Unmet needs for cardiovascular care in Indonesia

Implementation of mobile-health technology is associated with five-year survival among individuals in rural areas of Indonesia

There is an urgent need to focus on implementing cost-effective health interventions and policies to reduce the burden of cardiovascular disease in Indonesia. This study aims to evaluate whether a mobile technology-supported primary health care intervention, compared with usual care, would reduce the risk of all-cause mortality among people in rural Indonesia. Data were collected from 11,098 participants in four intervention villages and 10,981 participants in four control villages in Malang district, Indonesia. The baseline data were collected in 2016. All the participants were followed for five years, and the mortality data were recorded. Cox proportional hazard model was used to examine the association between the intervention and the risk of all-cause mortality, adjusted for the covariates, including age, gender, educational attainment, employment and marital status, obesity and the presence of diabetes mellitus. During the five-year follow-up, 275 participants died in intervention villages, compared with 362 in control villages. Participants residing in intervention villages were at 18% (95%CI = 4 to 30) lower risk of all-cause mortality. Higher education attainment and being married are associated with lower risks of all-cause mortality among respondents who lived in the control villages, but not among those living in the intervention villages. A mobile technology-supported primary health care intervention had the potential to improve the five-year survival among people living in villages in an upper-middle income country.

The impact of multimorbidity among adults with cardiovascular diseases on healthcare costs in Indonesia: a multilevel analysis

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia.

METHODS

This retrospective cohort study analyzed the NHI database from 2016-2018 for individuals with chronic diseases (n = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households.

RESULTS

The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (β = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres.

CONCLUSIONS

CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease.

The 30 Years of Shifting in The Indonesian Cardiovascular Burden-Analysis of The Global Burden of Disease Study

IMPORTANCE

Cardiovascular disease (CVD) remains the leading cause of mortality and morbidity. Compared with disease burden rates in 1990, significant reductions in Disability-Adjusted Life Years (DALYs) burden rates for CVD have been recorded. However, general DALYs rates have not changed in Indonesia in the past 30 years. Thus, assessing Indonesian CVD burdens will be an essential first step in determining primary disease interventions.

OBJECTIVE

To determine the national and province-level burden of CVD from 1990 to 2019 in Indonesia.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective observational study was conducted using data from the Global Burden of Disease (GBD) 2019, provided by the Institute of Health Metrics and Evaluation (IHME), to analyze trends in the burden of CVD, including mortality, morbidity, and prevalence characteristics of 12 underlying CVDs.

EXPOSURES

Residence in Indonesia.

MAIN OUTCOMES AND MEASURES

Mortality, incidence, prevalence, death, and DALYs of CVD.

RESULTS

CVD deaths have doubled from 278 million in 1990 to 651 million in 2019. All CVDs recorded increased death rates, except for rheumatic heart disease (RHD) (- 69%) and congenital heart disease (CHD) (- 37%). Based on underlying diseases, stroke and ischemic heart disease (IHD) are still the leading causes of mortality and morbidity in Indonesia, whereas stroke and peripheral artery disease (PAD) are the most prevalent CVDs. Indonesia has the second worst CVD DALYs rates compared to ASEAN countries after Laos. At provincial levels, the highest CVD DALY rates were recorded in Bangka Belitung, South Kalimantan, and Yogyakarta. In terms of DALYs rate changes, they were recorded in West Nusa Tenggara (24%), South Kalimantan (18%), and Central Java (11%). Regarding sex, only RHD, and PAD burdens were dominated by females.

CONCLUSIONS

CVD mortality, morbidity, and prevalence rates increased in Indonesia from 1990 to 2019, especially for stroke and ischemic heart disease. The burden is exceptionally high, even when compared to other Southeast Asian countries and the global downward trend. GBD has many limitations. However, these data could provide policymakers with a broad view of CVD conditions in Indonesia.

Effects of the COVID-19 pandemic on healthcare utilization among older adults with cardiovascular diseases and multimorbidity in Indonesia: an interrupted time-series analysis

BACKGROUND

The COVID-19 pandemic has disrupted healthcare utilization globally, but little is known about the effects among patients with cardiovascular diseases (CVDs) and other multimorbidities. This study analyzed the impacts of COVID-19 on healthcare utilization for patients aged 30 years and older with cardiovascular diseases (CVDs) with or without other chronic disease comorbidities in Indonesia.

METHODS

We designed a retrospective cohort study based on the Indonesian National Health Insurance (NHI) sample data from 2016-2020. We defined healthcare utilization as monthly outpatient and inpatient visits related to chronic diseases at the hospital and primary healthcare levels per 10,000 NHI members. We used interrupted time series analysis to evaluate how the healthcare utilization patterns had changed due to the COVID-19 pandemic.

RESULTS

Overall, hospital outpatient visits decreased by 39% when the pandemic occurred (95% Confidence Interval (CI): 0.48,0.76), inpatient visits by 28% (95% CI: 0.62,0.83), and primary healthcare visits by 34% (95% CI:0.55, 0.81). For patients with CVDs and multimorbidity, hospital outpatient and inpatient visit rates were reduced by 36% and 38%, respectively and primary healthcare visits by 32%. Some insignificant differences in the reduction of out-and inpatient visits were observed across diagnosis groups and regions.

CONCLUSION

Healthcare utilization among patients with chronic diseases decreased significantly during COVID-19 and consistently across different chronic diseases and regions. To cope with the unmet needs of healthcare utilization in the context of the pandemic, the healthcare system needs to be strengthened to cater to the needs of the population-at-risk, especially for patients with CVDs and multimorbidity.

Explaining the increase of incidence and mortality from cardiovascular disease in Indonesia: A global burden of disease study analysis (2000-2019)

BACKGROUND

In the last two decades, there has been a discernible shift in the distribution of mortality attributed to cardiovascular disease (CVD) between developing and developed nations; in developed nations, the percentage of deaths caused by CVD decreased from 48% in 1990 to 43% in 2010, while in developing nations, they increased from 18% to 25%. In Indonesia, CVD death has increased substantially and remained elevated in the last ten years. Current behavioral and metabolic risk factors, including hyperglycemia, obesity, dyslipidemia, hypertension, and smoking, enhance the risk of CVD mortality, according to several studies.

AIMS

We undertook a study to determine whether the increase in mortality and incidence of CVD can be attributed to changes in the most common metabolic and behavioral risk factors from 2000 to 2019 across 34 Indonesian provinces.

MATERIALS AND METHODS

Data from 34 province for CVD incidence and mortality and data on changes in metabolic and behavioural risk factors between 2000 and 2019 in Indonesia were obtained from the Global Burden study (GBD) by The Institute of Health Metrics and Evaluation (IHME). A statistical model was applied to calculate the fatalities attributable to the risk factors change using Population attributable fractions (PAF) and baseline year death numbers. Furthermore, we ran multivariate regressions on Summary Exposure Value of risk factors associated with the increasing mortality, incidence rates in a lag year analysis. R software used to measure heteroscedasticity-consistent standard errors with coeftest and coefci. Covariates were added to adjusted models, including the Socio-demographic Index, Primary health care facilities coverage, and GDP per capita.

RESULTS

The age-standardized mortality rate for CVD from 2000 to 2019 in Indonesia, increased from 356.05 to 412.46 deaths per 100,000 population among men and decreased from 357.52 to 354.07 deaths per 100,000 population among women, resulting in an increase of 270.928 per 100,0000 inhabitants of CVD deaths. In the same period, there was an increase in exposure to risk factors such as obesity by +9%, smoking by +1%, dyslipidemia by +1.3%, hyperglycemia by +2%, and hypertension by +1.2%. During this time span, an additional 14,517 men and 17,917 women died from CVD, which was attributable to higher obesity exposure. We apply multivariate regression with province-fixed and year-fixed analysis and find strong correlation between hyperglycemia in women (6; 95%CI 0 to 12, death per 1-point increase in hyperglycemia exposure) with an increasing death rate in ischemic heart disease. We also performed a year lag analysis and discovered a robust association between high low density lipoprotein (LDL) levels in men and women and the growing incidence of ischemic heart disease. The association between a 10-year lag of high LDL and the incidence of ischemic heart disease was five times stronger than that observed for other risk factors, particularly in men (5; 95%CI 2 to 8, incidence per 1-point increase in high LDL exposure).

CONCLUSION

Hyperglycemia in women is an important risk factor associated with increasing mortality due to Ischemic Heart Disease (IHD) in Indonesia This study also revealed that the presence of high LDL in both men and women were associated with an increase incidence of IHD that manifested several years subsequent to exposure to the risk factor. Additionally, the highest cardiovascular death portion were attributed to obesity. These findings suggest that policymakers should control high LDL and hyperglycemia 10 years earlier prior to the occurrence of IHD and employ personalized therapy to regulate associated risks.

Modifiable risk factors in adults with and without prior cardiovascular disease: findings from the Indonesian National Basic Health Research

Backgrounds

The majority of risk factors for cardiovascular diseases (CVDs) are modifiable. Continuous monitoring and control of these factors could significantly reduce the risk of CVDs-related morbidity and mortality. This study estimated the prevalence of modifiable risk factors in Indonesia and its co-occurence of multiple risk factors stratified by prior CVDs diagnosis status and sex.

Methods

Adult participants (> 15 years, N = 36,329, 57% women) with median age of 40 years were selected from a nationwide Indonesian cross-sectional study called Basic Health Research or Riset Kesehatan Dasar (Riskesdas) conducted in 2018. Thirteen risk factors were identified from the study, including smoking, a high-risk diet, inadequate fruit and vegetable consumption, a low physical activity level, the presence of mental-emotional disorders, obesity, a high waist circumference (WC), a high waist-to-height ratio (WtHR), hypertension, diabetes, a high total cholesterol level, a high low-density lipoprotein (LDL) cholesterol level, and a low high-density lipoprotein (HDL) cholesterol level. Age-adjusted prevalence ratios stratified by CVDs status and sex were calculated using Poisson regression with the robust covariance estimator.

Results

CVDs were found in 3% of the study population. Risk factor prevalence in the overall population ranged from 5.7 to 96.5% for diabetes and inadequate fruit and vegetable consumption respectively. Smoking, a high-risk food diet, and a low HDL cholesterol level were more prevalent in men, whereas a low physical activity level, the presence of mental-emotional disorders, obesity, a high WC, a high WtHR, hypertension, diabetes, a high total cholesterol level, and a high LDL cholesterol level were more prevalent in women. Approximately 22% of men and 18% of women had at least 4 risk factors, and these proportions were higher in participants with prior CVDs diagnosis.

Conclusions

There is a high prevalence of modifiable risk factors in the Indonesian adult population. Sex, age, and the presence of CVD are major determinants of the variations in risk factors. The presence of multiple risk factors, which are often inter-related, requires a comprehensive approach through health promotion, lifestyle modification and patient education.

Cost-effectiveness of a mobile technology-enabled primary care intervention for cardiovascular disease risk management in rural Indonesia

Cardiovascular diseases (CVD) are the leading cause of death in Indonesia, and there are large disparities in access to recommended preventative treatments across the country, particularly in rural areas. Technology-enabled screening and management led by community health workers have been shown to be effective in better managing those at high risk of CVD in a rural Indonesian population; however, the economic impacts of implementing such an intervention are unknown. We conducted a modelled cost-effectiveness analysis of the SMARThealth intervention in rural villages of Malang district, Indonesia from the payer perspective over a 10-year period. A Markov model was designed and populated with epidemiological and cost data collected in a recent quasi-randomized trial, with nine health states representing a differing risk for experiencing a major CVD event. Disability-Adjusted Life Years (DALYs) were estimated for the intervention and usual care using disability weights from the literature for major CVD events. Annual treatment costs for CVD treatment and prevention were $US83 under current care and $US144 for those receiving the intervention. The intervention had an incremental cost-effectiveness ratio of $4288 per DALY averted and $3681 per major CVD event avoided relative to usual care. One-way and probabilistic sensitivity analyses demonstrated that the results were robust to plausible variations in model parameters and that the intervention is highly likely to be considered cost-effective by decision-makers across a range of potentially acceptable willingness to pay levels. Relative to current care, the intervention was a cost-effective means to improve the management of CVD in this rural Indonesian population. Further scale-up of the intervention offers the prospect of significant gains in population health and sustainable progress toward universal health coverage for the Indonesian population.

"I just can't sit around and do nothing!": A qualitative study of Indonesian women's experiences diagnosed with heart disease

Research into cardiovascular disease and its management in Indonesia, where it currently accounts for 67% of all deaths, has heavily emphasized the biomedical aspects; little is known about the individual's experience of the disease, especially for Indonesian women. This study aimed to understand how gender shapes Indonesian women's experiences of living with heart disease in their daily lives. Twenty-six women aged 30-67 years were interviewed, and the transcriptions analyzed using a qualitative framework informed by intersectional approaches to gender and culture. Three major themes emerged: (i) the effect of cardiovascular disease on women's day-to-day activities, (ii) its effects on women's family relationships, and (iii) the women's coping strategies. The inability to fulfill their required social roles as mother or wife undermined the women's sense of self, a problem particularly acute in a cultural context where responsibility for maintaining harmony in the home and society is ascribed to women. Healthcare professionals should be aware of the ethnic and cultural backgrounds of women with cardiovascular disease, in order to deliver services that meet female patients' social, spiritual, and cultural needs.

Association of Multifaceted Mobile Technology-Enabled Primary Care Intervention With Cardiovascular Disease Risk Management in Rural Indonesia

Importance

Cardiovascular diseases (CVDs) are the leading cause of disease burden in Indonesia. Implementation of effective interventions for CVD prevention is limited.

Objective

To evaluate whether a mobile technology-supported primary health care intervention, compared with usual care, would improve the use of preventive drug treatment among people in rural Indonesia with a high risk of CVD.

Design, Setting, and Participants

A quasi-experimental study involving 6579 high-risk individuals in 4 intervention and 4 control villages in Malang district, Indonesia, was conducted between August 16, 2016, and March 31, 2018. Median duration of follow-up was 12.2 months. Residents 40 years or older were invited to participate. Those with high estimated 10-year risk of CVD risk (previously diagnosed CVD, systolic blood pressure [BP] >160 mm Hg or diastolic BP >100 mm Hg, 10-year estimated CVD risk of 30% or more, or 10-year estimated CVD risk of 20%-29% and a systolic BP >140 mm Hg) were followed up.

Interventions

A multifaceted mobile technology-supported intervention facilitating community-based CVD risk screening with referral, tailored clinical decision support for drug prescription, and patient follow-up.

Main Outcomes and Measures

The primary outcome was the proportion of individuals taking appropriate preventive CVD medications, defined as at least 1 BP-lowering drug and a statin for all high-risk individuals, and an antiplatelet drug for those with prior diagnosed CVD. Secondary outcomes included mean change in BP from baseline.

Results

Among 22 635 adults, 3494 of 11 647 in the intervention villages (30.0%; 2166 women and 1328 men; mean [SD] age, 58.3 [10.9] years) and 3085 of 10 988 in the control villages (28.1%; 1838 women and 1247 men; mean [SD] age, 59.0 [11.5] years) had high estimated risk of CVD. Of these, follow-up was completed in 2632 individuals (75.3%) from intervention villages and 2429 individuals (78.7%) from control villages. At follow-up, 409 high-risk individuals in intervention villages (15.5%) were taking appropriate preventive CVD medications, compared with 25 (1.0%) in control villages (adjusted risk difference, 14.1%; 95% CI, 12.7%-15.6%). This difference was driven by higher use of BP-lowering medication in those in the intervention villages (1495 [56.8%] vs 382 [15.7%]; adjusted risk difference, 39.4%; 95% CI, 37.0%-41.7%). The adjusted mean difference in change in systolic BP from baseline was -8.3 mm Hg (95% CI, -10.1 to -6.6 mm Hg).

Conclusions and Relevance

This study found that a multifaceted mobile technology-supported primary health care intervention was associated with greater use of preventive CVD medication and lower BP levels among high-risk individuals in a rural Indonesian population.

Cardiovascular disease risk factor prevalence and estimated 10-year cardiovascular risk scores in Indonesia: The SMARThealth Extend study

BACKGROUND

The brunt of cardiovascular disease (CVD) burden globally now resides within low- and middle-income countries, including Indonesia. However, little is known regarding cardiovascular health in Indonesia. This study aimed to estimate the prevalence of elevated CVD risk in a specific region of Indonesia.

METHODS

We conducted full household screening for cardiovascular risk factors among adults aged 40 years and older in 8 villages in Malang District, East Java Province, Indonesia, in 2016-2017. 10-year cardiovascular risk scores were calculated based on the World Health Organization/International Society of Hypertension's region-specific charts that use age, sex, blood pressure, diabetes status and smoking behaviour.

RESULTS

Among 22,093 participants, 6,455 (29.2%) had high cardiovascular risk, defined as the presence of coronary heart disease, stroke or other atherosclerotic disease; estimated 10-year CVD risk of ≥ 30%; or estimated 10-year CVD risk between 10% to 29% combined with a systolic blood pressure of > 140 mmHg. The prevalence of high CVD risk was greater in urban (31.6%, CI 30.7-32.5%) than in semi-urban (28.7%, CI 27.3-30.1%) and rural areas (26.2%, CI 25.2-27.2%). Only 11% and 1% of all the respondents with high CVD risk were on blood pressure lowering and statins treatment, respectively.

CONCLUSIONS

High cardiovascular risk is common among Indonesian adults aged ≥40 years, and rates of preventive treatment are low. Population-based and clinical approaches to preventing CVD should be a priority in both urban and rural areas.

The Association Between Socioeconomic Status and Adult Mortality in a Developing Country: Evidence From a Nationally Representative Longitudinal Survey of Indonesian Adults

OBJECTIVES

To estimate the association between socioeconomic status (SES) and adult mortality in Indonesia and determine the contribution of adult behavioral risk factors to SES differences in mortality.

METHODS

Discrete failure-time regression models and period life tables were used to estimate life expectancy at age 30 (e30) across wealth and consumption groups by sex and urban/rural residence.

RESULTS

For urban men, e30 increases by an average of 1.10 years per wealth quartile (p = .014) from 38.7 years (95% confidence interval (CI): 37.4-40.5) in the bottom wealth quartile to 42.1 years (95% CI: 40.3-44.1) in the top quartile; for rural men, e30 increases by an average of 1.35 years per quartile (p = .007) from 40.6 years (95% CI: 39.2-42.5) in the bottom wealth quartile to 44.3 years (95% CI: 42.4-46.6) in the top quartile. SES differences are smaller for women. Behavioral risk factors are inconsistently patterned across SES and do not explain SES differences in mortality.

DISCUSSION

The associations between SES and adult life expectancy in Indonesia are moderate when compared with developed countries and are not explained by traditional behavioral risk factors. In a context where behavioral risk factors are inconsistent across SES groups, mortality inequality may be driven by inequalities in health care access or other social factors.

Long-term incidence and risk factors of cardiovascular events in Asian populations: systematic review and meta-analysis of population-based cohort studies

BACKGROUND

Scientific studies on cardiovascular disease (CVD) burden and risk factors are predominantly based on short-term risk in Westerner populations, and such information may not be applicable to Asian populations, especially over the longer term. This review aims to estimate the long-term (>10 years) CVD burden, including coronary heart disease (CHD) and stroke, as well as associated risk factors in Asian populations.

METHODS

PubMed, Embase and Web of Science were systematically searched, and hits screened on: Asian adults, free of CVD at baseline; cohort study design (follow-up >10 years). Primary outcomes were fatal and non-fatal CVD events. Pooled estimates and between-study heterogeneity were calculated using random effects models, Q and I² statistics.

RESULTS

Overall, 32 studies were eligible for inclusion (follow-up: 11-29 years). The average long-term rate of fatal CVD is 3.68 per 1000 person-years (95% CI 2.84-4.53), the long-term cumulative risk 6.35% (95% CI 4.69%-8.01%, mean 20.13 years) and the cumulative fatal stroke/CHD risk ratio 1.5:1. Important risk factors for long-term fatal CVD (RR, 95% CI) were male gender (1.49, 1.36-1.64), age over 60/65 years (7.55, 5.59-10.19) and current smoking (1.68, 1.26-2.24). High non-HDL-c, and β- and γ-tocopherol serum were associated only with CHD (HR 2.46 [95% CI 1.29-4.71] and 2.47 [1.10-5.61] respectively), while stage 1 and 2 hypertensions were associated only with fatal stroke (2.02 [1.19-3.44] and 2.89 [1.68-4.96] respectively).

CONCLUSIONS

Over a 10 year + follow-up period Asian subjects had a higher risk of stroke than CHD. Contrary to CVD prevention in Western countries, strategies should also consider stroke instead of CHD only.

On the road to universal health care in Indonesia, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

As Indonesia moves to provide health coverage for all citizens, understanding patterns of morbidity and mortality is important to allocate resources and address inequality. The Global Burden of Disease 2016 study (GBD 2016) estimates sources of early death and disability, which can inform policies to improve health care.

METHODS

We used GBD 2016 results for cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years (DALYs), life expectancy at birth, healthy life expectancy, and risk factors for 333 causes in Indonesia and in seven comparator countries. Estimates were produced by location, year, age, and sex using methods outlined in GBD 2016. Using the Socio-demographic Index, we generated expected values for each metric and compared these against observed results.

FINDINGS

In Indonesia between 1990 and 2016, life expectancy increased by 8·0 years (95% uncertainty interval [UI] 7·3-8·8) to 71·7 years (71·0-72·3): the increase was 7·4 years (6·4-8·6) for males and 8·7 years (7·8-9·5) for females. Total DALYs due to communicable, maternal, neonatal, and nutritional causes decreased by 58·6% (95% UI 55·6-61·6), from 43·8 million (95% UI 41·4-46·5) to 18·1 million (16·8-19·6), whereas total DALYs from non-communicable diseases rose. DALYs due to injuries decreased, both in crude rates and in age-standardised rates. The three leading causes of DALYs in 2016 were ischaemic heart disease, cerebrovascular disease, and diabetes. Dietary risks were a leading contributor to the DALY burden, accounting for 13·6% (11·8-15·4) of DALYs in 2016.

INTERPRETATION

Over the past 27 years, health across many indicators has improved in Indonesia. Improvements are partly offset by rising deaths and a growing burden of non-communicable diseases. To maintain and increase health gains, further work is needed to identify successful interventions and improve health equity.

FUNDING

The Bill & Melinda Gates Foundation.

How is Indonesia coping with its epidemic of chronic noncommunicable diseases? A systematic review with meta-analysis

BACKGROUND

Chronic noncommunicable diseases (NCDs) have emerged as a huge global health problem in low- and middle-income countries. The magnitude of the rise of NCDs is particularly visible in Southeast Asia where limited resources have been used to address this rising epidemic, as in the case of Indonesia. Robust evidence to measure growing NCD-related burdens at national and local levels and to aid national discussion on social determinants of health and intra-country inequalities is needed. The aim of this review is (i) to illustrate the burden of risk factors, morbidity, disability, and mortality related to NCDs; (ii) to identify existing policy and community interventions, including disease prevention and management strategies; and (iii) to investigate how and why an inequitable distribution of this burden can be explained in terms of the social determinants of health.

METHODS

Our review followed the PRISMA guidelines for identifying, screening, and checking the eligibility and quality of relevant literature. We systematically searched electronic databases and gray literature for English- and Indonesian-language studies published between Jan 1, 2000 and October 1, 2015. We synthesized included studies in the form of a narrative synthesis and where possible meta-analyzed their data.

RESULTS

On the basis of deductive qualitative content analysis, 130 included citations were grouped into seven topic areas: risk factors; morbidity; disability; mortality; disease management; interventions and prevention; and social determinants of health. A quantitative synthesis meta-analyzed a subset of studies related to the risk factors smoking, obesity, and hypertension.

CONCLUSIONS

Our findings echo the urgent need to expand routine risk factor surveillance and outcome monitoring and to integrate these into one national health information system. There is a stringent necessity to reorient and enhance health system responses to offer effective, realistic, and affordable ways to prevent and control NCDs through cost-effective interventions and a more structured approach to the delivery of high-quality primary care and equitable prevention and treatment strategies. Research on social determinants of health and policy-relevant research need to be expanded and strengthened to the extent that a reduction of the total NCD burden and inequalities therein should be treated as related and mutually reinforcing priorities.

The Burden of Cardiovascular Disease Attributable to Major Modifiable Risk Factors in Indonesia

BACKGROUND

In Indonesia, coronary heart disease (CHD) and stroke are estimated to cause more than 470 000 deaths annually. In order to inform primary prevention policies, we estimated the sex- and age-specific burden of CHD and stroke attributable to five major and modifiable vascular risk factors: cigarette smoking, hypertension, diabetes, elevated total cholesterol, and excess body weight.

METHODS

Population attributable risks for CHD and stroke attributable to these risk factors individually were calculated using summary statistics obtained for prevalence of each risk factor specific to sex and to two age categories (<55 and ≥55 years) from a national survey in Indonesia. Age- and sex-specific relative risks for CHD and stroke associated with each of the five risk factors were derived from prospective data from the Asia-Pacific region.

RESULTS

Hypertension was the leading vascular risk factor, explaining 20%-25% of all CHD and 36%-42% of all strokes in both sexes and approximately one-third of all CHD and half of all strokes across younger and older age groups alike. Smoking in men explained a substantial proportion of vascular events (25% of CHD and 17% of strokes). However, given that these risk factors are likely to be strongly correlated, these population attributable risk proportions are likely to be overestimates and require verification from future studies that are able to take into account correlation between risk factors.

CONCLUSIONS

Implementation of effective population-based prevention strategies aimed at reducing levels of major cardiovascular risk factors, especially blood pressure, total cholesterol, and smoking prevalence among men, could reduce the growing burden of CVD in the Indonesian population.

Multimorbidity prevalence and pattern in Indonesian adults: an exploratory study using national survey data

OBJECTIVES

To estimate the prevalence and pattern of multimorbidity in the Indonesian adult population.

DESIGN

Cross-sectional study.

SETTING

Community-based survey. The sampling frame was based on households in 13 of the 27 Indonesian provinces, representing about 83% of the Indonesian population.

PARTICIPANTS

9438 Indonesian adults aged 40 years and above.

MAIN OUTCOME MEASURES

Prevalence and pattern of multimorbidity by age, gender and socioeconomic status.

RESULTS

The mean number of morbidities in the sample was 1.27 (SE ± 0.01). The overall age and sex standardised prevalence of multimorbidity was 35.7% (34.8% to 36.7%), with women having significantly higher prevalence of multimorbidity than men (41.5% vs 29.5%; p<0.001). Of those with multimorbidity, 64.6% (62.8% to 66.3%) were aged less than 60 years. Prevalence of multimorbidity was positively associated with age (p for trend <0.001) and affluence (p for trend <0.001) and significantly greater in women at all ages compared with men. For each 5-year increment in age there was an approximate 20% greater risk of multimorbidity in both sexes (18% in women 95% CI 1.14 to 1.22 and 22% in men 95% CI 1.18 to 1.26). Increasing age, female gender, non-Javanese ethnicity, and high per-capital expenditure were all significantly associated with higher odds of multimorbidity. The combination of hypertension with cardiac diseases, hypercholesterolemia, arthritis, and uric acid/gout were the most commonly occurring disease pairs in both sexes.

CONCLUSIONS

More than one-third of the Indonesian adult population are living with multimorbidity with women and the more wealthy being particularly affected. Of especial concern was the high prevalence of multimorbidity among younger individuals. Hypertension was the most frequently occurring condition common to most individuals with multimorbidity.