Community-based intervention of chronic disease management program in rural areas of Indonesia^†

Chronic disease (CD) is the leading cause of death and disability in the world. CD cases increased globally from all socio-economic classes and made up 73% of all deaths, 60% of the global disease burden, and 79% of deaths in developing countries.¹ Meanwhile, CDs are increasing in Indonesia, such as 10.9% of people experiencing strokes, 2% diabetes, 1.5% heart diseases, and 8.8% hypertension.² Indonesia has been aware that CD is becoming one of the health issues and cause of death, causing major global threats to Indonesia's economic development.³ Therefore, intervention to prevent CD should focus on controlling key risk factors in a well-integrated manner.¹

CD is linked by common and preventable biological risk factors, notably high blood pressure, high blood cholesterol and overweight, and related major behavioral risk factors: unhealthy diet, physical inactivity, and tobacco use.¹ Therefore, developing an integrated approach that will control and prevent these factors should be implemented in a particularly community-based intervention program for primary care.⁴ Primary care and community care are vital settings for CD's effective management.⁵ A self-management support program effectively prevents CD in primary care.⁶ Meanwhile, a self-help group as social support was designed to solve CD in Indonesia's rural areas.⁷ Furthermore, CD's risk factors in Indonesia are controlled by empowering the community through the Integrated Non-Communicable Diseases Health Post (Posbindu-NCD). The Posbindu-NCD operated by a community of health workers (CHWs) as cadres monitors and controls the CD each month.⁸

A previous study mentioned that effective integration of CHWs within the primary care system is essential for CHW's capacity buildings, necessary supervisory arrangements, supply of logistics and medications, and effective recording and reporting systems for prevention and control of NCDs in Nepal.⁹ Meanwhile, Posbindu cadres’ performance in the Indonesian setting has a strategic function for delivering CD's management because Posbindu agendas depend on cadres’ role in carrying out their duties and obligations.⁸ On the other hand, it is possible to implement an intervention integrating CD prevention and management services into primary care settings as a community-based intervention program.¹⁰

Therefore, this study aims to evaluate community-based intervention of CD management programs conducted by CHWs in Indonesia's rural areas.

Table 1 showed that there were statistically significant differences between participants who consumed alcohol and who had diabetes mellites (χ² = 10.455; P = 0.001). There were significant differences based on gender (χ²= 3.963; P = 0.047), ethnicity (χ² = 19.873; P < 0.001), and hypertension. In addition, there were also significant differences on ethnicity (χ² = 15.307; P < 0.001), vegetable consumption (χ² = 4.435; P = 0.035), physical exercise (χ² = 6.328; P = 0.012), and the current diseases of hypercholesterolemia of participants.

Table 2 shows the significant difference in blood glucose level and total cholesterol of participants who visit and do not visit Posbindu-NCD of guiding CHWs during 1-month, 6-month, and 12-month periods (P < 0.05). There was a decrease in the glucose blood level and total cholesterol level of participants who regularly visited Posbindu-NCD of guiding CHWs during 1-month, 6-month, and 12-month periods.

Figure 1A showed the number of participants visiting Posbindu-NCD per month during 2019. Figure 1B showed that 577 patients visited Posbindu-NCD regularly (69%) and the rest of them not regularly (31%).

Figure 1

The survival rate was significantly different among participants who regularly and non-regularly visited Posbindu-NCD (Figure 2) who were overweight, who had abdominal overweight, and who had hypertension, diabetes mellitus, and hypercholesterolemia. The survival rate of participants who are overweight who regularly visited Posbindu-NCD ranged from 0.4 to 1.0 (Figure 2A). The survival rate of participants regularly visited Posbindu-NCD who had abdominal overweight ranged from 0.6 to 1.0 (Figure 2B). The survival rate of participants with hyper-tension who regularly visited Posbindu-NCD ranged from 0.45 to 1.0 (Figure 2C). The survival rate of participants with diabetes mellitus who regularly visited Posbindu-NCD ranged from 0.2 to 1.0 (Figure 2D). The survival rate of participants with hypercholesterolemia who regularly visited Posbindu-NCD ranged from 0.65 to 1.0 (Figure 2E).

Figure 2

Table 3 showed significantly differences in BMI, abdominal circumferences, blood pressure, blood glucose level, and total cholesterol among participants who regularly and non-regularly visited Posbindu-NCD (P < 0.001). Participants who visited once during 12 months to Posbindu-NCD maintained their BMI, abdominal circumferences, blood pressure, level of blood glucose, and total cholesterol level.

The current study identified that the CD management program's community-based intervention through Posbindu-NCD conducted by CHWs effectively maintained NCD in Indonesia's rural areas. The BMI, abdominal circumferences, blood pressure, glucose blood level, and total cholesterol were controlled among participants who regularly visited Posbindu-NCD. Furthermore, the survival rates among participants who were overweight, had abdominal overweight, and had hypertension, diabetes mellitus, and hypercholesterolemia were also increasing among participants who regularly visited Posbindu-NCD compared with the ones who did not visit regularly.

The current study showed that community-based intervention of CD management program through Posbindu-NCD conducted by CHWs was effective to control NCD. This result is consistent with previous research that clinical-based interventions in communities could control NCD in rural areas.¹² The implementation of Posbindu-NCD through a five-desk system can facilitate regular monthly health checks from participants in the community¹¹ to carry out a self-care program thoroughly and independently.¹³ CHWs facilitate scheduled implementation of Posbindu-NCD activities by examining health and providing counselling for participants who have risk factors and health problems. Therefore, the scheduled implementation of Posbindu-NCD needs to be improved in the community to prevent and overcome NCD with local resources in rural areas.

Our finding showed that the BMI, abdominal circumferences, blood pressure, glucose blood level, and total cholesterol were kept at a better level among participants who regularly visited Posbindu-NCD. This result is since CHWs are empowered to provide services to the community.^10,14,15 Participants who came to Posbindu-NCD were checked for height and weight and abdominal circumference at desk III and blood pressure, blood sugar levels, and total cholesterol at desk IV of Posbindu-NCD. Thus, early NCD health problems experienced by participants were observed.¹⁶ Regular checks regarding the risk factors for NCD are essential in reducing health problems.¹⁷ Therefore, there is a need for continuity of community empowerment programs as social workers in Posbindu-NCD to screen activities from, by, and for people in rural areas.

Furthermore, the survival rates among participants who are overweight, who have abdominal overweight, who have hypertension, diabetes mellitus, and hypercholesterolemia increased among participants who regularly visited Posbindu-NCD. Being monitored regularly every month by CHWs in the community, the participant's health status in Posbindu-NCD was better monitored,^9,18,19 thus improving their health level more than that of participants who did not come regularly every month. Activeness to attendance to Posbindu-NCD regarding the characteristic of community should improve to reduce the risk factors of NCD and improve health status.^20,21 The activeness of visitors’ Posbindu-NCD could increase the survival rate at least ten times a year, which can increase the survival rate. Therefore, it requires actively participating in the community to participate in the community's monthly Posbindu-NCD activities.²²

The CD management program's community-based intervention through Posbindu-NCD conducted by CHWs effectively controlled NCD in rural areas of Indonesia. Therefore, this program can be further developed in conducting NCD management in the community with the active involvement of CHW so that the community becomes active in participating in Posbindu-NCD activities regularly. Community regularity in implementing the five desk system can detect overweight, abdominal overweight, hypertension, diabetes mellitus, and hyper-cholesterolemia with an active role of CHWs. Thus, community self-management is indispensable in the self-care of NCDs in communities facilitated by CHWs in Indonesia's rural areas.