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An increasing number of smokers is associated with an increased risk of tuberculosis (TB). The risk of TB can be reduced by two thirds if someone stops smoking. The purpose of this study was to determine smoking behavior in TB patients in three puskesmas in Banyuwangi District (Puskesmas Sobo, Puskesmas Kertosari, and Puskesmas Singotrunan). This research is a descriptive study with a cross-sectional approach, which was conducted for 6 (six) months, June to December 2017. This study used data from a study entitled "nutrition status, social support, and health-related quality of life in tuberculosis patients at the center Banyuwangi health services ". Data were collected by conducting a survey using a questionnaire to 71 TB patients, but only male TB patients (56.3%) were further investigated. The results of this study showed 15% of male TB patients continued to smoke, 7.5% smoked daily and 7.5% smoked occasionally. Of the male TB patients who do not currently smoke, 73% smoked daily, and 9% smoked occasionally. As many as 85% of male TB patients have smoked, 4% smoked 5 minutes after waking up, and 21% smoked 6 to 30 minutes after waking up. As many as 11% of male TB patients who smoke spend more than 31 cigarettes, and 14% use 21 to 30 cigarettes. It can be concluded that there are still male TB patients who continue to smoke. The results of this study indicate that the need for empowerment of the PMO (Drugs Supervisor) to monitor smoking behavior in TB patients, counseling in TB patients should be able to detect the existence of addiction to smoking and consultation efforts to stop smoking.

There is a major gap of action by the Indonesian government to control tobacco advertisement. This study aimed to compare outdoor tobacco advertisements (OTAs) in locations with and without OTA bans in relation to their proximity to children and adolescents. Global positioning system coordinates of all OTAs visible from the streets in Banyuwangi and Surabaya in East Java province were collected and analysed to determine their density at 0–100, >100–300 and >300–500 m from facilities used by children and adolescents. Hotspot analysis was conducted to identify places with exceptionally high densities of OTAs. The number and density of OTAs in Surabaya, where there was no policy for controlling OTAs, were greater than those in Banyuwangi, where OTAs were partially banned. Regardless of the existence of a ban, OTAs were 2.6–3.4 times denser in areas closer to facilities used by children and adolescents than further apart. The OTA point hotspots approximated the hotspots of tobacco retailers and facilities used by children and adolescents in both locations. A partial ban may only have a small impact. A total advertising ban, including at point of sale, should be encouraged for both locations for optimal protection of children and adolescents.

Rationale Brain development occurs rapidly during early childhood and continues throughout middle childhood. Early and later windows of opportunity exist to alter developmental trajectories. Few studies in low- and middle-income countries have examined the importance of the timing of exposure to risks for poor pre-adolescent cognitive and social-emotional outcomes. Methods We assessed 359 children who participated in two follow-up studies of the Supplementation with Multiple Micronutrients Intervention Trial conducted in Indonesia in 2001–2004: at 3.5 years in 2006 and 9–12 years in 2012–2014. Using structural equation models, we examined indicators of early childhood (3.5 y) and pre-adolescent (9–12 y) exposure to risks (child height-for-age z-score [HAZ], hemoglobin [Hb], maternal depressive symptoms [MDS], home environment [HOME]), with two developmental outcomes: cognitive ability and social-emotional problems. We characterized patterns of change by calculating residuals of indicators measured earlier (3.5 y) predicting the same indicators measured later (9–12 y), for example, the residual of 3.5 y MDS predicting 9–12 y MDS (rMDS). Results Three early risk indicators (HOME, Hb, and MDS) were indirectly associated with pre-adolescent cognitive scores through early cognitive scores (HOME: 0.15, [95% CI 0.09, 0.21]; Hb: 0.08 [0.04, 0.12], MDS: −0.07 [-0.12, −0.02]). Pre-adolescent cognitive scores were also associated with change in MDS (rMDS: −0.13 [-0.23, −0.02]) and Hb (rHb: 0.10 [0.00, 0.20]) during middle childhood. For pre-adolescent social-emotional problems, both early childhood MDS (0.31 [0.19, 0.44]) and change in MDS during middle childhood (rMDS: 0.48 [0.37, 0.60]) showed strong direct associations with this outcome. Conclusions Our findings confirm those of previous studies that prevention of risk exposures during early childhood is likely to support long-term child development. It also adds evidence to a previously scarce literature for the middle childhood period. Prevention of maternal depressive symptoms and child anemia during middle childhood should be assessed for effectiveness to support child development.

BACKGROUND: Hypertension is a disease that still a problem in the world. Hypertension is a risk factor for heart disease and stroke mortality. Economic development and an emphasis on coastal tourism may have an impact on public health conditions, such as hypertension. This study aimed to determine risk factors related to hypertension among adults in coastal communities in Indonesia.METHODS: This was a cross-sectional study of 123 respondents between the age of 18-59 years old selected by cluster sampling. This study was conducted among coastal communities in Banyuwangi District, East Java, Indonesia. Data was analyzed using multivariate logistic regression.RESULTS: Our study showed that the prevalence of systolic and diastolic hypertension among residents of coastal communities were as high as 33.33% and 31.71%, respectively. Increasing age was associated with systolic and diastolic hypertension (ORsystolic=1.11; 95% CI=1.03-1.19, p=0.01 and ORdiastolic=1.07; 95% CI=1.01-1.15, p=0.03) after controlling other variables. Respondents with the poorest and richer socio economic status had higher odds of having systolic and diastolic hypertension compared to respondents with the richest socio-economic status (ORsystolic-poorest =12.78; 95% CI=1.61-101.54, p=0.02; ORsystolicricher=10.74; 95% CI =1.55-74.37, p=0.02 and ORdiastolicpoorest= 10.36; 95% CI= 1.40-76.74, p=0.02;ORdiastolic-richer=6.45;95% CI=1.01-41.43, p=0.05) after controlling other variables.CONCLUSION: Being of older age and of the lower in socioeconomic status are significantly associated with increasing risk for systolic and diastolic hypertension in these coastal communities. More studies need to be done in these and other coastal village to help design appropriate health promotion and counseling strategies for coastal community.

IntroductionThe tobacco retail density in Indonesia is very high, and tobacco companies are creative at promoting their products at point of sale (POS). The study explores the strategies employed by tobacco companies through their retailer programmes in Banyuwangi, Indonesia.MethodsIn 2019 we conducted observation and indepth interviews with the owners/keepers of 12 retailers with Sampoerna Retail Community (SRC) signs and 6 retailers with Gudang Garam Strategic Partnership signs placed as store names in front of their stores. We analysed the data to identify key strategies used by each tobacco company.ResultsGudang Garam promoted more visibility of their own products, while Sampoerna promoted their products in a power wall and also rearranged other products sold in the store to attract more customers. Sampoerna educated their retailers to attract and retain more customers by using schemes such as reward points and coupons. Sampoerna also developed and promoted the use of a mobile application for online sales.ConclusionsBoth programmes promote product and brand display at retailers to create brand loyalty. The SRC mobile application for online sales is potentially attractive to young customers and allows for data collection about retail and customer purchase behaviours that can be used for tailored marketing. Tobacco sales promotion strategies should be strongly regulated. Banning indoor tobacco advertisement, promotion and tobacco display at POS should be encouraged.

Introduction There are weak regulations and controls on tobacco sales to adolescents in Indonesia, and these may have contributed to the increase in smoking prevalence among adolescents in the country. Our study aims to calculate the density of cigarette retailers near schools and ascertain the factors associated with sales to minors. Methods We conducted geographical mapping by recording the GPS position of cigarette retailers in 15 locations in Banyuwangi District, Indonesia, to assess the density and proximity of cigarette retailers to schools. We interviewed randomly selected retailers, from the geographical mapping, for information on sales to minors, the cheapest price cigarettes are sold and the most popular cigarette brand purchased by adolescents, as well as owners/keepers knowledge of the regulation regarding sales to minors. Results We identified 770 retailers of consumer goods in the study location; 28.1% (216) sold cigarettes, with mean density of 1.1 cigarette retailers per 100 m. Of the cigarette retailers, 6.9% were located

In the midst of tackling the persistent burden of maternal mortality and infectious diseases, Indonesia is facing an increasing burden of non-communicable diseases (NCDs). Although there are increasing national efforts in NCD prevention and control, the worsening trend of NCD risk factors and morbidity is alarming. We provided assessment and discussion on the policies and actions needed in the country including comprehensive efforts to reduce tobacco use and unhealthy diet, the need to reorient the health systems for better NCD prevention and control, and the promotion of NCD-related research that are still lacking.

Introduction The presence and density of tobacco retailers is associated with the perception of high availability of cigarettes and ease of purchase. Indonesia is the second largest cigarette market in the world with an increasing smoking rate among young people aged 10–18 years. Our study aims to assess density of cigarette outlets in neighbourhoods and around schools, and to evaluate correlation between retailer proximity to schools and retailer selling practices. Methods We conducted a geographical mapping and then an audit survey of 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia. We measured neighbourhood retailer density, and retailer proximity to schools. We linked the coordinate data to the audit data to assess the association between retailer distance from schools with likelihood of selling tobacco to young people and selling single cigarette sticks. Results We mapped 4114 cigarette retailers in Denpasar, the most common type was a kiosk, 3199 (77.8%), followed by mini market/convenience stores, 606 (14.7%). Retailer density was 32.2/km2 and 4.6/1000 population. We found that 37 (9.7 %) of the 379 schools in Denpasar have at least one cigarette retailer within a 25 m radius and 367 (96.8%) within a 250 m radius. Of the 485 audited retailers within a 250 m radius of a school, 281 (57.9%) admitted selling cigarettes to young people and 325 (67.0%) sold cigarettes as single sticks. Cigarette retailers were less likely to sell cigarettes to young people based on distance from schools, but this was only significant at the furthest distance of more than 500 m from schools. Conclusions In an unregulated retailer setting such as Indonesia, cigarette retailers are ubiquitous and selling to young people is commonplace. The Indonesian government should enforce the prohibition on selling to young people and should regulate cigarette retailers to reduce youth access to cigarettes.

OBJECTIVES: To determine the association of biomedical and socio-environmental risk factors during pregnancy, early, and later childhood with cognitive (IQ), motor, social-emotional (SE), and executive function (EF) at age 3.5 and 9–12 y in Indonesia. METHODS: Children born to pregnant women enrolled in the Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) in 2001–2004 participated in follow-up studies at age 3.5 y in 2006 and 9–12 y in 2013. We assessed 359 children at both time points for outcomes of IQ, motor, SE and EF. We also assessed predictors of outcomes including biomedical risks (small for gestational age at birth: SGA; height-for-age z-score: HAZ; and child hemoglobin: Hb) and socio-environmental risks (HOME Inventory; maternal depression: MD). We calculated the residuals of earlier risks predicting the later scores, e.g., the residual of SGA at birth predicting HAZ at 3.5 y (rHAZ1), representing the deviation of HAZ at 3.5 y from the child's expected HAZ based on SGA. In Model 1, we entered SGA, representing in utero exposures. In Model 2, we added indicators at 3.5 y (rHAZ1, Hb, HOME, MD). In Model 3, we added indicators at 9–12 y (rHAZ2, rHb, rHOME, rMD) and the corresponding 3.5 y IQ, motor, SE, or EF scores. RESULTS: The coefficients for outcomes at early and later time points (Figure 1) show that SGA was not associated with any scores. Early (3.5 y) childhood rHAZ1 was associated with early IQ, motor, and EF, but was not independently associated with later (9–12 y) IQ, motor, or EF. Later childhood rHAZ2 was not associated with any scores. Early childhood HOME was independently associated with both early and later IQ, motor, and EF, while later childhood rHOME was not associated with any scores. Early Hb was not associated with any scores and later rHb was associated with motor scores only. MD during early childhood and rMD during later childhood were independently associated with later childhood SE. CONCLUSIONS: These findings support the importance of early and continual intervention throughout childhood to support healthy growth and even more importantly maternal mental health and nurturing home environments. This is essential for longer-term IQ, motor, SE, and EF. FUNDING SOURCES: Grand Challenges Canada, Allen & Turner Foundations, UNICEF, Centre for Health and Human Development, USAID-Indonesia, USDA NIFA #CA-D-NTR-2493-H. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

Global child feeding practices remain suboptimal. In this study, we assess the determinants of age‐inappropriate breastfeeding, dietary diversity, and consumption of 3+ types of animal source foods (ASFs) using 11,687 observations from combined data from the Indonesian Demographic Health Survey of 2012 and 2017. We used linear and logistic regression after adjusting for the complex sampling design. Child's age and quality of antenatal care (ANC) were associated with all outcomes. Socio‐economic status and labour force participation were positively associated with higher dietary diversity score, ASF consumption, and age‐inappropriate breastfeeding. More ANC visits and having consultation at ANC were associated with more dietary diversity. Higher women's knowledge level was associated with more dietary diversity and consuming more ASF. Compared with western Indonesia, more children in eastern Indonesia were age‐inappropriately breastfed and had lower dietary diversity. The Indonesian government needs to develop programmes to improve child feeding particularly in eastern Indonesia, focusing on improving dietary diversity and ASF consumption in poorer households and on prolonging breastfeeding in richer households. Women's labour force participation should be encouraged, but programmes for working mothers are also needed to support continued breastfeeding and to express breast milk. ANC and postnatal programmes need improved consultation sessions for child feeding.

Background: Improving maternal health and reducing maternal mortality are part of the United Nations global Sustainable Development Goals for 2030. Ensuring every woman’s right to safe delivery is critical for reducing the maternal mortality rate. Our study aimed to identify determinants of safe delivery utilization among women in the eastern Indonesia. Methods: This study was cross-sectional and used a secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS). A total of 2,162 women who had their last child in the five years preceding the survey and lived in the eastern part of Indonesia were selected as the respondents. Chi-squared test and binary logistic regression were used to understand the determinants of safe delivery. Results: Higher child rank and interval ≤2 years (OR: 0.30, 95% CI: 0.19-0.47), unwanted pregnancy at time of becoming pregnant (OR: 1.48, 95% CI: 1.05-2.08), richest wealth quintile (OR: 5.59, 95% CI: 3.37-9.30), more than four antenatal care visits (OR: 3.62, 95% CI: 2.73-4.79), rural residence, good composite labor force participation, and a good attitude towards domestic violence were found to be significantly associated with delivery at health facility. Higher child rank and interval ≤2 years (OR: 0.49, 95% CI: 0.29-0.83), husband/partner having completed secondary or higher education (OR: 2.18, 95% CI: 1.48-3.22), being in the richest wealth quintile, and four other factors were found to be significantly associated with the assistance of skilled birth attendants. Conclusions: This research extends our knowledge on the determinants of safe delivery among women in the eastern part of Indonesia. This study revealed that the economic status of household remains an important issue in improving safe delivery among women in eastern part of Indonesia. An open innovation and partnership process to improve safe delivery program that engages the full range of stakeholders should be developed based on economic situation.

Early childhood deaths are caused by disease that can be prevented and treated like diarrhea. Women's empowerment must be deemed as a very critical component because it is commonly related with maternal and child health status, healthcare utilization and uptake of child health services. This study aims to determine the association between women's empowerment and diarrhea in children under two years in Indonesia. We extracted data from the dataset of the 2017 Indonesian Demographic Health Survey (IDHS) to evaluate the association between women's empowerment and diarrhea incidents. Data of 5526 mothers of children under two years were analyzed. Child's factors, maternal and paternal factors, household factors and access to health care factors were the covariates under investigation. We used principal component analysis (PCA) to create four empowerment components (Women's participation in the labor force, attitude towards wife-beating, decision-making and level of knowledge). Multivariate logistic regression was used to analyze the relationship between women's empowerment and children's recent history of diarrhea. Among the children, 17 had experienced diarrhea recently. Children of mothers with a medium attitude towards wife-beating had 29 (AOR = 0.71; 95 CI = 0.55�0.90, p = 0.01) lower odds of experiencing diarrhea recently compared to those of mothers with a poor attitude towards wife-beating. Children of mothers with a good attitude towards wife-beating had 24 (AOR = 0.76; 95 CI = 0.60�0.97, p = 0.03) lower odds of experiencing diarrhea recently compared to those of mothers with a poor attitude towards wife-beating. Children of women with a good knowledge level had 29 (AOR = 0.71; 95 CI = 0.55�0.92, p = 0.01) lower odds of experiencing diarrhea recently compared to those of women with a poor knowledge level. Women's empowerment is still an important indicator for reducing incident of diarrhea, especially women's knowledge level and attitude towards wife-beating components. Increasing women's knowledge level and good attitude toward wife-beating in societies would be a good way to help improve children's health with regard to experiencing diarrhea. Therefore, improving women's participation in joint decision making at family level are needed to improve the health of their children. © 2020 Elsevier Ltd

ObjectiveTo assess tobacco promotion intensity, retailer behaviours and tobacco company efforts to link retailer marketing to online channels.MethodsWe completed an audit of tobacco advertisements and promotions at 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia that included an observation checklist, digital photos and structured interviews with retailers. We then calculated the tobacco promotion index for each retailer and made comparisons based on store types. Next, we conducted a photo analysis from 100 randomly selected retailers to explore links to online channels and other promotional cues to engage young people.ResultsMini-markets have both the highest total number of promotions and the highest indoor promotion index with a mean score of 5.1 and 3.7, respectively. Kiosks have the highest outdoor promotion index with a mean score of 1.6. Most of the retailers (98.9%) displayed cigarettes, more than half of kiosk retailers (54.8%) and mini-market retailers (56.3%) admitted selling cigarettes to young people, and 74% of kiosk retailers sell single stick cigarettes. We found links to online marketing, including two hashtags and a company website. Promotional materials also included youth-focused content such as English taglines, new products and small packs.ConclusionTobacco companies in Indonesia have strategically differentiated their advertisements based on retailer type and have bridged conventional retailer marketing to online channels. Reforming Indonesian tobacco laws to include bans on single sticks and small pack sales, point-of-sale advertising, including displays, and enforcement of laws on sales to minors is urgently required.

IntroductionTobacco advertisement bans in Indonesia are rare and seldom evaluated. The recent introduction of an outdoor tobacco advertisement (OTA) ban in Banyuwangi District, East Java, Indonesia provided an opportunity to evaluate such policy.MethodsUsing a mixed-methods approach, we undertook an observational study of OTA in 15 locations where such advertising had been prohibited. We also interviewed a sample of 114 store-owners/storekeepers and 131 community members, and conducted indepth interviews with government officials and the Public Order Agency (POA), the designated enforcement agency.ResultsIn phase 1 we found only one location was free of advertisements. We identified 667 advertisement points and 1283 advertisement materials in the study location; of these, 7% and 7.8% were within 25 m of schools and religious sites, respectively. Phase 2 showed that 68% of the respondents were unaware of the regulation, but many supported an OTA ban. Indepth interviews revealed that not all members of the POA were familiar with the regulation. POA members believed they will enforce the regulation better if higher level regulation for ban on tobacco advertisements, promotions and sponsorships was made and digital application is available to support surveillance.ConclusionPolicy violations were evident 1 year after the launch of OTA ban in Banyuwangi. Tobacco advertisements are still visible, including near schools and religious sites, potentially stimulating adolescents to smoke. Regional regulation and setting specific violation reductions as a performance indicator for POA could improve compliance. App-based technology could assist violation surveillance and reporting, as could awareness-raising campaigns that encouraged community support to report violation through the apps.

Introduction: Blood glucose is an important component in the body produced by the consumption of carbohydrates, proteins, and fats. A blood glucose imbalance causes an increase in the blood glucose level in the body. The occurrence of economic changes due to tourism may lead to a change in diet that can lead to increased blood glucose levels. This study aims to analyse the factors related to random blood glucose in people living in coastal tourism areas in BanyuwangiMethods: The study used a cross-sectional survey. A total of 112 respondents were recruited using the random sampling method, using two-stage cluster sampling techniques taken from the Head of household data in multiple villages. The factors studied included demographic, socioeconomic, lifestyle, and family health history.Results: The results showed that men had 28% higher random blood glucose compared to woman. People living in Bangsring had 31% higher random blood glucose compared to those in Buluagung.Conclusion: Local health care services should put extra effort into include men and those living in Bangsring in programs to prevent Diabetes Mellitus in coastal areas.

Introduction: Improving health care-seeking behavior of the coastal communities is a pathway to improve their health. This analysis aims to explore the health care-seeking behavior of the coastal communities in Banyuwangi District to recommend the room for improvement for health promotion and health service improvement for these communities.Method: Data from a cross-sectional survey of metabolic syndrome and mental health conducted in coastal communities in Banyuwangi was used for analysis. Randomly selected participants from a list of members of Family Welfare Development Group (Pembinaan Kesejahteraan Keluarga /PKK) were asked for an interview at corresponding village office in Ketapang, Bangsring, Bulu Agung, Grajagan and Kampung Mandar village. Distribution of health care-seeking behaviors was analyzed individually and where possible were segregated by gender and age.Results: More than half of the coastal communities in Banyuwangi District went to health care service to seek health and 7 out of 10 turned to health care service to seek health for their family members. Women more than men turned to health care service when they or their family members fell ill. Private doctors rather than Puskesmas were more popular. Private midwives were the most popular service for antenatal care (ANC) and delivery. Although there was not a clear increase in health care service utilization over time, we found that contraceptive utilization increased with time.Conclusion: The utilization of health care service in Banyuwangi needs to be more promoted especially for men’s health.

Summary Background Brain and cognitive development during the first 1000 days from conception are affected by multiple biomedical and socioenvironmental determinants including nutrition, health, nurturing, and stimulation. An improved understanding of the long-term influence of these factors is needed to prioritise public health investments to optimise human development. Methods We did a follow-up study of the Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT), a double-blind, cluster-randomised trial of maternal supplementation with multiple micronutrients (MMN) or iron and folic acid (IFA) in Indonesia. Of 27 356 live infants from birth to 3 months of age in 2001–04, we re-enrolled 19 274 (70%) children at age 9–12 years, and randomly selected 2879 from the 18 230 who were attending school at a known location. Of these, 574 children were oversampled from mothers who were anaemic or malnourished at SUMMIT enrolment. We assessed the effects of MMN and associations of biomedical (ie, maternal and child anthropometry and haemoglobin and preterm birth) and socioenvironmental determinants (ie, parental education, socioeconomic status, home environment, and maternal depression) on general intellectual ability, declarative memory, procedural memory, executive function, academic achievement, fine motor dexterity, and socioemotional health. The SUMMIT trial was registered, number ISRCTN34151616. Findings Children of mothers given MMN had a mean score of 0·11 SD (95% CI 0·01–0·20, p=0·0319) higher in procedural memory than those given IFA, equivalent to the increase in scores with half a year of schooling. Children of anaemic mothers in the MMN group scored 0·18 SD (0·06–0·31, p=0·0047) higher in general intellectual ability, similar to the increase with 1 year of schooling. Overall, 18 of 21 tests showed a positive coefficient of MMN versus IFA (p=0·0431) with effect sizes from 0·00–0·18 SD. In multiple regression models, socioenvironmental determinants had coefficients of 0·00–0·43 SD and 22 of 35 tests were significant at the 95% CI level, whereas biomedical coefficients were 0·00–0·10 SD and eight of 56 tests were significant, indicating larger and more consistent impact of socioenvironmental factors (p Interpretation Maternal MMN had long-term benefits for child cognitive development at 9–12 years of age, thereby supporting its role in early childhood development, and policy change toward MMN. The stronger association of socioenvironmental determinants with improved cognition suggests present reproductive, maternal, neonatal, and child health programmes focused on biomedical determinants might not sufficiently enhance child cognition, and that programmes addressing socioenvironmental determinants are essential to achieve thriving populations. Funding Grand Challenges Canada Saving Brains Program.

Adequate maternity staffs (obstetric/gynecologists, midwives, and nurses) at referral hospitals are crucial to manage obstetric complications and to improve maternal outcomes. This study aims to describe the staffing levels and maternal outcomes in selected referral public hospitals in Java region of Indonesia. The data of 8,396 deliveries with live birth and 522 maternity staffs were collected from six referral hospitals in Java, Indonesia. Descriptive statistics were employed to summarize the study subjects. The maternity staffing levels of the study hospitals were relatively sufficient, however, the maternal mortality ratio and the severe maternal outcome ratio are moderately high. Further studies are recommended to understand the effect of staffing and other possible factors on maternal outcome. © 2019, Indian Journal of Public Health Research and Development. All rights reserved.

Background Stunting in early life has considerable human and economic costs. The purpose of the study was to identify factors associated with stunting among children aged 0-23 months in Indonesia to inform the design of appropriate policy and programme responses. Methods Determinants of child stunting, including severe stunting, were examined in three districts in Indonesia using data from a cross-sectional survey conducted in 2011. A total of 1366 children were included. The analysis used multiple logistic regression to determine unadjusted and adjusted odds ratios. Results The prevalence of stunting and severe stunting was 28.4 % and 6.7 %, respectively. The multivariate analysis on determinants of stunting identified a significant interaction between household sanitary facility and household water treatment (P for interaction = 0.007) after controlling for potential covariates: in households that drank untreated water, the adjusted odds on child stunting was over three times higher if the household used a unimproved latrine (adjusted odds ratio 3.47, 95 % confidence interval 1.73-7.28, P

Indonesia still faces several challenges in the areas of water, sanitation, and hygiene (WASH). Diarrhea remains a major killer of children and it is important to understand the local diarrhea transmission pathways to prioritise appropriate WASH interventions to reduce diarrhea burden. This study used a cross-sectional data set from a recent national household survey (the 2012 Indonesia Demographic and Health Survey) to examine the associations between diarrhea in children aged less than 24 months with WASH interventions and population characteristics. Unsafe disposal of child feces was strongly associated with an increased odds of child diarrhea (OR: 1.46; 95% CI: 1.18-1.82, p = 0.001). However, other WASH practices were not found to be associated. The findings underline the dangers of unsafe disposal of child feces and highlight the need for strengthening the related policies and program strategies and their implementation.

OBJECTIVE: To examine the determinants of low birthweight (LBW) small-for-gestation (SGA) and preterm births in Lombok Indonesia an area of high infant mortality. METHODS: Data from The Supplementation with Multiple Micronutrient Intervention Trial (SUMMIT) a double-blind cluster-randomised controlled trial were analysed. The odds ratio of factors known to be associated with LBW SGA and preterm birth was assessed and adjusted for the cluster design of the trial using hierarchical logistic regression. Determinants included constitutional demographic and psychosocial factors toxic exposure maternal nutrition and obstetric history and maternal morbidity during and prior to pregnancy. Population attributable risks of modifiable determinants were calculated. RESULTS: A cohort of 14040 singleton births was available for analysis of LBW with 13498 observations for preterm births and 13461 for SGA births. Determinants of LBW and SGA were similar and included infants sex womans education season at birth mothers residence household wealth maternal mid-upper arm circumference (MUAC) height and a composite variable of birth order and pregnancy interval. Socioeconomic indicators were also related to preterm births and included mothers education residence and household wealth while nutritional-related factors including low MUAC and birth order and interval were associated with preterm birth but not maternal height. Nausea was protective of preterm birth while diarrhoea was associated with higher odds of preterm birth. Oedema during pregnancy was protective of SGA but associated with higher odds of preterm delivery. Around 33% 13% and 13% of the determinants of LBW SGA and preterm births were preventable. CONCLUSION: Womens education maternal nutrition and household wealth and family planning are key factors to improving birth outcomes. (c) 2012 Blackwell Publishing Ltd.

Background Clinical trials can serve as an opportunity gateway for enhanced health benefits to the target population, above and beyond the specific intervention being tested. Objective The Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT), a randomized, controlled clinical trial in Lombok, Indonesia, found that supplementation during pregnancy with multiple micronutrients reduced 90-day infant mortality by nearly 20% as compared with iron–folic acid. This trial was designed as both a program and research trial and used community facilitators to serve as liaisons between the study and the pregnant women. This analysis documents the programmatic impacts of SUMMIT on health-seeking and early infant mortality resulting from community facilitators' field activities. Methods Data on compliance, human resource practices, health-seeking, and health outcomes from the 31,290 SUMMIT enrollees were analyzed. Results Overall compliance with either iron–folic acid or multiple micronutrients was high in the program, at 85.0%. Early prenatal care visits increased significantly. Sixty-three percent of primiparous women used a skilled birth attendant (SBA); among multiparous women, the rate of use of a SBA rose from 35% for the last birth to 53%. Use of a SBA resulted in a 30% reduction in early infant mortality (RR, 0.70; 95% CI, 0.59 to 0.83; p < .0001), independently of any reductions due to multiple micronutrients. The community facilitators played a central role in improving health-seeking; however, the quality of the community facilitators' performance was associated with the impact of the micronutrient supplement on infant health. In a subsample of community facilitators, better-performing facilitators were found to markedly improve the overall impact of the multiple micronutrients on early infant mortality (RR, 0.67; 95% CI, 0.49 to 0.92; p = .0117). In contrast, infants of women with poorly performing community facilitators were found to derive no additional benefit from the multiple micronutrients (RR, 1.04; 95% CI, 0.64 to 1.72; p = .8568). Conclusions Systematic enhancements to the quality of implementation of SUMMIT led to significant increases in use of SBAs at delivery, resulting in a 30% reduction in early infant mortality independent of the impact of micronutrient supplementation. Therefore, if women were to consume multiple micronutrients on a regular basis and were to use a SBA at delivery, the risk of early infant mortality could be reduced by nearly 50%. The impacts of community facilitators in effecting changes in women's health behaviors are notable and are applicable to other health programs. Enhancements to program implementation should be driven by evidence, be accountable to the communities the program serves, and be evaluated on the basis of measurable gains in health for women and children.

The Government of Indonesia launched the village-based midwife programme in 1989 in response to maternal mortality of over 400 per 100 000 livebirths and neonatal mortality of 32 per 1000 livebirths. The goal of the programme was to place a skilled birth attendant in every village to provide antenatal and perinatal care family planning other reproductive health services and nutrition counselling. The attendants were also to facilitate basic primary health-care services including immunisation and nutrition interventions. Lessons from the programme are particularly timely for 68 priority countries in Countdown many of which are attempting to scale up skilled birth attendance to achieve Millennium Development Goals (MDGs) 4 and 5. (excerpt)

Many micronutrients, including zinc, iodine, and B-vitamins, are needed for the rapid brain development that occurs during gestation and infancy, laying a foundation for lifelong brain function. Fe...

Low birthweight (LBW) and intrauterine growth restriction are linked with maternal nutritional status during pregnancy, and maternal supplementation with multiple micronutrients (MMNs) is reported to increase birthweight. Responses to MMN, however, might be modified by maternal nutrition.To examine the differential effects of maternal nutritional status on birthweight responses to prenatal MMN supplementation, data from the Supplementation with Multiple Micronutrient Intervention Trial, a cluster-randomized trial in Indonesia was analyzed. Birthweight outcomes of 7001 infants whose mothers received iron/folic acid were compared with 7292 infants whose mothers received MMN. The modifying effects of maternal short-term nutritional status (mid-upper arm circumference (MUAC) and long-term nutritional status (height) on the birthweight response to MMN supplementation were assessed.For women with higher MUAC (≥23.5 cm), MMN increased mean birthweight by 33 g (95% confidence interval (CI): -1 to 66, P=0.06) and significantly reduced LBW by 21% (relative risk: 0.79, 95% CI: 0.64-0.99, P=0.04). The modifying effect of MUAC on mean birthweight, LBW and small for gestational age was significant. There was no evidence of a modifying effect of maternal height on the response to MMN.Supplementation with MMN in pregnancy increased birthweight, but maternal nutritional status modified this response, with infants born to women with better short-term nutrition having greater birthweight response.

BACKGROUND Maternal nutrient supplementation in developing countries is generally restricted to provision of iron and folic acid (IFA). Change in practice toward supplementation with multiple micronutrients (MMN) has been hindered by little evidence of the effects of MMN on fetal loss and infant death. We assessed the effect of maternal supplementation with MMN, compared with IFA, on fetal loss and infant death in the setting of routine prenatal care services. METHODS In a double-blind cluster-randomised trial in Lombok, Indonesia, we randomly assigned 262 midwives to distribute IFA (n=15 ,86) or MMN (n=15,804) supplements to 31 290 pregnant women through government prenatal care services that were strengthened by training and community-based advocacy. Women obtained supplements, to be taken daily, every month from enrolment to 90 days post partum. The primary outcome was early infant mortality (deaths until 90 days post partum). Secondary outcomes were neonatal mortality, fetal loss (abortions and stillbirths), and low birthweight. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN34151616. FINDINGS Infants of women consuming MMN supplements had an 18% reduction in early infant mortality compared with those of women given IFA (35.5 deaths per 1000 livebirths vs 43 per 1000; relative risk [RR] 0.82, 95% CI 0.70-0.95, p=0.010). Infants whose mothers were undernourished (mid upper arm circumference