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Global Medical & Health Communication
pISSN 2301-9123 │ eISSN 2460-5441
Volume 8 Number 1, April 2020

TABLE OF CONTENTS

RESEARCH ARTICLES
Combination of Gabapentin and Vitamin B12 Compared with Gabapentin Monotherapy on 1
Pain Improvement of Diabetic Neuropathy Patients
Mochamad Firdaus Bhuanaputra, Alya Tursina, Yuktiana Kharisma
Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and 7
without Liver Cirrhosis
Hari Soekersi, Leni Santiana, Fetty Fatmawaty
Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms in Dr. Hasan 13
Sadikin General Hospital Bandung
Astrid Feinisa Khairani, Kuheinderan Radha Krishnan, Umar Islami,
Siti Aminah Sobana
Differences in Expulsion on Post-placenta Intrauterine Contraceptive Device between Mother 21
with Vaginal and Cesarean Delivery
Atika Zahria Arisanti, Tono Djuwantono, Sri Endah Rahayuningsih
Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months 27
Nur Eva Aristina, Dedi Rachmadi, Dewi Marhaeni Diah Herawati,
Hadi Susiarno, Dida Akhmad Gurnida, Deni Kurniadi Sunjaya
Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’ 34
Quality of Service in Teaching Hospital
Siska Nia Irasanti, Ieva Baniasih Akbar, Yani Dewi Suryani
Relationship of Soil-transmitted Helminth and Enterobius vermicularis Infection with Anemic 42
in Students in Aceh Besar
Faisal Heri, A.A. Depari, Merina Panggabean
Dermatoglyphics Pattern on Breast Cancer Patients in Dharmais Cancer Hospital 47
Faras Qodriyyah Sani, Mirfat, Iskandar
The Quality of Life on Asthmatic Adolescent and Its Correlation with the Severity and Control 53
of Asthma
Lisa Adhia Garina, Muhammad Ridho Grahadinta, Ferry Achmad
Firdaus Mansoer, Intan Puspitasari
The Effect of Health Education with Flashcard Media on Improvement of Knowledge and 59
Reduction of Anxiety Degree in Adolescents Primigravida
Dwie Yunita Baska, Tita Husnitawati Madjid, Ponpon S. Idjradinata
Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to the Level of Malondialdehyde 67
Meiyanti, Eveline Margo, Juni Chudri
The Effect of Low Impact Aerobic Exercise on Elderly with Dementia Cognitive Function 73
Raden Ayu Tanzila, Sheilla Yonaka Lindri, Nindia Rahma
A Comparative Evaluation of Community Periodontal Index (CPI) and the Presence of Nicotine 78
Stomatitis among Smokers after Oral Hygiene Instruction
Meta Maulida Damayanti, Yuktiana Kharisma, Fajar Awalia Yulianto,
Santun Bhekti Rahimah, Winni Maharani, Meike Rachmawati, Herri S.
Sastramihardja, Muhammad Alief Abdul ‘Aziiz, Muhammad Ilham Halim
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RESEARCH ARTICLE

Combination of Gabapentin and Vitamin B12 Compared with Gabapentin

Monotherapy on Pain Improvement of Diabetic Neuropathy Patients
Mochamad Firdaus Bhuanaputra,1 Alya Tursina,2 Yuktiana Kharisma3
Medical Undergraduate Study Program, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia,
1
2
Department of Neurology, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia, 3Department of
Pharmacology, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia

Abstract
Diabetic neuropathy is the most common microvascular complication of diabetes mellitus (DM) occurring in 60–
70% of the world's DM population, 40% of the DM population in Asia, and 41% of the DM population in Indonesia.
The primary treatment of diabetic neuropathy pain in Indonesia is gabapentin and vitamin B12. The study aimed to
compare pain improvements in diabetic neuropathy patients. The drug used was a combination of gabapentin and
vitamin B12 and gabapentin monotherapy. For the pain degree measurement, we used the visual analogue scale
(VAS). This experimental study was a pretest-posttest randomized control trial using a single-blind method at Dr.
M. Salamun Air Force Hospital Bandung from March to May 2017. Samples were 44, type two diabetic neuropathy
patients. The Mann-Whitney test to compare pain improvement between 2 groups applied. The results indicated
there were differences in pain improvement between diabetic neuropathy patients with gabapentin and vitamin B12
combination compare to gabapentin monotherapy (p=0.002). This result showed a synergistic effect of gabapentin
as an inhibitor of neurotransmitter and vitamin B12 expenditure as an improvement in peripheral nerve cells. This
study concluded that gabapentin and vitamin B12 combination is better in improving pain in diabetic neuropathy
patients compared to gabapentin monotherapy.
Key words: Diabetes mellitus, diabetic neuropathy, gabapentin, pain repair, vitamin B12

Kombinasi Gabapentin dan Vitamin B12 Dibanding dengan Monoterapi

Gabapentin terhadap Perbaikan Nyeri Pasien Neuropati Diabetik

Abstrak
Neuropati diabetik merupakan komplikasi mikrovaskular terbanyak diabetes melitus (DM) yang terjadi pada 60–
70% populasi DM di dunia, 40% populasi DM di Asia, dan 41% populasi DM di Indonesia. Pengobatan utama
nyeri neuropati diabetik di Indonesia adalah gabapentin dan vitamin B12. Tujuan penelitian ini membandingkan
perbaikan rasa nyeri pada pasien neuropati diabetik. Obat yang diberikan adalah kombinasi gabapentin dan vitamin
B12 serta monoterapi gabapentin. Pengukuran tingkat nyeri menggunakan visual analogue scale (VAS). Penelitian
eksperimental ini adalah pretest-posttest randomized control trial dengan menggunakan metode single-blind yang
dilakukan di RSAU Dr. M. Salamun Bandung dari bulan Maret hingga Mei 2017. Sampel berjumlah 44 jenis, dua
pasien neuropati diabetik. Sampel berjumlah 44, pasien neuropati diabetik tipe dua. Uji Mann-Whitney dilakukan
untuk membandingkan perbaikan nyeri antara 2 kelompok perlakuan. Hasil penelitian menunjukkan terdapat
perbedaan perbaikan rasa nyeri pasien neuropati diabetik yang diberi pengobatan kombinasi gabapentin dan
vitamin B12 dibanding dengan monoterapi gabapentin (p=0,002). Hasil ini menunjukkan efek sinergis gabapentin
sebagai inhibitor neurotransmiter dan vitamin B12 yang berfungsi memperbaiki sel saraf tepi. Simpulan penelitian
ini adalah pengobatan kombinasi gabapentin dan vitamin B12 lebih baik dalam memperbaiki rasa nyeri pada pasien
neuropati diabetik dibanding dengan gabapentin saja.
Kata kunci: Diabetes melitus, gabapentin, neuropati diabetik, perbaikan nyeri, vitamin B12

Received: 12 April 2018; Revised: 5 April 2020; Accepted: 22 April 2020; Published: 30 April 2020
Correspondence: Mochamad Firdaus Bhuanaputra. Medical Undergraduate Study Program, Faculty of Medicine, Universitas Islam
Bandung. Jln. Tamansari No. 22, Bandung 40116, West Java, Indonesia. E-mail: mochamadfirdausb@gmail.com

1
2 Mochamad Firdaus Bhuanaputra et al.: Combination of Gabapentin and Vitamin B12 Compared with Gabapentin

Introduction medicines on diabetic neuropathic, the researcher

will compare gabapentin combination treatment
Diabetic neuropathy is a common complication with or without vitamin B12 to the pain relief in
of diabetes mellitus that happens to 60–70% of diabetic neuropathic’s patients.
total patients of diabetes mellitus in the world.1
The prevalence of neuropathy and complications Methods
in the legs is counted high in the patients in
Asia, which is about 40% of the total population This experimental study was a pretest-posttest
of DM.2,3 Around 41% of DM’s patients have randomized control trial using a single blinding
neuropathy complications in Indonesia.4 method. The 44 study respondents divided
The symptoms caused are severe and acute into two groups—the first group consumed
pain like burnt, sore, allodynia, and electric gabapentin and vitamin B12 combination, and
shock. This pain has a significant effect on the the second group had gabapentin monotherapy.
patient’s life quality.5–8 Currently, there is still The patients asked to take the drugs respective
no curative diabetic neuropathy treatment. The to the groups for eight weeks. The pain checks
treatment based on four pillars, such as blood monitored using the monofilament and visual
glucose regulation approaching normal, therapy analogue scale (VAS) at the beginning and end
based on pathogenesis, symptomatic treatment, of week 8. Subjects are diabetic neuropathic
and avoiding risk factors and complications.5,9,10 patients who seek treatment at Dr. M. Salamun
The patient needs treatment pharmacologically Air Force Hospital Bandung from March to May
to relieve symptoms, especially great pain.11 2017. Statistical analyses used were the Friedman
Gabapentin is an anti-seizure medication that test and Wilcoxon test. The study instrument
affects the treatment of neuropathic pain.12–14 used is monofilament.18–20
Gabapentin gives the effect as a substance that This study has been through ethical studies
can increase gamma-aminobutyric acid (GABA) by the Health Research Ethics Committee of
synthesis, non-N-methyl-D-aspartate (NMDA) the Faculty of Medicine of Universitas Islam
receptor antagonist, and α2δ voltage-dependent Bandung with letter number: 045/Komite Etik.
calcium channels subunit bond that inhibits the FK/III/2017.
release of excitatory neurotransmitters.15,16 In
most patients, it needs 1.8 gram/day to relieve Results
pain symptoms.
Besides symptomatic treatment, neuropathy Table 1 shows that gabapentin and vitamin B12
patients need a supplement. Vitamin B12 has combination group have pain relief marked by
an essential role in the metabolism of essential average VAS score reduction in the 0 weeks until
fatty acids as the preservation of nerve myelin. the 8th week.
Prolonged vitamin B12 deficiency causes nerve Table 2 shows that the gabapentin
cell degeneration and irreversible nerve damage. monotherapy treatment group has pain relief
Diabetic neuropathy with or without vitamin B12 marked by average VAS score reduction in the 0
deficiency often treated with neuropathic vitamin weeks until the 8th week.
for decades.9,17 Based on Table 3 with the Friedman
The description above about the effect of both test, the results obtained on the gabapentin

Table 1 Average Result of VAS Score Check in the Gabapentin and Vitamin B12
Combination Group
Gabapentin and Vitamin B12 Combination Group
VAS Score
Average (SD) Median (Min–Max)
VAS 0 week 7.45 (0.50) 7 (7–8)
VAS 4th week 7.36 (0.49) 7 (7–8)
VAS 8th week 6.55 (0.59) 6.5 (6–8)
Note: VAS=visual analogue scale

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Mochamad Firdaus Bhuanaputra et al.: Combination of Gabapentin and Vitamin B12 Compared with Gabapentin 3

Table 2 Average Result of VAS Score Check in the Gabapentin Monotherapy Group
Gabapentin Group
VAS Score
Average (SD) Median (Min–Max)
VAS 0 week 7.27 (0.63) 7 (6–8)
VAS 4th week 6.77 (0.61) 7 (6–8)
VAS 8th week 7.09 (0.52) 7 (6–8)
Note: VAS=visual analogue scale

Table 3 VAS Score Different Test Before Therapy, After 4, and 8 Weeks Therapy
VAS Score p Value*
Gabapentin <0.001
Gabapentin and vitamin B12 combination <0.001
Note: * Statistic analysis with Friedman test, significant if p value≤0.05

Table 4 The Difference of Pain Relief Before Therapy, After 4 and 8 Weeks Therapy
Gabapentin and Vitamin B12
Gabapentin Monotherapy
Combination
Time
Average ∆VAS p Average ∆VAS p
(SD) Score Value* (SD) Score Value*
0 weeks 7.27 (0.63) 7.45 (0.50)
0.18 0.020 0.91 <0.001
8th week 7.09 (0.52) 6.54 (0.59)
Note: *Data analysis uses Wilcoxon test, significant if p value≤0.05; ∆=difference between weeks

Table 5 Pain Relief Comparison between Gabapentin and Vitamin B Combination and
Gabapentin Monotherapy
Gabapentin Gabapentin and Vitamin
Monotherapy B12 Combination p
Pain Relief Value*
Mean SD Median Mean SD Median
∆VAS score of 0 week 0.18 0.58 0.00 0.90 0.29 1.00 0.002
and 8th week
Note: *Mann-Whitney test, ∆=difference between weeks

monotherapy test and gabapentin and also Table 5 shows that there is a significant
vitamin B12 combination, which shows that difference in pain relief between gabapentin and
each has a significant different VAS score on two vitamin B12 combination group and gabapentin
measurements. monotherapy (p value<0.002).
Table 4 shows that there is a significant
average difference in pain relief between 0 week Discussion
and 8th week in both groups. The gabapentin
and vitamin B12 combination group has better In the gabapentin and vitamin B12 combination
average pain relief compared to the gabapentin group, there is a significant pain relief difference
monotherapy group. (p value<0.001) between 0 week and eighth

Global Medical and Health Communication, Volume 8 Number 1, April 2020

4 Mochamad Firdaus Bhuanaputra et al.: Combination of Gabapentin and Vitamin B12 Compared with Gabapentin

week. This result was consistent with the study The finding is consistent with the study
conducted by Mimenza Alvarado and Aguilar conducted by Mimenza Alvarado and Aguilar
Navarro.21 They stated that there is a significant Navarro.21 The gabapentin and vitamin B complex
pain relief difference (p value<0.001). administration compare to pregabalin shows
Gabapentin and vitamin B12 have synergistic better pain relief. The significant difference in
workability. The gabapentin increases gamma- pain relief between the treatment group and the
aminobutyric acid (GABA) synthesis, the receptor control group observed in the 0 week and eighth
antagonist of N-methyl-D-aspartate (NMDA), week (p value<0.001).
and subunit bond of α2δ voltage-dependent Gabapentin and vitamin B12 combination
calcium channels that inhibits the release of groups have better pain relief improvement than
excitatory neurotransmitters. That mechanism the gabapentin monotherapy group. The results
causes stimulation inhibition and pain reduction caused by better and more optimal treatment
in neuropathic patients who consume gabapentin. mix in gabapentin and vitamin B12 combination
The role of vitamin B12 is to repair peripheral group. The administration of gabapentin will give
nerve cells by becoming a cofactor that facilitates an inhibiting effect to release neurotransmitters
homocysteine methylation for methionine, which so that it will reduce the pain in diabetic
activated to S-adenosyl-methionine, which neuropathic patients. The usage combined with
donates the methyl group for methyl acceptors the administration of vitamin B12, which serves
like myelin, neurotransmitter, and phospholipid to maintain and repair peripheral nerve cells. The
membrane. The usage of gabapentin combined combination treatment effect will give better pain
with vitamin B12 has a synergic effect to relieve relief improvement.23–25
the pain of diabetic neuropathic patients.15,16,22
In the gabapentin treatment groups, a Conclusion
significant pain relief difference is observed (p
value=0.02) between 0 week and eighth week. A combination of gabapentin and vitamin B12
This study is following the study conducted by showed better pain relief compared to gabapentin
Surcheva et al.,23 which shows that there is a monotherapy in diabetic neuropathic patients.
significant pain relief difference (p value=001).
The difference in improvement observed during Conflict of Interest
0 week and eighth week.
Gabapentin is a medicine of choice which The authors declare that no conflict of interest in
mitigates the pain that works on the central this study.
nervous system but has a side effect that is classified
small. Gabapentin affects neurotransmitter Acknowledgment
inhibitors. Gabapentin has a modification effect of
releasing GABA. The release of GABA happened We appreciate the support from the Head of Dr.
either presynaptic or postsynaptic on the central M. Salamun Air Force Hospital Bandung during
or even the arrangement of peripheral nerves. the study.
Gabapentin increases GABA synthesis from
glutamate and increases the release of GABA References
from astrocytes. Some researches show that there
is a concentration increase of GABA in some 1. Bansal D, Gudala K, Muthyala H, Esam HP,
regions of the brain after the administration of Nayakallu R, Bhansali A. Prevalence and risk
gabapentin so that glutamic acid decarboxylase factors of development of peripheral diabetic
increases and also decarboxylase glutamic acid neuropathy in type 2 diabetes mellitus in
enzyme destruction decreases which eventually a tertiary care setting. J Diabetes Investig.
increases the production of GABA.15,16,23 2014;5(6):714–21.
The pain relief observed in the gabapentin and 2. Ramachandran A, Snehalatha C, Shetty AS,
vitamin B12 combination group and gabapentin Nanditha A. Trends in prevalence of diabetes
monotherapy group. The pain relief is significantly in Asian countries. World J Diabetes.
better in the gabapentin and vitamin B12 2012;3(6):110–7.
combination group compared to the gabapentin 3. Guariguata L, Whiting DR, Hambleton I,
monotherapy group with p value=0.002. Beagley J, Linnenkamp U, Shaw JE. Global

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Mochamad Firdaus Bhuanaputra et al.: Combination of Gabapentin and Vitamin B12 Compared with Gabapentin 5

estimates of diabetes prevalence for 2013 and neuropathic pain in adults. Cochrane
projections for 2035. Diabetes Res Clin Pract. Database Syst Rev. 2017;6:CD007938.
2014;103(2):137–49. 14. Murnion BP. Neuropathic pain: current
4. Indonesia Agency of Health Research definition and review of drug treatment. Aust
and Development, Ministry of Health of Prescr. 2018 Jun;41(3):60–3.
Republic of Indonesia. Basic health research 15. Attal N, Cruccu G, Baron R, Haanpää
(Riskesdas) 2013 [Internet]. Jakarta: M, Hansson P, Jensen TS, et al. EFNS
Indonesia Agency of Health Research and guidelines on the pharmacological treatment
Development, Ministry of Health of Republic of neuropathic pain: 2010 revision. Eur J
of Indonesia; 2013 [cited 2017 June 15]. Neurol. 2010;17(9):1113–23.
Available from: http://labdata.litbang. 16. Rosenquist RW, Vrooman BM. Chronic pain
kemkes.go.id/ccount/click.php?id=10. managament. In: Butterworth JF, Mackey
5. Malik VS, Popkin BM, Bray GA, Després DC, Wasnick JD, editors. Morgan and
JP, Willett WC, Hu FB. Sugar-sweetened Mikhail's Clinical Anesthesiology. 5th Edition.
beverages and risk of metabolic syndrome New York: McGraw-Hill Companies; 2013. p.
and type 2 diabetes: a meta-analysis. Diabetes 1023–86.
Care. 2010;33(11):2477–83. 17. Agency for Healthcare Research and Quality,
6. Jin W, Patti ME. Genetic determinants and U.S. Department of Health & Human Services.
molecular pathways in the pathogenesis Effectiveness of treatments for diabetic
of type 2 diabetes. Clin Sci (Lond). peripheral neuropathy [Internet]. May 13,
2009;116(2):99–111. 2016 [cited 2017 June 17]. Available from:
7. VA Center for Integrated Healthcare. Diabetic https://effectivehealthcare.ahrq.gov/sites/
neuropathies: the nerve damage of diabetes default/files/pdf/diabetic-neuropathy_
[Internet]. July 2013 [cited 2017 June 16]. research-protocol.pdf.
Available from: https://www.mirecc.va.gov/ 18. Baraz S, Zarea K, Shahbazian HB, Latifi SM.
cih-visn2/Documents/Provider_Education_ Comparison of the accuracy of monofilament
Handouts/Diabetic_Neuropathies_ testing at various points of feet in peripheral
Version_3.pdf. diabetic neuropathy screening. J Diabetes
8. Chawla R. Complications of diabetes. New Metab Disord. 2014;13(1):19.
Delhi: Jaypee Brothers Medical Publishers; 19. Wang F, Zhang J, Yu J, Liu S, Zhang R, Ma
2012. X, et al. Diagnostic accuracy of monofilament
9. Schreiber AK, Nones CF, Reis RC, Chichorro tests for detecting diabetic peripheral
JG, Cunha JM. Diabetic neuropathic pain: neuropathy: a systematic review and meta-
physiopathology and treatment. World J analysis. J Diabetes Res. 2017;2017:8787261.
Diabetes. 2015 Apr 15;6(3):432–44. 20. Dros J, Wewerinke A, Bindels PJ, van
10. Yagihashi S, Mizukami H, Sugimoto K. Weert HC. Accuracy of monofilament
Mechanism of diabetic neuropathy: where testing to diagnose peripheral neuropathy: a
are we now and where to go? J Diabetes systematic review. Ann Fam Med. 2009 Nov-
Investig. 2011;2(1):18–32. Dec;7(6):555–8.
11. Emerging Risk Factors Collaboration, Sarwar 21. Mimenza Alvarado A, Aguilar Navarro
N, Gao P, Seshasai SR, Gobin R, Kaptoge S, S. Clinical trial assessing the efficacy of
Di Angelantonio E, et al. Diabetes mellitus, gabapentin plus B complex (B1/B12)
fasting blood glucose concentration, and risk versus pregabalin for treating painful
of vascular disease: a collaborative meta- diabetic neuropathy. J Diabetes Res.
analysis of 102 prospective studies. Lancet. 2016;2016:4078695.
2010;375(9733):2215–22. 22. Jayabalan B, Low LL. Vitamin B
12. Wiffen PJ, Derry S, Moore RA, Aldington supplementation for diabetic peripheral
D, Cole P, Rice AS, et al. Antiepileptic drugs neuropathy. Singapore Med J. 2016;57(2):55–
for neuropathic pain and fibromyalgia - an 9.
overview of Cochrane reviews. Cochrane 23. Surcheva S, Todorova L, Maslarov
Database Syst Rev. 2013;(11):CD010567. D, Vlaskovska M. Preclinic and clinic
13. Wiffen PJ, Derry S, Bell RF, Rice AS, Tölle effectiveness of gabapentin and pregabalin
TR, Phillips T, et al. Gabapentin for chronic for treatment of neuropathic pain in rats

Global Medical and Health Communication, Volume 8 Number 1, April 2020

6 Mochamad Firdaus Bhuanaputra et al.: Combination of Gabapentin and Vitamin B12 Compared with Gabapentin

and diabetic patients. Biotechnol Biotechnol 25. Lal R, Sukbuntherng J, Luo W, Tovera
Equip. 2017;31(3):568–73. J, Lassauzet ML, Cundy KC. Population
24. Vinik AI, Casellini CM. Guidelines in the pharmacokinetics and pharmacodynamics
management of diabetic nerve pain: clinical of gabapentin after administration of
utility of pregabalin. Diabetes Metab Syndr gabapentin enacarbil. J Clin Pharmacol.
Obes. 2013;6:57–78. 2013;53(1):29–40.

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 Global Medical and Health Communication

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RESEARCH ARTICLE

Comparative Study Gallbladder Contractility Index Using

Ultrasound in Patients with and without Liver Cirrhosis
Hari Soekersi,1 Leni Santiana,1 Fetty Fatmawaty2,3
Department of Radiology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital,
1

Bandung, Indonesia, 2Radiology Study Program, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin
General Hospital, Bandung, Indonesia, 3R. Syamsudin, S.H. Regional General Hospital, Sukabumi, Indonesia

Abstract
Liver cirrhosis leads to impairment of gallbladder contractility resulting in bile stasis and facilitate the development
of gallstones that will aggravate the clinical symptoms of the patients. The gallbladder contractility index is an
indicator of gallbladder motility measured using ultrasound as the radiological choice of modality. This study aims
to determine differences in the gallbladder contractility index using ultrasound in patients with and without liver
cirrhosis. This study was an observational study of comparative analytic with cross-sectional design with sampling
conducted by consecutive admissions sampling at Dr. Hasan Sadikin General Hospital Bandung from December
2017 to February 2018. Statistical analysis than performed by using an independent t test to find out the difference
of gallbladder contractility index in patients with and without liver cirrhosis. A total of 22 subjects, 12 men, 10
women, with the youngest 37 years old and the oldest 70 years old. The result of the study was obtained mean fasting
gallbladder volume (35.56±22.16 mL) and postprandial (21.25±16.08 mL) in patients with liver cirrhosis higher
than without liver cirrhosis with mean fasting gallbladder volume (16.50±4.14 mL) and postprandial (5.44±2.10
mL). The average gallbladder contractility index on patients with liver cirrhosis (41.64±24.52%) smaller than
without liver cirrhosis (66.73±9.19%). The result of the statistical test showed that there was a significant difference
in the gallbladder contractility index on patients with liver cirrhosis than without liver cirrhosis (p=0.007, p≤0.05).
In conclusion, there was a significant difference in the gallbladder contractility index that measured by using
ultrasound between the patients with and without liver cirrhosis.
Key words: Contractility index, gallbladder, liver cirrhosis, ultrasound

Perbedaan Indeks Kontraktilitas Kandung Empedu Menggunakan

Ultrasonografi pada Penderita Sirosis Hati dan tanpa Sirosis Hati

Abstrak
Sirosis hati menyebabkan gangguan indeks kontraktilitas kandung empedu yang mengakibatkan stasis cairan
empedu dan memudahkan kejadian batu empedu yang akan memperberat gejala klinis pasien. Indeks kontraktilitas
kandung empedu merupakan indikator motilitas kandung empedu yang diukur menggunakan ultrasonografi (USG)
sebagai modalitas pilihan radiologi. Penelitian ini bertujuan mengetahui perbedaan indeks kontraktilitas kandung
empedu menggunakan ultrasonografi pada pasien sirosis hati dan tanpa sirosis. Penelitian ini menggunakan studi
observasional analitik komparatif dengan rancangan cross-sectional dan pengambilan sampel dilakukan secara
consecutive admissions sampling di RSUP Dr. Hasan Sadikin Bandung dari bulan Desember 2017 hingga Februari
2018. Uji statistik menggunakan independent t test. Subjek penelitian berjumlah 22, laki-laki 12 dan perempuan
10, serta usia termuda 37 tahun dan tertua 70 tahun. Hasil penelitian didapatkan volume rerata kandung empedu
puasa (35,56±22,16 mL) dan pascaprandial (21,25±16,08 mL) pada pasien sirosis hati lebih besar daripada tanpa
sirosis hati dengan volume rerata kandung empedu puasa (16,50±4,14 mL) dan pascaprandial (5,44±2,10 mL).
Indeks kontraktilitas rerata kandung empedu penderita sirosis hati (41,64±24,52%) lebih rendah dibanding dengan
tanpa sirosis hati (66,73±9,19%). Hasil uji statistik menunjukkan terdapat perbedaan bermakna antara indeks
kontraktilitas kandung empedu penderita sirosis hati dan tanpa sirosis hati (p=0,007; p≤0,05). Simpulan, terdapat
perbedaan bermakna antara indeks kontraktilitas kandung empedu menggunakan USG pada penderita sirosis hati
dan tanpa sirosis hati.
Kata kunci: Indeks kontraktilitas, kandung empedu, sirosis hati, ultrasonografi

Received: 7 May 2018; Revised: 26 January 2020; Accepted: 2 March 2020; Published: 30 April 2020
Correspondence: Fetty Fatmawaty, dr., Sp.Rad. R. Syamsudin, S.H. Regional General Hospital. Jln. Rumah Sakit No. 1, Sukabumi
43113, West Java, Indonesia. E-mail: tototi.ff@gmail.com

7
8 Hari Soekersi et al.: Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and without

Introduction neural path.12 Gallbladder contractility disorder

in cirrhotic patients is also affected by the
Liver cirrhosis is the third leading cause of thickening of the gallbladder wall. This thickening
death in patients who are 45–46 years old (after is due to edema and structural changes in the
cardiovascular and cancer). Liver cirrhosis is gallbladder wall due to hypoalbuminemia and
a disease characterized by diffuse and chronic portal hypertension. In addition to the above, the
inflammation of the liver progressively with disorder of gallbladder contractility in patients
distorted images of the hepatic architecture with liver cirrhosis also influenced by humoral
and the formation of regenerative nodules.1,2 changes.13–17
Worldwide, liver cirrhosis ranks seventh as the Humoral changes that occur in liver
cause of death. There are more male patients cirrhosis are due to cholecystokinin (CCK)
with liver cirrhosis compared with women with receptor resistance in the gallbladder. Thus, the
a ratio of about 1.6:1. The average age group is contraction of the gallbladder disrupted. Besides,
30–59 years old, with a peak of around the age decreased hepatic clearance also occurs in
of 40–49 years old.3,4 In 2015, the World Health patients with liver cirrhosis, increasing the level
Organization (WHO) reported that 720,000 of intestinal peptides that affect the relaxation
deaths caused by liver cirrhosis in the world.5 of the gallbladder wall. Gallbladder contractility
In 2012, liver cirrhosis in Indonesia is the disorders in patients with liver cirrhosis assessed
sixth cause of death, with 48.9 thousand deaths. by evaluating the gallbladder contractility index
The incidence of liver cirrhosis in Indonesia using ultrasound.13
due to hepatitis B ranged between 21.2–46.9% Ultrasound is the preferred modality for
and hepatitis C ranged 38.7–73.9%.6,7 In Dr. assessing the gallbladder contractility index
Hasan Sadikin General Hospital Bandung by measuring the volume of the gallbladder,
hospitalized patients with liver cirrhosis in 2012 and postprandial. Ultrasound is a radiological
until September 2017 were about 365 people, modality that is accurate, noninvasive, cheap,
and about 1,716 people went through internal easy to obtain, no radiation and repeated to
medicine polyclinic.8 assess the gallbladder contractility index.12,14,18
Patients with liver cirrhosis have a higher A research conducted by Buzaş et al.19
incidence and prevalence of gallstones than the suggested that the volume of gallbladder fasting
general population, with a prevalence of 25–30%. and postprandial volume using ultrasound was
Liver cirrhosis is one of the significant risk factors higher in patients with liver cirrhosis. Loreno et
for the formation of gallstones.9 Gallstones in al.14 also suggest that there was a difference in the
patients with liver cirrhosis are asymptomatic gallbladder contractility index in patients with
and symptomatic to cause complications. In liver cirrhosis compared with no liver cirrhosis.
patients with liver cirrhosis, Child-Pugh A and Acalovschi13 suggests that there was a decreasing
B with symptomatic gallstones recommended index of gallbladder contractility in patients with
doing cholecystectomy before the complication liver cirrhosis following the severity of cirrhosis.
that will aggravate the patient clinical condition It is contrary to research conducted by Kul et al.,12
and before the severe condition of the liver suggesting that there was an increase in gallbladder
symptoms.10 The formation of gallstones in contractility index in patients with liver cirrhosis
patients with liver cirrhosis is due to several compared with healthy control. Shirole et al.11
factors; one of them is due to bile stasis caused by suggest that patients with liver cirrhosis have a
the decrease in gallbladder contractility index.11 higher prevalence of the occurrence of gallstones
The decrease in the gallbladder contractility than in a healthy population. One of the causes is
index is due to the humoral, hypoalbuminemia, a decrease in the gallbladder contractility index.
and also neurological disorders. Neurological Because of differences in the above studies, the
disorders in patients with liver cirrhosis are researchers will determine differences in the
in the form of neuropathy. The severity of this gallbladder contractility index using ultrasound
neuropathy is proportional to an increase in in patients with and without liver cirrhosis.
liver damage. The patients with liver cirrhosis,
especially decompensated liver cirrhosis, usually Methods
have autonomic dysfunction directly affect the
contractility of the gallbladder through the This study was an analytic observational study

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Hari Soekersi et al.: Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and without 9

with a cross-sectional design conducted from Ethical approval for this study has obtained
December 2017 to February 2018. Sampling was from the Health Research Ethics Committee of
patients with liver cirrhosis and without liver Dr. Hasan Sadikin General Hospital Bandung
cirrhosis in Dr. Hasan Sadikin General Hospital with the letter number: LB.04.01/A05/EC/379/
Bandung, who matched the inclusion criteria XII/2017.
with consecutive admissions method (based on
the order of the registered patient). The inclusion Results
criteria were patients with adult liver cirrhosis
diagnosed from the Gastroentero-hepatology Table 1 shows that by gender, there were more
clinic of Dr. Hasan Sadikin General Hospital male patients than females with and without liver
Bandung and undiagnosed liver cirrhosis that cirrhosis who came to Dr. Hasan Sadikin General
had gone through ultrasound examination in the Hospital as many as 12 of 22.
Department of Radiology Dr. General Hospital The differences in gallbladder contractility
Hasan Sadikin and willing to follow the research. index using ultrasound in patients with and
Exclusion criteria for this study were patients without liver cirrhosis in Dr. Hasan Sadikin
with a history of bile disease, gallbladder hydrops, General Hospital can be seen in Table 2.
diabetes mellitus, post gastric resection surgery, Based on Table 2, it can be seen that the
and patients who were pregnant. average volume of fasting gallbladder using
Statistical analysis used to describe the ultrasound on the liver cirrhosis patients is
difference of gallbladder contractility index using 35.56 mL, with a standard deviation of 22.16
ultrasound in patients with and without liver mL. Patients without liver cirrhosis was 16.50
cirrhosis. A statistical test using the parametric mL, with a standard deviation of 4.14 mL. The
method, independent t test performed using SPSS mean postprandial gallbladder volume using
version 22.0 for Windows at a 95% confidence ultrasound in patients with liver cirrhosis was
level. 21.25 mL, with a standard deviation of 16.08 mL,

Table 1 Characteristics of Study Subjects by Age and Gender in Patients with and
without Liver Cirrhosis
Age and Gender n=22 Average (SD) Median (Min–Max)
Age (years)
30–40 5
49.45 (9.53) 48 (37–70)
41–50 8
>50 9
Gender
Male 12
Female 10

Table 2 The Differences in Gallbladder Contractility Index Using Ultrasound in Patients

with and without Liver Cirrhosis
Liver Cirrhosis Incident
Without Liver p
Gallbladder Liver Cirrhosis
Cirrhosis Value*
Average SD Average SD
Fasting gallbladder volume 35.56 22.16 16.50 4.14
Postpartum gallbladder volume 21.25 16.08 5.44 2.10 0.007
Gallbladder contractility index 41.64 24.52 66.73 9.19
Note: Independent t test
*

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10 Hari Soekersi et al.: Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and without

in this study were mostly male. The results are

consistent with Basic Health Research 2013 that
patients affected by hepatitis are more likely to be
men even when it is less significant and mostly
work-related that often occurs in patients who
work as farmers/laborers or fishermen.20,21
The results based on fasting gallbladder
volume show that the average fasting gallbladder
volume in liver cirrhosis patients was 35.56 mL,
with a standard deviation of 22.16 mL. The results
are higher than those without liver cirrhosis with
an average fasting gallbladder volume of 16.5 mL
and a standard deviation of 4.14 mL. It suggests
that most of the volume of the fasting gallbladder
in patients with liver cirrhosis is more significant
than without liver cirrhosis. It is under research
conducted by Buzaş et al.19 and Loreno et al.14
state that the average gallbladder volume of
fasting patients with liver cirrhosis is higher than
without liver cirrhosis. The mechanism of fasting
Figure The Differences in Gallbladder
gallbladder volume of patients with liver cirrhosis
Contractility Index Using
larger than without liver cirrhosis is suspected
Ultrasound in Patients with and
because increased intestinal peptides lead to the
without Liver
relaxation of gallbladder muscles and autonomic
nervous disorders resulting in lower gallbladder
contraction in the patients with liver cirrhosis.
whereas in patients without liver cirrhosis was The average postprandial gallbladder volume
5.44 mL, with a standard deviation of 2.10 mL. in liver cirrhosis patients is 21.25 mL with a
Based on Table 2, it can be seen that the standard deviation of 16.08 mL, while in the group
average gallbladder contractility index using without liver cirrhosis, the mean postprandial
ultrasound in patients with liver cirrhosis was gallbladder volume is 5.44 mL and a standard
41.64%, with a standard deviation of 24.52%. deviation of 2.1 mL. It appears that the average
Patients without liver cirrhosis were 66.73%, with of postprandial gallbladder volume in most liver
a standard deviation of 9.19%. The independent t cirrhosis patients tends to be higher than the
test result on a 95% confidence degree shows that average of postprandial gallbladder volume in
there was a significant difference in gallbladder patients without liver cirrhosis.22
contractility index using ultrasound in patients Based on the average gallbladder contractility
with and without liver cirrhosis (p=0.007, index, the index of biliary tactility in liver
p≤0.05). cirrhosis patients was 41.64%, with a standard
The differences in gallbladder contractility deviation of 24.52%. In comparison, the average
index using ultrasound in patients with and of gall gallbladder contractility in the group
without liver cirrhosis is in Figure. without liver cirrhosis was 66.73%, with a
standard deviation of 9.19%. It is under research
Discussion conducted by Loreno et al.14 and Acalovschi,13 who
suggest that the gallbladder contractility index in
The results of age-based, the age distribution of patients with liver cirrhosis is lower than without
most patients with liver cirrhosis in this study liver cirrhosis.
were in the age group >50 years. It is by the Independent t test analysis at 95% confidence
research conducted by Hussain et al.,10 which degree showed that there is a statistically
states that patients with liver cirrhosis are more significant difference between gallbladder
common in middle age and older age due to contractility index using ultrasound in patients
disease progression of liver cirrhosis that usually with and without liver cirrhosis (p=0.007,
takes 5–10 years. Patients with liver cirrhosis p≤0.05). It is consistent with the research

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Hari Soekersi et al.: Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and without 11

conducted by Loreno et al.14 and Acalovschi,13 S, editors. Buku ajar ilmu penyakit dalam. 6th
who suggest that there is a significant difference Edition. Jakarta: Interna Publishing; 2014. p.
in the gallbladder contractility index of patients 1978–83.
with and without liver cirrhosis. 8. Sistem Informasi Rumah Sakit (SIRS) RSUP
The causes of gallbladder contractility index Dr. Hasan Sadikin (RSHS). Pasien sirosis
differences in patients with liver cirrhosis may hati 2012–2017. Bandung: SIRS RSHS; 2017.
due to a decrease in CCK receptor sensitivity 9. Li X, Guo X, Ji H, Yu G, Gao P. Gallstones in
in the gallbladder, autonomic neuropathy, patients with chronic liver diseases. Biomed
hypoalbuminemia, and increased concentrations Res Int. 2017;2017:9749802.
of intestinal peptides that affect gallbladder 10. Hussain A, Nadeem MA, Nisar S, Tauseef
muscle relaxation.13 H. Frequency of gallstones in patients with
liver cirrhosis. J Ayub Med Coll Abbottabad.
Conclusion 2014;26(3):341–3.
11. Shirole NU, Gupta SJ, Shah DK, Gaikwad
There was a significant difference in gallbladder NR, Sankalecha TH, Kothari HG. Cirrhosis of
contractility index using ultrasound in patients liver is a risk factor for gallstone disease. Int
with and without liver cirrhosis in Dr. Hasan J Res Med Sci. 2017;5(5):2053–6.
Sadikin General Hospital Bandung. 12. Kul K, Serin E, Yakar T, Coşar AM, Özer
B. Autonomic neuropathy and gallbladder
Conflict of Interest motility in patients with liver cirrhosis. Turk
J Gastroenterol. 2015;26(3):254–8.
There is no ethical/legal conflict involved in the 13. Acalovschi M. Gallstones in patients with liver
article. All authors have no relevant financial cirrhosis: incidence, etiology, clinical and
interests related to the material. therapeutical aspects. World J Gastroenterol.
2014;20(23):7277–85.
References 14. Loreno M, Travali S, Bucceri AM, Scalisi G,
Virgilio C, Brogna A. Ultrasonographic Study
1. Siregar GA, Tampubolon SE. Comparison of of Gallbladder Wall Thickness and Emptying
lipid profile between degrees of severity of in Cirrhotic Patients without Gallstones.
hepatic cirrhosis in Haji Adam Malik General Gastroenterol Res Pract. 2009;2009:683040.
Hospital Medan. IOP Conf Ser Earth Environ 15. Butt Z, Hyder Q. Cholelithiasis in hepatic
Sci. 2018:125:012216. cirrhosis: evaluating the role of risk factors. J
2. Yeom SK, Lee CH, Cha SH, Park CM. Pak Med Assoc. 2010;60(8):641–4.
Prediction of liver cirrhosis, using 16. Son JY, Kim YJ, Park HS, Yu NC, Ko SM,
diagnostic imaging tools. World J Hepatol. Jung SI, et al. Diffuse gallbladder wall
2015;7(17):2069–79. thickening on computed tomography in
3. Zatoński WA, Sulkowska U, Mańczuk M, patients with liver cirrhosis: correlation with
Rehm J, Boffetta P, Lowenfels AB, et al. Liver clinical and laboratory variables. J Comput
cirrhosis mortality in Europe, with special Assist Tomogr. 2011;35(5):535–8.
attention to central and eastern Europe. Eur 17. Mohammadi A, Ghasemi-Rad M,
Addict Res. 2010;16(4):193–201. Mohammadifar M. Differentiation of benign
4. Blachier M, Leleu H, Peck-Radosavljevic M, from malignant induced ascites by measuring
Valla DC, Roudot-Thoraval F. The burden gallbladder wall thickness. Maedica (Buchar).
of liver disease in Europe: a review of 2011;6(4):282–6.
available epidemiological data. J Hepatol. 18. Popescu A, Sporea I. Ultrasound examination
2013;58(3):593–608. of normal gall bladder and biliary system.
5. World Health Organization (WHO). Global Med Ultrason. 2010;12(2):150–2.
hepatitis report 2017. Geneva: WHO; 2017. 19. Buzaş C, Chira O, Mocan T, Acalovschi M.
6. Widjaja FF, Karjadi T. Pencegahan Comparative study of gallbladder motility
perdarahan berulang pada pasien sirosis hati. in patients with chronic HCV hepatitis and
J Indon Med Assoc. 2011;61(10):417–24. with HCV cirrhosis. Rom J Intern Med.
7. Nurdjanah S. Sirosis hati. In: Sudoyo AW, 2011;49(1):37–44.
Setiyohadi B, Alwi I, Simadibrata KM, Setiati 20. Indonesia Agency of Health Research

Global Medical and Health Communication, Volume 8 Number 1, April 2020

12 Hari Soekersi et al.: Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and without

and Development, Ministry of Health of analisis hepatitis [Internet]. 2014 September

Republic of Indonesia. Basic health research [cited 2018 February 20]. Available from:
(Riskesdas) 2013 [Internet]. Jakarta: https://www.kemkes.go.id/resources/
Indonesia Agency of Health Research and download/pusdatin/infodatin/infodatin-
Development, Ministry of Health of Republic hepatitis.pdf.
of Indonesia; 2013 [cited 2017 June 15]. 22. Abdelmaksoud MA, El-Shamy MH, Hussein
Available from: http://labdata.litbang. HIM, Bihery AS, Ahmed H, El Hady HA.
kemkes.go.id/ccount/click.php?id=10. Frequency of cholelithiasis in patients with
21. Pusat Data dan Informasi, Kementerian chronic liver disease: a hospital-based study.
Kesehatan Republik Indonesia. Situasi dan AJIED. 2016;6(3):134–41.

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 Global Medical and Health Communication

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RESEARCH ARTICLE

Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic

Symptoms in Dr. Hasan Sadikin General Hospital Bandung
Astrid Feinisa Khairani,1 Kuheinderan Radha Krishnan,2
Umar Islami,3,4 Siti Aminah Sobana5
1
Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Sumedang, Indonesia,
2
Medical Undergraduate Study Program, Faculty of Medicine, Universitas Padjadjaran, Sumedang, Indonesia,
3
Graduate School of Biomedical Sciences Master Program, Faculty of Medicine, Universitas Padjadjaran,
Bandung, Indonesia, 4Department of Histology and Medical Biology, Faculty of Medicine, Universitas Islam
Bandung, Bandung, Indonesia, 5Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/
Dr. Hasan Sadikin General Hospital, Bandung, Indonesia

Abstract
Over 80% of the adult population will experience an episode of low back pain (LBP). Low back pain is a pain in the
lumbosacral region. When it progresses, which may be identified earlier with signs of a red flag, the manifestation
might become radiculopathy. Radiculopathies are nerve root disease which may show signs of neurologic symptoms
from the sensory, motoric, or autonomic origin. This study to help identify the clinical characteristics of a red flag
in low back pain patients, which became lumbar radiculopathy for prognostic and diagnostic use. It is a descriptive
quantitative cross-sectional study of medical records from patients hospitalized with complaints of low back pain
with lumbar radiculopathy between January 2013–December 2015 in the Department of Neurology, Dr. Hasan
Sadikin General Hospital, Bandung. It identifies a specific red flag and neurogenic symptoms. Patients most affected
were housewives (26%), females (60%), and middle-aged adults (31%). The highest recorded symptom being
sensory (76%), the highest progression was sensory to motoric (59%), affected by all three neurologic symptoms
(39%), and trauma was the highest red flag recorded (48%). Low back pain patients who have signs of red flag
show a high tendency to develop radiculopathy, which shows neurologic symptoms. If left untreated earlier, it may
become a permanent disability.
Key words: Low back pain, radiculopathy, red flag

Radikulopati Lumbar: Studi Deskriptif Gejala Klinis Red Flag dan

Gejala Neurologis di RSUP Dr. Hasan Sadikin Bandung

Abstrak
Lebih dari 80% populasi penduduk dewasa akan mengalami episode low back pain (LBP). Low back pain
merupakan nyeri pada bagian tulang belakang regio lumbo-sakral. Pada saat rasa sakitnya bertambah berat, gejala
berbahaya dapat menjadi awal perkembangan LBP menjadi radikulopati. Radikulopati merupakan penyakit saraf
pada daerah radiks neuron berupa gejala sensorik, motorik, dan otonomik. Penelitian ini bertujuan mengidentifikasi
karakteristik gejala klinis tanda berbahaya (red flag) pada pasien LBP yang berlanjut menjadi radikulopati lumbar
sebagai alat bantu diagnostik dan prognostik. Penelitian ini menggunakan metode penelitian cross-sectional
kuantitatif deskriptif dari rekam medis pasien yang dirawat dengan diagnosis LBP dan radikulopati lumbar antara
bulan Januari 2013–Desember 2015 di Departemen Ilmu Penyakit Saraf, RSUP Dr. Hasan Sadikin, Bandung.
Penelitian ini mengidentifikasi gejala klinis red flag spesifik dan neurologis. Pasien yang terkena terutama ibu
rumah tangga (26%), wanita (60%), usia dewasa pertengahan (31%). Gejala yang tercatat paling banyak adalah
sensorik (76%), perkembangan progresif sensorik ke motorik (59%), mengalami gangguan ketiganya (39%), dan
trauma menjadi penyebab red flag yang paling tinggi (48%). Pasien LBP yang memiliki gejala tanda berbahaya (red
flag) memiliki kecenderungan tinggi berkembang menjadi radikulopati yang menunjukkan gejala neurologis. Jika
tidak diobati lebih awal, ini dapat mengakibatkan kecacatan permanen.
Kata kunci: Low back pain, radikulopati, red flag

Received: 21 October 2019; Revised: 24 April 2020; Accepted: 25 April 2020; Published: 30 April 2020
Correspondence: Astrid Feinisa Khairani. Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran. Jln.
Raya Bandung-Sumedang km 21, Jatinangor, Sumedang 45363, West Java, Indonesia. E-mail: astrid.khairani@unpad.ac.id

13
14 Astrid Feinisa Khairani et al.: Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms

Introduction of lumbar radiculopathies involve the L5 and S1

nerve roots.12 Lumbar radiculopathy refers to a
Sometime during life, over 80 percent of the pathologic process involving the lumbar roots
population will experience an episode of low back causing radicular symptoms in a lower extremity.
pain (LBP).1 LBP defined as the complaint of pain The nerve root pathology arises primarily
in the area of spinal or paraspinal structures in from direct neural compression irrespective of
the lumbosacral region.2 According to the Global whether the etiology is an acute herniated or
Burden of Disease Study 2015 (GBD 2015), displaced disc, bony spurs, foraminal stenosis,
the expert group stated that among the top central stenosis, or hypermobility of a vertebral
ten high burden diseases and injuries, LBP is segment.13
one of them with an average number of DALYs While a substantial burden on our health-care
(disability-adjusted life years). It is higher than system, low back pain is typically self-limited,
HIV, tuberculosis, road injuries, lung cancer, with most cases resolving after conservative
chronic obstructive pulmonary disease, and management in 6 to 8 weeks.14 Most low back
preterm birth complications.3 Low back pain, if pain is nonspecific; patients with low back pain
left untreated with the red flag, may cause a more may have neurologic impairments or a severe
severe medical condition. Low back pain remains underlying pathology that requires timely and
a common condition among primary care patients accurate diagnosis. Low back pain that is due
with an estimated lifetime prevalence of 13.8% for to severe pathology occurs between 1% and 4%
chronic pain and 80% for any episode of pain.4–6 of the time and has been generally classified as
Low back pain affecting both men and women, related to 4 etiologies: fracture, malignancy,
with age, is the primary risk factor, as it occurs infection, and cauda equina syndrome.15–17
secondary to the degenerative process within Appropriate identification of these diagnoses for
the spinal column.7 Symptoms typically begin in their management is essential. Therefore, due to
midlife, with men often affected in the 40s while the prevalence, burden, and associated health-
women are affected in the 50s and 60s.8,9 Females care cost of low back pain, it is paramount to
have a higher risk in specific populations, with know the characteristics to detect severe disease.
physically demanding careers such as service in However, the data on LBP and its red flag, such
the military. Patients commonly present with back as lumbar radiculopathy, is extremely limited
pain that is associated with their radiculopathy. in Indonesia, specifically in the Department
By definition, radiculopathy describes pain that of Neurology in Dr. Hasan Sadikin General
radiates down the legs and is often described by Hospital, Bandung. This study conducted to help
patients as electric, burning, or sharp. The most in finding out the clinical characteristics of a red
common underlying cause of radiculopathy is flag in LBP patients with lumbar radiculopathy
irritation of a particular nerve, which can occur at by identifying the red flag. The neurologic
any point along the nerve itself and is most often symptoms are sensory, motoric, or autonomic to
a result of a compressive force. The diagnosis of help identify and diagnose that these symptoms
the causative agent and subsequent treatment are an underlying problem, which can become
starts with a thorough physical exam. something even more severe if left untreated.
The term red flags are symptoms and signs that This study aimed to help identify red flags in these
show a possible manifestation of more serious patients and the possible neurologic symptoms to
medical conditions, which may cause permanent occur in them.
disability and, if not managed correctly, may
even lead to death.10 These red flags seen in LBP Methods
patients, when neglected without treatment,
may become radiculopathy. Radiculopathies This study uses an observational descriptive
are a disease of nerve roots from inflammation quantitative cross-sectional study as a method
or impingement from a tumor or a bony spur.11 of study. Medical records used in this study
One form of radiculopathy is one that affects were from January 2013–December 2015.
the lumbar region. The prevalence of lumbar Subjects used for this study are LBP patients with
radiculopathy varies from about 2.2–8%, and the lumbar radiculopathy that hospitalized in the
incidence ranges from 0.7–9.6%. About 76.1% Department of Neurology in Dr. Hasan Sadikin

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Astrid Feinisa Khairani et al.: Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms 15

General Hospital, Bandung. Table 1 Distribution of LBP Patients with

A rough table is stating the needed Lumbar Radiculopathy and Their
characteristics such as occupation, sex, age, Age
symptoms to appear, the progression of
Range of Age Number
symptoms, and the red flag first created. The data Percentage
(Years) (n=54)
obtained for the first symptoms to appear also
classified into acute, sub-acute, and chronic. This 11–20 1 2
data was obtained by cross-checking medical 21–30 9 17
records for the required data from the history- 31–40 5 9
taking as well as the physical exam portion
41–50 11 20
of the medical record. Incomplete medical
records, medical records that did not state the 51–60 17 31
characteristics clearly, and patients who did not 61–70 9 17
have signs of LBP with lumbar radiculopathy as 71–80 1 2
well of the red flag excluded. The data tabulated 81–90 1 2
and analyzed accordingly.
This study approved by the Health Research
Ethics Committee of the Faculty of Medicine,
Universitas Padjadjaran, Bandung by ethics (not assessed). Other occupations which recorded
approval letter number: 571/UN6.C1.3.2/KEPK/ were pensioners, security guards, policemen,
PN/2016. students, privately employed staff, and self-
employed staff.
Results From the data describes the gender
demographic data of the patients (table not
In this study, the data used was secondary inserted), females have a higher tendency, which
data from medical records of patients from was a percentage of 60% to LBP with lumbar
the Department of Neurology in Dr. Hasan radiculopathy as compared to males at 40%.
Sadikin General Hospital, Bandung. A total of 54 Table 1 describes the distribution of age about
patient’s data recorded fit the inclusion criteria. LBP patients with lumbar radiculopathy, as
Based on the data, five tables created with the obtained from the data. The age range between
corresponding variables. 51–60 years had the highest frequency of patients,
Based on the data obtained in the study with a percentage of 31%. The data does show
from the occupational demography data (table that the middle-aged adults were more affected
not inserted), most of the patients who suffered by LBP and lumbar radiculopathy as compared to
from LBP with lumbar radiculopathy admitted those of younger age or older.
into Dr. Hasan Sadikin General Hospital were Table 2 shows the data for the first symptoms
housewives, 26% of the total patient population. with lumbar radiculopathy, as well as the time
The next majority was that the manual laborers for the manifestation. That be within the period
were 17%. However, 17 patients did not have of acute (less than three weeks), which showed
proper employment status and classified as N/A 18% sensory, 5% motoric, and 2% autonomic.

Table 2 Distribution of LBP Patients with Lumbar Radiculopathy and Their First
Symptom with the Duration for Manifestation of the Symptoms
Sensory Motoric Autonomic
Total
Onset of Symptoms (n=41) (n=12) (n=1)
(n=54)
76% 22% 2%
<3 weeks 10 (18%) 3 (5%) 1 (2%) 14
3 weeks–3 months 15 (28%) 7 (13%) 0 (0%) 22
>3 months 16 (30%) 2 (4%) 0 (0%) 18

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16 Astrid Feinisa Khairani et al.: Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms

Table 3 Distribution of LBP Patients Table 5 Distribution of LBP Patients with

with Lumbar Radiculopathy and Lumbar Radiculopathy and the
Their Progression from the First Signs of Red Flag
Symptom Red Flag Number
Percentage
Symptom Number Category (n=54)
Percentage
Progression (n=54) Cancer 18 33
Sensory–motoric 32 59 Infection 8 15
Sensory–autonomic 11 20 Trauma 26 48
Motoric–sensory 7 13 Neurogenic deficit 2 4
Motoric–autonomic 4 8

sensory and autonomic dysfunction was recorded

For the sub-acute phase (3 weeks to 3 months), in 7 (13%) patients, 1 patient had motoric and
28% showed sensory symptoms, 13% motoric, autonomic problems, and 21 (39%) patients had
and 0% autonomic. For chronic (more than three all 3 problems.
months), 30% showed sensory symptoms, 4% Table 5 describes the data obtained on the
showed motorically, and no patients recorded red flag signs of the patients divided into 4 sub-
with autonomic first symptoms. categories, which were cancer, infection, trauma,
Table 3 shows the progression of the symptoms and neurologic deficits. It is seen that the common
from the first symptom to appear in the patients. red flag seen in patients of LBP with lumbar
The progression from a sensory symptom to a radiculopathy has a red flag sign of trauma, which
motoric symptom seems to be higher at 59%. was 48%. Cancer-related signs were the next
Twenty percent of patients have a progression most seen in the patients with 33%. Neurogenic
from sensory symptoms to autonomic symptoms. signs were recorded with 4%, and infection signs
Progression from autonomic symptoms to were recorded at 15%.
sensory or motoric symptoms seems to be the Table 6 describes the working diagnosis of
lowest. the patients admitted to the hospital. Lumbar
Table 4 describes the current condition of the radiculopathy patients based on the cause being
patients, 12 (22%) had sensory problems only, 1 trauma is the highest, with 28%, the next was
patient had an only motoric symptom, 12 (22%) cauda equina syndrome based on cancer as the
patients had both sensory and motoric problems, cause was the second highest with 24%. However,
overall, the diagnosis for patients who come in
with low back pain is almost similar.
Table 4 Distribution of LBP Patients with
Lumbar Radiculopathy and Their Discussion
Current Symptoms
This study showed that patients with low back
Number pain who had the red flag signs could progress to
Symptoms Percentage
(n=54) a more serious medical condition. The conditions
Sensory only 12 22 could cause a neurologic dysfunction, may it
be sensory, motoric, or even autonomic. Thus,
Motoric only 1 2
the population observed were low back pain
Sensory+motoric 12 22 patients as a passage to the more severe condition
Sensory+ 7 13 becoming lumbar radiculopathy. The result was
autonomic also to help strengthen the primary goal for both
Motoric+ 1 2 prognostic and diagnostic functions. The data
autonomic showed that the majority of the patients admitted
with low back pain and having a red flag have had
Sensory+motoric+ 21 39
a progression in symptoms from either sensory,
autonomic
motoric, or even autonomic. Most of the patients

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Astrid Feinisa Khairani et al.: Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms 17

Table 6 Distribution of LBP Patients with Lumbar Radiculopathy and Their Working
Diagnosis
Number
Symptoms Percentage
(n=54)
Cauda equina syndrome based on trauma 8 15
Cauda equina syndrome based on cancer metastasis 13 24
Cauda equina based on spondylitis Tb 3 5
Low back pain based on degenerative, trauma, fracture 3 5
Low back pain based on sequel stroke 2 4
Lumbar radiculopathy based on trauma 15 28
Lumbar radiculopathy based on spondylitis Tb, infections 3 6
Lumbar radiculopathy based on cancer metastasis 5 9
Lumbar myeloradiculopathy based on spondylitis Tb 2 4

admitted did not only have one red flag but such as osteoporosis, lack of exercise, obesity,
multiple red flags. smoking for a woman due to menopause causing
It observed that homemakers have the highest estrogen production to decrease, causing bone
tendency to acquire LBP with radiculopathy with formation to decrease as well.22
a percentage of 26%. The similar result showed From the type of symptoms first appear in LBP
by Bener et al.,18 which stated that the prevalence patients with lumbar radiculopathy, out of 54
of LBP patients was 53% of the population. In patients’ 41 showed signs of sensory disturbance
the study done by Akter,19 homemakers are a risk either from pain or numbness. Twelve patients
factor for LBP due to the physical strain the reach showed signs of motoric disturbance, such as
doing household work such as standing for long being unable to walk correctly or stand properly,
periods or squatting for long periods. and one patient had autonomic problems such as
The study showed that gender does also affect weak anal sphincter or unable to control bowel
the prevalence of this problem as females had movements or urinary processes. This data shows
a higher prevalence (59%) to LBP with lumbar that in the study done by Shankar et al.,23 which
radiculopathy as compared to males. This data stated that chronic LBP did have autonomic
corresponds with the study done by Wang et al.,20 dysfunctions such as a reduced vagal tone and an
which had stated that the prevalence of LBP was increased sympathetic tone does not correspond
higher in females rather than males due to many with the findings from the study. For the time
factors, mainly hormonal. However, a study factor majority of the symptoms progressed from
by Fillingim et al.21 carried out in Sweden and one category to another from a time frame of 3
Norway did suggest that although the prevalence weeks to 3 months. This study showed that sub-
of LBP is higher in females, Norway men had a acute patients had the highest rate of symptoms
higher lifetime prevalence of LBP. showing, followed by chronic and acute. However,
Age was another factor that contributed to this does show that even though a patient is at
LBP in patients. Middle-age adults were the the acute, sub-acute, or chronic stage, they may
highest in the data recorded to have low back pain still develop the symptoms from either sensory,
with radiculopathy. In this study, data showed motoric, or even go to autonomic. Patients also
that between the ages of 51–60 is the highest can start with a motoric symptom and progress to
incidence of LBP with radiculopathy to 31%. sensory or autonomic dysfunctional conditions.
However, the incidence of the problem begins to The study relates to a study done by Friedman et
increase from the age of 31 years old and above. al.24 in which 30% of patients with acute LBP had
The result corresponded to the BP6.24 paper a functional impairment three months later.
updated in 2013, stating the prevalence of LBP The data also was recorded to obtain the
peaks between the ages of 35 to 55.2 Aging factors current condition of the patients. From that, 21

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18 Astrid Feinisa Khairani et al.: Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms

patients had shown all three signs of symptoms patients who had cauda equine caused by trauma.
may it be sensory, motoric, or even autonomic. There were two patients diagnosed with lumbar
Twelve patients showed they had only sensory myeloradiculopathy caused by spondylitis
problems, and 12 showed they had both sensory tuberculosis and low back pain caused by a
and motoric problems, and seven patients had stroke. Overall, it did prove that a previous study
sensory and autonomic problems. No patients that disc degeneration was the leading cause of
had only autonomic symptoms stating that low back pain worldwide.25
patients usually started with at least a sensory Many patients diagnosed with this problem
or motoric problem before it progressed to have not been treated to the full extent to fully
autonomic. Patients also showed that even cure their symptoms or prevent their symptoms
though they were in the acute, sub-acute, or even from progressing, as seen in the data obtained
the chronic period, they still could progress to from this study.
any other symptom. Gregory et al.25 state that
patients who come in with sensory problems can Conclusion
later develop into more severe motor and sensory
problems. The clinical characteristics of the red flag were
From the first symptom to appear, there gender, middle-age adults, history of trauma,
was a progression to another symptom in followed by cancer, infection, and neurogenic
most of the patients. Most of the progression, deficits. Low back pain patients who have
however, started from sensory problems and signs of red flag show a high tendency to
later progressed to either motoric or autonomic develop radiculopathy, which shows neurologic
problems. The highest rate of progression was symptoms. If left untreated earlier, it may become
from sensory to motoric seen in 32 patients (59%). a permanent disability. Intimate knowledge of
The next highest progression was from sensory to the signs, symptoms, and red flag warning signs
autonomic, as seen in 11 patients (20%). However, is a necessity.
the progression from motoric to another symptom
was low as compared to sensory, and there was Conflict of Interest
no progression from autonomic symptoms. The
symptom is usually due to the affected part of the All authors declare to have not to conflict of
spinal route, whereby externally affected roots interest in publishing this article.
usually show symptoms of sensory problems. As
it affects deeper into the spinal column, it affects Acknowledgments
motoric and autonomic functions as well.
Many of the patients had more than one red flag. Researchers would like to thank the Department
The data obtained classified the red flag into four of Neurology Faculty of Medicine, Universitas
major categories, which were infection, trauma, Padjadjaran/Dr. Hasan Sadikin General Hospital,
neurogenic deficits, and cancer. According to the Bandung, for the support and help implement
data obtained, the typical red flag seen in patients this study.
of LBP with lumbar radiculopathy has a 48% red
flag sign of trauma, which was cancer-related References
signs were the next most seen in the patients with
a 33%. Neurogenic signs recorded with 4% and 1. Ferguson SA, Merryweather A, Thiese MS,
infection signs recorded at 15%. Hegmann KT, Lu ML, Kapellusch JM, et al.
The working diagnosis of the patients recorded Prevalence of low back pain, seeking medical
as well. The data showed that the majority of care, and lost time due to low back pain
the patients had had a similar diagnosis, and among manual material handling workers
the causative agent almost the same in many. in the United States. BMC Musculoskelet
Lumbar radiculopathy caused by trauma was the Disord. 2019;20(1):243.
highest recorded in the patients with 15 people 2. Duthey B. Background paper 6.24: low
diagnosed. For patients diagnosed with cauda back pain. In: Kaplan W, Wirtz VJ, Mantel-
equina syndrome, many of them caused by a Teeuwisse A, Stolk P, Duthey B, Laing R,
metastasis of some form of cancer followed by editors. Priority medicines for Europe and

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Astrid Feinisa Khairani et al.: Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms 19

the world: 2013 updated. Geneva: WHO 2017;18(1):93.

Press; 2013. p. 6.24-1–29. 13. Berry JA, Elia C, Saini HS, Miulli DE. A
3. GBD 2015 Disease and Injury Incidence and review of lumbar radiculopathy, diagnosis,
Prevalence Collaborators. Global, regional, and treatment. Cureus. 2019;11(10):e5934.
and national incidence, prevalence, and years 14. Patrick N, Emanski E, Knaub MA. Acute and
lived with disability for 310 diseases and chronic low back pain. Med Clin North Am.
injuries, 1990–2015: a systematic analysis 2016;100(1):169–81.
for the Global Burden of Disease Study 2015. 15. Williams CM, Henschke N, Maher CG, van
Lancet. 2016;388(10053):1545–602. Tulder MW, Koes BW, Macaskill P, et al. Red
4. Raison NT, Alwan W, Abbot A, Farook M, flags to screen for vertebral fracture in patients
Khaleel A. The reliability of red flags in presenting with low-back pain. Cochrane
spinal cord compression. Arch Trauma Res. Database Syst Rev. 2013;(1):CD008643.
2014;3(1):e17850. 16. Underwood M, Buchbinder R. Red flags for
5. Delitto A, George SZ, van Dillen L, Whitman back pain. BMJ. 2013;347:f7432
JM, Sowa G, Shekelle P, et al. Low back pain: 17. Schoenfeld A, Laughlin M, Bader JO, Bono
clinical practice guidelines linked to the CM. Characterization of the incidence and
international classification of functioning, risk factors for the development of lumbar
disability, and health from the orthopaedic radiculopathy. J Spinal Disord Tech.
section of the American Physical Therapy 2012;25(3):163–7.
Association. J Orthop Sports Phys Ther. 18. Bener A, Dafeeah EE, Alnaqbi K. Prevalence
2012;42(4):A1–57. and correlates of low back pain in primary
6. Hooten WM, Cohen SP. Evaluation and care: what are the contributing factors in a
treatment of low back pain: a clinically rapidly developing country. Asian Spine J.
focused review for primary care specialists. 2014;8(3):227–36.
Mayo Clin Proc. 2015;90(12):1699–718. 19. Akter S. Prevalence of low back pain
7. Wong AY, Karppinen J, Samartzis D. Low among the housewives [dissertation].
back pain in older adults: risk factors, Dhaka: Bangladesh Health Professions
management options and future directions. Institute (BHPI); 2014 [cited 2016 January
Scoliosis Spinal Disord. 2017;12:14. 31]. Available from: http://dspace.crp-
8. Stochkendahl MJ, Kjaer P, Hartvigsen J, bangladesh.org:8080/xmlui/bitstream/
Kongsted A, Aaboe J, Andersen M, et al. handle/123456789/118/504%20Sonia%20
National Clinical Guidelines for non-surgical Akter.pdf?sequence=1&isAllowed=y.
treatment of patients with recent onset low 20. Wang C, Yu X, Yan Y, Yang W, Zhang S,
back pain or lumbar radiculopathy. Eur Xiang Y, et al. Tumor necrosis factor-α:
Spine J. 2018;27(1):60–75. a key contributor to intervertebral disc
9. Kreiner DS, Hwang SW, Easa JE, Resnick degeneration. Acta Biochim Biophys Sin
DK, Baisden JL, Bess S, et al. An evidence- (Shanghai). 2017 Jan;49(1):1–13.
based clinical guideline for the diagnosis and 21. Fillingim RB, King CD, Ribeiro-Dasilva
treatment of lumbar disc herniation with MC, Rahim-Williams B, Riley JL 3rd.
radiculopathy. Spine J. 2014;14(1):180–91. Sex, gender, and pain: a review of recent
10. Verhagen AP, Downie A, Popal N, Maher C, clinical and experimental findings. J Pain.
Koes BW. Red flags presented in current low 2009;10(5):447–85.
back pain guidelines: a review. Eur Spine J. 22. Wáng YXJ, Wáng JQ, Káplár Z. Increased
2016;25(9):2788–802. low back pain prevalence in females than in
11. Yusuf M, Finucane L, Selfe J. Red flags for males after menopause age: evidences based
the early detection of spinal infection in back on synthetic literature review. Quant Imaging
pain patients. BMC Musculoskelet Disord. Med Surg. 2016;6(2):199–206.
2019;20(1):606. 23. Shankar N, Thakur ML, Tandon OP, Saxena
12. Tawa N, Rhoda A, Diener I. Accuracy of clinical AK, Arora S, Bhattacharya N. Autonomic
neurological examination in diagnosing status and pain profile in patients of
lumbo-sacral radiculopathy: a systematic chronic low back pain and following
literature review. BMC Musculoskelet Disord. electro acupuncture therapy: a randomized

Global Medical and Health Communication, Volume 8 Number 1, April 2020

20 Astrid Feinisa Khairani et al.: Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms

control trial. Indian J Physiol Pharmacol. 2017;35(2):299–305.

2011;55(1):25–36. 25. Gregory DS, Seto CK, Wortley GC, Shugart
24. Friedman BW, Gensler S, Yoon A, Nerenberg CM. Acute lumbar disk pain: navigating
R, Holden L, Bijur PE, et al. Predicting three- evaluation and treatment choices. Am Fam
month functional outcomes after an ED visit Physician. 2008;78(7):835–42.
for acute low back pain. Am J Emerg Med.

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 Global Medical and Health Communication

Online submission: http://ejournal.unisba.ac.id/index.php/gmhc GMHC. 2020;8(1):21–6

DOI: https://doi.org/10.29313/gmhc.v8i1.3688 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

Differences in Expulsion on Post-placenta Intrauterine Contraceptive

Device between Mother with Vaginal and Cesarean Delivery
Atika Zahria Arisanti,1,2 Tono Djuwantono,3 Sri Endah Rahayuningsih4
Midwifery Master Study Program, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,
1
2
Department of Midwifery, Faculty of Medicine, Universitas Islam Sultan Agung, Semarang, Indonesia,
3
Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin
General Hospital, Bandung, Indonesia, 4Department of Child Health, Faculty of Medicine,
Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia

Abstract
Intrauterine device (IUD) is a long term, highly effective, and reversible contraception method. In Indonesia, the
number of IUD acceptors is still lower than other methods. An effort to improve the long term contraception is using
post-placental IUD that can be a choice for postpartum mother who has limited access to another contraception
service. The purpose of this study was to compare the incidence of expulsion in post-placental IUD insertion
between mother with vaginal delivery and cesarean delivery. This study design was a comparative cross-sectional
method with a consecutive sampling technique conducted at Dr. Hasan Sadikin General Hospital Bandung and Dr.
Kariadi General Hospital Semarang from November 2017 to February 2018. Subjects were postpartum mothers who
received post-placental IUD insertion at vaginal delivery and cesarean delivery. Samples were 96 women, consisting
of 48 women with IUD insertion in vaginal delivery and 48 women with IUD insertion in cesarean delivery. Data
obtained from interviews and transvaginal ultrasonography examination. The result showed there was a difference
in expulsions incidence between IUD’s insertion among vaginal delivery compared to cesarean delivery (p=0.041).
It concluded that expulsion’s to post-placental IUD insertion is higher in vaginal delivery compared to cesarean
delivery.
Key words: Cesarean delivery, expulsion, post-placental IUD, vaginal delivery

Perbedaan Kejadian Ekspulsi pada Pemasangan Alat Kontrasepsi dalam

Rahim Pascaplasenta antara Ibu dengan Persalinan per Vaginam
dan Persalinan Sectio Caesarea

Abstrak
Alat kontrasepsi dalam rahim (AKDR) merupakan kontrasepsi jangka panjang, efektif dan reversibel. Di Indonesia,
jumlah akseptor AKDR masih lebih rendah daripada metode lainnya. Salah satu upaya untuk meningkatkan
penggunaan kontrasepsi jangka panjang, yaitu dengan AKDR pascaplasenta yang dapat menjadi alternatif bagi ibu
pascasalin yang mempunyai akses terbatas untuk mendapatkan pelayanan kontrasepsi. Penelitian ini bertujuan
membandingkan kejadian ekspulsi pada pemasangan AKDR pascaplasenta antara ibu dengan persalinan per vaginam
dan persalinan sectio caesarea. Desain penelitian ini adalah cross-sectional komparatif dengan teknik pengambilan
sampel consecutive yang dilaksanakan di RSUP Dr. Hasan Sadikin Bandung dan RSUP Dr. Kariadi Semarang dari
bulan November 2017 hingga Februari 2018. Subjek penelitian adalah ibu pascasalin yang mendapatkan insersi
AKDR pascaplasenta pada persalinan per vaginam dan persalinan sesar. Jumlah sampel 96 ibu, terdiri atas 48 ibu
yang bersalin per vaginam dan 48 ibu yang bersalin sesar. Data didapatkan melalui wawancara dan pemeriksaan
ultrasonografi transvaginal. Hasil penelitian menunjukkan terdapat perbedaan kejadian ekspulsi pada pemasangan
AKDR antara ibu dengan persalinan per vaginam dan persalinan sectio caesarea (p=0,041). Simpulan, kejadian
ekspulsi pada pemasangan AKDR pascaplasenta lebih tinggi pada ibu dengan persalinan per vaginam dibanding
dengan persalinan sectio caesarea.
Kata kunci: AKDR pascaplasenta, ekspulsi, persalinan per vaginam, persalinan sectio caesarea

Received: 20 April 2018; Revised: 8 April 2020; Accepted: 25 April 2020; Published: 30 April 2020
Correspondence: Atika Zahria Arisanti, S.S.T., M.Keb. Diploma 3 Midwifery Study Program, Faculty of Medicine, Universitas Islam
Sultan Agung. Jln. Raya Kaligawe km 4, Semarang 50112, Central Java, Indonesia. E-mail: ika.zahria@gmail.com

21
22 Atika Zahria Arisanti et al.: Differences in Expulsion on Post-placenta Intrauterine Contraceptive Device between Mother

Introduction (>4 weeks postpartum) are 3–13%. Expulsion

generally occurs during the first three months
The use of contraceptives in Indonesia is still post-insertion and at most in the first 4–6 weeks.
dominated by modern contraceptive methods Expulsion is the exclusion of an IUD from within
that are short-term and contain a hormone the uterus that can occur partly or entirely.1,4
that generally has a low levels continuation rate Post-placental IUD insertion after vaginal
compared to long-term contraceptive methods.1,2 delivery has an expulsion rate of up to 24%.
The use of short-term contraceptives such as However, observational studies show that the
injections and pills is 40%, while the long- rate of expulsion in post-placental insertion after
term contraceptive (vasectomy, tubectomy, the cesarean section is much lower. In theory, it
intrauterine device, and implant) is 23.5%. The is because placement on the fundus is more likely
lower acceptance of long term contraception by to minimize the failure and likelihood that the
women in Indonesia caused by some factors. cervix is less fully dilate.5,6
These are the factor image of contraception, lack The purpose of this study was to compare
of information factor about benefits, effectiveness, the incidence of expulsion in post-placental IUD
and side effect of long term contraception.1 insertion between mother with vaginal delivery
The indicators of successful family planning and cesarean delivery.
are contraceptive prevalence rate (CPR) and
unmet need. The percentage of unmet needs in Methods
Indonesia increased by 8.5%. An increase in
unmet need indicates a decrease in CPR, which The design of this study was a comparative
means that contraceptive services and access cross-sectional. This study conducted at Dr.
to fertile-age couples to contraceptives are not Hasan Sadikin General Hospital Bandung and
enough.1 Dr. Kariadi General Hospital Semarang from
The main target of the family planning program November 2017 to February 2018. Samples
is in the unmet need group and the postpartum selected by consecutive sampling technique,
mother, both in normal and cesarean delivery. which meets the selection criteria. The inclusion
One of the efforts to increase the coverage of criteria in this study were mothers who gave
family planning participation and to improve the vaginal delivery and cesarean delivery. They
quality of postpartum mother’s health is to seek received post-placebo IUD insertion with the
family planning after delivery. Postpartum family duration of use at least 4–6 weeks post-insertion,
planning is the use of contraceptive methods using a CuT 380A IUD. The subject of the study
immediately after delivery to 6 weeks (42 days).2,3 was the mother who gets insertion post-placenta
Population and family planning programs IUD, both vaginal delivery and cesarean delivery.
offer a range of relatively safe and effective The subjects used have met the inclusion and
contraceptive methods of postpartum delivery, exclusion criteria with the sample number of 96
one of which is the post-placebo intrauterine respondents.
device (IUD). Following the Indonesian The data used in this study are primary
Health Technology Assessment issued by the and secondary. Primary data were obtained
Ministry of Health on family planning during from respondents through interview technique
the breastfeeding period, one of the efforts in and transvaginal ultrasound examination to
increasing the use of long-term contraceptives determine the location and position of IUD
aimed at postpartum mothers by using post- related to expulsion occurrence. In contrast,
placebo IUD in regulating gestational distances secondary data obtained from maternity register
without affecting the production of breast milk in the hospital.
(air susu ibu/ASI).1,4 The selection of study subjects was conducted
The results of the Indonesian Health by looking at the existing maternity registers
Technology Assessment Indonesia study showed in each study site that met the inclusion and
several levels of expulsion at the time of insertion. exclusion criteria. After obtaining the data through
For insertion on premature post-placenta (10 the maternity registers, the researcher contacted
minutes after placenta born) are 9.5–12.5%, each respondent by phone and mail to confirm
immediately insertion after delivery (more than whether the respondent was willing to include
10 minutes to 48 hours postpartum) are 25–37%, in the study. Respondents selected and willing to
and insertion during the postpartum interval undergo the transvaginal ultrasound to observe

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Atika Zahria Arisanti et al.: Differences in Expulsion on Post-placenta Intrauterine Contraceptive Device between Mother 23

the location and position of the IUD recruited and cesarean delivery. Age characteristics had p
for the study. The transvaginal ultrasound value=0.174 and parity p value=0.343.
examination aims to determine the occurrence of Table 2 shows that there are differences in
expulsion on post-placebo IUD insertion in the the occurrence of expulsion on the insertion
vaginal delivery and cesarean delivery mother. of a post-placenta intrauterine contraceptive
Transvaginal ultrasound examination performed device between mothers with vaginal delivery
by obstetric and gynecologist specialist on duty at and cesarean delivery with p value=0.041. All
the study site. respondents who experienced the occurrence of
The processing of the data collected analyzed expulsion in the vaginal delivery group of 4 (8%)
using SPSS version 17 applications. The statistical respondents.
test used in this study is the chi-square test (×2) Table 3 shows the relationship between age
with a 95% confidence level and 0.05 significance and parity with expulsion occurrence. The result
level. As an alternative test, Fisher's exact test was the p value=0.638 on variable age and p
used if the chi-square test is not appropriate. value=0.934 on variable parity.
This study approved by the Health Research
Ethics Committee of Faculty of Medicine of Discussion
Universitas Padjadjaran Bandung with the letter
number: 1228/UN6.C.10/PN/2017. The respondent characteristic shows that the
majority of respondents aged 20–35 years, 40
Results respondents in the vaginal delivery group, and 39
respondents in the cesarean delivery group with
Table 1 shows the frequency distribution of p value=0.174. Based on parity in two groups, it
respondent characteristics on the insertion was almost equal between the vaginal delivery
of a post-placental intrauterine contraceptive group and cesarean delivery with p value=0.343.
device between mothers with vaginal delivery Based on these results, it can be concluded that

Table 1 The Frequency Distribution of Respondent Characteristic on Two Group

Groups
Respondent
Vaginal Delivery Cesarean Delivery p Value*
Characteristic
(n=48) (n=48)
Age (years)
<20 1 (2%) 5 (11%)
20–35 40 (83%) 39 (81%)
0.174
>35 7 (15%) 4 (8%)
Mean (SD) 29.03 (6.5) 29.03 (6.5)
Range 16–47 16–47
Parity
Primiparous 13 (27%) 15 (31%)
0.343
Multiparous 33 (69%) 33 (69%)
Grand multiparous 2 (4%) 0 (0%)
Note: *Chi-square test

Table 2 The Relationship between the Post-placental IUD on Cesarian Delivery and
Vaginal Delivery with Expulsion Occurrence
Expulsion Occurrence
Post-placental IUD Insertion p Value*
Yes (n=4) No (n=92)
Vaginal delivery 4 (8%) 44 (92%)
0.041
Cesarean section 0 (0%) 48 (100%)
Note: *Fisher exact test

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24 Atika Zahria Arisanti et al.: Differences in Expulsion on Post-placenta Intrauterine Contraceptive Device between Mother

Table 3 The Relationship between Age and Parity with Expulsion Occurence
Expulsion Occurrence
Age and Parity p Value*
Yes (n=4) No (n=92)
Age (year)
<20 0 6
0.638
20–35 4 75
>35 0 11
Parity
Primiparous 1 27
0.934
Multiparous 3 63
Grand multiparous 0 2
Note: *Chi-square test

age and parity are homogeneous and feasible to respondents in a vaginal delivery experienced
compare.7,8 partial expulsion. Expulsion is the exclusion of
From the statistics results by using Fisher an IUD from within the uterus that can occur
exact test, obtained p value=0.041, it means that partly or entirely. Partial expulsion is a condition
there are differences in the expulsion occurrence in which the IUD stem located below the internal
of post-placenta IUD insertion between mother os and cervical canal. In contrast, total expulsion
with vaginal delivery and cesarean delivery. A is a condition in which the IUD stems out from
percentage of vaginal deliveries with an expulsion inside the uterus through the cervix e.g., in the
occurrence is higher, found in 4 (8%) respondents vagina.15,17,18
than the cesarean delivery, in which all In this study, transvaginal ultrasound to
respondents had no expulsion. The results mean evaluate the expulsion confirmed by obstetric
that the post-placenta IUD insertion in vaginal and gynecologist specialists. Observed on two
delivery has a higher occurrence of expulsion respondents with the location of the IUD stem is
than in cesarean delivery with a difference in under internal os, and on two other respondents,
age and parity.7–8 Expulsion occurrence is higher the IUD stem located in the cervical canal. The
on vaginal delivery than cesarean delivery expulsion rate of the IUD via vaginal insertion
because there is maximal dilatation cervix than was not only the one helped by midwives but
cesarean.10,11 also found in mothers helped by medical doctors
Post-placental IUD expulsion in vaginal too. The results of interviews showed that
delivery occurs due to the cervical dilatation in some respondents complained of pain during
the lower segment of the uterus as well as the sex, experiencing spots (spotting), and feel the
development of a thin lower uterine segment.12 It is discomfort because the IUD strings are too long,
estimated to be the cause of partial expulsion.13–15 which interfering with sexual activity.
While the cesarean delivery that is not planned The risk factors that may lead to an IUD
before and conducted while entering the active expulsion include age, parity, insertion time
period has a high risk as well.16 In this study, all (cervix dilatation), previous expulsion history,
cesarean delivery is upon indication and planned type and size of the IUD, insertion techniques,
so that the risk of expulsion minimized because and the attending medical personnel.18–21
it does not pass through an active phase of Another factor is age and parity. In this study,
delivery that the cervix is not fully dilated. Post- the majority of respondents who experienced
placental IUD insertion after vaginal delivery has the incidence of expulsion mostly aged 20–35
been shown to have an expulsion rate of up to years with parity of 2–4 (multipara). There was
24%. However, observational studies show that no significant association with age and parity
the rate of expulsion in post-placental insertion of the incidence of expulsion. The result of this
after cesarean is much lower. Theoretically, study supported by the study of Sucak et al.7 that
because placement on the fundus is more likely mentioned there is no significant correlation
to minimize the failure and likelihood, the cervix between the age of respondents with the incidence
is less fully dilate.15 of IUD expulsion, both from normal labor and
The results of this study found that all cesarean ones. Although there is no statistically

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Atika Zahria Arisanti et al.: Differences in Expulsion on Post-placenta Intrauterine Contraceptive Device between Mother 25

significant relationship, it showed the percentage F, Chomba E, et al. Postpartum contraceptive

of incidence of expulsion higher at <35 years old use and unmet need for family planning in
more (5%) than age >35 years (none).22–24 five low-income countries. Reprod Health.
In this study, there was no relationship 2015;12(Suppl 2):S11.
between parity and expulsion occurrence. 4. Pusat Data dan Informasi, Kementerian
This study wasn’t differenced with the study Kesehatan Republik Indonesia. Situasi dan
from Garishah25 that there was a significant analisis keluarga berencana [Internet]. 2014
relationship between parity and the incidence of June 29 [cited 2018 July 22]. Available from:
expulsion in post placental IUD insertion, with https://pusdatin.kemkes.go.id/resources/
a greater percentage of multiparous (66.3%), download/pusdatin/infodatin/infodatin-kb.
primipara (33.7%), and grand multipara pdf.
(25.9%). Parity is a risk factor for expulsion, the 5. Lester F, Kakaire O, Byamugisha J, Averbach
occurrence of expulsion increases in multiparous S, Fortin J, Maurer R, et al. Intracesarean
with vaginal delivery due to cervical dilatation in of the copper T380A versus 6 week
the lowest uterine segment. Unplanned section postcesarean: a randomized clinical trial.
cesarea deliveries also have a high risk but the Contraception. 2015;91(3):198–203.
effect of cervical dilatation and expulsion is still 6. Chhari A, Zutshi V, Sharma R, BatraS.
not enough evidence.7 Comparison of post placental IUD with
interval IUD. Int J Reprod Contracept Obstet
Conclusion Gynecol. 2015;4(4):1090–3.
7. Sucak A, Ozcan S, Çelen Ş, Çağlar T, Göksu
There was a difference in expulsion occurrence on G, Danışman N. Immediate postplacental
post-placental intrauterine device contraceptive insertion of a copper intrauterine device:
insertion between mother with vaginal delivery a pilot study to evaluate expulsion rate by
and cesarean delivery. The expulsion occurrence mode of delivery. BMC Pregnancy Childbirth.
of vaginal delivery is higher than cesarean 2015;15:202.
delivery. 8. American College of Obstetricians and
Gynecologists’ Committee on Gynecologic
Conflict of Interest Practice; Long-Acting Reversible
Contraceptive Expert Work Group.
There is no conflict of interest at all authors. Committee Opinion No 672: clinical challenge
of long-acting reversible contraceptive
References methods. Obstet Gynecol. 2016;128(3):e69–
77.
1. Direktorat Jenderal Bina Gizi dan Kesehatan 9. Letti Muller AL, Lopes Ramos JG,
Ibu dan Anak, Kementerian Kesehatan Martins-Costa SH, Palma Dias RS, Valerio
Republik Indonesia. Pedoman pelayanan EG, Hammes LS, et al. Transvaginal
keluarga berencana pasca persalinan di ultrasonographic assessment of expulsion
fasilitas kesehatan [Internet]. Jakarta: rate of intrauterine device inserted in the
Kementerian Kesehatan Republik Indonesia; immediate postpartum period: a pilot study.
2014 [cited 2018 June 20]. Available Contraception. 2005;72(3):192–5.
from: http://kesga.kemkes.go.id/images/ 10. Affandi B, Adriaansz G, Gunardi ER,
pedoman/Buku%20Pedoman%20KB%20 Koeno H. Buku panduan praktis pelayanan
Pasca%20Persalinan.pdf. kontrasepsi. 3rd Edition. 4th Printing. Jakarta:
2. United Nations, Department of Economic PT Bina Pustaka Sarwono Prawirohardjo;
and Social Affairs, Population Division. 2014.
World contraceptive use 2018 [Internet]. 11. Cunningham FG, Leveno KJ, Bloom SL,
New York: United Nations; 2018 [cited Hauth JC, Rouse DJ, Spong CY. Obstetri
2018 July 22]. Available from: https://www. Williams. 23rd Edition. Volume 1. Jakarta:
un.org/en/development/desa/population/ EGC; 2012.
publications/dataset/contraception/ 12. Kapp N, Curtis KM. Intrauterine device
wcu2018/UNPD_WCU2018_Country_ insertion during the postpartum period:
Data_Survey-Based.xlsx.. a systematic review. Contraception.
3. Pasha O, Goudar SS, Patel A, Garces A, Esamai 2009;80(4):327–36.

Global Medical and Health Communication, Volume 8 Number 1, April 2020

26 Atika Zahria Arisanti et al.: Differences in Expulsion on Post-placenta Intrauterine Contraceptive Device between Mother

13. Jatlaoui TC, Marcus M, Jamieson DJ, LZ, Kim YH. Ultrasonography of intrauterine
Goedken P, Cwiak C. Postplacental devices. Ultrasonography. 2015;34(3):183–
intrauterine device insertion at a teaching 94.
hospital. Contraception. 2014;89(6):528–33. 20. Lindheim SR, Uhler ML. Pelvic
14. Rahaman M, Sood AK, Srivasta AK. ultrasonography and sonohysterography.
Evaluation of spontaneous expulsion In: Falcone T, Hurd WW, editors. Clinical
after immediate postpartum intrauterine reproductive medicine and surgery.
contraceptive devices (PPIUCDs) insertion. Philadelphia: Mosby Elsevier; 2007. p. 441–
IOSR-JDMS. 2017;16(5):60–3. 60.
15. Putri FH. Pengaruh penjahitan AKDR 21. Evans A. Postpartum contraception. Womens
terhadap insiden ekspulsi pada pemasangan Health Med. 2005;2(5):23–6.
AKDR CuT 380A pascasalin seksio sesaria 22. The ACQUIRE Project. The postpartum
[thesis]. Jakarta: Universitas Indonesia; intrauterine device: a training course for
2014 [cited 2018 March 30]. Available from: service providers: participant handbook.
http://lib.ui.ac.id/file?file=digital/2016- New York: EngenderHealth/The ACQUIRE
2/20391336-SP-Farani%20Harida%20 Project; 2008.
Putri.pdf. 23. Eroğlu K, Akkuzu G, Vural G, Dilbaz B, Akin
16. Hubacher D, Reyes V, Lillo S, Pierre-Louis B, A, Taşkin L, et al. Comparison of efficacy
Zepeda A, Chen PL, et al. Preventing copper and complications of IUD insertion in
intrauterine device removals due to side immediate postplacental/early postpartum
effects among first-time users: randomized period with interval period: 1 year follow-up.
trial to study the effect of prophylactic Contraception. 2006;74(5):376–81.
ibuprofen. Hum Reprod. 2006;21(6):1467– 24. Fritz MA, Speroff L. Clinical gynecologic
72. endocrinology and infertility. 8th Edition.
17. Goldthwaite LM, Sheeder J, Hyer J, Tocce Philadelphia: Wolters Kluwer; 2011.
K, Teal SB. Postplacental intrauterine device 25. Garishah GH. Hubungan antara paritas
expulsion by 12 weeks: a prospective cohort terhadap kejadian ekspulsi IUD pada
study. Am J Obstet Gynecol. 2017;217(6):674. akseptor IUD post placental delivery pada
e1–8. persalinan spontan di Kota Magelang
18. Fernandes JHA, Lippi U. A clinical and [undergraduate thesis]. Yogyakarta:
ultrasound study on the use of postplacental Universitas Muhammadiyah Yogyakarta;
intrauterine device. Einstein (São Paulo). 2013 [cited 2018 October 19]. Available
2004;2(2):110–4. from: http://repository.umy.ac.id/
19. Nowitzki KM, Hoimes ML, Chen B, Zheng handle/123456789/7117.

Global Medical and Health Communication, Volume 8 Number 1, April 2020

 Global Medical and Health Communication

Online submission: http://ejournal.unisba.ac.id/index.php/gmhc GMHC. 2020;8(1):27–33

DOI: https://doi.org/10.29313/gmhc.v8i1.3885 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

Eel Cookies Supplement and Incidence of Diarrhea in

Children Aged 12–24 Months
Nur Eva Aristina,1 Dedi Rachmadi,2 Dewi Marhaeni Diah Herawati,3
Hadi Susiarno,4 Dida Akhmad Gurnida,2 Deni Kurniadi Sunjaya5
1
Midwifery Department, Politeknik Kesehatan Kementerian Kesehatan Malang, Malang, Indonesia,
2
Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital,
Bandung, Indonesia, 3Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran,
Sumedang, Indonesia, 4Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas
Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia, 5Department of
Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia

Abstract
Diarrhea is one of the main causes of death in infants and toddlers in Indonesia. The Indonesian eel is a source
of animal protein that contains high nutrients, including vitamin A and zinc, so it can be used to boost immunity.
The objective of this study was to analyze the effect of eel cookies on the incidence of diarrhea in children. This
was a double-blind randomized control trial (RCT) posttest study on 44 children aged 12–24 months at Garuda
Public Health Center, Bandung city, who were selected using the simple random sampling method. The study
was conducted for 2 months from January to February 2017. Data were analyzed using the Wilcoxon test. Results
showed that there was an effect of eel cookies in reducing diarrhea incidence in toddlers (p<0.001), with no diarrhea
condition seen among the toddlers among 18 children who had a history of diarrhea in the past and among 20 other
children with no history of past diarrhea. In conclusion, eel cookies can reduce the incidence of diarrhea in children
aged 12–24 months. Hence, it can be used as a functional food to improve child immunity as one of the efforts to
prevent infectious diseases, especially diarrhea.
Key words: Diarrhea, eel cookies, supplementation

Suplementasi Cookies Ikan Sidat terhadap Kejadian Diare

pada Balita Usia 12–24 Bulan

Abstrak
Penyakit diare merupakan salah satu penyebab kematian utama pada bayi dan balita di Indonesia. Ikan sidat
merupakan salah satu sumber protein hewani yang banyak mengandung vitamin A dan seng sehingga dapat
meningkatkan kekebalan tubuh. Tujuan penelitian ini adalah menganalisis pengaruh pemberian cookies ikan sidat
terhadap kejadian diare pada balita. Desain penelitian dengan randomized controll trial (RCT) posttest group
design dengan double blind. Subjek penelitian adalah balita usia 12–24 bulan di Puskesmas Garuda Kota Bandung
sebanyak 44 responden. Penelitian dilakukan selama 2 bulan mulai Januari–Februari 2017. Pengambilan sampel
dilakukan secara acak sederhana. Analisis data menggunakan Uji Wilcoxon. Hasil penelitian menunjukkan pengaruh
pemberian cookies ikan sidat terhadap penurunan kejadian diare pada balita (p<0,001), yaitu tidak ada perubahan
kondisi balita dari tidak diare menjadi diare dan terdapat 18 balita yang pernah memiliki riwayat penyakit diare
mengalami perubahan setelah diberikan perlakuan sehingga tidak mengalami diare, sedangkan 20 orang di antara
yang tidak memiliki riwayat penyakit diare setelah mendapatkan perlakuan tetap tidak mengalami diare. Simpulan,
terdapat pengaruh pemberian cookies ikan sidat terhadap penurunan kejadian diare pada balita usia 12–24 bulan.
Oleh karena itu, cookies ikan sidat dapat digunakan sebagai makanan fungsional untuk meningkatkan imunitas
anak sebagai upaya pencegahan terhadap penyakit infeksi terutama diare.
Kata kunci: Cookies sidat, diare, suplementasi

Received: 30 July 2018; Revised: 10 May 2019; Accepted: 2 March 2020; Published: 30 April 2020
Correspondence: Nur Eva Aristina, S.S.T., M.Keb. Midwifery Department, Politeknik Kesehatan Kementerian Kesehatan Malang.
Jln. Besar Ijen No. 77C, Malang 65112, East Java, Indonesia. E-mail: nearistina@gmail.com

27
28 Nur Eva Aristina et al.: Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months

Introduction Methods

Diseases, particularly diarrhea, is a primary cause This was an experimental double-blind,

of death in babies and toddlers in Indonesia, randomized control trial (RCT) post-test group
contributing 31.4% and 25.2% of the total number study. Neither the researchers nor the subjects of
of deaths, respectively. Diarrhea is closely related this study knew which intervention was provided
to the nutrition issue, especially malnutrition. to a particular subject. Subjects were chosen
Diarrhea in all ages is one of the top four causes using a random sampling method and divided
of death (13.2%) with the rates of 214 per 1,000 into two groups, namely the experimental group
people for all ages and 900 per 1,000 for toddlers which received eel cookies and the control group
in 2012. The highest incident of diarrhea for which received cookies without eel content. The
toddlers is seen in the 12 to 24-month-old age observed variable was the incidence of diarrhea.
group (7.6%).1,2 The eel cookies formulation was performed
Low nutrition status is a significant risk factor using chemical analysis to determine the water
that may cause diarrhea for babies and toddlers.3 content, ash content, fat, protein, carbohydrate,
The nutrition status related to malnutrition can vitamin A, and zinc. The results of the analysis
increase the morbidity and mortality caused by were used as the basis for the formulating cookies
the defense system of the human body, which using the best formula and method, which should
continues to weaken and change body immunity.4 be suitable for cookies based on the nutritional
Nutrition status influences every single value obtained from the list of food compositions.
aspect of children's health, including growth, Experts then produced the cookies at the Baking
development, physical activities, and responses Research and Development (BReAD) Unit of
towards infectious diseases. The cause of Bogor Agricultural University. The subjects in
malnutrition is lack of nutrients and lack of this study include toddlers ranging from 12 to 24
food absorption in the digestive system.5 Several months old who lived in the area of the Garuda
studies have revealed that macronutrient Public Health Center Bandung who met the
or micronutrient deficiency might cause inclusion criteria. This research was performed
vulnerabilities to infectious diseases, including from January to February 2017.
diarrhea. An infectious disease occurs due The screening applied to the subjects through
to reduced body's immunity, including cell several stages. First, toddlers aged 12–24 months
immunity and IgA secretion. were registered and information on daily health
Eel is an alternative source of protein which care was obtained. These toddlers then received
is better than beef because it has low cholesterol a physical check-up to determine their health
content and cheaper. Indonesia has a significant status. Lastly, 40 research subjects were obtained
potential for the fishery, yet it is not corresponding and randomized to determine which toddlers
with the increase in domestic fish consumption.6,7 went into the experimental group and which went
The Indonesian eel (Anguilla spp.) is a fish that to the control group.
has an economic value both for local and foreign Data collected consisted of cookies consumed
markets. The eel contains higher nutrients during the intervention by the subjects. Data on
such as protein, fat, vitamin, and minerals such cookies consumption were collected every week
as phosphor, zinc, selenium, and iron when and recorded into the daily cookies consumption
compared to other fish.8–10 form. Food consumption was evaluated using
One of the by-products of eels is eel flour.11 the three-day estimated food recording method
This flour can be used as a material of food (2 days of consumption and one day without
diversification as well as food supplements and consumption) before consuming cookies and
functional food products. One of the forms of after 30 days of intervention. Data on food
the functional food products made of eels is eel consumption were then converted into nutrient
cookies.11 units and averaged to obtain daily consumption
This study aimed to analyze the effect of eel- numbers. The Nutrisurvey 2007 application was
based cookies consumption on the reduction of used to convert basic data into nutrients data. The
diarrhea incidence among toddlers aged 12–24 Wilcoxon test was chosen for statistical analysis.
months old. The study protocol was approved by the

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Nur Eva Aristina et al.: Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months 29

Health Research Ethics Committee of the Faculty Discussion

of Medicine, Universitas Padjadjaran, Bandung,
Indonesia through the issuance of the ethical Table 1 presents the characteristics of subjects by
clearance letter number: 22/UN6.C1.3.2/KEPK/ the child sex, maternal occupational status, and
PN/2017. maternal education level. Child sex distribution
was similar between the intervention and
Results control groups. The maternal occupational
status did not differ greatly between the two
The characteristics of the research subjects groups with most mothers did not work (80%
and the number of eel cookies consumed are vs 70% in the intervention group and control
presented in Table 1. group, respectively). The highest maternal
The difference in the average body weight and education level was high school graduates (45%
the protein, vitamin A, and zinc inputs before and in both groups). Most toddlers received exclusive
after consuming the cookies are listed in Table 2. breastfeeding (65% vs 80% in the intervention
The analysis of the effect of eel cookies on the and control groups, respectively). The incidence
reduction of diarrhea incidence is presented in of diarrhea before the treatment did not differ
Table 3. greatly between the two groups, with 55% had a
Table 3 presents that eel cookies affect diarrhea history of diarrhea in the intervention group and
incidence reduction with p<0.001 (p=0.000), 45% of the toddlers in the control group had a
meaning that there was no change in the condition history of diarrhea.
of toddlers from not having diarrhea to having Education influences knowledge. The
diarrhea. There were 18 toddlers with a history mother's knowledge about diarrhea will play an
of diarrhea who did not experience diarrhea important role in improving the risk factors in her
after the treatment. Besides, 20 toddlers without family that will eventually reduce the frequency
any history of diarrhea maintain the absence of of diarrhea occurrence among her family
diarrhea after receiving the treatment. members. Lower knowledge and understanding

Table 1 General Characteristics of Subjects and Their Parents

Group and Number of Subject
Characteristics Eel Cookies Control Cookies
(n=20) (n=20)
Sex
Male 9 9
Female 11 11
Mother’s occupational status
Working mother 4 6
Non-working mother 16 14
Mother’s education status
Elementary school 1 1
Junior high school 6 3
Senior high school 9 13
Higher education/equivalent 4 3
Breastfeeding
Exclusive breastfeeding 13 16
Non-exclusive breastfeeding 7 4
Pre-intervention diarrhea occurrence
Occur 11 9
Does not occur 9 11
Post-intervention diarrhea occurrence
Occur 0 2
Does not occur 20 18

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30 Nur Eva Aristina et al.: Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months

Table 2 Analysis of Difference in Body Weight, Protein Input, Vitamin A Input, and Zinc
Input
Groups
Difference Eel Cookies Controlled Cookies p Value*
(n=20) (n=20)
Body weight
Before 23.45 17.55 0.114
After 24.60 16.40 0.024
Protein input
Before 21.78 19.23 0.489
After 23.68 17.33 0.086
Vitamin A input
Before 17.28 23.83 0.072
After 23.83 17.18 0.072
Zinc input
Before 21.50 19.25 0.579
After 23.25 17.75 0.126
Note: *Mann-Whitney test

of diarrhea can result in a poorer ability to apply nutritional status. Several studies suggested that
diarrhea information in daily life. Good maternal nutritional status has a significant risk factor in
knowledge about diarrhea is expected to further causing diarrhea in infants and toddlers. A low
improve the ability of mothers in handling and nutritional status in infants and toddlers is an
preventing diarrhea.12 important risk factor that can lead to diarrhea,
The result of the analysis showed that there especially in children aged 0–24 months.
were no differences in the characteristics of the The result of the analysis of the characteristics
child's body weight before cookies provision (p of protein input in children before the intervention
value=0.114). After an intervention, a significant showed that no difference was seen between
difference was seen between the bodyweight of the intervention group and the control group
toddlers in the intervention group and the control (p=0.489). After the intervention, this situation
group (p value=0.024). did not change (p=0.086).
Bodyweight is the most important and most The main function of protein for the body is
commonly used anthropometric measure in to form new tissues and maintain the existing
newborns (neonates). During infancy, weight can tissues. Protein can also function as a type of
be used to observe the physical growth rate and fuel if the body's energy needs are not met by
nutritional status. Bodyweight is chosen because carbohydrates and fats. Protein can regulate the
it has the best parameters and it is easy to use, balance of fluids in tissues and blood vessels by
easy to understand, and provides an overview causing a colloidal osmotic pressure that can
of the current nutritional status. Bodyweight draw fluid from the tissues into the blood vessels.
is one of the parameters for determining one's Another function of the protein relates to child

Table 3 Analysis of Effect of Eel Cookies to the Reduction of Diarrhea Incidence

Mean Rank
Diarrhea Occurrence Before and After n=40 p Value*
(Min–Max)
Negative rank 0 0 0.000
Positive rank 18 9.50
Equal 22
Note: *Wilcoxon test

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Nur Eva Aristina et al.: Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months 31

growth and the development of child hormones, consumed is still very dependent on what is
enzymes, and antibodies. The body's ability to provided by the mother or parents. The pattern
fight infection depends on its ability to produce of food consumption in children under five is also
antibodies against organisms that can cause still strongly influenced by the pattern of food
infections or to foreign substances that enter the consumption of parents or families.
body. The body also has the ability to detoxify The statistical analysis of the effect of
toxins, which is controlled by enzymes, especially providing eel cookies to the incidence of
those found in the liver. In a state of protein diarrhea showed that eel cookies consumption
deficiency, the body's ability to inhibit the toxic reduced the incidence of diarrhea (p=0.000).
effects of toxic substances may decrease.13 No diarrhea incident happened during the study
There was no difference seen in the and 18 toddlers with a history of diarrhea became
characteristics of vitamin A input between better after consuming the cookies, which was
the intervention group and the control group apparent from the lack of diarrhea incidence.
(p=0.072), which did not change after the The 20 toddlers without a history of diarrhea still
intervention (p value=0.072). maintain the absence of diarrhea incidence after
Vitamins are essential substances that consuming the cookies.
are needed to help nutrient absorption and Diarrhea prevention is important because
metabolism processes. A vitamin deficiency diarrhea can cause death and deficiencies in
will cause health problems. Therefore, a certain infants and children. Efforts to reduce the
amount of daily vitamin inputs need to be incidence of diarrhea in children require the
obtained, ideally from food. Other than its effect right intervention so infants and children
on eye health, vitamin A also acts as an anti- become healthy and infectious diseases that
infection agent. The body's immune system may cause diarrhea can be prevented. The
function is reduced in vitamin A deficiency, proven interventions to prevent the occurrence
making it susceptible to infectious diseases. If of diarrhea include improving child nutrition
this occurs on the surface of the intestinal wall, through the promotion of exclusive breastfeeding
diarrhea will occur. Children under five are and complementary foods, provision of clean
susceptible to vitamin A deficiency.14 and safe drinking water, hygienic and healthy
Analysis of zinc input before intervention living behavior supported by the community and
showed no difference between the intervention families, good sanitation and child immunization,
group and the control group (p value=0.0579). and vitamin A and zinc supplements.
This stayed the same after the intervention (p Findings in this study are in line with
value=0.128). Asfianti et al.15 that suggested vitamin A and zinc
Zinc plays a role in immunity cells, namely in supplement provision to children aged 12–60
the function of the T cells and in the formation months can reduce the incidence of diarrhea. The
of antibodies by the B cells. Zinc also plays a role incidence of diarrhea has decreased from 28.40%
in several reactions that zinc deficiency will affect to 26.1% after vitamin A and zinc supplements are
a lot of body tissues, especially during growth, provided. Adequate nutrients, especially vitamins
and the body’s immunity, especially against and minerals, are important to maintain an
infectious diseases such as diarrhea. Zinc affects optimum immune system. Because most vitamins
both the gastrointestinal system and, indirectly, and minerals cannot be synthesized by the body,
the immune system. Zinc also plays a role in the consumption of diverse and balanced foods is
maintaining the integrity of the intestinal mucus very important especially food that becomes the
through its function in cell regeneration and cell source of vitamins and minerals such as fruits,
membrane stability. Zinc deficiency damages the vegetables, and animal-based foods.16
epidermis and gastrointestinal mucus, facilitating A study by Widayani et al.17 on vitamin A and
an invasion of germs in the gastrointestinal iron-containing biscuits to children under five
tract.14 showed significantly higher hemoglobin, ferritin,
The average inputs of protein, vitamin A, and retinol, and total G immunoglobin levels at the end
zinc before and after the intervention were not of the intervention. Another study that involved
significantly different between the intervention providing biscuits enriched with albumin protein
and the control groups. Toddlers aged 1–3 years of cork fish in children aged 4–5 years showed an
are passive consumers, so the input of food increase in energy, protein, zinc, and Fe levels.18

Global Medical and Health Communication, Volume 8 Number 1, April 2020

32 Nur Eva Aristina et al.: Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months

Providing eel cookies with formulated nutrients Malnutrition and gastrointestinal and
that include protein, vitamin A, and zinc is an respiratory infections in children: a public
effort to prevent infectious diseases, especially health problem. Int J Environ Res Public
diarrhea. Eel cookies are a type of functional food Health. 2011;8(4):1174–205.
that is enriched with eel head flour. 6. Sokib N, Palupi NS, Suharjo B. Strategi
peningkatan konsumsi ikan di Kota Depok,
Conclusion Jawa Barat. Manaj IKM. 2012;7(2):166–71.
7. Utami DP, Gumilar I, Sriati. Analisis
In summary, eel cookies provision affects the bioekonomi penangkapan ikan layur
reduction of diarrhea incidence in children aged (Trichirus sp.) di Perairan Parigi Kabupaten
12–24 months. Therefore, eel cookies can be Ciamis. JPK. 2012;3(3):137–44.
used as a functional food to improve children's 8. Okfrianti Y, Kamsiah, Veli DG. Pengaruh
immune systems as an effort to prevent infectious penambahan tepung ikan sidat (Anguilla spp)
diseases, especially diarrhea. pada pembuatan tortilla chips terhadap nilai
gizi, kadar air dan daya terima organoleptik.
Conflict of Interest JSPI. 2013;8(2):139–52.
9. Polak-Juszczak L, Robak S. Macro- and
The authors declare no conflict of interest. microelements in eel (Anguilla anguilla)
from the northern regions of Poland. J
Acknowledgments Elementol. 2015;20(2):385–94.
10. Suseno SH. Fatty acid profiles of tropical eel
We would like to thank Faculty of Medicine, (Anguilla sp.) by-products. Adv J Food Sci
Universitas Padjadjaran, Bandung, Indonesia as Technol. 2014;6(6):802–6.
well as Malang Health Polytechnic, the Ministry 11. Tarau E. Pengaruh kombinasi tepung ikan
of Health, PT. Carmelitha Lestari Bogor, and PT. sidat (Anguilla marmorata (Q.) Gaimard.)
Iroha Sidat Indonesia Banyuwangi. dan tepung terigu terhadap kualitas biscuit
crackers [undergraduate thesis]. Yogyakarta:
References Universitas Atma Jaya Yogyakarta; 2011
[cited 2018 February 20]. Available from:
1. Kementerian Kesehatan Republik Indonesia. http://e-journal.uajy.ac.id/1547/.
Profil kesehatan Indonesia tahun 2013. 12. Fathia H, Tejasari M, Trusda SAD. Hubungan
Jakarta: Kementerian Kesehatan Republik tingkat pendidikan dan pengetahuan ibu
Indonesia; 2014. tentang diare dengan frekuensi kejadian
2. Indonesia Agency of Health Research diare balita di wilayah kerja Puskesmas
and Development, Ministry of Health of Tamansari Bandung Oktober 2013–Maret
Republic of Indonesia. Basic health research 2014. GMHC. 2015;3(1):13–8.
(Riskesdas) 2013 [Internet]. Jakarta: 13. Yunita R, Anggraini M, Wiyono S. Hubungan
Indonesia Agency of Health Research and antara asupan protein, zink, vitamin A dan
Development, Ministry of Health of Republic kejadian infeksi saluran pernafasan akut
of Indonesia; 2013 [cited 2017 July 22]. (ISPA) non pneumonia pada balita di RW
Available from: http://labdata.litbang. 06 Kelurahan Cempaka Putih Kecamatan
kemkes.go.id/ccount/click.php?id=10. Ciputat Timur Tangerang Selatan. Nutrire
3. Adisasmito W. Faktor risiko diare pada bayi Diaita. 2014;6(2):99–113.
dan balita di Indonesia: systematic review 14. Arnisam, Salfiyadi T, Lura LS. Hubungan
penelitian akademik bidang kesehatan asupan mineral zinc (seng) dan vitamin
masyarakat. MJHR. 2007;11(1):1–10. A dengan kejadian diare pada balita di
4. Khalili B, Hart A, Mardani M, Khalili M, Kecamatan Seulimeum. INJ. 2013;4(3):66–
Mcardle F, Cuevas L. Diarrhea-associated 73.
micronutrient deficiencies and risk of 15. Asfianti F, Nazir HM, Husin S, Theodorus.
subsequent diarrhea in admitted children to Pengaruh suplementasi seng dan vitamin A
Hajar hospital in Shahrekord, Iran. Arch Clin terhadap kejadian ISPA dan diare pada anak.
Infect Dis. 2007;2(3):121–8. Sari Pediatri. 2013;15(2):93–8.
5. Rodríguez L, Cervantes E, Ortiz R. 16. Siswanto, Budisetyawati, Ernawati F.

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Nur Eva Aristina et al.: Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months 33

Peran beberapa zat gizi mikro dalam sistem Available from: https://repository.ipb.ac.id/
imunitas. Gizi Indon. 2013;36(1):57–64. handle/123456789/40899.
17. Widayani S, Syarief H, Sulaeman A, Setiawan 18. Sari DK, Marliyati SA, Kustiyah L, Khomsan
B, Muhilal. Efikasi dan preferensi biskuit A. Role of biscuits enriched with albumin
yang difortifikasi vitamin A dan zat besi (Fe) protein from snakehead fish, zinc and iron
dan kaitannya dengan konsumsi, status gizi, on immune response of under five children.
dan respons imun anak balita [dissertation]. Pakistan J Nutr. 2014;13(1):28–32.
Bogor: IPB; 2007 [cited 2018 April 30].

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 Global Medical and Health Communication

Online submission: http://ejournal.unisba.ac.id/index.php/gmhc GMHC. 2020;8(1):34–41

DOI: https://doi.org/10.29313/gmhc.v8i1.5863 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

Implementation of Importance-Performance Analysis (IPA) for

Improving Medical Students’ Quality of Service in Teaching Hospital
Siska Nia Irasanti,1 Ieva Baniasih Akbar,2 Yani Dewi Suryani3
1
Department of Public Health, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia,
2
Department of Physiology, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia,
3
Department of Pediatric, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia

Abstract
One of the most relevant elements for improving the quality of an organization is the recognition of customer
satisfaction and perceived quality of services. During their clerkship, medical students are required to work with
different medical specializations in rotation and treat patients under the supervision of the attending physicians.
The purpose of the study is to explore the medical students' quality of service using the importance-performance
analysis (IPA) diagram that focused on the conformance level (CLi) between the actual service performance score
and patient expectation score. This was a cross-sectional study involving 160 patients and patient caregivers at
the Department of Pediatric of West Java Provincial Al-Ihsan Regional General Hospital Bandung, who was a
purposive sampling method to participate in the study during January 2018. Results showed that the total CLi was
less than 100%. The CLi scores for responsiveness, empathy, assurance, and reliability components were 84.57%,
84%, 83.56%, and 83.45%, respectively. It can be concluded that the services provided were good, but have not
yet been able to meet the expectation of the patients. Overall, the IPA is useful to identify areas for strategic focus
in improving the quality of services provided by medical students to help the hospital managers and faculty of
medicine develop education management strategies.
Key words: Clerkship, IPA, service quality

Penerapan Importance-Performance Analysis (IPA) untuk

Meningkatkan Kualitas Pelayanan Mahasiswa Selama
Kepaniteraan di Rumah Sakit Pendidikan

Abstrak
Salah satu elemen yang paling relevan untuk meningkatkan kualitas organisasi adalah mengetahui kepuasan dan
kualitas layanan yang dirasakan oleh konsumen. Selama kepaniteraan, mahasiswa kedokteran diwajibkan untuk
berotasi melalui berbagai spesialisasi medis dan merawat pasien di bawah pengawasan dokter. Tujuan penelitian
ini mengetahui kualitas pelayanan mahasiwa kedokteran dengan menggunakan diagram importance-performance
analysis (IPA) yang berfokus pada tingkat kesesuaian (Tki) antara skor kinerja layanan aktual dan skor harapan
pasien. Penelitian ini merupakan penelitian cross-sectional yang melibatkan 160 pasien dan penunggu pasien di
Departemen Ilmu Kesehatan Anak di RSUD Al-Ihsan Provinsi Jawa Barat Bandung dengan metode purposive
sampling selama bulan Januari 2018. Hasil penelitian menunjukkan bahwa total Tki kurang dari 100%. Skor Tki
untuk komponen respons, empati, assurance, dan reliabilitas masing-masing adalah 84,57%, 84%, 83,56%, dan
83,45%. Dapat disimpulkan bahwa faktor layanan yang diberikan baik, tetapi belum memenuhi harapan pasien.
Meskipun demikian, IPA berguna untuk mengidentifikasi area untuk fokus strategis dalam meningkatkan kualitas
layanan yang diberikan mahasiswa kedokteran untuk membantu manajer rumah sakit dan fakultas kedokteran
mengembangkan strategi manajemen pendidikan.
Kata kunci: IPA, kepaniteraan, kualitas pelayanan

Received: 7 April 2020; Revised: 15 April 2020; Accepted: 24 April 2020; Published: 30 April 2020
Correspondence: Siska Nia Irasanti, drg., M.M. Department of Public Health, Faculty of Medicine, Universitas Islam Bandung. Jln.
Tamansari No. 22, Bandung 40116, West Java, Indonesia. E-mail: siska_drg@rocketmail.com

34
Siska Nia Irasanti et al.: Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’ 35

Introduction diagram which reflects patients and patient

caregivers satisfaction with the services provided
Consumer satisfaction in health care services by medical students during the clerkship period.
is particularly important to create greater
involvement of the clients during health care Methods
processes and also to achieve higher patient
compliance and avoid dissatisfaction that may This study was a cross-sectional method, and
trigger them to seek treatment elsewhere.1 One the analysis tool used in this study was the IPA
of the most relevant elements for improving the diagram with the conformance level to compare
quality of an organization is the understanding of the actual service performance score to the
customer satisfaction and customer's perceived patient expectations score for services provided
quality of services.2 Zulkarnain et al.3 suggested by medical students.6 Responses obtained from
that patients with a lower educational background 160 patients and caregivers purposively sampling
are generally more satisfied than those with higher at the Department of Pediatric of the West Java
education. Gaps are often observed between the Provincial Al-Ihsan Regional General Hospital,
expectation categories and overall perception of which is the main teaching hospital of the Faculty
quality. of Medicine, Universitas Islam Bandung period
Service quality can be measured from the January 2018.
perspectives of patient perception, patient A modified SERVQUAL instrument had
expectation, patient satisfaction, and patient developed with 13 matched pair items for
attitude. Due to the intangibility, inseparability, expectation and perception, which represented
heterogeneity, and perishability characteristics four attributes that considered to have a high and
of services, it is very difficult to define service significant correlation with patient satisfaction
quality. In the context of increasing access to in the health care setting. The four attributes
information, along with tougher competition, included in this instrument were responsiveness,
patients become more demanding than ever. assurance, empathy, and reliability dimension.
The advances in technology also enable patients Five-point Likert response format (ranging from
to make comparisons quickly and accurately strongly agree=5 to strongly disagree=1) was used
between available services.4 SERVQUAL is instead of the seven-point scale format based on
an instrument that is useful to measure the the results of discussion with experts and the
functional quality of the organization, which is hospital management (Table 1).5,7,8
defined as the manner in which the health care The dimensions included in the questionnaire
service is delivered to the patients. The functional listed in Table 2.
quality cannot be sustained in a health care setting This study was with a tentative population size.
without accurate diagnoses and procedures.5 The sample size calculated using the Lemeshow
During the clerkship, medical students formula as follows.9
are required to work with different medical
specializations in rotation and treat patients Z2 × P (1−P)
n=
under the supervision of the attending physicians. d2
The importance-performance analysis (IPA) Description: n=the required minimum sample size;
enables the hospital management to evaluate Z=confidence level with the z score at 95%=1.96;
and identify the major strengths and weaknesses P=estimates of the population proportion with the
maximum estimated=0.5; d= alpha (0.10) or sampling
in the performance that become the key success error=10%
factors of the hospital and the importance of the
quality of services provided by medical students. The calculation of the sample size gave a
The importance-performance analysis is a useful minimum sample size of 96 participants. The
tool for directing continuous quality improvement researchers then decided to use a sample size of
towards higher education.6 160 participants.
This study aimed to assess the performance The IPA was performed by calculating scores
and the importance of the quality of services of importance and performance of system
provided by medical students, as well as to attributes resulted from users’ perceptions and
determine the quality of services provided by depicted on a two-dimensional grid.10–14
medical students based on the performance and The conformance level of the respondents was
importance through the use of the cartesian performed by comparing the service performance

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36 Siska Nia Irasanti et al.: Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’

assessment score to the actual score of the patient Health Research Ethics Committee of the Faculty
expectations by using the following formula.15 of Medicine, Universitas Islam Bandung.

Xi Results
CLi = ×100%
Yi
The results showed the total CLi was <100%,
Description: CLi=conformance level of respondent;
Xi=actual service performance assessment score; where the CLi for the responsiveness, empathy,
Yi=patient expectation score assurance, and reliability dimension was 84.57%,
84%, 83.56%, and 83.45%, respectively (Table 3).
Through the calculation of the conformance Figure 2 described the IPA of the quality of
level, the quality of services provided by medical services provided by medical students. Quadrant
students in the teaching hospital can be assessed A of the diagram indicated a high patient
to understand whether the services provided expectation towards the service factors, but the
were satisfactory or not. actual performance of the service was poor (Figure
To understand the meaning of the 1). Hence, factors in this quadrant should become
conformance level score of each service factor, a the top priority for correction and improvement.
cartesian diagram was used. The horizontal axis There were 3 (three) factors in this quadrant,
(X) represented the actual service performance namely responsiveness 4 (services provided
score while the vertical axis (Y) represented the quickly and responsively to patients), assurance
patient expectation score. To make it simple, each 3 (serving patients promptly), and empathy 1
service factor that influence patient satisfaction (spend adequate time to serve patients).
was determined using the formula below.15 Quadrant B indicated a high patient
expectation towards the service factor and
ΣXi ΣYi high actual performance of the factors. Thus,
X= Y=
n n these need to be maintained. achievement of
these services factors must be maintained. This
The cartesian diagram was used to determine quadrant consisted of 5 (five) service factors, i.e.
the service factors with high-performance reliability 2 (asking for information to patients in
according to the patients and the service factors a good and clear manner), empathy 2 (pay serious
that were expected to have the best performance attention to patients), responsiveness 1 (willing
by the patients. The formula used was as follow.15 to respond to patients’ complaints) and 2 (receive
and serve patients well).
n n Quadrant C indicated that patient expectation
∑i = 1Xi ∑i = 1Yi was low for the service factors and the actual
X= Y=
K K performance of the service factors was also
low. Thus, even though they were not really a
Where K represented the number of service priority, the performance of these factors was
dimensions that could affect patient satisfaction. needed. There were 5 (five) the service factors
The cartesian diagram used to map service quality in this quadrant, namely reliability 1 (say
is shown in Figure 1. greetings “assalamualaikum wr. wb.” before
The study protocol had approved by the asking for information to patients), reliability

Table 1 Scale Used in Questionnaire

Five-Points Likert Scale Responses
1) Actual service performance variable (X)
1 2 3 4 5
Disappointing Poor Good Satisfactory Highly satisfactory
2) Patient expectation variable (Y)
1 2 3 4 5
Highly unimportant Unimportant Quite important Important Very important

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Siska Nia Irasanti et al.: Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’ 37

Table 2 Questionnaire Dimensions

Reliability
1 Say greetings “assalamualaikum wr. wb.” before asking for information to patients.
2 Asking for information to patients in a good and clear manner.
3 Describe actions that will be performed to patients (anamnesis).
4 Say “alhamdulillahirabbilalamin” after finishing the session with patients.
Responsiveness
1 Willing to respond to patients’ complaints.
2 Receive and serve patients well.
3 Provide fair and non-discriminatory services to patients.
4 Services provided quickly and responsively to patients.
Assurance
1 Convincing attitude and ability to make patients feel safe.
2 Polite and friendly when serving patients.
3 Serving patients promptly.
Empathy
1 Spend adequate time to serve patients.
2 Pay serious attention to patients.

3 (describe actions that will be performed further attention for improvement was needed.
to patients (anamnesis)), reliability 4 (say No service factor was assigned in this quadrant.
“alhamdulillahirabbilalamin” after finishing the The service performance assigned to the
session with patients), responsiveness 3 (provide right side of the average performance line or in
fair and non-discriminatory services to patients) quadrant B could be categorized as service factors
and assurance 1 (convincing attitude and ability with good performance based on the average
to make patients feel safe). performance value of 5 out of 13 service factors,
Quadrant D presented service factors with or 38.5%. Since almost half of the service factor
low patient expectation but the high actual performance was in this category, it can be stated
performance of service that the performance of that the performance of services by the medical
the service indicators here was excessive and no students during clerkship in the teaching hospital
was generally good.
The cartesian diagram also enables us to
understand the level of patient expectation
towards high-quality service performance for
4.5 each service factor. The upper the position of a
factor on the cartesian diagram, which is parallel
to the Y-axis, indicates that the service factor
has received attention from the service provider
3.5 because it is considered important. Therefore,
service factors located in this area are considered
to be satisfactory. Service factors above the
2.5

Table 3 Conformance Level (Cli)

1.5 Dimension CLi (%)
Responsiveness 84.57
1.5 3.5 Empathy 84
Assurance 83.56
Figure 1 Cartesian Diagram7 Reliability 83.45

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38 Siska Nia Irasanti et al.: Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’

4.70

4.68

4.66

4.64
Importance

4.62

4.60

4.58

4.56

4.54

4.52

4.50
3.70 3.75 3.80 3.85 3.90 3.95 4.00 4.05 4.10 4.15

Performance
Figure 2 Importance-Performance Analysis (IPA) of the Quality of Services Provided by
Medical Students During Clerkship in Teaching Hospital

average expectation line, or in quadrant A In terms of patient ratings, the best service
and B, are the focus of services performance performance dimension for services provided by
development because they have exceeded the medical students in Al-Ihsan Teaching Hospital
average expectations. at the time of the study was the responsiveness

Table 4 Average Score of Service Performance and Patients Expectation per Dimension
Number of per Performance Expectation
Instrument Dimensional
Dimension
Number Instrument Score Average Score Average
1 Reliability 4 3.84 3.8 4.58 4.58
2 3.88 4.67
3 3.74 4.53
4 3.76 4.54
5 Responsiveness 4 3.96 3.93 4.63 4.63
6 4.05 4.65
7 3.86 4.59
8 3.84 4.63
9 Assurance 3 3.84 3.91 4.59 4.62
10 4.13 4.63
11 3.76 4.65
12 Empathy 2 3.79 3.87 4.63 4.66
13 3.94 4.69

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Siska Nia Irasanti et al.: Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’ 39

dimension a score of 3.93, which was the highest important by the patients and the implementation
among all dimensions as depicted in Table 4. In by the hospital was mediocre. These factors
contrast, the reliability dimension was considered should become lower priorities for improvement
as the poorest dimension, especially regarding because they were less important, even though
describing actions that will be performed on they were less satisfactory. The factors considered
the patients (anamnesis). The average score of in this group were greetings and salam in Islam.
service performance and patients expectation per This is different with the study of Rafik and
dimension is shown in Table 4. Priyono,16 who is finding that the presence of
When patient expectation scores were ranked good environment and Islamic value embodiment
by dimension, the order of the scores was, from the supporting learning programs on campus is
highest to the lowest: empathy, responsiveness, the most significant trigger for the knowledge
assurance, and reliability. The sequence describes development.
the level of patient expectation on service factors in This result is different from the findings of
each dimension. The higher the expectation score Zulkarnain et al.3 where the responsiveness
is, the more patients expect satisfactory service domain demonstrates the largest unfavorable
performance. In this study, patients expected gaps between performance and expectation,
the best service in the empathy dimension that and the direction of the gaps indicates a higher
comprised of adequate time to serve patients and perceived quality than expected. Campos et al.17
pay serious attention to patients. However, the also revealed different aspects of the attributes
results as shown in Table 4 presented that the considered to be the most important, namely
score for the service performance in the empathy explanation and level of knowledge as well as
dimension was still less than the scores in the attention dispensed by health professionals,
assurance and responsiveness dimensions. This which were included in the reliability dimension.
will lead to a reduced level of patient satisfaction The biggest gap in the service performance
despite the overall high service performance level from the perspective of patient expectation
achieved by the medical students. towards services provided by medical students is
identified in the empathy dimension. In addition,
Discussion there are gaps in the assurance and responsiveness
dimensions, although not as big as in the
The service performances were good in general empathy dimension. From the perspective of
but still unable to meet the expectation of the service performance, the responsive dimension is
patients. Medical students were seen to be willing considered the best and the reliability dimension
to respond to patient complaints; receive and is considered the poorest.
serve the patients well; ask for information to The service factors that are considered to have
the patients in a good and clear manner; had a met patients’ expectation are the willingness
convincing attitude and make patients feel safe to respond to patient complaints, ability to
and pay serious attention to patients. This shows receive and serve patients well, ability to ask for
that the basic service elements were successfully information from patients in a good and clear
implemented and should be maintained as very manner, ability to show convincing attitude and
important and very satisfactory service elements. make patients feel safe, and also ability to pay
On the other hand, there were also service attention seriously to the patients. These factors
factors that received high expectations from the need to be maintained.
patients but the actual performance was poor. In contrast, factors that are considered not
These included the elements of services provided satisfactory by patients due to the gap between
quickly and responsively to patients; serving patient expectation and actual performance of
patients promptly; and spend adequate time to service are quick and responsive to patient, serve
serve patients. These service factors should be a patients promptly, and adequate time for serving
top priority for correction and improvement. patients. These service factors should become
Several factors underlie this poor performance the top priority for correction and improvement.
including limited consultation time, too many Other factors also need to be improved, albeit in
patients visiting the pediatrics department, and lower priority.
the lack of privacy during medical student and Once the patients’ requirements have been
patient interactions due to limited space. clearly identified and understood, a manager
Other factors were considered as less will likely be in a better position to anticipate

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40 Siska Nia Irasanti et al.: Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’

and cater to their desires and needs rather than healthcare sector. A critical review of some
merely react to their dissatisfaction.18 The role of empirical studies. IJEPT. 2014;4(2):168.
the management here mainly includes training 2. Rodrigo-Rincón I, Reyes-Pérez M, Martínez-
students in physical examination skills, patient Lozano ME. Personalizing the reference
expectation assessment, and relational and level: gold standard to evaluate the quality of
humanistic aspects of communication to show service perceived. Rev Esp Med Nucl Imagen
respect to individual patients.19–21 Mol. 2014;33(2):65–71.
Evaluating a health care center’s performance 3. Zulkarnain AK, Kristina SA, Saraswati
from the patient’s point of view will improve MS. Perceived service quality and patient
the manager’s understanding of customer satisfaction at pharmacy department
satisfaction. Patients who are satisfied with their in Yogyakarta Indonesia. Value Health.
health care services are more likely to spread 2017;20(9):A157.
favorable word-of-mouth publicity.22 4. Sachdev SB, Verma HV. Relative importance
The IPA of the quality of services provided of service quality dimensions: a multisectoral
by the medical students during clerkship is study. J Serv Res, 2004;4(1):94–116.
useful for identifying areas that should become 5. Akhade GN, Jaju SB, Lakhe RR. Healthcare
the strategic focus of the hospital managers and service quality dimensions in various
the faculty of medicine in developing education countries. IOSR-JNHS. 2016;5(3):70–6.
management strategies. Further studies are 6. O’Neill MA, Palmer A. Importance-
needed to determine the effectiveness of IPA of the performance analysis: a useful tool for
quality of services provided by medical students directing continuous quality improvement
during clerkship in a larger group. In addition, it in higher education. Qual Assur Educ.
is also necessary to study the effectiveness of this 2004;12(1):39–52.
simulation model to improve a service quality in 7. Hindarwati EN, Jayasari A. Analisis kualitas
other teaching hospital departments in the future. pelayanan PT Jasa Raharja dengan metode
SERVQUAL. BBR. 2004;5(2):626–37.
Conclusion 8. Sarjono H, Natalia. SERVQUAL dalam
pelayanan kelas pada laboratorium
The service performances were good in general manajemen. Binus Business Rev.
but still unable to meet the expectation of 2014;5(1):404–17.
the patients. The biggest gap in the service 9. Lwanga SK, Lemeshow S. Sample size
performance from the perspective of patient is determination in health studies: a practical
in the empathy dimension. The service factors manual. Geneva: WHO; 1991.
that considered to meet patients’ expectation is 10. Martilla JA, James JC. Importance-
the willingness to respond to patient complaints, performance analysis. J Mark. 1977;41(1):77–
ability to receive and serve patients well, ability to 9.
ask for information from patients in a good and 11. Ainin S, Hisham NH. Applying importance-
clear manner, ability to show convincing attitude performance analysis to information
and make patients feel safe, and also ability to systems: an exploratory case study. JIITO.
pay attention seriously to the patients. 2008;3:95–103.
12. Cohen JF, Coleman E, Kangethe MJ. An
Conflict of Interest importance-performance analysis of hospital
information system attributes: a nurses’
All authors declare no conflict of interest. perspective. Int J Med Inform. 2016;86:82–
90.
Acknowledgments 13. Sukumaran AKS, Anushan SCS, Alamelu R,
Thiyagarajan S. Diagnosing SWOT through
We sincerely thank the Faculty of Medicine, importance-performance analysis. Res J
Universitas Islam Bandung, for funding our Appl Sci Eng Tech. 2015;9(9):792–6.
study. 14. Aggelidis VP, Chatzoglou PD. Hospital
information systems: measuring end user
References computing satisfaction (EUCS). J Biomed
Inform. 2012;45(3):566–79.
1. Coțiu MA. Consumer satisfaction in the 15. Supranto J. Pengukuran tingkat kepuasan

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Siska Nia Irasanti et al.: Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’ 41

pelanggan untuk menaikkan pangsa pasar. 2002;325(7368):818–21.

4th Printing. Jakarta: Rineka Cipta; 2011. 20. Hammond M, McLean E. What parents
16. Rafik A, Priyono A. A new insight into and carers think medical students should
alumni satisfaction model for Islamic higher be learning about communication with
education institutions (IHEI). Manag Res children and families. Patient Educ Couns.
Rev. 2018;41(12):1411–37. 2009;76(3):368–75.
17. Campos DF, Negromonte Filho RB, 21. Ericson KA. Deliberate practice and the
Castro FN. Service quality in public health acquisition and maintenance of expert
clinics: perceptions of users and health performance in medicine and related domains.
professionals. Int J Health Care Qual Assur. Acad Med. 2004;79(10 Suppl):S70–81.
2017;30(8):680–92. 22. Rodrigo-Rincón I, Reyes-Pérez M, Martínez-
18. Fornell C. A national customer satisfaction Lozano ME. Personalizing the reference
barometer: the Swedish experience. J Mark. level: gold standard to evaluate the quality of
1992;56(1):6–21. service perceived. Rev Esp Med Nucl Imagen
19. Wykurz G, Kelly D. Developing the role of Mol. 2014;33(2):65–71.
patients as teachers: literature review. BMJ.

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RESEARCH ARTICLE

Relationship of Soil-transmitted Helminth and Enterobius vermicularis

Infection with Anemic in Students in Aceh Besar
Faisal Heri,1 A.A. Depari,2 Merina Panggabean2
1
Master Program in Tropical Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia,
2
Department of Parasitology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia

Abstract
Helminthiasis is a disease caused by parasites in the form of worms, one of which is the type of soil-transmitted
helminth (STH), A. lumbricoides, T. trichiura, N. americanus, and A. duodenale which infect humans through
soil transmission. Enterobius vermicularis is the most common intestinal parasite in the whole world. Worms
that live in the human intestine can cause malnutrition and anemic. This study aims to determine the relationship
STH and Enterobius vermicularis infection with anemic of students in several elementary schools in Aceh Besar
regency, Aceh province. This study was an analytical study using a cross-sectional study design conducted from May
to November 2015. The sample consisted of the total sampling of 736 elementary school students, as well as using
the inquiry method of Kato with stool specimens, cellophane tape anal swab, and hemoglobin. The correspondents
who suffered from anemia and STH type helminthiasis, namely ancylostomiasis 7/7 students (100%, p=0.000);
trichuriasis 30/58 students (51.7%, p=0.000) and 28 students not anemic (48.3%); and ascariasis 13/22 students
(59.9%, p=0.002) and 9 students not anemic (41.1%). In enterobiasis infection, anemic students were 46/146
students (31.5%) and nonanemic students were 100 students (68.5%, p=0.634). In conclusion, all STH types related
to the anemic status of the correspondent, and no correlation between anemic and infection of enterobiasis.
Key words: Anemic, Enterobius vermicularis, soil-transmitted helminth

Hubungan Infeksi Soil-Transmitted Helminth dan Enterobius

vermicularis dengan Anemia pada Siswa di
Kabupaten Aceh Besar Provinsi Aceh

Abstrak
Kecacingan adalah penyakit yang disebabkan oleh parasit berupa cacing, salah satunya jenis soil-transmitted
helminth (STH), yaitu A. lumbricoides, T. trichiura, N. americanus, dan A. duodenale yang menginfeksi manusia
melalui transmisi tanah. Enterobius vermicularis adalah parasit usus yang paling umum di seluruh dunia. Cacing
yang hidup di usus manusia ini dapat menyebabkan kurang gizi dan anemia. Penelitian ini bertujuan mengetahui
hubungan infeksi STH dan Enterobius vermicularis dengan anemia pada siswa sekolah dasar di Kabupaten Aceh
Besar, Provinsi Aceh. Penelitian ini merupakan penelitian analitik menggunakan rancangan cross-sectional study
yang dilaksanakan dari bulan Mei sampai November 2015. Sampel berupa total sampling 736 siswa sekolah dasar,
serta menggunakan metode pemeriksaan Kato dengan spesimen feses, cellophane tape anal swab, dan hemoglobin.
Koresponden yang menderita anemia dan kecacingan jenis STH, yaitu ancylostomiasis 7/7 siswa (100%, p=0,000);
trichuriasis 30/58 siswa (51,7%; p=0,000) dan 28 siswa tidak anemia (48,3%); serta askariasis 13/22 siswa (59,9%;
p=0,002) dan 9 siswa tidak anemia (41,1%). Pada infeksi enterobiasis, siswa yang anemia adalah 46/146 siswa
(31,5%) dan tidak anemia 100 siswa (68,5%; p=0,634). Simpulan, semua kecacingan jenis STH berhubungan erat
dengan status anemia pada koresponden, serta tidak terdapat hubungan antara anemia dan infeksi enterobiasis.
Kata kunci: Anemia, Enterobius vermicularis, soil-transmitted helminth

Received: 17 April 2019; Revised: 7 April 2020; Accepted: 8 April 2020; Published: 30 April 2020
Correspondence: Faisal Heri. Master Program in Tropical Medicine, Faculty of Medicine, Universitas Sumatera Utara. Jln. Abdul
Hakim, Padang Bulan, Medan 20222, North Sumatra, Indonesia. E-mail: faisalheri8@gmail.com

42
Faisal Heri et al.: Relationship of Soil-transmitted Helminth and Enterobius vermicularis Infection with Anemic in 43

Introduction Pengendalian Penyakit Bersumber Binatang)

Tanah Bumbu in 2008 in South Kalimantan
World Health Organization (WHO) reported found that out of 1,964 examined children, 451
that the case of helminthiasis in the world is children (22.9%) were positive for helminthiasis.
still high. In the world, over 1 billion people The most infection was ascariasis in 192 people
infected by ascariasis, 795 million by trichuriasis, (42.5%), trichuriasis found in 167 people (37%),
500 million by enterobiasis, and 740 million ancylostomiasis (hookworm) in 63 people
by ancylostomiasis.1 Helminthiasis is a disease (13.9%), and enterobiasis in 15 people (7.93%).14
caused by parasites in the form of worms. One In the previous research at the Elementary
of the causes of helminthiasis is soil-transmitted School Gedong Bina Remaja in Semarang city, the
helminth (STH), which is the worm that lives result of the examination between helminthiasis
in the intestine that transmitted to humans and anemic showed that the percentage of
through soil contaminated feces containing respondents with anemia was higher (46.7%)
infectious worm eggs.2,3 Worms classified as STH compared to the one without anemia (11.8%).9
were Ascaris lumbricoides, Trichuris trichiura, According to a study in Makassar City,
Necator americanus, Ancylostoma duodenale, the number of students suffering from severe
and Strongyloides stercoralis.1–5 helminthiasis with anemic was 27 people (27.8%),
The STH infection is a chronic infection caused mild infections, and anemic 63 people (64.9%),
by parasitic worms with a high prevalence and non-infected and anemic seven people (7.21%) of
mostly affects children under five and elementary the 97 students.15
school-age children. The contamination of worm Anemia is a public health problem throughout
eggs occurs because of soil contamination by the world, with an estimated prevalence of 24.8%.
feces. It eases the transmission of eggs from the Anemic can be defined as a condition in which
ground to humans through hands contaminated the erythrocyte mass of circulating hemoglobin
by parasitic worm eggs, and then it goes into the mass cannot fulfill its function to provide oxygen
mouth with food.6–8 to body tissues. In Indonesia, the prevalence of
Worms that live in the human intestine make anemia in school-aged children reaches 29%.16,17
a substantial contribution to the cases of other Anemia because chronic bleeding, one of which is
diseases. Examples of diseases caused by the due to worm infections, is generally more tolerable
worm are malnutrition because of roundworm because the body will gradually compensate.15,18
infestations and anemia caused by hookworms. Hemoglobin is a protein that is substantial in
Roundworm consumes carbohydrates and iron. It has an affinity, combining power, toward
proteins in the intestine before being absorbed by oxygen, and it can form oxyhemoglobin in red
the body. Hookworms suck blood in the intestine, blood cells. Through this function, oxygen carried
causing iron deficiency anemia (microcytic from the lungs to the tissues. The hemoglobin
hypochromic). The symptom of anemia is pale also functions to maintain the red blood cells
and lethargic. These worms harm the growth and normal shape.17
development of humans.7,9–11 This study aims to determine the relationship
Enterobius vermicularis is the most common of STH infection and E. vermicularis with
intestinal parasite in the whole world. Enterobiasis anaemic of students in several primary schools in
is also a family disease that is easy to spread Aceh Besar regency, Aceh province.
its eggs through clothing and other household
appliances. Children aged 5–11 years more often Methods
experience E. vermicularis worms because of the
lack of personal hygiene compared to adults who This study was analytical research using a cross-
are more able to maintain cleanliness.12 sectional study design. The location of the study
In Indonesia, the prevalence of children was in 10 elementary schools in Aceh Besar
with helminthiasis in 2008 is around 24.1%. regency, Aceh province which conducted from
Distribution of the prevalence of helminthiasis May to November 2015. The sample was all
caused by ascariasis was 14.5%, trichuriasis was students in the first and second degrees.
13.9%, and ancylostomiasis was 3.60%.13 The Stool specimen collected and anal swab
results of a survey conducted by the Research and performed. The fecal examination used the
Development Center for Animal Source Disease Kato method and cellophane tape for anal swab
Control (Balai Penelitian dan Pengembangan for Enterobius vermicularis to determine the

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44 Faisal Heri et al.: Relationship of Soil-transmitted Helminth and Enterobius vermicularis Infection with Anemic in

student's worm status. The specimens examine Several factors greatly influence the spread of
to determine hemoglobin degree to define anemic worm infections including climate—such as
status. rainfall, behavior, household conditions, poverty,
In this study, the researcher tries to associate and slum environment.20
between the dependent variable (STH and The number of students suffering from
Enterobius vermicularis) with the independent helminthiasis was 87, while the ones with
variable (hemoglobin). trichuriasis were 58 students (7.9%). Treatment
The data were analyzed using SPSS version with albendazole 400 mg orally with a single
20 for Windows. The data correlation used a chi- dose is not sufficient. According to the Centers
square correlation test with a significance level for Disease Control and Prevention (CDC),21
determined error of α=5% (0.05). patients with T. trichiura should be treated with
The study protocol had approved by the albendazole 400 mg for three consecutive days.
Health Research Ethical Committee, Faculty of Ascariasis infection found in 22 students
Medicine, Universitas Sumatera Utara, Medan, (3.0%) and ancylostomiasis infection found in 7
with letter number: 503/KOMET/FK USU/2015. students (1.0%). A patient infected by ascariasis
and ancylostomiasis treated with albendazole
Results 400 mg (single dose). According to research by
Dewayani et al.19 in children of Public Elementary
The result of the study found that the mostly School I in the village of Tanjung Anom,
respondents from class 1 of elementary school Pancur Batu sub-district, Deli Serdang regency,
as many as 381 respondents (51.8%). Most of the North Sumatra, the success of a single dose of
respondents were female, with a percentage of albendazole 400 mg reaches 100% cure rate.
52.9%. Respondents suffering from helminthiasis However, according to Annisa et al.22 in children
were 233 students (31.7%) of 736 students (Table in Perokonda village, Southwest Sumba, the
1). effectiveness of a single dose of albendazole for
The highest number of STH helminthiases the treatment of ascariasis was only 69%.
was trichuriasis with 58 respondents (7.9%) and Enterobiasis infection from laboratory tests
enterobiasis with 146 respondents (19.8%). The using the anal swab examination method found
other 87 students (11.9%) positively infected by in 146 students (19.8%) from 736 students.
STH and 146 students (19.8%) were positive to These worms generally infect children whose
enterobiasis (Table 2). personal hygiene and live in an unfavorable
Of the 87 students suffered from STH, 22 environment. Bad personal hygiene and
infected by ascariasis (3.0%), and 13 of 22 sanitation such as rarely changing bedsheets,
had anemia (p=0.002). Students infected by sleeping in groups, exchanging clothes, and the
trichuriasis were 58 students (7.9%), 30 of 58 frequency of changing underwear also speeds up
students had anemia (p=0.000). Those suffering the transmission of enterobiasis.12 Also, the lack
from ancylostomiasis were 7 students (1.0%), all of children's knowledge on the transmission and
student suffering from anemia (p=0.000). 146 prevention of helminthiasis causes enterobiasis
students (19.8%) infected by enterobiasis, 46 of infection. Enterobiasis can occur through 3 paths,
146 students suffer from anemic (p=0.634). which are from hand to mouth (autoinfection), by
The students non-suffering from helminthiasis
were 503 students (68.3%), suffering from
anaemic were 124 students (24.7%), and non- Table 1 Characteristic of Respondents
suffering from anaemic were 379 students (75.3%,
Table 3). Characteristic n=736 Percentage
Class
Discussion 1 381 51.8
2 355 48.2
From the results of fecal specimens and anal Gender
swabs, the prevalence of helminthiasis in Male 347 47.1
elementary school students in Aceh Besar Female 389 52.9
regency was 233 (31.7%). Providing students Worm infestation
with albendazole 400 mg of worm medicine twice Positive 233 31.7
a year is effective in eradicating helminthiasis.19 Negative 503 68.3

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Faisal Heri et al.: Relationship of Soil-transmitted Helminth and Enterobius vermicularis Infection with Anemic in 45

Table 2 Characteristic of Respondents

Percentage Anemic Nonanemic
Infection Type n=233 p Value
(31.7) (n=96) (n=137)
Ascariasis 22 3.0 13 9 o.oo2
Trichuriasis 58 7.9 30 28 0.000
Ancylostomiasis 7 1.0 7 0 0.000
Enterobiasis 146 19.8 46 100 0.634

breathing air contaminated with E. vermicularis students (p=0.634). This worm does not cause
eggs infectious, and transmission by retro- anemia in patients because this worm does not
infection which is the transmission that occurs in suck blood from the patient's body. Enterobiasis
the patient.23 only causes pruritus perianal, anxiety, loss of
All respondents who had ancylostomiasis were appetite, insomnia, and irritability, especially in
also anemic (100%). These indicate that there children with high parasitic infections. This worm
was a close relationship between ancylostomiasis also causes children to become lazy and often
and anemia. Ancylostomiasis can cause anemic sleepy because they cannot sleep well at night.12
hemorrhage (blood loss) because ancylostomiasis
sucks blood as much as 0.005–0.1 mL/worm/ Conclusion
day.24
Trichuriasis in respondents suffering from This study concluded that all STH types related to
anemic were 30 students (52%) out of 58 students the anemic status of the children and that there is
(p=0.000), 28 students were not anemia (48%). no correlation between anemia and infection of
This worm also sucks the blood of the host as enterobiasis.
many as 0.005 mL/worm/day so that anemia
occurs. This study indicates that there was a Conflict of Interest
significant relationship between trichuriasis as
the cause of anemia in children.23 There is no conflict of interest at all authors.
Respondents with ascariasis were 13 students
out of 22 students (p=0.002). This worm sucks References
the essence of food from the patient's body that
the patients were malnourished and consequently 1. World Health Organization (WHO). WHO
experiencing nutritional anemic. From these plans major scale-up of interventions for soil-
results, it shows that there is a close relationship transmitted helminthiases (intestinal worms)
between ascariasis and anemic in respondents [Internet]. 2012 June 8 [cited 2015 November
who are the object of research. According to 4]. Available from: https://www.who.int/
Ideham and Pusarawati,25 A. lumbricoides can neglected_diseases/STH_scale_up_2012/
cause protein-energy malnutrition (PEM). In en/.
children with ascariasis, they can lose 4 grams of 2. World Health Organization (WHO). Soil-
protein from a diet containing 35–50 grams of transmitted helminth infections [Internet].
protein/day. 2015 March 30 [cited 2015 November 6].
In students with enterobiasis, anemic found Available from: https://www.who.int/news-
in 46 of 146 students, and nonanemic were 100 room/fact-sheets/detail/soil-transmitted-
helminth-infections.
3. World Health Organization (WHO). Soil-
transmitted helminthiasis: eliminating soil-
Table 3 Hemoglobin Level of Students
transmitted helminthiasis as a public health
with No Helminthiasis
problem in children: progress report 2001–
Category n=503 Percentage 2010 and strategic plan 2011–2020. Geneva:
Anemic 124 24.7 WHO Press; 2012.
4. Parija SC, Chidambaram M, Mandal J.
Nonanemic 379 75.3
Epidemiology and clinical features of soil-

Global Medical and Health Communication, Volume 8 Number 1, April 2020

46 Faisal Heri et al.: Relationship of Soil-transmitted Helminth and Enterobius vermicularis Infection with Anemic in

transmitted helminths. Trop Parasitol. 15. Ibrahim IA. Ascariasis dan trichuriasis
2017;7(2):81–5. sebagai faktor penentu kejadian anemia gizi
5. Khurana S, Sethi S. Laboratory diagnosis of besi anak SD di permukiman kumuh Kota
soil transmitted helminthiasis. Trop Parasitol. Makassar. MGP. 2012;8(1):48–54.
2017;7(2):86–91. 16. Indonesia Agency of Health Research and
6. Safar R. Parasitologi kedokteran: protozoologi, Development, Ministry of Health of Republic
helmintologi, entomologi. Bandung: Yrama of Indonesia. Basic health research (Riskesdas)
Widya; 2010. 2013 [Internet]. Jakarta: Indonesia Agency of
7. Ali AR. Penyakit cacing pada anak SD Health Research and Development, Ministry
di Polewali Mandar tahun 2006–2007 of Health of Republic of Indonesia; 2013
[Internet]. 2009 February 19 [cited 2015 [cited 2017 June 15]. Available from: http://
April 4]. Available from: https://arali2008. labdata.litbang.kemkes.go.id/ccount/click.
wordpress.com/2009/02/19/penyakit- php?id=10.
cacing-anak-sd-di-polewali-mandar- 17. Hoffbrand AV, Mass PAH. Essential
tahun-2006-2008/. haematology. 6th Edition. Oxford: Blackwell
8. Baharuddin. Pengaruh perilaku higienitas Publising; 2011.
terhadap kejadian kecacingan pada 18. Raspati H, Reniarti L, Susanah S. Anemia
murid sekolah dasar negeri di Kecamatan defisiensi besi. In: Permono HB, Sutaryo,
Meurebo Kabupaten Aceh Barat. Master Ugrasena IDG, Windiastuti E, Abdulsalam M,
[thesis]. Medan: Universitas Sumatera editors. Buku ajar hematologi-onkologi anak.
Utara; 2010 [cited 2016 January 2]. 2nd Printing. Jakarta: Badan Penerbit IDAI;
Available from: http://repository.usu.ac.id/ 2006. p. 30–43.
handle/123456789/23779. 19. Dewayani BS, Situmeang R, Sembiring
9. Ali MA, Sugiyanto Z, Suharyo. 2011. T, Hamid ED, Pasaribu S, Lubis CP.
Hubungan infeksi helminthiasis dengan kadar Albendazole pada soil transmitted
hemoglobin (Hb) pada siswa SD Gedong Bina helminthiasis. 2004 [cited 2016 January 2].
Remaja Kota Semarang 2011. Jurnal Visikes. Available from: http://repository.usu.ac.id/
2012;11(2):80–7. handle/123456789/2015.
10. Tan X, Cheng M, Zhang J, Chen G, Liu D, Liu 20. Chaiyos J, Suwannatrai K, Thinkhamrop
Y, et al. Hookworm infection caused acute K, Pratumchart K, Sereewong C, Tesana S,
intestinal bleeding diagnosed by capsule: a et al. MaxEnt modeling of soil-transmitted
case report and literature review. Korean J helminth infection distributions in Thailand.
Parasitol. 2017;55(4):417–20. Parasitol Res. 2018;117(11):3507–17.
11. Centers for Disease Control and Prevention 21. Centers for Disease Control and Prevention
(CDC). Parasites - trichuriasis (also known as (CDC). Parasites - trichuriasis (also known as
whipworm infection) [Internet]. January 10, whipworm infection): treatmeant [Internet].
2013 [cited 2016 January 2]. Available from: January 10, 2013 [cited 2016 January 2].
https://www.cdc.gov/parasites/whipworm/ Available from: https://www.cdc.gov/
index.html. parasites/whipworm/treatment.html.
12. Chu TB, Liao CW, Nara T, Huang YC, Chou 22. Annisa I, Damayanti R, Trianto DM, Wiratama
CM, Liu YH, et al. Enterobius vermicularis MP, Wahdini S, Sungkar S. Pengaruh
infection is well controlled among preschool pengobatan albendazol dosis tunggal
children in nurseries of Taipei City, Taiwan. terhadap infeksi soil-transmitted helminth
Rev Soc Bras Med Trop. 2012;45(5):646–8. dan status gizi anak di Desa Perokonda,
13. Departemen Kesehatan Republik Indonesia. Sumba Barat Daya. eJKI. 2017;5(2):114–20.
Profil kesehatan Indonesia 2008. Jakarta: 23. Sutanto I, Ismid IS, Sjarifuddin PK, Sungkar
Departemen Kesehatan Republik Indonesia; S. Buku ajar parasitologi kedokteran. 4th
2009. Edition. Jakarta: Badan Penerbit Fakultas
14. Balai Penelitian dan Pengembangan Kedokteran Universitas Indonesia; 2011.
Pengendalian Penyakit Bersumber Binatang 24. Irianto K. Parasitologi medis (medical
(Balai Litbang P2B2) Tanah Bumbu. Hasil parasitogy). Bandung; Alfabeta; 2013.
survei tinja pada anak sekolah di SD Batuah 25. Ideham B, Pusarawati S. Helmintologi
I Pagatan, Kecamatan Kusan Hilir. Batulicin: kedokteran. Surabaya: Airlangga University
Balai Litbang P2B2 Tanah Bumbu; 2009. Press; 2007.

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RESEARCH ARTICLE

Dermatoglyphics Pattern on Breast Cancer Patients in

Dharmais Cancer Hospital
Faras Qodriyyah Sani,1 Mirfat,2 Iskandar3
1
Medical Undergraduate Study Program, Faculty of Medicine, Universitas YARSI, Jakarta, Indonesia,
2
Department of Biology, Faculty of Medicine, Universitas YARSI, Jakarta, Indonesia,
3
Department of Surgical Oncology, Dharmais Cancer Hospital, Jakarta, Indonesia

Abstract
Dermatoglyphics is a study of the epidermal ridge in fingers, palms, soles, toes, and formed under genetic
control at the beginning of the development of the fetus around 6–7 weeks and continues until 20–21 weeks. The
development of the breast begins in a 6-week-old fetus in the epidermis and at the bottom of the mesenchyme.
The development of the finger ridges and breast occurs at six weeks of gestation, and the abnormal genomes can
be detected at this period and observed through dermatoglyphics. The purpose of this study was to determine
the dermatoglyphic patterns of breast cancer patients in Dharmais Cancer Hospital from 12 December 2018 to 1
January 2019. The study was a descriptive study with a purposive sampling method for the determination of the
sample. The quantitative data collected using questionnaires while the prints of dermatoglyphic patterns were from
the fingertips of the respondent. From 100 respondents, the left-hand fingers and right-hand fingers dominated by
radial loop pattern with the most significant percentage on the middle finger 62% and 77%, respectively. While the
ring finger dominated by the plain whorl pattern 43%. In conclusion, the dermatoglyphics pattern on breast cancer
patients in Dharmais Cancer Hospital dominated by a radial loop pattern.
Key words: Breast cancer, dermatoglyphics, Dharmais Cancer Hospital

Pola Dermatoglifi Tangan Pasien Kanker Payudara di

Rumah Sakit Kanker Dharmais

Abstrak
Dermatoglifi merupakan ilmu yang mempelajari tentang pola sulur pada jari, telapak tangan, telapak kaki, dan jari
kaki yang terbentuk di bawah kontrol genetik pada awal perkembangan usia janin sekitar 6–7 minggu serta terus
berkembang sampai usia 20–21 minggu. Perkembangan payudara dimulai pada janin berusia 6 minggu dalam
bentuk gumpalan padat yang berada di epidermis dan di bagian bawah mesenkim. Perkembangan sulur dermal
dan payudara terjadi pada usia kehamilan enam minggu dan genom tidak abnormal dapat dideteksi pada periode
ini dan dapat teramati melalui dermatoglifi. Tujuan penelitian ini mengetahui pola dermatoglifi pada pasien kanker
payudara di Rumah Sakit Kanker Dharmais dari tanggal 12 Desember 2018 hingga 1 Januari 2019. Penelitian
ini merupakan studi deskriptif dengan metode purposive sampling untuk penentuan sampel. Data kuantitatif
diperoleh dengan menggunakan kuesioner, sedangkan cetakan pola dermatoglifi berasal dari ujung jari tangan
responden. Dari 100 responden, jari tangan kiri dan jari tangan kanan didominasi oleh pola radial loop dengan
persentase terbesar pada jari tengah sebesar 62% dan 77% masing-masing. Sementara jari manis didominasi oleh
pola plain whorl sebesar 43%. Simpulan, pola dermatoglifi pada pasien kanker payudara di Rumah Sakit Kanker
Dharmais didominasi oleh pola radial loop.
Kata kunci: Dermatoglifi, kanker payudara, Rumah Sakit Kanker Dharmais

Received: 26 February 2019; Revised: 13 April 2020; Accepted: 21 April 2020; Published: 30 April 2020
Correspondence: Mirfat S.Si, M.Si. Department of Biology, Faculty of Medicine, Universitas YARSI. Menara YARSI, Kav. 13 Lt.
1, Jln. Letjend Suprapto No. 1, Central Jakarta 10510, Special Capital Region of Jakarta, Indonesia. E-mail: mirfat2104@gmail.com

47
48 Faras Qodriyyah Sani et al.: Dermatoglyphics Pattern on Breast Cancer Patients in Dharmais Cancer Hospital

Introduction of all incident breast cancer cases), while the

death is 521.907.15 In the Asian continent, breast
Dermatoglyphics is a study of the epidermal cancer was also the highest incidence of breast
ridge in fingers, palms, soles, and toes.1–7 cancer in women at 650,983 (21%) of the female
Dermatoglyphics was formed under genetic population, while the mortality rate is second only
control at the beginning of pregnancy development to lung cancer, which is 231,013 (13%) of female
around 6–7 weeks in the form of volar pads and residents.16 In the Indonesian region, according
continues to develop and then will form on the to 2014 Country Profiles WHO estimates, the
surface of the skin until the age of 20–21 weeks, incidence of breast cancer in women was first in
but can be affected by environmental factors 48,988 (30,5%) of the total population, whereas
during the first trimester of pregnancy.1–4 This the highest mortality rate is 19,750 (21.4%).17
pattern will become permanent after four months Breast cancer is a genetic disease that may
of pregnancy and will not change throughout life.8 show a typical dermatoglyphic pattern in the
Early development of the breast begins in risk group. Breast cancer is most common in
the 6-week-old fetus in the epidermis and at the women from the age group of 45–55 years
bottom of the mesenchyme. The development of and dermatoglyphics can help identify an
the finger ridges was in the form of volar pads and increased risk of developing breast cancer in
occurred at six weeks of gestation and will reach women. Dermatoglyphic can also be the earliest
maximum size at 12–13 weeks of gestation. The diagnostic tool for breast cancer.12 The study of
genetic information that is in the normal and the dermatoglyphic pattern is simple, does not
abnormal genomes can be detected in this period need repetition, does not require much time, is
and can be observed through dermatoglyphics.9 not invasive, and inexpensive.18 The purpose of
The dermatoglyphic study used to prove this study was to determine the dermatoglyphic
whether specific fingerprint patterns correlate pattern on breast cancer patients at Dharmais
with several diseases. Some diseases reported Cancer Hospital.
correlating with fingerprint patterns such as down
syndrome, mental retardation, multiple sclerosis, Methods
and thalassemia.10 Raizada et al.11 researched
dermatoglyphics to carcinoma breast patients This study using descriptive study and
in India to determine whether dermatoglyphics determination of sample was using purposive
could be used for screening or guide future sampling. The quantitative data obtained from
research for breast cancer. In their research, it questionnaires and the results dermatoglyphic
found that there were significant dermatoglyphic patterns used printed fingertips of the
differences between breast cancer patients and respondent. This study was carried out on 12
healthy people. Sukre et al.12 conducted a similar December 2018–1 January 2019 at Dharmais
study, the results of their study showed that Cancer Hospital, Jakarta. The sample was 100
dermatoglyphics among breast cancer patients respondents, and the data collected after the
with healthy people were different too. The result subject agreed and signed informed consent. The
of their research, it was stated that there was a target population in this study were breast cancer
significant difference percentage in finger pattern patients who were seeking treatment at Dharmais
found in breast cancer patients where the whorl Cancer Hospital. The samples used in this study
pattern on the right-hand thumb was 52% while were respondents who met the criteria, which
the whorl pattern on the right hand of healthy were breast cancer patients who had upper limbs,
people was 38%. mainly hands without any deformity on one of
Breast cancer is a malignancy in breast tissue the fingers. They were willing and filled out the
that can originate from the ductal epithelium research questionnaire and present it at the time
or lobule.13 Breast cancer generally occurs in of sampling. The type of fingerprint pattern in this
women, at least about one-third of women who study divided into eight categories, plain whorl,
have cancer is breast cancer.14 double loop whorl, central pocket loop whorl,
Based on estimated data from the International accidental whorl, plain arch, tented arch, radial
Agency for Research on Cancer (IARC) of the loop, and ulnar loop. The type of data used in
World Health Organization (WHO) in 2012, this study is quantitative data from the results of
breast cancer was the highest incidence of cancer the questionnaire. Cross-sectional data analysis
worldwide in women as many as 1,671,149 (25% used descriptive statistical techniques that were

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Faras Qodriyyah Sani et al.: Dermatoglyphics Pattern on Breast Cancer Patients in Dharmais Cancer Hospital 49

processed using SPSS version 22.0. 62%. The right hand dominated by a radial loop
This study had approved by the Health with the highest found on the right middle finger
Research Ethics Committee of the Faculty of that was 77% while the ring finger dominated by
Medicine of the University of YARSI by ethical the plain whorl (Figure b) pattern that was 43%.
approval letter number: 230/KEP-UY/BIA/ In this study, respondents were grouped based
IX/2018. on data on age, gender, ethnicity of the father, and
ethnic group. The following is the distribution of
Results respondent data based on demographic data in
Table 2.
The following is a data distribution of fingerprint Based on Table 2, breast cancer patients were
patterns on the right and left hand is in Table 1. all females (100%) and over 40 years old (88%).
Based on Table 1, the frequency distribution Based on the ethnic characteristics of parents, the
type of fingerprint pattern of breast cancer respondents in this study dominated by Javanese
patients consisted of radial loop 53.8%, plain parents.
whorl 23.2%, double loop whorl 8.3%, plain arch
5.7%, central pocket loop whorl 3.7%, ulnar loop Discussion
3.6%, tented arch 1.0%, and accidental whorl
0.7%. The left-hand fingers dominated by a radial The dermatoglyphics pattern of breast cancer
loop pattern (Figure a) with the most significant patients in Dharmais Cancer Hospital dominated
percentage on the left middle finger, which was by radial loop patterns. Madhavi et al.18 conducted

Table 1 Frequency Distribution of Finger Ridges

Frequency of Finger Ridges
Left Hand (n=100) Right Hand (n=100)
Total
Finger Ridges
Thumb

Thumb
Middle

Middle
(%)
Finger

Finger

Finger

Finger

Finger

Finger

Finger

Finger
Index

Index
Little

Little
Ring

Ring
Plain whorl 24 23 15 33 15 25 24 12 43 18 23.2
Double loop whorl 20 8 6 3 8 19 6 3 6 4 8.3
Central pocket loop whorl 1 5 4 4 4 1 6 0 6 6 3.7
Plain arch 7 9 7 5 9 3 6 4 5 2 5.7
Tented arch 0 2 1 2 2 0 1 1 0 1 1.0
Radial loop 44 38 62 52 59 51 50 77 39 66 53.8
Ulnar loop 2 13 5 1 2 1 6 3 1 2 3.6
Accidental whorl 2 2 0 0 1 0 1 0 0 1 0.7

(a) (b)
Figure (a) Radial Loop Pattern and (b) Plain Whorl Pattern on Right
Hand Breast Cancer Patients in Dharmais Cancer Hospital

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50 Faras Qodriyyah Sani et al.: Dermatoglyphics Pattern on Breast Cancer Patients in Dharmais Cancer Hospital

Table 2 Demographics based on Age, were all female (100%) and over 40 years old
Father and Mother Tribe (88%). According to YKPI,19 being a woman and
Breast Cancer increasing age would increase the incidence of
Categories breast cancer.20 Breast cancer is cancer that is
n=100 (%)
more common in women.21 Women are 100 times
Age (years)
more at risk of breast cancer than men.22 At the
≤40 12
age of ≥40 years, the hormone progesterone
>40 88
cannot be produced in sufficient quantities so
Gender
that the production of the hormone estrogen
Women 100
cannot be resisted.23 These theories support the
Father’s tribe result of this study.
Sunda 28 Based on the ethnic characteristics of the
Jawa 39 respondent’s parents, the respondents in this
Betawi 11
study dominated by parents who were Javanese.
Sumatera 16
Pusat Data dan Statistik Pendidikan dan
Sulawesi 2
Kebudayaan (PDSPK) stated that is most tribes
Kalimantan 3
in Indonesia are Javanese.24
Flores 1
Purbasari and Sumadji25 researched on
Mother’s tribe
fingerprint pattern in ethnic groups. In their
Sunda 29
research, it mentioned that people who were
Jawa 36
Javanese and female sex dominated by a loop
Betawi 11
pattern of 62.38%.
Sumatera 17
Sulawesi 2
Kalimantan 4 Conclusion
Flores 1
The dermatoglyphic pattern of breast cancer
patients at Dharmais Cancer Hospital was a
radial loop pattern.
a study of fingerprint patterns between breast
cancer patients and non-cancer people in India. Conflict of Interest
The results of their study showed that breast
cancer patients’ right hand were dominated by the All authors stated that there was no conflict of
whorl pattern, which was equal to 53.2%, whereas, interest in this article.
in healthy people, the whorl pattern was 15.8%.
While in the left-hand, breast cancer patients Acknowledgments
dominated by the whorl pattern, which was equal
to 56%, and in healthy people, the whorl pattern Thanks to the doctors, nurses, respondents, staff
was only 16.2%. The results of their study did not at Dharmais Cancer Hospital who have helped
specifically mention which whorl pattern in breast the author for the implementation of this study.
cancer patients. Lavanya et al.9 also conducted a
similar study in India. The results of the study References
showed that breast cancer patients dominated
by the whorl pattern, which equal to 53.3% and 1. Abilasha S, Harisudha R, Janaki CS.
in healthy people 23.3%. Therefore, based on the Dermatoglyphics: a predictor tool to analyze
results of the above studies, the finger pattern the occurrence of breast cancer. IJMRHS.
of breast cancer patients in this study and India 2013;3(1):28–31.
had different dominance. Radial loop patterns 2. Pakhale SV, Borole BS, Doshi MA, More
dominated the breast cancer dermatoglyphics in VP. Study of the fingertip pattern as a tool
this study, while whorl patterns dominated the for the identification of the dermatoglyphic
fingerprint pattern of breast cancer in India. The trait in bronchial asthma. J Clin Diagn Res.
differences in the results of these studies may 2012;6(8):1397–400.
differ due to environmental, ethnic, and racial 3. Raizada A, Johri V, Ramnath T, Chowdhary
influences.14 D, Garg R. A cross-sectional study on the
This study found that breast cancer patients palmar dermatoglyphics in relation to

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Faras Qodriyyah Sani et al.: Dermatoglyphics Pattern on Breast Cancer Patients in Dharmais Cancer Hospital 51

carcinoma breast patients. J Clin Diagn Res. Cancer fact sheets: breast cancer [Internet].
2013;7(4):609–12. 2016 [cited 2018 September 25]. Available
4. Sharma A, Sood V, Singh P, Sharma A. from: https://gco.iarc.fr/today/data/pdf/
Dermatoglyphics: a review on fingerprints fact-sheets/cancers/cancer-fact-sheets-15.
and their changing trends of use. CHRISMED pdf
J Health Res. 2018;5(3):167–72. 16. International Agency for Research on Cancer
5. Singh S, Khurana AK, Harode HA, (IARC) World Health Organization (WHO).
Tripathi A, Pakhare A, Chaware P. Study Population fact sheets: Asia [Internet]. 2012
of fingerprint patterns to evaluate the role [cited 2018 September 25]. Available from:
of dermatoglyphics in early detection of https://documentcloud.adobe.com/link/tr
bronchial asthma. J Nat Sci Biol Med. ack/?pageNum=1&uri=urn%3Aaaid%3As
2016;7(1):43–6. cds%3AUS%3Aa0b12e73-ac7a-45ea-ae11-
6. Vaidya P, Mahale S, Badade P, Warang A, Kale ce06671e5f39.
S, Kalekar L. Dermatoglyphics in periodontics: 17. World Health Organization (WHO). Cancer
an assessment of the relationship between country profiles: Indonesia [Internet]. 2014
fingerprints and periodontal status - a cross- [cited 2018 September 25]. Available from:
sectional observation study. Indian J Dent https://www.who.int/cancer/country-
Res. 2017;28(6):637–41. profiles/idn_en.pdf..
7. Kc S, Maharjan N, Adhikari N, Shrestha P. 18. Madhavi D, Dorairaj S, Dorairaj SSJ,
Qualitative analysis of primary fingerprint Kommuru H. Dermatoglyphic study in breast
pattern in different blood group and gender in carcinoma patients. IJSR. 2016;5(10):837–
Nepalese. Anat Res Int. 2018;2018:2848974. 40.
8. Singh A, Gupta R, Zaidi SHH, Singh A. 19. Yayasan Kanker Payudara Indonesia (YKPI).
Dermatoglyphics: a brief review. Int J Adv Tentang kanker payudara: penjelasan umum
Integr Med Sci. 2016;1(3):111–5. [Internet]. 2015 [cited 2019 January 9].
9. Lavanya J, Saraswathi P, Vijayakumar J, Available from: https://pitapink-ykpi.or.id/
Prathap S. Analysis of dematoglyphic traits in tentang-kanker-payudara/.
patients with breast cancer. J Pharm Biomed 20. Sjamsuhidajat R, Prasetyono TOH, Rudiman
Sci. 2012;23(24):1–5. R, Riwanto I, Tahalele P. Buku ajar ilmu
10. Jamalian M, Mesri M, Vishteh HRK, bedah. 4th Edition. Volume 2. Jakarta: EGC;
Solhi H, Salehpour R. Fingerprints: a 2017.
simple method for screening hemophilic 21. Kumar V, Abbas AK, Aster JC, Ham M,
patients. Bangladesh Med Res Counc Bull. Saraswati M. Buku ajar patologi Robbins. 9th
2014;40(2):85–8. Edition. Philadelphia: Saunders; 2015.
11. Raizada A, Johri V, Ramnath T, Chowdhary 22. Sihombing M, Sapardin AN. Faktor risiko
DS, Garg RP. A cross-sectional study on tumor payudara pada perempuan umur 25–
the palmar dermatoglyphics in relation to 65 tahun di lima kelurahan Kecamatan Bogor
carcinoma breast patients. J Clin Diagn Res. Tengah. Kespro. 2014;5(3):175–84.
2013 Apr;7(4):609–12. 23. Irawan ED, Wahyuningsih, Fatimah FS.
12. Sukre SB, Laeeque M, Mahajan A, Shewale Hubungan antara usia menarche dan
SN. Dermatoglyphics in the identification of riwayat keluarga dengan kejadian kanker
women either with or at risk of breast cancer. payudara pada wanita usia 35–60 tahun
IJBMS. 2012;3(5):160–5. di Ruang Kemoterapi RSUD Panembahan
13. Moore KL, Dalley AF. Anatomi berorientasi Senopati Bantul Yogyakarta [undergraduate
klinis. 5th Edition. Jilid 1. Jakarta: Penerbit thesis]. Yogyakarta: Universitas Alma Ata;
Erlangga; 2013. 2017 [cited 2019 January 12]. Available
14. Sariri E, Kashanian M, Vahdat M, Yari from: http://elibrary.almaata.ac.id/707/1/
S. Comparison of the dermatoglyphics naspub%20eko.pdf.
characteristics of women with and without 24. Pusat Data dan Statistik Pendidikan
breast cancer. Eur J Obstet Gynecol Reprod dan Kebudayaan (PDSPK) Kementerian
Biol. 2012;160(2):201–4. Pendidikan dan Kebudayaan Republik
15. International Agency for Research on Cancer Indonesia. Analisis kearifan lokal ditinjau
(IARC) World Health Organization (WHO). dari keragaman budaya [Internet]. Jakarta:

Global Medical and Health Communication, Volume 8 Number 1, April 2020

52 Faras Qodriyyah Sani et al.: Dermatoglyphics Pattern on Breast Cancer Patients in Dharmais Cancer Hospital

PDSPK Kementerian Pendidikan dan E89FEB2D2EDB_.pdf.

Kebudayaan Republik Indonesia; 2016 [cited 25. Purbasari K, Sumadji AR. Variasi pola sidik
2019 January 13]. Available from: http:// jari mahasiswa berbagai suku bangsa di Kota
publikasi.data.kemdikbud.go.id/uploadDir/ Madiun. Florea. 2017;4(2):47–54.
isi_F9B76ECA-FD28-4D62-BCAE-

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 Global Medical and Health Communication

Online submission: http://ejournal.unisba.ac.id/index.php/gmhc GMHC. 2020;8(1):53–8

DOI: https://doi.org/10.29313/gmhc.v8i1.5871 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

The Quality of Life on Asthmatic Adolescent and Its Correlation with

the Severity and Control of Asthma
Lisa Adhia Garina,1 Muhammad Ridho Grahadinta,2
Ferry Achmad Firdaus Mansoer,3 Intan Puspitasari2
1
Department of Pediatric, Faculty of Medicine, Universitas Islam Bandung, Jakarta, Indonesia,
2
Medical Undergraduate Study Program, Faculty of Medicine, Universitas Islam Bandung, Bandung, Indonesia,
3
Department of Obstetrics and Gynecology, West Java Provincial Al-Ihsan Regional General Hospital,
Bandung, Indonesia

Abstract
Asthma is considered a global health problem that, if not managed properly, can reduce the sufferers' quality of
life. The purpose of the study was to evaluate the quality of life from the perspectives of asthma severity and the
asthma control level. A cross-sectional study was conducted from February to June 2018 on asthmatic adolescents
aged 12–14 years old in two public junior high schools in Bandung city, Indonesia. The diagnosis, history of asthma,
severity, and asthma control were established based on the National Asthma Guidelines from the Indonesian
Pediatric Society, Global Initiative for Asthma (GINA), asthma control test (ACT), and ISAAC questionnaire.
Statistical analysis performed using SPSS v.20 with Spearman's rho to determine the significance. The gender
distribution of the 98 subjects was almost similar with slightly more girls (51%). The median age was 13±1 years
with average ACT, FVC, and PAQLQ(S) total scores of 20±4, 78±16%, and 5.3±1.3, respectively. The domain scores
for symptoms, activity limitations, and emotional function were 4.9±1.4, 5.0±1.3, and 5.7±1.1, respectively. There
are correlations between the total PAQLQ(S) score and asthma severity (p<0.001, r=−0.5) and the level of asthma
control (p<0.001, r=0.6). In summary, the quality of life has a relationship with asthma severity and the level of
asthma control. Asthma management should not only focus on medication but also ways to maintain a good quality
of life.
Key words: Adolescents, asthma, PAQLQ(S), quality of life

Kualitas Hidup Remaja Asma dan Hubungannya dengan Kekerapan

Gejala dan Derajat Kendali Asma

Abstrak
Asma masih menjadi masalah kesehatan penting yang jika tidak ditangani baik, asma dapat menurunkan kualitas
hidup anak. Tujuan penelitian ini menilai kualitas hidup dan hubungannya dengan kekerapan gejala dan derajat
kendali asma. Penelitian cross-sectional ini dilaksanakan dari bulan Februari hingga Juni 2018 pada remaja asma
berusia 12–14 tahun di dua SMPN di Kota Bandung, Indonesia. Diagnosis, riwayat asma, kekerapan gejala, dan
derajat kendali asma berdasar atas Pedoman Nasional Asma Anak Ikatan Dokter Anak Indonesia, Global Initiative
for Asthma (GINA), asthma control test (ACT), dan kuesioner dari ISAAC. Analisis statistik menggunakan SPSS
v.20 dengan uji Spearman’s rho untuk menentukan signifikansi. Distribusi gender dari 98 subjek penelitian
hampir sama dengan sedikit lebih banyak perempuan (51%). Usia rerata subjek 13±1 tahun dengan skor rerata
ACT, FVC, PAQLQ(S) masing-masing 20±4, 78±16%, dan 5,3±1,3. Skor domain gejala, keterbatasan beraktivitas,
dan fungsi emosi masing-masing 4,9±1,4; 5,0±1,3; dan 5,7±1,1. Terdapat hubungan skor total PAQLQ(S) dengan
kekerapan gejala (p<0,001; r=−0,5) dan dengan derajat kendali asma (p<0,001; r=0,6). Simpulan, kualitas
hidup berhubungan dengan kekerapan gejala dan derajat kendali asma. Pengelolaan asma sebaiknya tidak hanya
memperhatikan pengobatan, tetapi juga menjaga kualitas hidup yang baik.
Kata kunci: Asma, kualitas hidup, PAQLQ(S), remaja

Received: 1 April 2020; Revised: 11 April 2020; Accepted: 14 April 2020; Published: 30 April 2020
Correspondence: Lisa Adhia Garina, dr., M.Si.Med., Sp.A. Department of Pediatric, Faculty of Medicine, Universitas Islam
Bandung. Jln. Tamansari No. 22, Bandung 40116, West Java, Indonesia. E-mail: lisa.adhia@gmail.com

53
54 Lisa Adhia Garina et al.: The Quality of Life on Asthmatic Adolescent and Its Correlation with the Severity and Control

Introduction and partly controlled asthma children presented

a total value of Pediatric Asthma Quality of Life
Asthma is a disease caused by chronic Questionnaire (PAQLQ) that is higher than those
inflammation of the respiratory tract that has with uncontrolled asthma (p<0.001). The group
various symptoms and is characterized by a with mild asthma also had a higher total PAQLQ
history of wheezing, chest tightness, and time value, symptom domain, and emotional function
and intensity-based coughing accompanied by domain compared to the moderate and severe
limited expiratory airflow.1 Asthma symptoms asthma groups (p<0.001).10
are chronic or recurrent and reversible. They are The purpose of this study was to evaluate the
also more severe at night or in early mornings, quality of life of asthmatic adolescents and the
usually arose when there is a trigger.2 correlation between the quality of life and the
The prevalence of asthma is 1–18% of the severity and level of asthma control.
population in many countries.1 In Indonesia,
the prevalence of asthma among adolescents Methods
aged 13–14 years old is 2.6 to 24.4%.2 A previous
study stated that the prevalence of asthma among A cross-sectional observational study on 98
adolescents aged 13–14 years old in Jakarta is adolescents with asthma aged 12–14 years old
12.2%.3 The global community has agreed on in two junior high schools in Bandung was
the target to decrease the prevalence of asthma conducted from February to June 2018. The
by 2025;4 however, in the last two decades, the inclusion criteria for this study were male and
prevalence of asthma has continued to increase, female adolescents with asthma aged 12–14
especially in developing countries.2,5 Globally, years old and parents or caregivers of asthmatic
asthma is ranked 16th among the leading causes children who were willing to participate in this
of years lived with disability and 28th among the study. Participants were excluded if they had an
leading causes of the burden of disease.6 acute attack or exacerbation of asthma, fever,
The reason why asthma is still a global coughing, and runny nose during the study.
common heath problem is that it has not been Those who could not do spirometry examination
managed properly; therefore, it reduces the and had cognitive and motoric limitations were
quality of children's life, restricts their daily also excluded.
activities, disturbs sleeping, increases the rate of Asthma diagnosis and history were made
absenteeism of school, and decrease academic based on the Global Initiative for Asthma
achievement. If asthma is not well-controlled, it (GINA), National Asthma Guidelines Indonesian
can increase health costs.2 Childhood asthma is Pediatric Society (Pedoman Nasional Asma Anak
linked to many physical health and psychosocial Ikatan Dokter Anak Indonesia/PNAA-IDAI), and
health conditions, which may cause significant questionnaires from the International Study of
decreases in the health-related quality of life of Asthma and Allergies in Childhood (ISAAC). The
the children and their caregivers.7 criteria for asthma severity were made based on
Quality of life assessment is a multidimensional the PNAA-IDAI with the following categories:
assessment as it does not only assess the effect of intermittent (episodes of asthma symptoms <6
treatment on the physical or psychological aspects times per year or distance between symptoms
of the patients but also describes the health ≥6 weeks), mild persistence (episodes of asthma
condition of the patients and families during symptoms >1 time per month, <1 time per
or after treatment.8 Thus, the determination week), moderate persistence (episodes of asthma
of the quality of life of these patients can make symptoms >1 time per week, but not every day),
the treatment decision making easier hence new and severe persistence (episodes of asthma
solutions can be offered to the treatment team.9 symptoms occur almost every day). The degree
A previous study suggested that the rate of of asthma control is categorized based on the
impaired quality of life in asthma is relatively high PNAA-IDAI and asthma control test (ACT) for
(26.8–35%) with the degree of partly controlled 12 years old into uncontrolled, partly controlled,
and uncontrolled asthma variable becomes the and controlled with or without drugs. Asthma
risk factor for the low quality of life.8 Children was considered to be controlled if the score
and adolescents with controlled asthma with was 25. A score of between 20–24 represented
intermittent asthma attacks and a history of low asthma that was partly controlled while a score of
drug use have a better quality of life.10,11 Controlled <19 indicated that the asthma was uncontrolled.

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Lisa Adhia Garina et al.: The Quality of Life on Asthmatic Adolescent and Its Correlation with the Severity and Control 55

The quality of life was assessed based on the was severely impaired (2.9±0.6), as described in
Pediatric Asthma Quality of Life Questionnaire Table 2.
(Standardized) (PAQLQ(S)) that consists of 23 There was a correlation between the total
questions in three domains, namely symptoms, quality of life score (PAQLQ(S)) and the asthma
activity, and emotional function. A scale of 1 to severity (p<0.001, r=−0.5). Subjects with
7 was used, with 1 indicated severe interference, intermittent asthma had a higher total PAQLQ(S)
and 7 indicated no interference. The quality of life score and overall domain scores. The less the
of adolescents with asthma was classified into the frequency of symptoms is the higher the total
following categories: minimum or no impairment PAQLQ score.
(score ≥6.0), moderate impairment (score 3.0– Table 3 shows that the mean total PAQLQ(S)
5.9), and severe impairment (score <3.0). score in the uncontrolled asthma group was lower
Examination of pulmonary function using (4.6[0.9]) than in the controlled asthma group
spirometry conducted to determine the force (5.9[2.4]). There was a strong correlation between
expiratory volume 1 minute (FEV1) and force the total score of the quality of life (PAQLQ(S))
vital capacity (FVC) values as well as the FEV1/ and the asthma control level (p<0.001, r=0.6).
FVC ratio. Data were analyzed using SPSS v.20 Subjects with uncontrolled asthma had a lower
software, and the significance of variables was total PAQLQ(S) score and overall domain score.
identified using the Spearman 's rho test.
This study had approved by the Health Discussion
Research Ethics Committee of the Faculty of
Medicine, Universitas Islam Bandung, Indonesia, The results of this study revealed that the majority
through the issuance of the ethical clearance of subjects experienced intermittent asthma. A
number: 313/Komite Etik.FK/III/2018. study by Banasiak12 also found that most subjects
had intermittent asthma in primary care. A
Results previous study identified that children treated
by asthma specialists were more likely to have
There were 105 students identified with asthma severe persistent asthma and poorly controlled
from a total of 2,579 students (4.1%). By applying asthma compared with those seen by primary
the inclusion and exclusion criteria using the care physicians.13 This study was conducted in
consecutive sampling approach, 98 research the community so the results will be different if
subjects were obtained. the study was done in a tertiary referral hospital
The number of female subjects (51%) was
slightly higher than the male subjects while the
mean age of these subjects was 13±1 years. The
Table 1 Distribution of Asthma Severity,
average ACT score was 20±4 and the FVC value
Asthma Control Level, and
was 78±16%. The total score for PAQLQ(S)
Quality of Life
was 5.3±1.3 while the PAQLQ(S) scores for the
symptom domain, activity limitation domain, Variables n=98 (%)
and emotional function domain were 4.9±1.4, Asthma severity
5.0±1.3, and 5.7±1.1, respectively. Intermittent 42 (43)
The characteristics of the study subjects based Mild persistence 35 (36)
on the asthma severity, asthma control level, and Moderate persistence 17 (17)
quality of life are listed in Table 1. Severe persistence 4 (4)
Based on Table 1, most subjects had Asthma control
intermittent asthma (43%), partly controlled Controlled 37 (38)
asthma (55 people), and moderate impairment. Partly controlled 55 (56)
The correlation between the components Uncontrolled 6 (6)
of quality of life and asthma severity as well as Quality of life (PAQLQ(S))*
between quality of life and asthma control level Without and minimal 34 (35)
can be seen in Table 2 and Table 3. The total impairment
PAQLQ(S) score and the PAQLQ(S) scores for Moderate impairment 61 (62)
all domains in severe persistent asthma group Severe impairment 3 (3)
were lower than those in other severity levels of
Note: *PAQLQ(S)= Pediatric Asthma Quality of Life
asthma. In severe persistent asthma, the quality Questionnaire (Standardized)

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56 Lisa Adhia Garina et al.: The Quality of Life on Asthmatic Adolescent and Its Correlation with the Severity and Control

Table 2 Correlation between Quality of Life Domain (PAQLQ(S)) Score and Asthma
Severity
Asthma Severity
PAQLQ(S) Score Mild Moderate Severe r p*
Intermittent
Persistence Persistence Persistence
Total
Mean (SD)** 5.8 (1.4) 5.1 (0.9) 4.9 (0.9) 3.9 (0.3) −0.5 <0.001
Symptoms
Mean (SD) 5.5 (1.3) 4.6 (1.2) 4.5 (1.2) 2.9 (0.6) −0.4 0.001
Activity limitations
Mean (SD) 5.6 (1.3) 4.7 (1.1) 4.6 (1.1) 3.3 (0.9) −0.4 0.001
Emotional function
Mean (SD) 6.1 (1.1) 5.4 (0.9) 5.3 (0.7) 4.1 (0.5) −0.5 <0.001
Note: *Spearman's rho; **SD: standard deviation; significantly statistic (p<0.05)

where asthma cases with different severity are assessment tools used in the respective country.
seen. One study has shown that the subjects of the
This study indicated that the majority of study, recruited from the pulmonology clinic,
the study subjects with partly controlled and experienced severe and uncontrolled asthma.
intermittent asthma. Silva et al.14 also found that This will certainly be different if the subjects
the majority of subjects in his study had partly were recruited from general practitioner clinics,
controlled asthma. A previous study stated that general pediatricians, and family doctors as they
most of its subjects had controlled asthma and may only have mild asthma (controlled asthma).17
other studies found that the majority of subjects The findings of the current study suggested
experienced mild asthma.15,16 Banjari et al.17 found that the quality of life is related to asthma
that most subjects in their study experienced severity and asthma control level in adolescents.
uncontrolled asthma, while a different study Intermittent and controlled asthma presents a
found that the majority of patients with asthma higher total PAQLQ(S) score compared to severe
were uncontrolled before being given inhaler and uncontrolled persistent asthma. Matsunaga
therapy for six weeks.18 Another study also found et al.10 also stated that the quality of life is directly
that only 12% of the subjects had controlled related to controlled asthma and severity of
asthma.19 The percentage of asthma control level asthma in children and adolescents, which is
varies in different countries, which might depend better in controlled asthma and mild asthma.
on the method used, the sample size, and the In controlled and partly controlled asthma,

Table 3 Correlation between the Quality of Life Domain Score (PAQLS(S)) and Asthma
Control Level
Asthma Control Level
PAQLQ(S) Score Partly r p*
Controlled Uncontrolled
Controlled
Total 0.6 <0.001
Mean (SD)** 5.9 (2.4) 5.7 (1.1) 4.6 (0.9)
Symptoms 0.6 <0.001
Mean (SD) 5.8 (2.4) 5.5 (1.0) 4.1 (1.2)
Activity limitations 0.5 <0.001
Mean (SD) 5.8 (2.4) 5.4 (1.0) 4.3 (1.1)
Emotional function 0.5 <0.001
Mean (SD) 5.8 (2.4) 6.0 (0.8) 5.0 (0.9)
Note: *Spearman's rho; **SD: standard deviation; significantly statistic (p<0.05)

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Lisa Adhia Garina et al.: The Quality of Life on Asthmatic Adolescent and Its Correlation with the Severity and Control 57

the PAQLQ(S) and overall domain scores were Available from: https://ginasthma.org/wp-
higher than uncontrolled asthma (p<0.001).10 content/uploads/2020/04/GINA-2020-full-
Uncontrolled asthma that is identified through report_-final-_wms.pdf.
frequent waking up at night, frequent wheezes, 2. Rahajoe N, Kartasasmita CB, Supriyatno B,
visits to the emergency rooms (ER), or hospital Setyanto DB. Pedoman nasional asma anak.
admission is associated with poor quality of life 2nd Edition. 2nd Printing. Jakarta: Ikatan
of both asthmatic children and their caregivers.20 Dokter Anak Indonesia; 2016.
Previous studies also found that groups with 3. Yunus F, Rasmin M, Sutoyo DK, Wiyono WH,
controlled asthma had higher PAQLQ scores.21,22 Antariksa B, Fitriani F, et al. Prevalens asma
El-Gilany et al.23 also found that patients with pada siswa usia 13–14 tahun berdasarkan
controlled asthma have significantly better kuesioner ISAAC di Jakarta. J Respir Indo.
total score and domain scores from the three 2011;31(4):176–80.
domains. Also, patients with severe asthma have 4. Global Asthma Network. The global asthma
significantly worse total and categorical PAQLQ report 2014. Auckland, New Zealand:
scores.23 Global Asthma Network: 2014 [cited 2020
There is a strong correlation between the January 13]. Available from: http://www.
PAQLQ score and the asthma control test globalasthmanetwork.org/publications/
(ACT) score in moderate to severe asthma.18 Global_Asthma_Report_2014.pdf.
Several previous studies also indicate a strong 5. Global Initiative for Asthma (GINA). Pocket
correlation between ACT and PAQLQ,24,25 that guide for asthma management and prevention
the degree of controlled asthma can affect the for adults and children older than 5 years: a
total score of quality of life for parents, children, pocket guide for health professionals. Update
and adolescents with asthma.26 Management 2020. Bethesda: GINA; 2020 [cited 2020
of asthma should not only be seen as a medical April 13]. Available from: https://ginasthma.
treatment. It should also include psychological org/wp-content/uploads/2020/04/Main-
supports and counseling to maintain the quality pocket-guide_2020_04_03-final-wms.pdf.
of life.27 6. Global Asthma Network. The global asthma
This study has a limitation in not examining report 2018. Auckland, New Zealand:
other factors related to the quality of life of Global Asthma Network: 2018 [cited
asthmatics adolescents. 2020 April 14]. Available from: http://
www.globalasthmareport.org/Global%20
Conclusion Asthma%20Report%202018.pdf.
7. Qu CX, Zhang ZK. Current views of pediatric
Quality of life is correlated with asthma severity asthma. Eur Rev Med Pharmacol Sci.
and asthma control level in adolescents. 2017;21(4 Suppl):106–8.
8. Wigoeno Y, Sekartini R, Setyanto DB,
Conflict of Interest Hadinegoro SRS. Assessing the quality of
life of asthmatic children using the PedQL™.
Authors declare no conflict of interest in this Paediatr Indones. 2011;51(5):245–51.
article. 9. Kouzegaran S, Samimi P, Ahanchian H,
Khoshkhui M, Behmanesh F. Quality of
Acknowledgments life in children with asthma versus healthy
children. Open Access Maced J Med Sci.
Faculty of Medicine of Universitas Islam 2018;6(8):1413–8.
Bandung, 1 and 9 Junior High Schools Bandung 10. Matsunaga NY, Ribeiro MAGDO, Saad
city, Bandung Education Office, and Bandung IAB, Morcillo AM, Ribiero JD, Toro AADC.
City Health Office. Evaluation of quality of life according to
asthma control and asthma severity in
References children and adolescents. J Bras Pneumol.
2015;41(6);502–8.
1. Global Initiative for Asthma (GINA). 11. Miadich SA, Everhart RS, Borschuk AP,
Global strategy for asthma management Winter MA, Fiese BH. Quality of life in children
and prevention. 2020 Update [Internet]. with asthma: a developmental perspective. J
Bethesda: GINA; 2020 [cited 2020 April 14]. Pediatr Psycol. 2015;40(7):672–9.

Global Medical and Health Communication, Volume 8 Number 1, April 2020

58 Lisa Adhia Garina et al.: The Quality of Life on Asthmatic Adolescent and Its Correlation with the Severity and Control

12. Banasiak NC. Implementation of the asthma Abulaban O, Almaghrabi S, Felmban O.

control test in primary care to improve Quality of life of asthmatic children and their
patient outcomes. J Pediatr Health Care. caregivers. Pak J Med Sci. 2019;35(2):521–6.
2018;32(6):591–9. 21. Al-Gewely MS, El-Hosseiny M, Abou Elezz
13. Nyenhuis SM, Akkoyun E, Liu L, Schatz M, NF, El-Ghoneimy DH, Hassan AM. Health-
Casale TB. Real-world assessment of asthma related quality of life in childhood bronchial
control and severity in children, adolescents, asthma. Egypt J Pediatr Allergy Immunol.
and adults with asthma: relationships to care 2013;11(2):83–93.
settings and comorbidities. J Allergy Clin 22. Voorend-van Bergen S, Vaessen-Verberne
Immunol Pract. 2020;8(3):989–96. AA, Landstra AM, Brackel HJ, van den Berg
14. Silva AAMD, Maciel ÁCC, Furtado PR, NJ, Caudri D, et al. Monitoring childhood
Tomaz RR, Macêdo TMF, Mendonça KMPP. asthma: web-based diaries and the asthma
Applicability of a generic questionnaire control test. J Allergy Clin Immunol.
for quality of life assessment for asthmatic 2014;133(6):1599–605.
children. Rev Paul Pediatr. 2018;36(2):207– 23. El-Gilany AH, El Desoky T, El-Hawary AK,
13. Farrag M. Quality of life of children with
15. Halwani R, Al-kufeidy R, Muharib BA, bronchial asthma and their caregivers:
Alkhashram FM, Hussain SIB, Alhenaki RS, a hospital-based study. Prog Med Sci.
et al. Impact of asthma on the quality of life 2018;2(1):1–8.
of adolescent patients from Saudi Arabia. J 24. Nordlund B, Konradsen JR, Pedroletti C, Kull
Lung Dis Treatment. 2016;2(3):1000114. I, Hedlin G. The clinical benefit of evaluating
16. BinSaeed AA, Torchyan AA, Alsadhan health-related quality-of-life in children with
AA, Almidani GM, Alsubaie AA, Aldakhail problematic severe asthma. Acta Paediatr.
AA, et al. Determinants of asthma control 2011;100(11):1454–60.
among children in Saudi Arabia. J Asthma. 25. Amaral LM, Moratelli L, Palma PV,
2014;51(4):435–9. Leite IC. The quality of life of Brazilian
17. Banjari M, Kano Y, Almadani S, Basakran adolescents with asthma: associated clinical
A, Al-Hindi M, Alahmadi T. The relation and sociodemographic factors. J Asthma.
between asthma control and quality of life in 2014;51(6):660–6.
children. Int J Pediatr. 2018;2018:6517329. 26. Costa DD, Pitrez PM, Barroso NF, Roncada
18. Karadeniz P, Özdoğan Ş, Ayyıldız-Emecen C. Asthma control in the quality of life
D, Öncül Ü. Asthma control test and levels of asthmatic patients’ caregivers:
pediatric asthma quality of life questionnaire a systematic review with meta-analysis
association in children with poor asthma and meta-regression. J Pediatr (Rio J).
control. Turk J Pediatr. 2016;58(5):464–72. 2019;95(4):401–9.
19. Al Zahrani SS, El Morsy EMA, Dorgham 27. Nair S, Nair S, Sundaram KR. A prospective
LS. The impact of bronchial asthma on study to assess the quality of life in children
quality of life among affected children and with asthma using the pediatric asthma
adolescents in Taif city, Saudi Arabia. Life Sci quality of life questionnaire. Indian J Allergy
J. 2014;11(6):283–91. Asthma Immunol. 2014;28(1):13–8.
20. Ibrahim NK, Alhainiah M, Khayat M,

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 Global Medical and Health Communication

Online submission: http://ejournal.unisba.ac.id/index.php/gmhc GMHC. 2020;8(1):59–66

DOI: https://doi.org/10.29313/gmhc.v8i1.5192 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

The Effect of Health Education with Flashcard Media on Improvement of

Knowledge and Reduction of Anxiety Degree in Adolescents Primigravida
Dwie Yunita Baska,1,2 Tita Husnitawati Madjid,3 Ponpon S. Idjradinata4
Department of Midwifery, Politeknik Kesehatan Kementerian Kesehatan Bengkulu, Bengkulu, Indonesia,
1
2
Midwifery Master Study Program, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,
3
Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan
Sadikin General Hospital, Bandung, Indonesia, 4Department of Child Health, Faculty of Medicine,
Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia

Abstract
The education about the reproductive health of pregnancy is needed to increase knowledge and reduce anxiety in
adolescent primigravida, one of them is by conducting flashcard media. Flashcards are pictorial media in the form
of cards that have words; it’s proven to be able to create fun learning, attracts attention, and stimulates critical
thinking. The purpose of the study was to analyze the effect of education with flashcard media on knowledge and
anxiety degree in adolescent primigravidas. The research method used in this study was a one-group pretest-
posttest quasi-experimental design. The number of samples as many as 30 people (<20 years old) at Sawah Lebar
Public Health Center and Padang Serai Public Health Center in Bengkulu city from May to July 2018, by using
consecutive sampling. The data of this study obtained from pretest and posttest questionnaires of knowledge, and
Zung Self-rating Anxiety Scale (ZSAS), Shapiro-Wilk, Wilcoxon, and chi-square test statistics. The results showed
a significant increase in knowledge before and after the intervention of p value=0.001 (p<0.05), an increase in the
average score of knowledge of series one card amounts to 35.0% and knowledge of series 2–3 card amounted to
30%. A significant decrease in anxiety degree of 9.2% after the treatment (p<0.05). In conclusion, flashcards can
increase knowledge and reduce the anxiety of adolescents primigravida mothers so that health workers use this
educational approach appropriately.
Key words: Adolescent primigravida, anxiety, education, flashcard, knowledge

Pengaruh Edukasi Kesehatan dengan Media Flashcard terhadap

Peningkatan Pengetahuan dan Penurunan Derajat Kecemasan pada
Primigravida Remaja

Abstrak
Edukasi tentang kesehatan reproduksi kehamilan penting untuk meningkatkan pengetahuan dan mengurangi
kecemasan pada primigravida remaja, salah satunya dengan media flashcard. Flashcard adalah media bergambar
dalam bentuk kartu yang dilengkapi kata-kata; terbukti mampu menciptakan pembelajaran yang menyenangkan,
menarik perhatian, dan merangsang untuk berpikir kritis. Penelitian ini bertujuan menganalisis pengaruh edukasi
dengan media flashcard terhadap pengetahuan dan derajat kecemasan pada primigravida remaja. Metode yang
digunakan dalam penelitian ini adalah one-group pretest-posttest quasi-experimental design. Jumlah sampel
30 orang (<20 tahun) di Puskesmas Sawah Lebar dan Puskesmas Padang Serai di Kota Bengkulu dari bulan Mei
hingga Juli 2018 dengan menggunakan consecutive sampling. Data penilaian didapat dari kuesioner pretest dan
posttest pengetahuan, Zung Self-rating Anxiety Scale (ZSAS), Shapiro-Wilk, Wilcoxon, dan statistik uji chi-square.
Hasil penelitian menunjukkan peningkatan yang signifikan pada pengetahuan sebelum dan sesudah intervensi
nilai p=0,001 (p<0.05), kenaikan skor rerata pengetahuan kartu seri 1 (35,0%) serta pengetahuan kartu seri 2–3
(30%). Penurunan signifikan derajat kecemasan 9,2% setelah perlakuan (p<0,05). Simpulan, flashcard mampu
meningkatkan pengetahuan dan menurunkan kecemasan ibu primigravida remaja sehingga pendekatan edukasi
ini dianggap efektif bagi pemberi asuhan.
Kata kunci: Edukasi, flashcard, kecemasan, pengetahuan, primigravida remaja

Received: 1 October 2019; Revised: 20 April 2020; Accepted: 21 April 2020; Published: 30 April 2020
Correspondence: Dwie Yunita Baska, S.S.T., M.Keb. Department of Midwifery, Politeknik Kesehatan Kementerian Kesehatan
Bengkulu. Jln. Indragiri Padang Harapan No.3, Bengkulu 38115, Bengkulu, Indonesia. E-mail: baskadwi@gmail.com

59
60 Dwie Yunita Baska et al.: The Effect of Health Education with Flashcard Media on Improvement of Knowledge

Introduction or 25×30cm. In individual learning, this chosen

media can involve more senses following the
Indonesia is the 7th country with a high prevalence theory of learning, that humans use 75% visual
of young marriage in the world.1 The regional and 13% audio.11,12
average rate of births per 1,000 females 15–19 Flashcard is an effective way used in the
years of age is 48, with the estimated median age teaching and learning process, because it creates
at first marriage is 20.4 years for women.2 fun learning, provides meaningful experience,
There are many health consequences of develops critical thinking skills in life as well
early marriage, partly because young mothers as social skills. Flashcard is useful to facilitate
are immature and lack access to social and repetition because it can translate abstract ideas
reproductive services. Examples of such problems into a more realistic form. Flashcard makes it
are increased risks for sexually transmitted easier for educators to provide small pieces of
diseases, cervical cancer, and transmission of information memorably and interestingly with
HIV infection, bleeding, miscarriage, death affordable materials and are easily available in
during childbirth, and anemia during pregnancy, textbooks and magazines. Moreover, it can also
as well as increased risks of preeclampsia and save time and energy; attract attention; clarify a
eclampsia, obstetric fistula, and obstructed problem in various fields, and are used by all ages.
labor. Girls’ offspring are at increased risk for Flashcard media can also create fun learning,
premature birth, low birth weight, asphyxia, provide a meaningful experience, develop critical
congenital neonatal infections, and death as thinking skills in life and social skills.16–19
neonates, infants, or children.3-5 The purpose of the study was to analyze the
The role of psychological factors in the healthy effect of education with flashcard media on
behaviors of pregnant women is a significant knowledge and anxiety degree in adolescent
issue.6 During pregnancy, women experience primigravidas.
hormonal changes, which include estrogen
and progesterone, which will cause various Methods
complaints such as nausea, vomiting, cravings,
and emotional instability; the most prominent The research method used in this study was a
is anxiety.7–9 Lack of knowledge and planning one-group pretest-posttest quasi-experimental
for the pregnancy of mothers about reproductive design, conducted in one group of adolescent
health problems and changes that occur during primigravida, without a control group. The study
pregnancy will undoubtedly increase the anxiety was in the working area of Sawah Lebar Public
that can increase the risk of pregnancy failure.8 Health Center and Padang Serai Public Health
When sensory systems detect information Center in Bengkulu city from May to July 2018.
or stimulus in the brain, it will create a learning The samples in this study were taken by using
process in a person. The results of processing are consecutive sampling or based on the order
stored in memory in the form of knowledge,10 and of arrival of patients who meet the inclusion
improvement in the learning process can even criteria.20 The number of samples was 30 teenage
reduce anxiety by up to 72% in middle and high mothers (<20 years old), pregnant in the second
school students tested in the final semester.11 and third trimesters, and experienced mild to
The provision of care related to psychological moderate anxiety.
aspects is still very minimal in Indonesian The researchers directly involved not only
society, especially in conducting antenatal care as of the providers of health education but also
examinations. The importance of health education for collecting data directly. The activities were
in adolescent primigravida will increase their carried out in several places, for example, in the
knowledge in dealing with pregnancy and make public health center, midwife’s house, and cadre’s
themselves ready to adapt well. Anxiety during house. During activities, the respondents divided
pregnancy can be managed and controlled.12,13 into small groups consisting of 6–8 people per
Effective education needs the media to group.
facilitate the delivery of information and attract The stages of this study activities comprise of
the attention of the audience, one of which is three phases. In phase one, knowledge pretest
the image media or visual media. Flashcard is of series one card (maternal pregnancy and
visual media in the form of picture cards that are infants growth and development) and anxiety
equipped with words and measuring 10×12.5 cm questionnaires administered to the respondents,

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Dwie Yunita Baska et al.: The Effect of Health Education with Flashcard Media on Improvement of Knowledge 61

then the respondents were given the face-to-face of Medicine, Universitas Padjadjaran Bandung,
education by using the flashcard media with the with letter number: 548/UN6.KEP/EC/2018.
lecture and discussion method for ±120 minutes.
In phase two (one week later), knowledge Results
pretest of series 2–3 cards (series 2: stages
of growth and development of infants, series Table 1 shows the average age of mothers is 19
3: physiological changes, breast care, and years old, mostly in the second trimester of
breastfeeding techniques of the puerperal pregnancy, with the education level of high school,
mother) administered to the respondents. dominantly homemakers/unemployed, and the
Afterward, continued by another session for ±120 economic status of less than Bengkulu regional
minutes, while the posttest conducted at the end minimum wage (upah minimum regional/UMR).
of the meeting. The level of knowledge converted Table 2 shows the comparison of the
into a value of 100. It is categorized into a level of knowledge scores and the knowledge levels of
knowledge of good if reached 76–100%, adequate one card series and a 2–3 card series. Knowledge
if the score is 56–75%, and inadequate if the value scores are significant differences between groups
is <56%. before and after reproductive health education
In phase three (one week later), the researchers was given with flashcard media. An average
went to the respondent’s house to administer increase observed to 35.3% in the knowledge
an anxiety posttest. Data analysis of this study score of one card series and 30.2% in the
used the Shapiro-Wilk test for data normality knowledge score of 2–3 card series. Knowledge
test, significance test to compare knowledge and levels were a significant difference in the before
anxiety pretest-posttest. The characteristics of and after results. The group with the reproductive
the study group analyzed using the Wilcoxon test health education treatment with flashcard
and chi-square test (x2) with significance criteria media, increase from inadequate and adequate
of p<0.05, which means the result is significant.21 knowledge to a good level in all 30 participants.
The instruments used in this study were There was a significant difference in the
knowledge questionnaires of series one card, groups before and after reproductive health
series 2–3 cards, and Zung Self-rating Anxiety education with flashcard media to the degree
Scale (ZSAS). The researchers developed of anxiety (Table 3). Before being educated,
information in the flashcard media by referring to mothers who experienced mild anxiety were 24
several references, with the flashcard design was people, and who experienced medium anxiety
done by an expert from Visual Communication
Design of Institut Teknologi Bandung. Before
used, the contents of the flashcard discussed
Table 1 Characteristics of Research
and tested by several experts in educational
Subjects
psychology and a media design expert for the
visual approach. Variables n=30
The protocol of this study has approved by Age (years)
the Health Research Ethics Committee, Faculty Mean±Std 19.40±0.968
Median 20.00
Range (min–max) 16.00–20.00
Age of pregnancy
Trimester II 19
Trimester III 11
Last education
Elementary school 1
Middle school 2
High school 27
Job status
Employed 25
Unemployed 5
Economic status
Less than UMR 17
Figure Flashcard Media More than UMR 13

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62 Dwie Yunita Baska et al.: The Effect of Health Education with Flashcard Media on Improvement of Knowledge

Table 2 Differences in Knowledge Score and Knowledge Level of Series 1 Card

and Series 2–3 Cards on Interventions before and after the Provision of
Reproductive Health Education with Flashcard Media
Groups (n=30)
Variables p Value
Pretest Posttest
Knowledge score
Knowledge of series 1 card
Mean (SD) 55.0 90.3 <0.000*
Median 56 89
Range (min–max) 44–72 83–100
Knowledge of series 2–3 cards
Mean (SD) 60.0 90.2 <0.000*
Median 61 89
Range (min–max) 44–72 83–94
Knowledge level
Card series 1
Inadequate 13 0 0.000**
Adequate 17 0
Good 0 30
Card series 2–3
Inadequate 5 0 0.000**
Adequate 25 0
Good 0 30
Note: *Wilcoxon test, **Shapiro-Wilk test

was 6 people. After being educated, mothers who anxiety are five. Whereas, in the posttest
were no anxiety were 20 people, who experienced treatment group, the level of good knowledge was
mild anxiety were 10 people, and there were no proven to reduce the degree of anxiety of mothers
more mothers with medium anxiety. who initially had medium or mild anxiety to be
There is no statistically significant relationship not anxious, but there were still 10 mothers who
between the level of knowledge and the degree experienced mild anxiety.
of anxiety before (Table 4) and after (Table 5)
treatment. The result from the knowledge of Discussion
series one card was; mothers with an adequate
knowledge level who experienced mild anxiety The process of learning or thinking that occurs in
were 15 people and who experienced medium the memory system of the human brain produces
anxiety were two people. On the knowledge of a model of information processing in the learning
series 2–3 cards, mothers with an adequate process (theory learning). When an individual
knowledge level who experienced mild anxiety receives certain information or stimulus, it will
were 20 people, and who experienced medium be detected by sensory systems in the brain. It

Table 3 Differences of ZSAS’s Anxiety Degree on Interventions before and after the
Provision of Reproductive Health Education with Flashcard Media
Groups (n=30)
ZSAS’s Anxiety Degree p Value*
Pretest Posttest
No anxiety 0 20 0.000
Mild anxiety 24 4
Medium anxiety 6 6
Note: *Chi-square/Fisher exact test

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Dwie Yunita Baska et al.: The Effect of Health Education with Flashcard Media on Improvement of Knowledge 63

Table 4 Relationship between Level of Knowledge and ZSAS's Anxiety in Both Groups
before the Provision of Reproductive Health Education with Flashcard Media
ZSAS Anxiety Pretest Group (n=30)
Knowledge Level Total p Value*
Mild Anxiety Medium Anxiety
Card series 1
Inadequate 9 4 13 0.240
Adequate 15 2 17
Total 24 6 30
Card series 2–3
Inadequate 4 1 5 0.360
Adequate 20 5 25
Total 24 6 30
Note: *Chi-square/Fisher exact test

will create a learning process of an individual, flashcard group, an increase in knowledge in

and the results of processing stored in memory the intervention group reached 90% and in the
in the form of knowledge, that will be used later control group was only 30% in mothers who had
in a real event.10 This sensory system is composed a good level of knowledge.
of receptors and connecting neurons from the At present, we did not find any theories or
five senses (hear, see, smell, taste, and feel), other studies that conflicted with the effectiveness
and the area that processes visual information and the use of flashcard learning media. As
is the occipital lobe and actively connected to Muhson said,24 learning media is a tool that
the prefrontal cortex as the center of rational can be manipulated and used to affect student’s
thinking.10,22 minds, feeling, attention, and attitude. Flashcards
The tool serves to facilitate the continuity of can help the learning process easier. A similar
the learning process based on the principle that study that supports that opinion suggested that
the knowledge possessed by every human being in balancing the functions of the left brain and
is received or captured through the senses, where the right brain with a flashcard media is quite
someone can remember 50% of what was seen sufficient to boost the ability of children, this
and heard. The result is consistent with Dale’s even considered as one of the right stimuli in the
learning experience, which stated that in learning, child’s brain to be given as early as possible.16
humans use 75% visual and 13% audio sensory, so Anxiety is an emotional experience that arises
the more senses are used to receive information, because of an unclear threat or something that
the more clear the knowledge obtained.14,15,19,23 is not objective, both from outside and within
Based on the study conducted by Pipitcahyani the individual.25 Anxiety is closely related to
and Safitri,17 the results showed a significant the hypothalamic-pituitary-adrenal axis, which
difference between the flipchart groups and the can cause stress hormone release, including

Table 5 The Relationship between the Level of Knowledge of the Card Series 1,2,3 on
Anxiety in the Group after was Given Reproductive Health Education with
Flashcard Media
ZSAS Anxiety Posttest Group (n=30)
Knowledge Level Total p Value*
No Anxiety Mild Anxiety
Card series 1
Good 20 10 30 0.720
Total 20 10 30
Card series 2–3
Good 20 10 30 1.000
Total 20 10 30
Note: *Chi-square/Fisher exact test

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64 Dwie Yunita Baska et al.: The Effect of Health Education with Flashcard Media on Improvement of Knowledge

adrenocorticotropic hormone, cortisol, beta- Although after statistical tests, there is no

endorphin, growth hormone (GH), prolactin, and meaningful relationship between anxiety and
luteinizing hormone (LH) or follicle stimulating maternal knowledge. The results might be caused
hormone (FSH). If these stress hormones appear by mothers who still experience mild anxiety, and
excessively, it will affect the increased risk of there is no control group as a comparison.
congenital abnormalities in the fetus. The risks However, in the further development of this
are labio-palate, risk of birth with a caesarian, study, it is necessary to have a control group with
labor with a tool, premature birth, low birth a different treatment. Role-playing simulation
weight (LBW), stunting, behavior, and emotional method, video, and card games involving
disorders of children in the long run.26,27 Also, at many family members were some examples.
risk for complications of labor and postpartum.28 If this media is applied directly in real life, the
Before the release of these hormones, anxiety absorption of knowledge obtained will be better,
was initially centered and sourced from the and the use of the media will be more optimal.
brain. A good level of knowledge in a person will
reduce anxiety. In adolescent primigravidas, the Conclusion
information about reproductive health is still
very minimal, and it will increase anxiety. The flashcard as a tool of learning is effective in
Knowledge form through the learning increasing the level of knowledge and reduce the
process. Knowledge of cognitive ability is a anxiety of adolescents primigravida mothers.
fundamental domain for the formation of one’s
actions.29 Through reproductive health education Conflict of Interest
with flashcard media, it can divert attention and
activate thinking functions in the brain (active TAll authors stated that there was no conflict of
prefrontal cortex function), which is the cognitive interest in this article.
center of the individual.22,30
This theory supported by Bak and Mastalerz,31 Acknowledgments
which stated there was a relationship between
age and the subjective assessment or education Thanks to the Center for Quality Improvement
of women and fear of childbirth. Education Human Resources of Health, the Board for
differentiates the ability to apply in practice the Development and Empowerment Human
knowledge and skill learned in Lamaze classes. Resources of Health, Ministry of Health of the
The older the woman is, the more likely she Republic of Indonesia, who have helped scholars
is to experience anxiety as she approaches or for the implementation of this study. Thanks to
during birth. Both older women and younger the Faculty of Visual Communication Design,
women need more mental support to increase Institut Teknologi Bandung, who assisted in the
their awareness and capabilities because anxiety design of this flashcard media.
during pregnancy can lead to premature birth
and low birth weight, also another complication References
risk.
Another study that supports is Agarwal et 1. United Nations International Children's
al.11 stated that with an increase in the learning Emergency Fund (UNICEF) Indonesia.
process, it could reduce anxiety by up to 72% in Child marriage in Indonesia: progress on
middle and high school students tested in the final pause [Internet]. 2016 November [cited
semester. A similar study that was conducted by 2019 January 20]. Available from: https://
Ossai, also showed that the learning affects the www.girlsnotbrides.org/wp-content/
degree of anxiety and achievement of students, uploads/2016/11/UNICEF-Indonesia-Child-
one of them with flashcard training that students Marriage-Research-Brief-1.pdf.
can learn in improving their ability to process 2. Statistics Indonesia (BPS), National
information and think critically.32 Population and Family Planning Board
In this study, the use of flashcard learning (BKKBN), Ministry of Health (Kemenkes),
media in the delivery of reproductive health ICF. Indonesia demographic and health
education is very influential on changes in the survey 2012. Jakarta: BPS, BKKBN,
degree of anxiety. These changes related to Kemenkes, ICF; 2013.
increased knowledge experienced by mothers. 3. Gipson JD, Koenig MA, Hindin MJ. The

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Dwie Yunita Baska et al.: The Effect of Health Education with Flashcard Media on Improvement of Knowledge 65

effects of unintended pregnancy on infant, http://repo.iain-tulungagung.ac.id/6891.

child, and parental health: a review of the 16. Hayati N. Menstimulus otak kiri dan otak
literature. Stud Fam Plann. 2008;39(1):18– kanan anak dengan flash card [Internet].
38. Yogyakarta: Universitas Negeri Yogyakarta;
4. Hanum Y, Tukiman. Dampak pernikahan 2007 [cited 2019 March 8]. Available from:
dini terhadap kesehatan alat reproduksi http://staff.uny.ac.id/sites/default/files/
wanita. JKSS. 2015;13(2):36–43. Artikel%20Flash%20Card.pdf.
5. Lee-Rife S, Malhotra A, Warner A, Glinski 17. Pipitcahyani TI, Safitri CA. The effectiveness
AM. What works to prevent child marriage: of “flash card" in improving mothers’
a review of the evidence. Stud Fam Plann. knowledge on pregnancy. Proc Int Conf Appl
2012;43(4):287–303. Sci Health. 2017;2:151–7.
6. Omidvar S, Faramarzi M, Hajian-Tilak K, 18. Lutfitasari H, Meikawati W, Salawati T.
Nasiri Amiri F. Associations of psychosocial Efektivitas penyuluhan gizi dengan media
factors with pregnancy healthy life styles. flash card dan poster dalam peningkatan
PLoS One. 2018;13(1):e0191723. pengetahuan siswa tentang keamanan
7. Bustos M, Venkataramanan R, Caritis S. makanan jajanan sekolah (studi pada
Nausea and vomiting of pregnancy - what's siswa SDN Pandean Lamper 03 Semarang)
new? Auton Neurosci. 2017;202:62–72. [undergraduate thesis]. Semarang:
8. World Health Organization (WHO). Mental Universitas Muhammadiyah Semarang; 2017
health aspects of women’s reproductive [cited 2019 April 10]. Available from: http://
health: a global review of the literature. repository.unimus.ac.id/1041.
Geneva: WHO Press; 2009. 19. Mahnun N. Media pembelajaran (kajian
9. Susanti NN. Psikologi kehamilan. Jakarta: terhadap langkah-langkah pemilihan media
EGC; 2008. dan implementasinya dalam pembelajaran).
10. Solso RL, Maclin OH, Maclin MK. Psikologi An-Nida'. 2012;37(1):27–34.
kognitif. 8th Edition. Jakarta: Penerbit 20. Swarjana IK. Statistik kesehatan. Yogyakarta:
Erlangga; 2008. Penerbit ANDI; 2016.
11. Agarwal PK, D’Antonio L, Roediger HL III, 21. Dahlan MS. Statistik untuk kedokteran
McDermott KB, McDaniel MA. Classroom- dan kesehatan: deskriptif, bivariat, dan
based programs of retrieval practice reduce multivariat. 6th Edition. 3rd Printing. Jakarta:
middle school and high school students’ Epidemiologi Indonesia; 2015.
test anxiety. J Appl Res Mem Cogn. 22. Kuswana WS. Taksonomi berpikir. Bandung:
2014;3(3):131–9. Rosda; 2011.
12. Larasati IP, Wibowo A. Pengaruh 23. Masters K. Edgar Dale's Pyramid of Learning
keikutsertaan senam hamil terhadap in medical education: a literature review.
kecemasan primigravida trimester ketiga Med Teach. 2013;35(11):e1584–93.
dalam menghadapi persalinan. JBK. 24. Muhson A. Pengembangan media
2012;1(1):26–32. pembelajaran berbasis teknologi informasi.
13. Dunkel Schetter C, Tanner L. Anxiety, JPAI. 2010;8(2):1–10.
depression and stress in pregnancy: 25. Badrya L. Perbedaan tingkat kecemasan
implications for mothers, children, research, antara mahasiswa kedokteran laki-laki dan
and practice. Curr Opin Psychiatry. perempuan angkatan 2011 FKIK UIN Syarif
2012;25(2):141–8. Hidayatullah Jakarta dalam menghadapi
14. Daryanti, Firman, Neviyarni. Peran media ujian OSCE [undergraduate thesis]. Jakarta:
pembelajaran dalam meningkatkan Universitas Islam Negeri Syarif Hidayatullah;
kemampuan siswa menulis. J Basicedu. 2014 [cited 2019 May 3]. Available from:
2019;3(4):2089–94. http://repository.uinjkt.ac.id/dspace/
15. Permatasari I. Pengaruh media pembelajaran handle/123456789/25818.
audio-visual dan media cetak terhadap 26. Leigh B, Milgrom J. Risk factors for antenatal
minat belajar siswa kelas VIII pada mata depression, postnatal depression and
pelajaran fiqih di MTS Ma'arif Udanawu parenting stress. BMC Psychiatry. 2008;8:24.
Blitar [undergraduate thesis]. Tulungagung: 27. Glover V. Stress in pregnancy can change fetal
Institut Agama Islam Negeri Tulungagung; and child development. In: Leach P, editor.
2017 [cited 2019 February 28]. Available from: Transforming infant wellbeing: research,

Global Medical and Health Communication, Volume 8 Number 1, April 2020

66 Dwie Yunita Baska et al.: The Effect of Health Education with Flashcard Media on Improvement of Knowledge

policy and practice for the first 1001 critical 30. Sadock BJ, Sadock VA, Ruiz P. Kaplan and
days. Abingdon: Routledge; 2017. p. 98–106. Sadock’s synopsis of psychiatry: behavioral
28. Zhao Y, Munro-Kramer ML, Shi S, Wang sciences/clinical psychiatry. 11th Edition.
J, Zhao Q. Effects of antenatal depression Philadelphia: Wolters Kluwer; 2015.
screening and intervention among Chinese 31. Bąk B, Mastalerz M. Effectiveness of
high-risk pregnant women with medically childbirth classes in reducing anxiety before
defined complications: a randomized birth depending on age and education. Med
controlled trial. Early Interv Psychiatry. Stud. 2016;32(1):10–7.
2019;13(5):1090–8. 32. Ossai OV. Influence of study skills on test
29. Bascandziev I, Tardiff N, Zaitchik D, Carey anxiety and levels and achievement of senior
S. The role of domain-general cognitive secondary school students in english language
resources in children’s construction of a [thesis]. Nsukka, Nigeria: University of
vitalist theory of biology. Cogn Psychol. Nigeria Nsukka; 2012.
2018;104:1–28.

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 Global Medical and Health Communication

Online submission: http://ejournal.unisba.ac.id/index.php/gmhc GMHC. 2020;8(1):67–72

DOI: https://doi.org/10.29313/gmhc.v8i1.5415 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to

the Level of Malondialdehyde
Meiyanti,1 Eveline Margo,2 Juni Chudri2
1
Department of Pharmacology and Medical Pharmacy, Faculty of Medicine, Universitas Trisakti, Jakarta,
Indonesia, 2Department of Physiology, Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia

Abstract
Increased age causes an increase in degenerative diseases. Antioxidants in the body unable to neutralize the increased
concentration of free radicals. The flesh of the Phaleria macrocarpa (Scheff.) Boerl contains flavonoids which have
antioxidant effects. At present, there are still very limited clinical trials of Phaleria macrocarpa (Scheff.) Boerl. This
study was an experimental pretest and posttest involving 30 healthy volunteers receiving glucose loads in November
2018–February 2019 in Jakarta. This study aimed to assess the antioxidant effect of Phaleria macrocarpa (Scheff.)
Boerl dry fruit extract in various dosage ranges. Subjects of this study aged 30–55 years. The data collection included
anthropometric examination and malondialdehyde levels before and after administration of dry fruit extract doses
of 62.5 mg, 125 mg, and 250 mg at 150 minutes after oral glucose induction. Data analysis using a paired t test with
p<0.05. Decreased levels of malondialdehyde in the administration of Phaleria macrocarpa (Scheff.) Boerl with
a dose of 62.5 mg, 125 mg, and 250 mg by 40.9%, 22.9%, and 18.3% compared to the baseline malondialdehyde
level (1,608 nmol/mL). Statistical analysis using a paired t test showed p=0.000 for all three doses compared with
baseline levels. Dry fruit extract of Phaleria macrocarpa (Scheff.) Boerl has an antioxidant effect; the antioxidant
effect of the extract is not directly proportional to the dose.
Key words: Extract, malondialdehyde, Phaleria macrocarpa

Efek Antioksidan Ekstrak Kering Phaleria macrocarpa (Scheff.) Boerl

terhadap Kadar Malondialdehid

Abstrak
Pertambahan usia menyebabkan peningkatan penyakit degeneratif. Antioksidan dalam tubuh tidak mampu
menetralkan peningkatan konsentrasi radikal bebas. Daging buah Phaleria macrocarpa (Scheff.) Boerl mengandung
flavonoid mempunyai efek antioksidan. Saat ini masih sangat terbatas uji klinis Phaleria macrocarpa (Scheff.)
Boerl. Penelitian ini merupakan uji eksperimental sebelum dan sesudah perlakuan pada 30 sukarelawan sehat yang
diinduksi dengan glukosa yang dilaksanakan pada bulan November 2018–Februari 2019 di Jakarta. Penelitian
ini bertujuan menilai efek antioksidan ekstrak kering buah Phaleria macrocarpa (Scheff.) Boerl dalam beberapa
kisaran dosis yang diberikan. Subjek penelitian berusia 30–55 tahun. Pengumpulan data meliputi pemeriksaan
antropometri serta kadar malondialdehid sebelum dan sesudah pemberian ekstrak kering dosis 62,5 mg, 125 mg,
dan 250 mg pada menit 150 setelah dilakukan induksi glukosa oral. Analisis data menggunakan uji t berpasangan
dengan p<0,05. Penurunan kadar malondialdehid pada pemberian ekstrak Phaleria macrocarpa (Scheff.) Boerl
dosis 62,5 mg, 125 mg, dan 250 mg sebesar 40,9%, 22,9%, dan 18,3% dibanding dengan kadar malondialdehid
sebelum pemberian (1.608 nmol/mL). Analisis statistik menggunakan uji t berpasangan didapatkan p=0,000 untuk
ketiga dosis dibanding dengan kadar awal. Ekstrak kering buah Phaleria macrocarpa (Scheff.) Boerl mempunyai
efek antioksidan; efek antioksidan ekstrak tidak berbanding lurus dengan dosis.
Kata kunci: Ekstrak, malondialdehid, Phaleria macrocarpa

Received: 11 December 2019; Revised: 23 April 2020; Accepted: 23 April 2020; Published: 30 April 2020
Correspondence: Meiyanti, dr., Sp.F.K. Department of Pharmacology and Medical Pharmacy, Faculty of Medicine, Universitas
Trisakti. Jln. Kyai Tapa No. 260, Grogol, West Jakarta, Special Capital Region of Jakarta, Indonesia. E-mail: meiyanti@trisakti.ac.id

67
68 Meiyanti et al.: Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to the Level of Malondialdehyde

Introduction extract PM in a range of doses. It is necessary to

determine the antioxidant effects of dried extract
At present, the development of medical science and the range of doses that provide the best
is so rapid that it raises an increase in one's antioxidant effect.
life expectancy. Life expectancy is the leading
indicator of a person's health quality.1 In 1999 life Methods
expectancy in Indonesia was 66.2 years. In 2007,
it increased to 70 years, and in 2014, it became Respondents of this study were 30 healthy adult
71 years,1,2 causing an increase in risk for various volunteers who fulfilled the following inclusion
degenerative diseases. Degenerative diseases criteria. The criteria were men and women
found in many communities are cancer, heart aged 30–55 years, having a healthy body weight
disease, diabetes, arthritis, liver disease, and (body mass index 18.5–25 kg/m2). They are
others. not having chronic diseases and no history of
These degenerative diseases caused the chronic diseases in the family, especially diabetes
inability of antioxidants in the body to neutralize mellitus, hypertension, heart disease, supported
the increase in free radical concentration. Free by laboratory tests showing routine blood tests,
radicals are molecules that in their outer orbit liver function (SGPT, alkaline phosphatase),
have one or more unpaired electrons; they are and normal kidney function (creatinine levels).
very labile and very reactive so that they can cause They also have not consumed herbs or vitamin
damage to the cell components. An example is supplements a week before the study takes place/
superoxide formed from hydroxyl radical, which during the study. Subjects in the previous 24
initiates lipid peroxidation. The compound hours do not consume drinks containing caffeine,
causes damage to the endothelial plasma fruit juice, or smoking, and willing to take part in
membrane, lipoproteins, and deoxyribonucleic research and sign an informed consent. Exclusion
acid (DNA) genetic carrier. Hydrogen peroxide criteria were pregnant or breastfeeding, consumed
causes oxidative stress, one of which can be other drugs for the previous a week, or during the
measured by using malondialdehyde (MDA). study that can affect blood glucose levels such as
Lipid peroxidation can be detected indirectly by corticosteroid drugs, and participating in other
measuring plasma hydrolysis of lipoperoxidase to studies within three months before this study.
MDA form.3,4 The PM pericarp (without seed coat and seed)
One of the degenerative diseases, diabetes obtained from plant nurseries in the region of
mellitus (DM), is currently a worldwide health Semarang, Central Java. At each visit, subjects
problem. In 2011 around 366 million adults were given a glucose load of 400 calories (or 75
suffered from DM. It estimated that in 2030 grams of glucose). The first visit only glucose load
there would a substantial increase of up to 551 is given, whereas, in the second visit, 62.5 mg
millions patients with DM.5 The condition of PME was given. They wash out for one week, and,
hyperglycemia results in an increase in oxidative at the next visit, subjects consumed 125 mg, and
stress, where it results from an imbalance between the following week consumed 250 mg PME. The
the formation of free radicals and antioxidants, parameters used to measure MDA levels.
which is an essential factor in the occurrence of Antioxidant effects were assessed by measuring
blood vessel disorders. Previous clinical studies MDA levels by determining MDA levels in serum
report that oxidative stress plays a significant after reacting with thiobarbituric acid (TBA)
role in the pathogenesis and development of at hot temperatures in an acidic atmosphere.
complications of DM.3,4,6 This reaction produces a red solution, which
One of the medicinal plants that are known then measured using a spectrophotometer.
to have antioxidant effects and widely used in The reagents used are the MDA standard,
the community is Phaleria macrocarpa (Scheff.) trichloroacetic acid (TCA), and TBA. Before the
Boerl (PM). Some laboratory analysis studies research took place, accuracy and precision test of
show that PM showed an antioxidant effect, the MDA examination carried out. This research
especially in young fruit and leaves.7,8 Currently, has passed the ethical review of the Research
scarce clinical trials are conducted to prove the Ethics Committee of Faculty of Medicine of
antioxidant effects of PM. This study aims to Universitas Trisakti with letter number: 137/
assess the antioxidant effects of dried fruit pulp KER/FK/I/2019.

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Meiyanti et al.: Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to the Level of Malondialdehyde 69

Results Table 3 Effect PME on Level MDA

p
A total of 40 subjects examined for anthropometry Variables
Value*
(body weight and height) and body mass MDA baseline vs MDA PME 62.5 mg 0.000
index examination. Besides, laboratory tests
MDA baseline vs MDA PME 125 mg 0.000
(hematology, blood sugar, SGPT, and creatinine)
MDA baseline vs MDA PME 250 mg 0.000
also carried out. Of the 40 subjects examined,
Note: *Paired t test, p<0.05 significant difference
only 30 people met the inclusion and exclusion
criteria. Of the 30 volunteer subjects, 16 were
women, and 14 were men. Personal data from 30
subjects are in Table 1. of 62.5 mg, 125 mg, and 250 mg. From the results,
In this study, the average age of subjects was there is a significant difference (p<0.05) between
41.4 years, body weight in the range of 40–70 the two groups.
kilograms, height was 143–174 cm, and body From Figure 1, it is seen that the MDA level
mass index was 18.66–24.84 kg/m2. decreases on a fairly large scale compared to the
This study used auto control to monitor baseline at the PME dose of 62.5 mg, while the
subjects. At the beginning of the study, all PME dose of 125 mg and 250 mg shows a decrease
subjects tested for oral glucose tolerance with in MDA levels but not too large compared to the
75 grams of glucose and blood samples taken 62.5 mg dose.
in 150 minutes after glucose induction as the
baseline measure. After a week washout, subjects Discussion
consumed glucose induction and PME at a dose
of 62.5 mg, 125 mg, and 250 mg, respectively. The In this study, 30 volunteered with an average age
washout is performed one week before treatment of 41.4 years to show the antioxidant effect of PME.
with different doses. MDA was at 150 minutes Age or aging associated with free radicals. Aging is
after glucose induction. The results of the average a biological process that cannot be avoided and is
examination of MDA levels in the 150th minute related to biochemical and physiological changes
are in Table 2. that are gradual and spontaneous and increase
Table 3 shows the results of the statistical the body's susceptibility to disease. Scientific
analysis of baseline MDA levels with PME doses studies have shown that the aging process causes
a decrease in the body's ability to use calories
from food, decrease hormone function, suppress
Table 1 Characteristics of the Subject enzyme function, and decrease the body's
Mean±SD
Characteristics
n=30
Age (years) 41.40±6.41
Sex 1.60
Female 16
Estimated Marginal Means

Male 14
Weight (kg) 56.05±7.68 1.40

Height (m) 1.58±0.09

Body mass index (kg/m2) 22.29±2.04 1.20

1.00
Table 2 Baseline MDA and PME Level
MDA Level
PME Doses 1 2 3 4
(Average±SD) Doses
Baseline 1.608±0.509
Figure The Effect of PME on MDA Level
PME 62.5 mg 0.950±0.215
(nmol/mL) of Subject Baseline
PME 125 mg 1.239±0.230 (1), and PME Dose 62.5 mg (2),
PME 250 mg 1.313±0.323 125 mg (3), and 250 mg (4)

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70 Meiyanti et al.: Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to the Level of Malondialdehyde

resistance to fight disease. Aging results from old fruit has an 83.08% inhibitory effect, meaning
an accumulation of changes caused by reactions that the old fruit PM has a higher antioxidant
in the body that are started by high reactive effect.11–14
molecules known as 'free radicals.' These changes This study used an oral glucose tolerance
produce free radicals believed to be a significant test procedure. In a hyperglycemic state, it will
cause of the aging process.1,3 produce free radicals. The highest MDA levels
Free radicals define as an atom, molecule, or were seen in 150 minutes after 45-gram glucose
component that contains unpaired electrons, so loading, such as a glucose tolerance test. MDA
that it is generally unstable, has a short life, and levels in the 150th minute will be taken as a
is very reactive. The free radicals produced due baseline (without the administration of PME),
to the use of oxygen in the metabolic process. and MDA levels will be measured again at the
These free radicals are produced by healthy body same time (150 minutes) with extracts of 62.5
cells through metabolic processes, and also by mg, 125 mg, and 250 mg.
external sources such as carcinogenic compounds This study is an advanced study of the
and ionizing radiation.3,9 utilization of PME as an anti-hypoglycemic and
Free radicals produced from the results of the antioxidant drug in patients with DM. Diabetes
body's metabolism. They also caused by external characterized by a relative or absolute deficiency of
factors such as cigarette smoke, the results of insulin secretion and resistance. It causes chronic
ultraviolet irradiation, organic trigger substances hyperglycemia and impaired carbohydrate, lipid,
in foods, and other pollutants. Disease caused by and protein metabolism. DM is known as an
free radicals is chronic. It will take years to become oxidative stress disorder that occurs due to an
apparent or show any symptoms. Examples imbalance between the formation of free radicals
of diseases that are often associated with free and the natural antioxidant abilities of the body.
radicals are heart attacks, cancer, cataracts, and Many studies have reported that oxidative stress
decreased kidney function. To prevent or reduce plays a role in systemic inflammation, endothelial
chronic disease because free radicals are needed dysfunction, impaired pancreatic β cell secretion,
antioxidants. The human body can neutralize and impaired glucose utilization in peripheral
these free radicals; only if the amount is excessive, tissues.3,4,6
the ability to neutralize it will decrease.10,11 This oxidative stress also plays a vital role in
Research on the chemical content of eggshell complications that occur in diabetic patients.
seeds and fruit flesh PM showed that in hexane, Sources of oxidative stress in diabetes include
ethyl acetate and methanol extract flavonoids, enzymatic, non-enzymatic, and mitochondrial
phenols, tannins, saponins, and sterols/terpenes pathways. Many factors influence the increased
with the highest content is saponins.12–14 oxidative stress in DM. The dominant factor is
The four main parts of MD plants that often the auto-oxidation of glucose, which causes an
used in society are the stems, leaves, seed shells, increase in free radicals. Increased extracellular
and fruit flesh.8,15 Research on the chemical glucose levels will induce the dysregulation of
content of seeds and fruit flesh obtained reactive oxygen and nitrogen pathways. This
alkaloid compounds, saponins, flavonoids, and situation will cause disruption of the vascular
polyphenols. Besides having the antioxidant effect endothelium and the production of nitric
of flavonoid content, the use of PME in DM cases oxide (NO). Superoxide, when joining NO on
can increase insulin expenditure by changing endothelial cells, will produce peroxynitrite,
the metabolism of Ca2+ and can regenerate which is a cytotoxic antioxidant.18,19
the island of Langerhans, especially β cells. This research can be done in humans
Flavonoid contained in MD as an antioxidant because PM is relatively safe and has been
that will protect pancreatic cell damage from free used for generations in Indonesian society. PM
radicals.16,17 extracted with water and ethanol to obtain active
Flavanoids are a natural antioxidant and have ingredients that are antioxidants.20,21 The volume
biological activities, including antioxidants that of medicinal ingredients is less than that of PM
can inhibit various oxidation reactions and can meat powder, with a ratio of 1 gram of PM powder
act as reducing hydroxyl radicals, superoxide, and equal to 250 mg of dried extract of the god's
peroxyl radicals. Extract the ethanol of young PM crown (PME).
fruits has an inhibitory power of 78.48%, and the The MDA level decreases on a reasonably large

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Meiyanti et al.: Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to the Level of Malondialdehyde 71

scale compared to the baseline at the PME dose of Acknowledgments

62.5 mg, while the PME dose of 125 mg and 250
mg shows a decrease in MDA levels but not too The researchers thank the Faculty of Medicine
large compared to the 62.5 mg dose. MDA levels of Universitas Trisakti and Research Institution
assessed at 150 minutes after glucose induction. (Lembaga Penelitian) of Universitas Trisakti for
The mean MDA baseline level was 1,608, and funding this study. Thanks are also due to the
with a dose of 62.5 mg PME, we found a decrease Dhammasavana Foundation, and all subjects
in MDA levels of 40.9% compared to the baseline. participate in this study.
Giving a PME dose of 125 mg and 250 mg
obtained a decrease in MDA levels of 22.9% and References
18.3% compared to MDA baseline levels.
PME antioxidant activity from phenolic 1. Pangkahila W. Anti-aging: tetap muda dan
components and flavonoids contained in PM sehat. Jakarta: Penerbit Buku Kompas; 2011.
fruit.22 Karimi et al.23 reported that the content 2. Muziburrahman. Usia harapan hidup
of the fruit consisted mainly of flavonoids and Indonesia [Internet]. 2014 August 23 [cited
kaempferol, myricetin, naringin, quercetin. 2019 April 28]. Available from: http://zi-
Correlation of flavonoid content in PM fruit bur.blogspot.com/2014/08/usia-harapan-
with antioxidant activity caused by the presence hidup-indonesia.html.
of 3-hydroxyl groups in heterocyclic rings. In 3. Zishan M, Ahmad Z, Idris S, Parveen Z,
contrast, additional hydroxyl or methoxyl groups Hussain MW. Diabetes mellitus: role of free
at position 3.5, and 7 rings A and C appear to be radicals and oxidative stress. World J Pharm
of less importance. Highly active flavonoids have Pharm Sci. 2017;6(5):448–70.
ring B, which is occupied by 3'4'-dihydroxy and 4. Sheikhpour R. Diabetes and oxidative stress:
3-OH groups.24,25 the mechanism and action. Iran J Diabetes
From the results of statistical analysis, Obes. 2013;5(1):40–5.
using a paired t test between baseline and MDA 5. International Diabetes Federation. Global
administration level after PME was given a diabetes plan 2011–2021. Last update: 2017
significant difference (p<0.05). August 1 [cited 2019 April 28]. Available
Complaints found in the subject are nausea from: https://www.idf.org/our-activities/
and fullness on 250 mg PME; this is probably due advocacy-awareness/resources-and-
to the high saponin content in the PM fruit, which tools/129-global-diabetes-plan-2011-2021.
can cause gastrointestinal irritation. Besides, the html.
effect of reducing blood pressure in subjects with 6. Matough FA, Budin SB, Hamid ZA, Alwahaibi
125 mg or 250 mg PME doses were apparent. This N, Mohamed J. The role of oxidative stress
effect caused by the presence of PM fruit action and antioxidants in diabetic complications.
mechanism such as ACE receptor inhibitors.25 Sultan Qaboos Univ Med J. 2012;12(1):5–18.
The main limitation of this study is the design 7. Altaf R, Asmawi MZ, Dewa A, Sadikun A,
as a pre-post test experimental study without Umar MI. Phytochemistry and medicinal
controls—further studies needed with the properties of Phaleria macrocarpa
standards of a good clinical trial. (Scheff.) Boerl extracts. Pharmacogn Rev.
2013;7(13);73–80.
Conclusion 8. Alara OR, Olalera OA. A critical overview on
the extraction of bioactive compounds from
Dry fruit extract of Phaleria macrocarpa (Scheff.) Phaleria macrocarpa (Thymelaceae). Nat
Boerl has an antioxidant effect; the extract dose Prod Chem Res. 2016;4(5);1000232.
of 62.5 mg has an antioxidant effect better than 9. Zatalia SR, Sanusi H. The role of antioxidants
other doses. The antioxidant effect of the extract in the pathophysiology, complications, and
is not directly proportional to the dose. management of diabetes mellitus. Acta Med
Indones. 2013:45(2);141–7.
Conflict of Interest 10. Kangralkar VA, Patil SD, Bandivadekar RM.
Oxidative stress and diabetes: a review. Int J
The authors do not have any conflict of interest Pharm Appl. 2010;1(1):38–45.
to declare. 11. Phaniendra A, Jestadi DB, Periyasamy L.

Global Medical and Health Communication, Volume 8 Number 1, April 2020

72 Meiyanti et al.: Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to the Level of Malondialdehyde

Free radicals: properties, sources, targets, management of diabetes mellitus. Acta Med
and their implication in various diseases. Indones. 2013;45(2):141–7.
Indian J Clin Biochem. 2015;30(1):11–26. 19. Giacco F, Brownlee M. Oxidative stress
12. Othman SNAM, Sarker SD, Nahar L, Basar and diabetic complications. Circ Res.
N. The ethnomedicinal, phytochemical and 2010;107(9):1058–70.
pharmacological properties of Phaleria 20. Rahmi E, Wahyuni WT, Darusman LK,
macrocarpa (Scheff). Boerl. TANG. Suparto IH. Combination of ethanolic
2014;4(4):e22. extract of α-glucosidase inhibitory activity of
13. Alara OR, Alara JA, Olalere OA. Review Phaleria macrocarpa (Scheff). Boerl. fruits
on Phaleria macrocarpa pharmacological and Annona muricata Linn. leaves. Trad
and phytochemical properties. Drug Des. Med J. 2016;21(1):63–8.
2016;5(3):1000134. 21. Hendra R, Haryani Y. Phaleria macrocarpa
14. Ramdani ED, Marlupi UD, Sinambela (Boerl.) Scheff fruit: a potential source of
J, Tjandrawinata RR. Isolation and natural antioxidant. PCPR. 2018;3(1):1–4.
identification of compounds from Phaleria 22. Yanti AR, Radji M, Mun’im A, Suyatna FD.
macrocarpa (Scheff.) Boerl fruit extract. Antioxidant effect of methanolic extract
Asian Pac J Trop Biomed. 2017;7(4):300–5. of Phaleria macrocarpa (Scheff.) Boerl in
15. Susilawati, Matsjeh S, Pramono HD, Anwar fructose 10%-induced rats. Int J PharmTech
C. Antioxidant activity of 2,6,4’- trihydroxy- Res. 2015;8(9):41–7.
4-methoxy benzophenone from ethyl acetate 23. Karimi E, Oskoueian E, Hendra R, Jaafar
extract of leaves of mahkota dewa (Phaleria HZE. Evaluation of Crocus sativus L.
macrocarpa (Scheff.) Boerl.). Indo J Chem. stigma phenolic and flavonoid compounds
2011;11(2):180–5. and its antioxidant activity. Molecules.
16. Yayah W, Hudaya T, Prasetyo S, Wangsa J. 2010;15(9):6244–56.
Pretreatment and optimization studies on 24. Kefayati Z, Motamed SM, Shojaii A,
the extraction of antioxidant components Noori M, Ghods R. Antioxidant activity
from Phaleria macrocarpa fruit. ASEAN Eng and phenolic and flavonoid contents of
J Part B. 2016;5(1):46–60. extract and subfractions of Euphorbia
17. Chang CLT, Lin Y, Bartolome AP, Chen YC, splendida Mobayen. Pharmacognosy Res.
Chiu SC, Yang WC. Herbal therapies for 2017;9(4):362–5.
type 2 diabetes mellitus: chemistry, biology, 25. Hendra R, Ahmas S, Sukari A, Shukor
and potential application of selected plants MY, Oskoueian E. Flavonoid analyses and
and compounds. Evid Based Complement antimicrobial activity of various parts of
Alternat Med. 2013;2013:378657. Phaleria macrocarpa (Scheff.) Boerl fruit. Int
18. Zatalia SR, Sanusi H. The role antioxidants J Mol Sci. 2011;12(6):3422–31.
in the pathophysiology, complications, and

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 Global Medical and Health Communication

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DOI: https://doi.org/10.29313/gmhc.v8i1.5462 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

The Effect of Low Impact Aerobic Exercise on Elderly with

Dementia Cognitive Function
Raden Ayu Tanzila,1 Sheilla Yonaka Lindri,2 Nindia Rahma Putri3
1
Department of Physiology, Faculty of Medicine, Universitas Muhammadiyah Palembang, Palembang, Indonesia,
2
Department of Public Health, Faculty of Medicine, Universitas Muhammadiyah Palembang, Palembang,
Indonesia, 3Medical Undergraduate Study Program, Faculty of Medicine,
Universitas Muhammadiyah Palembang, Palembang, Indonesia

Abstract
In the elderly population, at least 10% of those over 65 years old and 50% of those over 80 years old experience
a decline in cognitive function that varies from a cognitive decline due to normal aging (age-associated memory
impairment/AAMI) to a mild cognitive decline (mild cognitive impairment/MCI) and dementia. Dementia is an
intellectual disorder that affects the cognitive function, memory, language function, and visuospatial function that
causes irreversible changes. Many studies have stated that lifestyle management in the form of increased physical
activity has a protective effect on impaired cognitive functions, inhibits cognitive function decline, and even
improves cognitive function in healthy elderly people and elderly with mild cognitive impairment to dementia. Low
impact aerobic exercise is a physical activity that is useful and suitable for the elderly. This study aimed to determine
the effect of low impact aerobic exercise on the cognitive function of elderly people with dementia. This was a quasi-
experimental study with one group pretest-posttest method that involved elderly people from Tresna Werdha Teratai
Palembang, South Sumatera, Indonesia who were selected based on the inclusion and exclusion criteria (n=38)
from December 2018 to February 2019. Treatment provided was a low impact aerobic exercise 3 times a week for 5
weeks. Dementia was then measured before and after treatment using the Mini-mental State Examination (MMSE).
The mean values of gymnastics before the treatment and after the treatment were 18.36±4.559 and 19.69±5.724,
respectively. A p value of 0.000 was obtained using the Wilcoxon test. In summary, low impact aerobic exercise
influences the cognitive function of the elderly with dementia.
Key words: Cognitive function, elderly, low impact aerobic exercise

Pengaruh Senam Aerobik Low Impact terhadap Fungsi Kognitif

Usila dengan Demensia
Abstrak
Pada usia lanjut (usila), sedikitnya 10% dari yang berusia lebih dari 65 tahun dan 50% dari yang berusia lebih dari
80 tahun mengalami penurunan fungsi kognitif yang bervariasi mulai dari penurunan kognitif karena penuaan
normal (age-associate memory impairment/AAMI) serta penurunan kognitif ringan (mild cognitive impairment/
MCI) hingga demensia. Demensia adalah gangguan intelektual yang meliputi fungsi kognitif, daya ingat, bahasa,
fungsi visuospasial, dan bersifat ireversibel. Banyak studi menyatakan bahwa manajemen gaya hidup berupa
peningkatan aktivitas fisik mempunyai efek protektif terhadap gangguan fungsi kognitif, menghambat penurunan
fungsi kognitif, serta bahkan meningkatkan fungsi kognitif pada usila yang sehat dan usila dengan penurunan
fungsi kognitif ringan sampai demensia. Senam aerobik low impact merupakan aktifitas fisik yang bermanfaat dan
cocok diberikan kepada usila. Penelitian ini bertujuan mengetahui pengaruh senam aerobik low impact terhadap
fungsi kognitif usila dengan demensia. Penelitian ini merupakan studi quasi-experimental dengan metode pretest-
posttest one group yang melibatkan usila dari Tresna Werdha Teratai Palembang, Sumatera Selatan, Indonesia
yang dipilih berdasar atas kriteria inklusi dan eksklusi (n=38) dari bulan Desember 2018 hingga Februari 2019.
Perlakuan yang diberikan berupa senam aerobik low impact 3 kali per minggu selama 5 minggu. Demensia
kemudian diukur sebelum dan sesudah perlakuan menggunakan Mini-mental State Examination (MMSE). Nilai
rerata senam sebelum perlakuan dan setelah perlakuan adalah 18,36±4,559 dan 19,69±5,724 masing-masing. Nilai
p=0,000 didapatkan dengan menggunakan Uji Wilcoxon. Simpulan, senam aerobik low impact memengaruhi
fungsi kognitif usila dengan demensia.
Kata kunci: Fungsi kognitif, senam aerobik low impact, usila

Received: 2 January 2020; Revised: 12 April 2020; Accepted: 13 April 2020; Published: 30 April 2020
Correspondence: Raden Ayu Tanzila, dr., M.Kes. Department of Physiology, Faculty of Medicine, Universitas Muhammadiyah
Palembang. Jln. K.H. Balqi No. 13 Ulu, Palembang 30116, South Sumatera, Indonesia. E-mail: ratanzila247@gmail.com

73
74 Raden Ayu Tanzila et al.: The Effect of Low Impact Aerobic Exercise on Elderly with Dementia Cognitive Function

Introduction the intervention to 20 after the intervention.

This shows that sports interventions positively
The elderly population size had increased from affect cognitive functions.10 This study aimed
14.4 million people (7.18%) in 2000 to 16.8 to determine the effect of low impact aerobic
million people (7.78%) and 23.9 million people exercise on the elderly with dementia.
(9.77%) in 2010. However, a decrease is seen in
2017. There were 23.66 million elderly people Methods
in Indonesia (9.03%) and the estimated elderly
population size in 2020 is 28.8 million people This was a quasi-experimental pretest-posttest
(11.34%). In 2010, South Sumatra province had one group study performed from December
454.554 senior citizens, which then increased to 2018 to February 2019 on 38 elderly people in
582.643 in 2016. This province has an estimated Tresna Werdha Teratai Palembang, which is a
annual population increase of about 60 thousand nursing home for the Elderly in South Sumatera,
people with around 7% are elderly people.1 Indonesia. Participants were recruited using the
The increasing number of elderly people total sampling method in which all elderly people
brings the consequence of increasing age-related who met the inclusion criteria were included. The
common disorders, such as age-related cognitive inclusion criteria used were elderly with dementia
function decline. Among elderly people, at least (MMSE≤24), able to walk without any assistive
10% of those over 65 years old and 50% of those device, minimum education of elementary school,
over 80 years old experience a decline in cognitive willing to voluntarily participate in the study, as
functions that varies from the cognitive decline evident by signing the informed consent, to do
due to normal aging (age-associated memory routine gymnastic exercise 3 times a week for 5
impairment/AAMI) to a mild cognitive decline weeks at Tresna Werdha Teratai Palembang.
(mild cognitive impairment/MCI) and dementia.2 The low impact aerobic gymnastic program
Data regarding health problems experienced assigned to the participants consisted of warming
by the elderly show that the biggest health up (10 minutes), core exercise comprising various
problem among elderly people is degenerative aerobic movements (30 minutes), and cooling
diseases, including dementia.3 Dementia is a down (10 minutes). Data were collected before
syndrome caused by a disease or brain disorder and after the low impact aerobic exercise using
that is usually chronic and progressive in nature the MMSE to assess the cognitive function. The
and affects multiple higher cognitive cortical MMSE is a widely used test for assessing elderly
functions, including memory, thinking ability, cognitive function. It includes tests of orientation,
orientation, comprehension, arithmetic, learning attention, memory, language, and visuospatial
ability, language, and value power (judgment).4,5 skills. The MMSE test includes simple questions
Decreased cognitive functions in the form of and problems in some areas: time and place of
dementia can be inhibited by taking preventive test, repeating list of words, arithmetic including
measures. serial sevens, language use and comprehension,
Various literature has revealed that physical and basic motor skill.11
exercise provides great health benefits. Exercise Data collected were processed by using a
does not only prevent and reduce symptoms of computer program system and then analyzed
various diseases but also clinically plays a role in univariately to understand the average
healing and recovery from diseases.6–8 cognitive function of the elderly before and after
One of the preventive measures that can be gymnastics. Bivariate analyses using paired t test
implemented by the elderly is aerobic exercises and Wilcoxon test as the alternative test were used
to increase their physical activities.9 Low impact to determine the effects of low impact aerobic
aerobic exercise is the type of low-intensity exercise on the cognitive function of elderly
aerobic exercise suitable for the elderly. people with dementia. Results were considered
Previous research conducted by Cai et al.10 significant if p value<0.05.
shows that sports interventions for 4 weeks This study has received ethical clearance from
positively affect the cognitive function in the Research Ethics Committee of the Bioethics,
Alzheimer's patients aged over 70 years which Humanities, and Islamic Medicine Unit
is evident from the increase in the Mini-mental (UBHKI) of the Faculty of Medicine, Universitas
State Examination (MMSE) value from 19 before Muhammadiyah Palembang with letter number:

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Raden Ayu Tanzila et al.: The Effect of Low Impact Aerobic Exercise on Elderly with Dementia Cognitive Function 75

006/EC/UBHKI/FK-UMP/X/2018. by the participants, as well as the duration

and frequency of the exercise. It is commonly
Results understood that 85% of the lack of effect on
cognitive function is caused by the type of
Table 1 showed cognitive function mean values dementia that is a post-stroke vascular dementia
before and after low impact gymnastics. It is with lesions in several parts of the brain lobes.14,15
apparent that the 38 respondents presented A study in Ngesrep village shows that routine
different mini-mental status (MMSE) scores physical exercises result in a significant influence
between before (18.36±4.559, p value=0.003) on the cognitive performance of older people
and after the low impact aerobic physical activity who visited the posyandu (integrated health
(19.69±5.724, p value=0.002). This proved post) routinely.16 A meta-analysis involving 29
that the data gained did not follow the normal randomized controlled trials of healthy elderly
distribution. people without dementia found that aerobic
The Wilcoxon test on data from 38 respondents exercises improved cognitive functions including
presented a p value of 0.000 (p<0.05), meaning memory, attention, speed of information
that the low impact aerobic exercise in this study processing, and executive functions.17
affected the cognitive function of the elderly with A beneficial effect on the cognitive functions
dementia (Table 2). of the elderly with dementia has been linked to
physical exercise activities.18 Aerobic exercise
Discussion influences the Papez circuit limbic system,
especially at the relay station as neural impulses
This study found that the routine low impact received at this station are influenced by
aerobic exercises increased the cognitive several neurotransmitters, like norepinephrine,
functions of elderly people with dementia (p dopamine, and acetylcholine. The aerobic
value=0.000). This is in line with the finding of a physical activities can activate the hypothalamus
study conducted by Rohana12 stating the influence to synthesize corticotropin-releasing factors
of aerobic physical activities on cognitive function (CRFs), which will influence the release of
in the elderly with dementia. Besides, another neurotransmitters like acetylcholine, serotonin,
study conducted by Yolanda and Fatmawati13 dopamine, and norepinephrine. This, in turn,
suggested a significant difference in the cognitive will affect the impulse of the Papez circuit. The
function of the elderly before and after doing impulse will travel through the arch of the fornix
aerobic physical activities in the form of brain to the corpus of mamillare and then will be
vitality exercises. Hence, it can be stated aerobic delivered to the anterior nucleus of the thalamus,
physical activities indeed influence the cognitive which will project it into the cinguli girus
function of the elderly with dementia. thereby increasing nerve growth factor (NGF)
In contrast, several studies have suggested and brain-derived neurotrophic factor (BDNF)
that there is no increase in the cognitive function in the cinguli gyrus, hippocampus, and dentate
of the elderly after doing exercises. One study on girus. Furthermore, the CRF synthesized by the
141 women and 45 men who did exercises for 4 hypothalamus will be sent to the pituitary to
months obtained a p value of 0.11, which means synthesize adrenocorticotropic hormone (ACTH)
that the exercise does not affect the cognitive and this ACTH will later be sent to the adrenal
functions of these elderly people. This may relate gland to synthesize the cortisol hormone that
to the severity of dementia condition suffered increases the memory consolidation.19–21 Aerobic
physical activities change the blood flow; thereby

Table 1 Cognitive Function Mean Values

before and after Low Impact Table 2 Effect of Low Impact Aerobic
Gymnastics Gymnastics on Cognitive
Mean±SD Function
Gymnastics p Value*
(n=38) Cognitive Function p Value*
Before 18.36±4.559 0.003 Before gymnastics 0.000
After 19.69±5.724 0.002 After gymnastics 0.000
Note: *Shapiro-Wilk test Note: *Wilcoxon test

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76 Raden Ayu Tanzila et al.: The Effect of Low Impact Aerobic Exercise on Elderly with Dementia Cognitive Function

increasing the intake of oxygen and glucose, Kesehatan Republik Indonesia. Situasi lanjut
as well as lipid metabolism, to the brain that usia (lansia) di Indonesia [Internet]. 2016
reduces the process of ischemia and damages to May [cited 2019 May 5]. Available from:
the microvascular (reperfusion injury). It also https://pusdatin.kemkes.go.id/resources/
reduces the production of reactive oxygen species download/pusdatin/infodatin/Infodatin-
(ROS) which are destructive and tends to form lansia-2016.pdf.
free radicals. Hence, the NGF and BDNF of the 4. Mandolesi L, Polverino A, Montuori S, Foti
nerve cells increase and they provide a protective F, Ferraioli G, Sorrentino P, et al. Effects of
effect for cell neurons as well as reducing the physical exercise on cognitive functioning
amyloid build-up on neurons that can cause an and wellbeing: biological and psychological
increase in cognitive abilities in elderly people.22,23 benefits. Front Psychol. 2018;9:509.
Physical activities also improve the physical 5. Maslim R. Buku saku diagnosis gangguan
capacity of patients with dementia. Multiple jiwa: rujukan ringkas dari PPDGJ-III dan
exercises that are combined into physical activity DSM-5. Jakarta: Bagian Ilmu Kedokteran
for patients with dementia have shown to have Jiwa FK-Unika Atmajaya; 2013.
the largest effect. Therefore, a physical activity 6. Powers SK, Howley ET. Exercise physiology:
program that includes various activities is theory and application to fitness and
recommended to be included in the treatment for performance. 10th Edition. New York:
elderly patients with dementia.24,25 It is expected McGraw-Hill Education; 2018.
that the findings of this study will be able to 7. Wahyuni NPDS. Sehat dan bahagia
provide inputs when considering treatment dengan senam bugar lansia. J Penjakora.
for people with dementia, especially in taking 2015;3(1):66–77.
the advantage of the low impact exercise as an 8. Sauliyusta M, Rekawati E. Aktivitas fisik
alternative approach to improve memory among memengaruhi fungsi kognitif lansia. JKI.
elderly people. 2016;19(2):71–7.
9. Tulak TG, Umar M. Pengaruh senam lansia
Conclusion terhadap penurunan tekanan darah lansia
penderita hipertensi di Puskesmas Wara
Low impact aerobic exercises improve the Palopo. Perspektif. 2017;2(1):169–72.
cognitive functions of elderly people with 10. Cai H, Li G, Hua S, Liu Y, Chen L. Effect of
dementia in Tresna Werdha Teratai Palembang, exercise on cognitive function in chronic
South Sumatera, Indonesia. disease patients: a meta-analysis and
systematic review of randomized controlled
Conflict of Interest trials. Clin Interv Aging. 2017;12:773–83.
11. Schweizer TA, Al-Khindi T, Macdonald
There is no conflict of interest at all authors. RL. Mini-Mental State Examination versus
Montreal Cognitive Assessment: rapid
References assessment tools for cognitive and functional
outcome after aneurysmal subarachnoid
1. Badan Pusat Statistik. Statistik penduduk hemorrhage. J Neurol Sci. 2012;316(1–
lanjut usia 2017. Jakarta: Badan Pusat 2):137–40.
Statistik; 2018 [cited 2019 May 20]. Available 12. Rohana S. Senam vitalisasi otak lebih
from: https://www.bps.go.id/publication/ meningkatkan fungsi kognitif kelompok
2018/04/13/7a130a22aa29cc8219c5d153/ lansia daripada senam lansia di Balai
statistik-penduduk-lanjut-usia-2017.html. Perlindungan Sosial Propinsi Banten.
2. Masruroh. Efek aktivitas berjalan kaki Fisioterapi. 2011;11(1):15–35.
terstruktur dalam memelihara fungsi 13. Yolanda J, Fatmawati V. Perbedaan pengaruh
kognitif pada usia lanjut: uji klinis acak senam vitalisasi otak dan senam lansia
tersamar tunggal [thesis]. Jakarta: terhadap peningkatan fungsi kognitif pada
Universitas Indonesia; 2014 [cited 2019 lansia [undergraduate thesis]. Yogyakarta:
May 3]. Available from: http://lib.ui.ac. Universitas ‘Aisyiyah; 2017 [cited 2019
id/file?file=digital/2016-3/20405274-SP- April 30]. Available from: http://digilib.
Masruroh.pdf. unisayogya.ac.id/2858/1/NASKAH%20
3. Pusat Data dan Informasi, Kementerian PUBLIKASI%20PDF.pdf.

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Raden Ayu Tanzila et al.: The Effect of Low Impact Aerobic Exercise on Elderly with Dementia Cognitive Function 77

14. Wan M, Wong RY. Benefits of exercise in the physical exercise on memory, peripheral
elderly. CGS J CME, 2014;4(1):5–8. BDNF, and cortisol in young adults. Neural
15. Kenney WL, Wilmore JH, Costill DL. Plast. 2016;2016:6860573.
Physiology of sport and exercise. 5th Edition. 20. Rodwell VW, Bender DA, Botham KM,
Champaign: Human Kinetics; 2012. Kennelly PJ, Weil PA. Biokimia Harper. 30th
16. Kusumowardani A, Wahyuni ES. Pengaruh Edition. Jakarta: EGC; 2017.
latihan fisik terhadap kemampuan kognitif 21. Baehr M, Frotscher M. Diagnosis topik
lansia di Desa Ngesrep Kecamatan Ngemplak neurologi Duus: anatomi, fisiologi, tanda,
Kabupaten Boyolali. Interest. 2017;6(2):168– gejala. 5th Edition. Jakarta: EGC; 2017.
78. 22. Bherer L, Erickson KI, Liu-Ambrose T. A
17. Teri L, Logsdon RG, McCurry SM. Exercise review of the effects of physical activity and
interventions for dementia and cognitive exercise on cognitive and brain functions in
impairment: the Seattle Protocols. J Nutr older adults. J Aging Res. 2013;2013:657508.
Health Aging. 2008;12(6):391–4. 23. Myers JS. Factors associated with changing
18. Setiawan RA. Pengaruh senam otak dengan cognitive function in older adults:
fungsi kognitif lansia demensia di Panti implications for nursing rehabilitation.
Wredha Dharma Bakti Kasih Surakarta Rehabil Nurs. 2008;33(3):117–23.
[undergraduate thesis]. Surakarta: STIKes 24. Sherwood L. Fisiologi manusia: dari sel ke
Kusuma Husada Surakarta; 2014 [cited 2019 sistem. 9th Edition. Jakarta: EGC; 2018.
May 6]. Available from: http://digilib.ukh. 25. Lee HS, Park SW, Park YJ. Effects of physical
ac.id/files/disk1/12/01-gdl-rochmadagu- activity programs on the improvement of
566-1-skripsi_-n.pdf. dementia symptom: a meta-analysis. Biomed
19. Hötting K, Schickert N, Kaiser J, Röder B, Res Int. 2016;2016:2920146.
Schmidt-Kassow M. The effects of acute

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DOI: https://doi.org/10.29313/gmhc.v8i1.5915 pISSN 2301-9123 │ eISSN 2460-5441

RESEARCH ARTICLE

A Comparative Evaluation of Community Periodontal Index (CPI) and

the Presence of Nicotine Stomatitis among Smokers
after Oral Hygiene Instruction
Meta Maulida Damayanti,1 Yuktiana Kharisma,2 Fajar Awalia Yulianto,3 Santun
Bhekti Rahimah,2 Winni Maharani,4 Meike Rachmawati,1 Herri S. Sastramihardja,2
Muhammad Alief Abdul ‘Aziiz,5 Muhammad Ilham Halim5
Department of Pathology, 2Department of Pharmacology, 3Department of Public Health,
1

4
Department of Microbiology, 5Medical Undergraduate Study Program, Faculty of Medicine,
Universitas Islam Bandung, Bandung, Indonesia

Abstract
Smoking can cause periodontal disease as well as lesions in the oral mucosa. Nicotine stomatitis is inflammation
caused by heat stimuli injury on the hard and soft palate of the oral cavity; smokers commonly suffer from this
condition. Knowledge of how oral hygiene affects the health of dental and oral cavity. The purpose of this study
was to describe the differences in community periodontal index (CPI) and nicotine stomatitis in smokers after oral
hygiene instruction. The study subjects were 54 men who have a history of active smoking for more than five years.
The experiment was carried out in the Biomedical Laboratory of Faculty of Medicine Universitas Islam Bandung
in September 2018–January 2019. Dental examination initiated before and after dental health instructions. CPI
and nicotine stomatitis tests performed on all subjects by dentists using dental instruments. After six weeks of
information about oral hygiene, all subjects re-examined. The results show that there is a statistically significant
difference in the average CPI value in smokers before and after dental instruction with a p value<0.001 (p≤0.05).
In contrast, the condition of nicotine stomatitis remains the same. CPI value influenced by oral and dental hygiene
showed that dental health instruction is very effective. However, stomatitis has not healed as long as the cause is
not eliminated.
Key words: Community periodontal index, smokers, stomatitis nicotine

Evaluasi Komparatif Community Periodontal Index (CPI) dan Stomatitis

Nikotin di Kalangan Perokok setelah Instruksi Kebersihan Mulut

Abstrak
Merokok dapat menyebabkan penyakit pada periodontal maupun lesi pada mukosa mulut. Stomatitis nikotin
merupakan inflamasi yang disebabkan oleh panas yang terdapat pada palatum keras dan lunak; perokok umumnya
menderita kondisi ini. Pengetahuan mengenai tata cara kebersihan mulut memengaruhi kesehatan gigi dan rongga
mulut. Tujuan penelitian ini menilai perbedaan community periodontal index (CPI) dan stomatitis nikotin pada
perokok setelah instruksi kebersihan mulut. Subjek penelitian adalah 54 pria yang memiliki riwayat merokok aktif
selama lebih dari lima tahun. Penelitian dilakukan di Laboratorium Biomedik, Fakultas Kedokteran, Universitas
Islam Bandung pada bulan September 2018–Januari 2019. Pemeriksaan dental dilakukan sebelum dan setelah
instruksi kesehatan gigi. Pemeriksaan CPI dan stomatitis nikotin dilakukan kepada seluruh subjek oleh dokter
gigi menggunakan instrumen gigi. Setelah enam minggu mendapatkan penyuluhan mengenai kebersihan mulut,
seluruh subjek diperiksa kembali. Hasil penelitian menunjukkan bahwa terdapat perbedaan bermakna secara
statistik nilai CPI rerata pada perokok sebelum dengan setelah dilakukan instruksi kesehatan gigi dengan p<0,001
(p≤0,05). Sebaliknya, kondisi stomatitis nikotin tetap sama. Nilai CPI dipengaruhi oleh kebersihan gigi dan mulut
sehingga instruksi kesehatan gigi sangat efektif. Akan tetapi, stomatitis tidak dapat sembuh selama penyebabnya
tidak dihentikan.
Kata kunci: Community periodontal index, perokok, stomatitis nikotin

Received: 12 April 2020; Revised: 19 April 2020; Accepted: 21 April 2020; Published: 30 April 2020
Correspondence: Meta Maulida Damayanti, drg., M.Kes. Department of Pathology, Faculty of Medicine, Universitas Islam Bandung.
Jln. Tamansari No. 22, Bandung 40116, West Java, Indonesia. E-mail: meta_md@unisba.ac.id

78
Meta Maulida Damayanti et al.: A Comparative Evaluation of Community Periodontal Index (CPI) and the Presence of 79

Introduction Methods

Smoking with tobacco increases the possibilities The study was at the Biomedical Laboratory,
of periodontal disease by affecting periodontal Faculty of Medicine, Universitas Islam Bandung
attachment, pocket formation, and bone loss. (Unisba), from September 2018 to January
Besides, smoking will cause inflammation on the 2019. Subjects were Unisba security officers with
gingiva, and cause stains on the teeth interfere inclusion criteria, adults aged over 20 years, and a
with the aesthetics and halitosis.1–3 Smoking also history of active smoking for more than five years.
causes damage to almost all organs and body The research subjects were 54 men. The method
systems. Oral health is an area that receives is by examining the periodontal health status
less attention, but it is a vital area. If the normal based on the criteria of the CPI and lesions on the
flora of the mouth changes, it will cause various palate that is nicotine stomatitis before and after
diseases, both local and systemic. The smoke instructions regarding dental and oral hygiene.
of the cigarette can cause the oral mucosal CPI examination by evaluating the community
epithelium to be susceptible to the pathogen.4 periodontal index treatment needs (CPITN)
Periodontal disease often occurs, and there are as follows; Code 0 to Code 4 (Code 0: healthy
some risk factors such as smoking, the knowledge periodontal conditions; Code 1: gingival bleeding
of dental health, socioeconomic status, diabetes, on probing; Code 2: calculus and bleeding; Code 3:
senility, heredity, genetics, oral hygiene, lifestyle, periodontal sac 4–5 mm; and Code 4: periodontal
and stress are related to periodontal disease.5–7 sac ≥6 mm). Nicotine stomatitis examination is
Cigarettes have a hazardous composition such done with anamnesis and examination using a
as gas, nicotine, tar, and also contains more than mouth glass by the dentist.10,13
4,000 chemical constituents. Nicotine and tar The data were processed using SPSS, and
able to stimulate injuries that will cause changes differences in CPI values analyzed with the
in the oral cavity such as changes in pH of the Wilcoxon signed ranks test while for nicotine
oral cavity, oral moisture, increasing intraoral stomatitis analyzed with a chi-square test. The
temperature, changing immune response, and data presented in tabular form. The Health
resistance to infections, especially fungal and Research Ethics Committee of Faculty of Medicine
virus infections.2,8 Universitas Islam Bandung has approved this
Nicotine stomatitis is a lesion that formed research, with the ethical clearance number: 379/
due to physical irritation from smoke.9 The Komite Etik.FK/X/2018.
temperature at the tip of the tobacco cigarette
combustion reaches 650°C (470°C–812°C), and Results
the core temperature of the cigarette can reach
824°C–897°C. During inhalation of smoke, the A total of 54 subjects were included in this study,
mouth can reach 190°C. High-temperature fumes had an average age of 34 years, with 74% had a
that come into direct contact with the mucous history of having a toothache.
palate causing irritation and inflammation of the Table 1 shows that before oral hygiene
minor salivary glands in the hard palate.2 instructions, most smokers in Code 1 as much
Periodontal screening is to prevent periodontal as 37 people (68%), whereas after instruction,
disease and improve oral health. Community most in Code 0 as much as 45 people (83%). The
periodontal index (CPI) or periodontal screening results of the analysis using the Wilcoxon signed
record should be performed for assessing the ranks test at 95%CI that there are statistically
periodontal tissue.10–12 significant differences in the average CPI value in
Instructions on oral hygiene such as tooth smokers before and after oral hygiene instruction
brushing techniques, frequency, and time of at Unisba, with a p value<0.001 (p≤0.05).
brushing are essential knowledge to improve Table 2 shows stomatitis in smokers before
dental and oral hygiene and health. The research and after oral hygiene instruction. Before oral
aimed to see how the prevalence of nicotine hygiene instructions, most smokers experience
stomatitis and the value of CPI in smokers after stomatitis as much as 37 people (69%), while
oral hygiene instruction that is needed to detect after instructions, most smokers also experience
severe periodontal disease. stomatitis are 35 people (65%).

Global Medical and Health Communication, Volume 8 Number 1, April 2020

80 Meta Maulida Damayanti et al.: A Comparative Evaluation of Community Periodontal Index (CPI) and the Presence of

Table 1 Differences of Average in CPI Values of Smokers before and after Oral Hygiene
Instruction
Groups (n=54)
CPI Values p Value*
Before After
CPI codes
Code 0 15 (28%) 45 (83%)
Code 1 37 (68%) 8 (15%)
Code 2 2 (4%) 1 (2%)
CPI value <0.001
Average (SD) 0.76 (0.51) 0.19 (0.43)
Median (min–max) 1 (0–2) 0 (0–2)
Note: *Wilcoxon signed ranks test; Code 0: healthy periodontal conditions; Code 1: gingival bleeding on probing; Code 2:
calculus and bleeding

Table 3 shows smokers with stomatitis before oral hygiene instruction with p value=0.500 (p
and after instruction. They were 35 people value>0.05).
(95%), while smokers without stomatitis before
counseling with stomatitis after instruction Discussion
were none (0%). Stomatitis before and after
the instruction found in two people (5%), while Smoking is a significant risk factor associated
subjects without stomatitis before and after with a lifestyle that causes periodontal disease.
instruction were 17 people (100%). Oral hygiene instruction is the most effective
Based on Table 3, the results of the chi-square way to change people's behavior regarding the
test with the 95%CI indicate that there were no importance of oral and dental hygiene, starting
statistically significant differences in smokers with proper technique, frequency, and time of
who experience stomatitis before and after brushing.14
This study shows that the periodontal disease
that is assessed by CPI before the oral and
dental health instruction is higher than after
Table 2 Overview of Nicotine Stomatitis the instruction, and it is useful for explaining
in Smokers before and after Oral the pathogenesis of periodontal disease caused
Hygiene Instruction by smoking. Sajjad et al.1 and Saribas et al.7
Groups (n=54) stated there is a high correlation between the
Stomatitis consumption of tobacco and gingival index, the
Before After plaque index, and the community periodontal
Yes 37 (69%) 35 (65%) index of treatment needs, there was a high
correlation between intake of tobacco and the
No 17 (31%) 19 (35%) gingival score.

Table 3 Differences in Nicotine Stomatitis Conditions in Smokers before and after Oral
Hygiene Instruction
Stomatitis after
Stomatitis before Total (%) p Value*
Yes (%) No (%)
Yes (%) 35 (95) 2 (5) 37 (100) 0.500
No (%) 0 (0) 17 (100) 17 (100)
Total (%) 35 (65) 19 (35) 54 (100)
Note: McNemar test; chi-square test
*

Global Medical and Health Communication, Volume 8 Number 1, April 2020

Meta Maulida Damayanti et al.: A Comparative Evaluation of Community Periodontal Index (CPI) and the Presence of 81

Nicotine can inhibit alveolar bone repair. smoking. Research that is conducted by Ain et al.3
Smokers have periodontitis four times more regarding various oral lesions where the subject
than nonsmokers. In general, calculus deposits has various bad habits; the most common is
are higher and also gingival inflammation.15 The smoking (56.46 %).
results showed that smoking is very susceptible
to periodontal disease. Smoking affects the Conclusions
periodontitis process through an immunological
mechanism and vascular damage. The Smoking is closely related to the onset of
periodontal status index and gingival melanin periodontal disease. Assessment and diagnosis of
pigmentation were significantly worse in smokers periodontal conditions of a smoker is a complex
than nonsmokers; it indicates that chronic and challenging task to prevent serious diseases.
smoking habits can affect dental health and can Instructions regarding effective oral hygiene can
cause different periodontal disease. The level of reduce the risk of periodontal disease but cannot
gingival melanin pigmentation can correlate with cure nicotine stomatitis.
worsening periodontal status and can be used
as an early symptom of developing periodontal Conflict of Interest
disease.16–18
History of stomatitis in the study showed no There is no conflict of interest in this study.
difference between before and after oral hygiene
instruction. Mild nicotine stomatitis does not need Acknowledgments
therapy. However, if it worsens, it can be treated
palliatively, giving the instructions for improving The authors convey gratitude to all staff of
oral hygiene and stop smoking.2 Nicotine Biomedical Laboratory staff of Faculty of
stomatitis is a keratosis in the palate caused Medicine, Universitas Islam Bandung.
by tobacco. Palatal mucosa initially appeared
reddish. Furthermore, in the vicinity of the References
minor salivary gland ducts shows inflammation
and dilated holes, many micronodules from the 1. Sajjad F, Mumtaz M, Ramsha Sajjad R.
red punctate region forming and making diffuse Effects of tobacco chewing and smoking and
grayish-white wrinkles. The epithelial lining its relationship with periodontal health. Natl
of the oral mucosa is the first immune system J Health Sci. 2017;2(3):106–8.
to invading microorganisms and carcinogenic 2. Prabowo DMS, Widodo HB. Nicotine
agents.19 stomatitis in smokers: a case report. J
Etiology of nicotine stomatitis increased Dentomaxillofac Sci. 2018;3(1):58–60.
because of the temperature, rather than 3. Ain TS, Gowhar O, Sultan S, Tangade P.
the tobacco chemicals. The temperature is Prevalence of oral mucosal lesions and
responsible for this lesion. Among elderly Indian associated habits in Kashmir, India. Int J Res
and Thailandian people, the general oral mucosal Med Sci. 2016;4(8):3525–30.
lesion type is smoker’s palate with an incidence 4. Ozturk O, Fidanci İ, Unal M. Effects of
of 43%. Lesions mostly involve the maxillary hard smoking on oral cavity. J Exp Clin Med.
palate region with a prevalence of 23.1%.19,20 2017;34(1):3–7.
During an intraoral examination, different 5. Robbihi AI, Sulaeman ES, Rahardjo SS. Path
oral lesions also recorded. The most common analysis: the effect of smoking on the risk of
oral lesion was oral submucosal fibrosis, which periodontal disease. IJM. 2018;3(2):99–109.
affected 12.2% of subjects, followed by nicotine 6. Nazir MA. Prevalence of periodontal disease,
stomatitis (10.8%).21 Other studies state that its association with systemic diseases and
there are effects of smoking at different sites of prevention. Int J Health Sci (Qassim).
the oral cavity and show the potential effects of 2017;11(2):72–80.
smoking on buccal mucosal microbiota.22 The 7. Saribas E, Acun Kaya F, Dogru AG, Yildirim
heterogeneity of the oral microbe ecosystem TT. Determination of periodontal status and
found can contribute to the stability of the oral smoking habits with CPITN index. Int Dent
microbiota in most locations, when environmental Res. 2017;7(2):26–31.
disturbances occurred, such as those caused by 8. Horinouchi T, Higashi T, Mazaki Y, Miwa

Global Medical and Health Communication, Volume 8 Number 1, April 2020

82 Meta Maulida Damayanti et al.: A Comparative Evaluation of Community Periodontal Index (CPI) and the Presence of

S. Carbonyl compounds in the gas phase 16. Goyal V, Devaraj GC. Correlation of smoking,
of cigarette mainstream smoke and their periodontal health status and gingival
pharmacological properties. Biol Pharm Bull. melanin pigmentation. Int J Health Sci Res.
2016;39(6):909–14. 2017;7(1):109–14.
9. Visconti MJ, Ashack KA. Dermatologic 17. Kubota M, Yanagita M, Mori K, Hasegawa S,
manifestations associated with electronic Yamashita M, Yamada S, et al. The effects of
cigarette use. J Am Acad Dermatol. cigarette smoke condensate and nicotine on
2019;81(4):1001–7. periodontal tissue in a periodontitis model
10. Nomura Y, Okada A, Kakuta E, Gunji T, mouse. PLoS One. 20;11(5):e0155594.
Kajiura S, Hanada N. A new screening 18. Leite FRM, Nascimento GG, Scheutz F,
method for periodontitis: an alternative to López R. Effect of smoking on periodontitis:
the community periodontal index. BMC Oral a systematic review and meta-regression. Am
Health. 2016;16(1):64. J Prev Med. 2018;54(6):831–41.
11. Kobayashi T, Suda T, Mizutani K, Aoyama N, 19. Koray M, Tosun T. Oral mucosal trauma
Koyanagi T, Hayakumo S, et al. Clarification of and injuries. In: Gözler S, editor. Trauma
quantitative intraoral circumstances with the in dentistry [e-book]. London: IntechOpen
community periodontal index of treatment Limited; 2019 [cited 2020 January 30].
needs data using covariance structure Available from: https://www.intechopen.
analysis. J Clin Diagn Res. 2019;13(6):ZC41– com/books/trauma-in-dentistry/oral-
4. mucosal-trauma-and-injuries.
12. Susanto A, Carolina DN, Amaliya A, Setia 20. Regezi JA, Sciubba J, Jordan RCK. Oral
Pribadi IM, Miranda A. Periodontal health pathology: clinical pathologic correlations.
status and treatment needs of the community 7th Edition. Elsevier Health Sciences. St.
in Indonesia: a cross sectional study. J Int Louis: Elsevier; 2017.
Oral Health. 2020;12(2):114–9. 21. Alshayeb M, Mathew A, Varma S, Elkaseh A,
13. Naz I, Butt AM, Bashir U, Memon H. Kuduruthullah S, Ashekhi A, et al. Prevalence
Periodontal tissue; effect of fix orthodontic and distribution of oral mucosal lesions
treatment. Prof Med J. 2017;24(6):930–4. associated with tobacco use in patients
14. Amoo-Achampong F, Vitunac DE, Deeley visiting a dental school in Ajman. Oncol
K, Modesto A, Vieira AR. Complex patterns Radiother. 2019;13(2):29–33.
of response to oral hygiene instructions: 22. Mushatat SF, Khalaf AA, Al-Deen Taher JM.
longitudinal evaluation of periodontal A clinical study about oral lesions and normal
patients. BMC Oral Health. 2018;18(1):72. variants of the oral mucosa. J Pharm Sci Res.
15. Handa S, Koui H, Khurana C. Insight into 2018;10(7):1755–7.
nicotine addiction. CHRISMED J Health
Res. 2017;4(2):69–75.

Global Medical and Health Communication, Volume 8 Number 1, April 2020

 Authors Index

A Lisa Adhia Garina 53

A.A. Depari 42
Alya Tursina 1 M
Astrid Feinisa Khairani 13 Meike Rachmawati 78
Atika Zahria Arisanti 21 Meiyanti 67
Merina Panggabean 42
D Meta Maulida Damayanti 78
Dedi Rachmadi 27 Mirfat 47
Deni Kurniadi Sunjaya 27 Mochamad Firdaus Bhuanaputra 1
Dewi Marhaeni Diah Herawati 27 Muhammad Alief Abdul ‘Aziiz 78
Dida Akhmad Gurnida 27 Muhammad Ilham Halim 78
Dwie Yunita Baska 59 Muhammad Ridho Grahadinta 53

E N
Eveline Margo 67 Nindia Rahma 73
Nur Eva Aristina 27
F
Faisal Heri 42 P
Fajar Awalia Yulianto 78 Ponpon S. Idjradinata 59
Faras Qodriyyah Sani 47
Ferry Achmad Firdaus Mansoer 53 R
Fetty Fatmawaty 7 Raden Ayu Tanzila 73

G S
Gaga Irawan Nugraha 7 Santun Bhekti Rahimah 78
Sheilla Yonaka Lindri 73
H Siska Nia Irasanti 34
Hadi Susiarno 27 Siti Aminah Sobana 13
Hari Soekersi 7 Sri Endah Rahayuningsih 21
Herri S. Sastramihardja 78
T
I Tita Husnitawati Madjid 59
Ieva Baniasih Akbar 34 Tono Djuwantono 21
Intan Puspitasari 53
Iskandar 47 U
Umar Islami 13
J
Juni Chudri 67 W
Winni Maharani 78
K
Kuheinderan Radha Krishnan 13 Y
Yani Dewi Suryani 34
L Yuktiana Kharisma 1, 78
Leni Santiana 7
 Subjects Index

A K
Adolescent primigravida 59, 60, 64 Knowledge 59–64
Adolescents 53–57
Anemic 42–45 L
Anxiety 59–64 Liver cirrhosis 7–11
Asthma 53–57 Low back pain 13, 14, 16–18
Low impact aerobic exercise 73–76
B
Breast cancer 47–50 M
malondialdehyde 67, 68
C
Cesarean delivery 21–25 P
Clerkship 34, 35, 37, 40 Pain repair 1
Cognitive function 73–76 PAQLQ(S) 53, 55–57
Community periodontal index 78–79 Phaleria macrocarpa 67, 68, 71
Contractility index 7–11 Post-placental IUD 21, 22, 24

D Q
Dermatoglyphics 47–50 Quality of life 53–57
Dharmais Cancer Hospital 47–50
Diabetes mellitus 1, 2 R
Diabetic neuropathy 1, 2 Radiculopathy 13–18
Diarrhea 27–32 Red flag 13–18

E S
Education 59–61, 64 Service quality 34–36, 40
Eel cookies 27–29, 31, 32 Smokers 78–81
Elderly 73–76 Soil-transmitted helminth 42, 43
Enterobius vermicularis 42–44 Stomatitis nicotine 78
Expulsion 21–25 Supplementation 27
Extract 67, 68, 70, 71
U
F Ultrasound 7–11
Flashcard 59–61, 63, 64
V
G Vaginal delivery 21–25
Gabapentin 1–4 Vitamin B12 1–4
Gallbladder 7–11

I
IPA 34–36, 40
The Editor would like to thank you for the effort and expertise of all reviewers, without which it would
be impossible to maintain the high standards of peer-reviewed journals.

Prof. Dr. Budi Setiabudiawan, dr., Sp.A.(K.), M.Kes.

Prof. Cordia Chu, B.Sc., M.A., Ph.D.
Ermi Ndoen, B.Sc.P.H., M.Sc.P.H., Ph.D.
Ferry Efendi, S.Kep.Ns., M.Sc., Ph.D.
Prof. Dr. Hendro Sudjono Yuwono, dr., Sp.B.V.(K.)
Prof. Dr. Herri S. Sastramihardja, dr., Sp.F.K.(K.)
Prof. Hidayat Wijayanegara, dr., Sp.O.G.(K.)
Prof. Dr. Ieva Baniasih Akbar, dr., A.I.F.
Dr. Lelly Yuniarti, S.Si., M.Kes.
Leri Septiani, dr., Sp.O.G., Ph.D.
Prof. Dr. M. Ahmad Djojosugito, dr., Sp.B., Sp.O.T.(K.), M.H.A.
Dr. Maya Tejasari, dr., M.Kes.
Mirasari Putri, dr., Ph.D.
Prof. Dr. Niniek Lely Pratiwi, drg., M.Kes.
Nunik Kusumawardani, S.K.M., M.P.H., Ph.D.
Prof. Nuzirwan Acang, dr., DTM&H, Sp.P.D.-K.H.O.M.
Prof. Dr. Thaufiq S. Boesoirie, dr., M.S., Sp.T.H.T.-K.L.(K.)
Prof. Dr. Tony S. Djajakusumah, dr., Sp.KK(K)
Prof. Umar Fahmi Achmadi, dr., M.P.H., Ph.D.
Dr. Wahyu Widowati, M.Si.
Dr. Wawang S. Sukarya, dr., Sp.O.G.(K.), M.A.R.S., M.H.Kes.
Dr. Yani Triyani, dr., Sp.P.K., M.Kes.
RESEARCH ARTICLES
Combination of Gabapentin and Vitamin B12 Compared with Gabapentin Monotherapy on 1
Pain Improvement of Diabetic Neuropathy Patients
Mochamad Firdaus Bhuanaputra, Alya Tursina, Yuktiana Kharisma
Comparative Study Gallbladder Contractility Index Using Ultrasound in Patients with and 7
without Liver Cirrhosis
Hari Soekersi, Leni Santiana, Fetty Fatmawaty
Lumbar Radiculopathy: a Descriptive Study on Red Flag and Neurologic Symptoms in Dr. 13
Hasan Sadikin General Hospital Bandung
Astrid Feinisa Khairani, Kuheinderan Radha Krishnan, Umar Islami,
Siti Aminah Sobana
Differences in Expulsion on Post-placenta Intrauterine Contraceptive Device between 21
Mother with Vaginal and Cesarean Delivery
Atika Zahria Arisanti, Tono Djuwantono, Sri Endah Rahayuningsih
Eel Cookies Supplement and Incidence of Diarrhea in Children Aged 12–24 Months 27
Nur Eva Aristina, Dedi Rachmadi, Dewi Marhaeni Diah Herawati,
Hadi Susiarno, Dida Akhmad Gurnida, Deni Kurniadi Sunjaya
Implementation of Importance-Performance Analysis (IPA) for Improving Medical Students’ 34
Quality of Service in Teaching Hospital
Siska Nia Irasanti, Ieva Baniasih Akbar, Yani Dewi Suryani
Relationship of Soil-transmitted Helminth and Enterobius vermicularis Infection with 42
Anemic in Students in Aceh Besar
Faisal Heri, A.A. Depari, Merina Panggabean
Dermatoglyphics Pattern on Breast Cancer Patients in Dharmais Cancer Hospital 47
Faras Qodriyyah Sani, Mirfat, Iskandar
The Quality of Life on Asthmatic Adolescent and Its Correlation with the Severity and 53
Control of Asthma
Lisa Adhia Garina, Muhammad Ridho Grahadinta, Ferry Achmad Firdaus
Mansoer, Intan Puspitasari
The Effect of Health Education with Flashcard Media on Improvement of Knowledge and 59
Reduction of Anxiety Degree in Adolescents Primigravida
Dwie Yunita Baska, Tita Husnitawati Madjid, Ponpon S. Idjradinata
Effect of Phaleria macrocarpa (Scheff.) Boerl Dry Extract to the Level of Malondialdehyde 67
Meiyanti, Eveline Margo, Juni Chudri
The Effect of Low Impact Aerobic Exercise on Elderly with Dementia Cognitive Function 73
Raden Ayu Tanzila, Sheilla Yonaka Lindri, Nindia Rahma
A Comparative Evaluation of Community Periodontal Index (CPI) and the Presence of 78
Nicotine Stomatitis among Smokers after Oral Hygiene Instruction
Meta Maulida Damayanti, Yuktiana Kharisma, Fajar Awalia Yulianto,
Santun Bhekti Rahimah, Winni Maharani, Meike Rachmawati, Herri S.
Sastramihardja, Muhammad Alief Abdul ‘Aziiz, Muhammad Ilham Halim