションの ための保健ニーズアセスメント 水谷 真由美1),田代 順子2),Maftuhah3) 1)聖路加国際大学大学院博士課程,2)聖路加国際大学,3)Syarif Hidayatullah State Islamic University

 目的:本研究の目的は,インドネシア西ジャワ州 A 県における保健専門職の保健ニーズを記述・アセスメントし, ヘルスプロモーションに向けた地域保健・看護強化のための戦略を探索することである.  方法:研究デザインは,ケーススタディを用いた.Precede−Proceed Model を枠組みとし,文書とインタビューに より,県の保健ニーズに関するデータを収集・分析した.文書は,インドネシア保健省,西ジャワ州保健局,県庁,県 保健局のウェブサイトおよび県保健局と県看護学校の資料をレビューした.県保健局,県看護学校,保健センターから の7人の対象者にインタビューを実施した.  結果:県の保健ニーズは,疫学,教育・組織,運営・政策の側面から得られた.疫学的側面は,残存する母子保健の ニーズ,衛生へのアクセス不十分,増加する非感染性疾患,増加する HIV/AIDS があり,関連する環境要因は,平均 寿命の延伸による人口構造変化,石油産業の収入による経済,労働者の移動の増加,衛生システムの整備不足があっ た.教育・組織的側面は,不十分なリファラルシステム,健康増進のための保健人材不足,保健セクターの予算不足で あった.運営・政策的側面は,大多数のナースが最小限の看護基礎教育,最小限の地域看護教育を受けていること,母 子保健,衛生,HIV/AIDS,非感染性疾患についての県保健戦略が存在すること,地域看護の役割のなかで非感染性疾 患への焦点が限られていることであった.  結論:西ジャワ州 A 県の主要な保健ニーズは,母子保健,衛生,HIV/AIDS,非感染性疾患,不十分なリファラル システム,健康増進のための保健人材不足,保健セクターの予算不足であった.県保健局は,住民の健康増進のため に,この複雑な保健ニーズに対応することが課題である.また県保健局は,住民と協働して,住民の健康的なライフス タイル行動の促進,ハイリスク集団の発見とフォローアップを行っていくための地域保健担当看護師への継続教育の 強化が必要であると提言される. キーワード:健康促進,ニーズアセスメント,インドネシア

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Health Needs Assessment for Health Promotion in an Indonesian

聖路加看護学会誌 Vol.18 No.2 January 2015 原 著 Health Needs Assessment for Health Promotion in an Indonesian District of West Java Mayumi Mizutani1), Junko T...

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