Dengue Prevention and Control in Indonesia: Sulistyawati

Dengue Prevention and Control in Indonesia
A case study in Yogyakarta City
Sulistyawati
Department of Epidemiology and Global Health

Umeå 2020
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To God—Allah SWT
‘O mankind, there has to come to you instruction from your Lord and healing for what
is in the breasts and guidance and mercy for the believers.’
Wahai manusia! Sungguh, telah datang kepadamu pelajaran (Al-Qur'an) dari Tuhanmu,
penyembuh bagi penyakit yang ada dalam dada dan petunjuk serta rahmat bagi orang yang
beriman
(QS. Yunus, 57)
Also, for Suyanto, Cicha, Dito and my Parents…
with love and gratitude.

Table of Contents
Table of contents ................................................................................................................... i
Abstract................................................................................................................................. iii
Abbreviations ...................................................................................................................... iv
Summary in Bahasa ...............................................................................................................v
Original papers .................................................................................................................... vi
Introduction ........................................................................................................................... 1
Background ............................................................................................................................ 4
Current dengue fever situation in Indonesia .................................................................. 5
Dengue prevention and control in Indonesia ................................................................. 5
Dengue diagnostics enforcement tool ............................................................................. 8
Dengue diagnostics workflow, case management and case reporting .......................... 9
Integrated surveillance and outbreak preparedness .................................................... 11
Integrated vector management ...................................................................................... 11
Study aim and objectives .................................................................................................... 13

Overall aim ..................................................................................................................... 13
Specific objectives ........................................................................................................... 13
Materials and methods........................................................................................................ 14
Study location ................................................................................................................. 14
Study design ................................................................................................................... 14
Data collection and analysis ........................................................................................... 15
Community knowledge, attitudes and practices as a foundation for intervention
development (Objective 1)............................................................................................ 15
Executing the control card as a vector control intervention (Objective 2) ...................... 16
Exploring the implementation of the ‘Jumantik’ vector control programme (Objective 3)
................................................................................................................................... 17
Assessing the hospital dengue surveillance system: Case management and reporting
(Objective 4)................................................................................................................ 18
Ethical considerations..................................................................................................... 20
Results .................................................................................................................................. 21
Dengue and vector control knowledge, attitudes and practices in Yogyakarta
(Objective 1) .................................................................................................................... 21
Control card feasibility study (Objective 2)................................................................... 30
Implementation of the ‘Jumantik’ vector control programme (Objective 3) ............... 30
Perceived roles and responsibilities ............................................................................... 34
i
People´s perception of dengue....................................................................................... 35
Perceived benefits of the ‘Jumantik’ and PSN programmes ............................................ 35
Perceived barriers to LMCs’ tasks ................................................................................ 36
Perceived willingness to participate in the ‘Jumantik’ programme ................................. 36
Perceived capacity and self-efficacy .............................................................................. 37
Possible improvements for vector control in the future .................................................. 37
Hospital-based dengue surveillance system: Case management and reporting
(Objective 4) .................................................................................................................... 37
Challenging disease diagnostics ................................................................................... 39
Mismatch in regulatory frameworks and interplay with regulatory bodies ..................... 40
Unequal internal prerequisites for dengue management ................................................ 41
Discussion ............................................................................................................................ 43
Consequences of insufficient dengue prevention and control knowledge .................. 44
Complex interplay of the stakeholders involved in dengue prevention and control . 47
Inconsistent and incomplete standard operating procedures ...................................... 49
Insufficient support for diagnosis and case management ............................................ 51
Study limitations and strengths ......................................................................................... 52
Study limitations ............................................................................................................ 52
Study strengths ............................................................................................................... 53
Conclusions and recommendations ................................................................................... 54
Acknowledgements ............................................................................................................. 56
References ............................................................................................................................ 58
ii
Abstract
Background: Integrated efforts that involve many public health sectors are required to
combat dengue in any setting. Hospitals are responsible for providing accurate diagnosis
and reporting confirmed dengue cases to the health authorities, which serves as an alarm
for increasing preventive measures. Community participation in dengue vector control is
essential because it affects sustainability and cost-effectiveness of preventive and control.
This thesis aimed to provide an in-depth understanding of dengue prevention and control
in Yogyakarta, Indonesia, in order to contribute to strengthening the country’s health
system and the implementation of standardized and well-accepted dengue control
strategies. Several aspects have been studied in term of dengue prevention and control
(case management and reporting, surveillance and vector control) in a dengue-endemic
region of Indonesia—namely, Yogyakarta.
Methods: This thesis comprises four individual research studies: Knowledge, Attitude
and Practice (KAP) survey, control card intervention, implementation of the Jumantik
programme and dengue case management and reporting in hospital. Descriptive and
analytic studies, followed by a pre-post assessment, was performed in the community. A
mixed-method approach was used for assessing the Jumantik programme and a
qualitative study was conducted for the hospital study.
Results: The findings indicated that: (i) KAP regarding dengue vector control were
sufficient but certain aspects still had weaknesses; (ii) level of community participation in
vector control was not satisfactory for several reasons, including lacking time, being busy
with work and member of the community feel that vector control was not their
responsibility; (iii) the Jumantik programme dealt with various obstacles, especially those
related to public acceptance; (iv) coordination between the district health office and
hospitals for early dengue detection did not run optimally. We also found that standard
operating procedures for dengue management differed between hospitals.
Conclusions: The results suggest that dengue prevention and control efforts in
Yogyakarta face certain challenges that must be addressed. While many World Health
Organization recommendations are being followed, the weaknesses reported in some
aspects of the implementation, as well as the lack of integration for various dengue
prevention and control elements, need to be promptly addressed.
Keywords: dengue, control and prevention, community empowerment, diagnostic and

case reporting
iii
Abbreviations
BPJS Badan Penyelenggara Jaminan Sosial (Indonesian
National Insurance)
DENV Dengue Virus
DF Dengue Fever
DHF Dengue Haemorrhagic Fever
CHO City Health Office
DHO District Health Office
EI Epidemiological Investigation
GPs General Practitioners
HBM Health Believe Model
IgG Immunoglobulin G
IgM Immunoglobulin M
Jumantik Juru Pemantau Jentik (Larva Monitoring Cadre)
KAP Knowledge, Attitudes and Practices
KDRS Kewaspadaan Dini Rumah Sakit (Hospital Early
Warning)
Km2 Square kilometres
LFR Larva Free Rate
LMC Larva Monitoring Cadre
MRO Medical Record Officer
NS1 Non-Structural Protein 1
PSN Pemberantasan Sarang Nyamuk (Mosquito Nest
Eradication)
RT-PCR Reverse Transcription Polymerase Chain Reaction
RW Rukun Warga (Residence Group)
SOP Standard Operating Procedure
WHO World Health Organization
3M Menutup, Menguras and Mengubur (Covering,
Cleaning and Burying)
iv
Summary in Bahasa
Latar Belakang: Upaya terpadu yang melibatkan berbagai sector diperlukan untuk
menangani Demam Berdarah Dengue (DBD). Rumah sakit bertanggung jawab untuk
melakukan diagnosis yang akurat dan melaporkan kasus DBD kepada otoritas kesehatan
untuk kewaspadaan dini. Partisipasi masyarakat dalam pengendalian vektor DBD sangat
penting untuk keberlanjutan program. Tesis ini bertujuan untuk memberikan
pemahaman yang mendalam tentang pencegahan dan pengendalian demam berdarah di
Yogyakarta, Indonesia, dalam rangka berkontribusi pada penguatan sistem kesehatan
nasional dan penerapan strategi pengendalian demam berdarah yang terstandarisasi dan
diterima dengan baik oleh pihak yang terlibat. Beberapa aspek dipelajari dalam hal
pencegahan dan pengendalian DBD antara lain (manajemen kasus dan pelaporan,
surveilans dan pengendalian vektor) di daerah endemis DBD di Indonesia yaitu Kota
Yogyakarta.
Metode penelitian: Tesis ini meliputi 4 penelitian yaitu survey KAP, uji coba kartu
kendali pembersihan larva, penelitian implementasi program Jumantik dan manajemen
kasus serta pelaporan kasus dengue di rumah sakit. Analisis deskriptif dan analitik diikuti
dengan penilaian pre-post dilakukan di masyarakat pada study KAP dan kartu kendali.
Mixed-method digunakan pada penilaian program Jumantik dan kualitatif - content
analisis digunakan dalam studi di rumah sakit.
Hasil penelitian: Penelitian ini menunjukkan (i) pengetahuan, sikap, dan praktik
pengendalian vektor DBD sudah memadai tetapi masih terdapat kelemahan; (ii) tingkat
partisipasi masyarakat dalam pengendalian vektor kurang memuaskan karena beberapa
alasan: seperti waktu, sibuk bekerja dan merasa bahwa itu bukan tanggung jawabnya; (iii)
Jumantik mengalami berbagai kendala dalam implementasinya, terutama dalam hal
penerimaan masyarakat; (iv) kesenjangan antara dinas kesehatan dan rumah sakit
menyebabkan deteksi dini DBD tidak berjalan optimal, selain itu SOP yang tidak seragam
antar rumah sakit perlu dikontrol agar dapat menjamin kualitas pelayanan.
Kesimpulan: Tesis ini secara jelas menunjukkan bahwa upaya pencegahan dan
penanggulangan DBD di Yogyakarta menghadapai tantangan, yang berimplikasi juga
pada program nasional. Meskipun rekomendasi WHO telah dijalankan, masih terdapat
kelemahan dibeberapa bagian. Integrasi berbagai elemen pencegahan dan pengendalian
DBD masih belum memadai.
Kata kunci: demam berdarah, kontrol dan pencegahan, pemberdayaan masyarakat,

diagnostik dan pelaporan kasus
v
Original papers
This thesis is based on the following three individual papers:
I. Sulistyawati S, Astuti FD, Umniyati SR, Satoto TBT, Lazuardi L, Nilsson

M, Holmner A. Dengue Vector Control through Community
Empowerment: Lessons Learned from a Community-Based Study in
Yogyakarta, Indonesia. Int J Environ Res Public Health. 2019; 16(6): 1013.
Available from: https://www.mdpi.com/1660-4601/16/6/1013
II. Sulistyawati S, Nilsson M, Ekasari MP, Mulasari SA, Sukesi WS,
Padmawati RS, Holmner Å. Untapped potential—A qualitative study of
a hospital-based dengue surveillance system. Am J Trop Med Hyg. 2020;
103(1): 120–131. Available from:
http://www.ajtmh.org/content/journals/10.4269/ajtmh.19-0719
III. Sulistyawati S, Nilsson M, Carlisle K, MacLaren D, Wibowo TA,
Whittaker M, Holmner A. Challenges in vector control programme
implementation in Indonesia: a mixed-method study. (Manuscript).
vi
Introduction
Dengue fever is a mosquito-borne viral disease that is transmitted by female
Aedes aegypti. This disease has spread rapidly in recent decades, both in terms of
geographical distribution as well as in relation to the increase in the number of
cases reported worldwide (1,2). The dengue virus (DENV) is a member of the
Flavivirus genus of the Flaviviridae family and is responsible for dengue infections
in humans. Currently, there are four serotypes of DENV 1–4 identified globally.
While the distribution of these serotypes was uneven in 1970, confirmed DENV
1-4 cases were found spread across the entire globe by 2004 (3). DENV is
transmitted to humans by Aedes mosquitoes when they feed. These mosquitoes
dwell in tropical and subtropical countries because they need warm weather to
accelerate their growth (4). Aedes are mostly found in urban and suburban areas
that are associated with high population densities and the availability of
containers and stagnant water locations in which these mosquitoes to breed
(1,2,5).
Globally, the World Health Organization (WHO) estimates that 3.9 billion people
are at risk of being infected with the dengue virus in more than 100 countries
(6,7,8). Annually, around 500,000 people are hospitalised as a result of severe
dengue infection, leading to 12,500 (1). However, dengue is an underreported
disease and many cases are misclassified (1,9). Consequently, the actual dengue
burden is unknown. The situation resembles the iceberg phenomenon, where
current reported cases represent the tip of the iceberg while even more cases
remain invisible or unreported—despite enormous diagnostic endeavours of
physicians and community disease surveillance procedures (10).
Combatting dengue fever is challenging because of the complex interplay

between human, mosquito, viral and environmental factors. In addition, there is
no medication available to treat the disease and the existing vaccine intended and
currently used for dengue prevention has turned out to actually pose a significant
problem for preventing and controlling the spread of this disease instead. Hence,
the best current dengue prevention methods are avoiding being bitten by Aedes
mosquitoes and reducing their population. For infected people, mortality can be
prevented by early symptom recognition and subsequent proper treatment
1
provision. Finally, a robust surveillance system can offer early warnings and
enhance the dengue control capacity through a timely approach.
In 2012, the WHO released global strategy guidelines to assist countries around
the world with reducing their dengue burden (11). These guidelines are not the
only document issued by the WHO—various efforts to eradicate dengue have
continuously been initiated over numerous decades. Five technical elements
compose the 2012 WHO strategy: diagnosis and case management, integrated
surveillance and outbreak preparedness, sustainable vector control, future
vaccine implementation and basic operational and implementation research
(Figure 1). This thesis focused on three of these elements—diagnosis and case
management, integrated surveillance and outbreak preparedness as well as
sustainable vector control—while operational research constituted a cross-
cutting element.
Hospitals, both primary and referral, play a significant role in reducing dengue
transmission because hospitals are responsible for providing accurate diagnosis
and reporting positive cases for early warning purposes (12). Hospitals must
ensure detection of early and severe cases, increase in health services and
building of capacities, provision of dengue prevention courses and preparation
of vaccines (11). According to the WHO surveillance guidelines, standard case
investigation should be performed within 24 hours of the initial case notification
(13). This notification is used to perform surveillance activity through
epidemiological investigation (EI), which needs to be conducted within a 100-
metre radius from the home of a confirmed dengue case in order to seek the
presence of other people with a suspected dengue infection. Furthermore, this
activity also investigates the search for larvae existence in potential breeding
places (14). Consequently, such activity serves to inform decision-makers who
are responsible for determining the interventions that aim to stop transmissions
and prevent outbreaks.
2
Figure 1. The framework of the thesis follows the WHO global strategy for
dengue burden reduction (50% mortality) (11).
The WHO encourages sustainable dengue control, considering it to be a low-cost

intervention with long-term effects on both health and environment (15). Their
recommendations include using integrated and sustainable vector control to
reduce human-vector contact, which can be performed through environmental
management and chemical and biological control (16). Community participation
is fundamental for running the mentioned approach and to guarantee the
programme’s sustainability (7,17).
At the national level, Indonesia follows and implements the WHO’s

recommendations for dengue prevention and control. However, it is unknown
to what extent these strategies are implemented and followed from the local
perspective in Indonesia—the quality of diagnosis and case management is
unknown, information regarding surveillance and outbreak prevention is
lacking and little evidence for how and if vector control programmes work exists.
Thus, the completeness and degree of implementation of dengue control
strategies needs to be evaluated at the local level.
3
Background
Indonesia is a large archipelago state in Southeast Asia, where the transmission
of dengue has become hyperendemic (18,19) in recent decades. Dengue
underreporting is also evident in Indonesia, where it is potentially influenced by
the country’s geographical characteristics as well as its epidemiological, clinical,
laboratory and health system challenges (20). A segregated reporting and
recording system has exacerbated this situation among districts (21). The
performance of clinical surveillance is vital for effective disease management and
underreporting can directly aggravate an outbreak situation (22). Some
prevention efforts were developed to mitigate outbreaks, such as involving the
community in dengue prevention programmes and building a national report
system tiered according to all health sectors involved, e.g. hospitals. However,
assessment of how these programmes are implemented to support integrated
vector control has not yet been performed. Consequently, in this thesis, the focus
is on certain dimensions of dengue prevention and control, such as case
management and reporting, surveillance system and vector control.
Note: Continues line: authority

Dotted line: technical supervision
Figure 2. Actors involved in vector control in Indonesia.
4
Figure 2 illustrates the various actors involved in controlling dengue vectors in
Indonesia. The Ministry of Health controls all dengue programmes, which are
then implemented in stages (Provincial Health Offices, District Health Offices
and Primary Health Centres [Puskesmas]), although different regions are given
freedom to develop their own programmes. The Puskesmas is at the lowest level
of health care, directly dealing with the community. In addition, these centres
collaborate with other actors at the same level to run dengue programmes.
Current dengue fever situation in Indonesia

Indonesia is an archipelago in Southeast Asia and was the fourth most populous
state in the world in 2018 (23), with 266,794,980 inhabitants (24). In 2017, 57% of
the population was concentrated on Java Island (25), making Java the most
densely populated part of the country. Accordingly, Java has the highest number
of dengue cases in Indonesia. In January 2019, it was reported that more than 50%
of dengue cases in Indonesia—out of a total of more than 10,000 cases—were
found on Java (26). However, underreporting of cases may disguise the real
dengue incidence situation.
Indonesia has been dengue-endemic for the past five decades, almost since the
first cases were discovered in Jakarta and Surabaya on Java island in 1968. During
the first outbreak in Indonesia, 58 dengue cases were reported and 24 of them led
to patient death (27). During the initial outbreak period, dengue spread rapidly
across the country, leading to dengue transmission quickly becoming
hyperendemic in the country (27,28,29), with cases continuing to increase sharply
as time passed. By the 2000s, the number of dengue cases continued to increase
(30,31) and four DEN Viruses, 1–4, came to be identified in Indonesia, with most
cases resulting from DENV-3 infection (29).
Dengue prevention and control in Indonesia

The government of Indonesia, through the Ministry of Health, has built vertical
programmes that are implemented in a tiered approach, from the top (national)
level to the bottom levels—i.e. provincial, district and sub-district—with the aim
to synchronously control and prevent the spread of dengue between levels. These
programmes integrate epidemiology surveillance, vector control, public health
campaigns as well as education, training and research (32). Dengue programmes
5
were immediately initiated as soon as the dengue virus was first discovered in
Indonesia in 1968. In a situation in which there is absence of routine vaccination
and specific antivirals to combat the disease, the vector control approach is the
best way to mitigate transmission. Figure 3 illustrates the history of dengue
vector control programmes in Indonesia from their inception to the present.
Figure 3. The Indonesian dengue vector control journey: 1968–2020.
In the 1970s, a dengue vector control strategy—called the ‘firefighting’ strategy—

was established. This strategy involved perifocal spraying of the area within a
100-metre radius from the houses of positive dengue cases and it also included
health education and case management. Perifocal spraying was conducted only
when an outbreak was in progress, targeting adult mosquitoes (33). Health
education was conducted in several ways and through the involvement of
various sectors, with the aim to change the behaviour of people (34,35). Case
management was undertaken at health facilities to prevent dengue fatalities,
such as diagnosis, laboratory tests and triage management decisions (11).
In the 1980s, the use of larvicides was implemented on a massive scale to

complement the perifocal spraying method. This programme was modified
during the 1986–1999 period to a selective larviciding, which was only
implemented in cities that had dengue haemorrhagic fever cases for three
consecutive years in order to avoid resistance development in the mosquitoes. To
strengthen selective larviciding, it was complemented by two cycles of fogging
(weekly intervals) in villages with a high prevalence of dengue haemorrhagic
fever cases in 1990–1991 (31).
6
In 1992, the Ministry of Health initiated the so-called 3M programme, where the
three Ms stand for Menutup, Menguras and Mengubur, meaning water container
covering, water container cleaning and discarded water container burying. This
was later followed by the 3M plus programme, which included specific activities
that aimed to reduce mosquito breeding places and to educate people about
protective behaviours. The 3M programme was implemented together with the
so-called Jumantik programme—a community-based programme in which ‘larva
monitoring cadres’ (LMCs) or ‘Jumantik’ were employed at the village level to
monitor and support local cleaning activities in private as well as public areas.
Larva monitoring cadres continue to be recruited from communities and
typically tend to be women. LMCs have the responsibility to perform door-to-
door visits in order to inspect for larvae presence at residential houses and to
perform health education activities (36,37).
In 2004, the government introduced the Communication for Behavioural Impact

(COMBI) programme as one possible dengue control approach, where education
activities are conducted that aim to change behaviour in relation to mosquito nest
eradication (PSN) implementation through local socio-cultural activities. Three
years later, the COMBI was combined with PSN to strengthen the programme
and promote community participation in it (38). In 2015, the Indonesian
government further introduced the One-House One-Jumantik (1 rumah 1
Jumantik) program, as a form of community participation in dengue control, to
complement the Jumantik programme that had run previously. This program
required every house to actively participate in monitoring for larvae existence in
their homes by implementing the 3Ms (39,40).
The Indonesian government responded to the release of WHO guidelines in 2012

by strengthening its previously built control and prevention system, directing it
towards the WHO’s target of reducing the dengue burden (50% mortality) by
2020. In addition, the government aimed to strengthen not only vector control
but also hospitals, surveillance systems and early warning systems but also to
encourage research that aims to provide input on dengue control policies in this
country.
7
Dengue diagnostics enforcement tool
According to the 2012 WHO guidelines, in order to reduce 50% of dengue
mortality by 2020, two major paths should be taken by each country: 1)
improving case management and diagnosis to prevent dengue mortality and 2)
improving technical capacity, building at organizational and individual levels
(11).
For the provision of accurate and efficient diagnosis, rapid laboratory tests and
early dengue response are essential elements of clinical care, corresponding to
the WHO path. In addition, clinical incidence data are important for preparing
outbreak control, particularly in relation to early recognition of a clinical
problem. Laboratory testing using non-structural protein 1 (NS1), as well as both
antigen and Enzyme-linked immunosorbent assay (ELISA), can provide early
diagnosis in febrile patients as a marker of severe dengue infection (41). Using
NS1 disease surveillance can be performed effectively to also act as an effective
control measure.
The WHO states that several examinations can be performed to confirm dengue.
During the early stage of infection—or up to the first six days of illness (febrile)—
virus isolation and viral nucleic acid or antigen detection are the best methods
for diagnosing dengue infection. At the end of the acute phase, on the other hand,
immunological tests are the method of choice for diagnosis (42,43). Hence,
recognizing the febrile phase is essential for a doctor to determine the supporting
diagnosis examination. The problem arises because some people still have low
awareness of fever as a dengue symptom (44). This problem occurs in practically
any country in which many infectious diseases are found with similar symptoms,
such as malaria and influenza, that causes acute febrile illness (45).
Virus culture assays are generally conducted through the inoculation of samples
(serum, plasma or buffy coat) into mosquito cell lines, such as C6/36 and AP61,
or mammalian cell lines, such as Vero and LLC-MK2 (46). Virus RNA detection
can be discovered through the polymerase chain reaction (PCR) from tissues,
blood or sera gathered during the acute phase of the infection using primers
(47,48). These two assays require specialized expertise, a long period of time and
are expensive. Furthermore, an RT-PCR (Reverse Transcription Polymerase
Chain Reaction) can also be conducted, however, this test is costly. Serology (anti-
8
dengue IgG and IgM) and routine hepatology tests are commonly used today.
Unfortunately, these examinations have the disadvantage of not being able to
detect dengue early on because new sufferers can only have blood samples taken
for the above test starting from the third to the fifth day of experiencing a fever
(49,50).
Dengue diagnostics workflow, case management and case reporting

Diagnosis begins when a patient attends a health facility with symptoms that
correspond to febrile symptoms. A doctor first records the patient’s medical
history (anamnesis) by asking for chronology, symptom recognition and fever
onset. The assessment further guides the doctor to decide whether to use
laboratory testing or the rapid NS1-test to confirm the disease. Clinical judgment
is made to determine the degree of infection severity and the course of treatment
as well as whether or not the patient needs to be hospitalised or can be sent home
with observation after educating the patient.
The Indonesian health system implements a tiered order, from the local to the
national levels, as shown in Figure 4. Health data go from a Primary Health
Centre (PHC), called Puskesmas, or a relevant health facility to a District/City
Health Office (DHO/CHO), then continue on to a Provincial Health Office (PHO),
ultimately reaching the Ministry of Health. In DHO and PHO levels, the hospitals
have a position equal to the health office.
According to Indonesian health regulations, once a patient is diagnosed as

dengue positive, the so-called hospital early warning report (KDRS) must be sent
to a DHO within the first 24 hours for prevention purposes, which is in line with
the WHO guidelines. The KDRS should be reported ultimately, accurately and in
a timely manner (51). As soon as they receive the KDRS, the DHO coordinates
with the PHC to conduct an EI.
A PHC officer visits the dengue patient’s address to inspect 20 houses in the
neighbourhood—or within a 100-metre radius—to seek other people who have a
fever without a clear cause. Furthermore, this officer inspects potential breeding
places in the area for the presence of larvae. These two pieces of information must
be reported to the DHO immediately so that the prevention policy can be
executed. If one or more persons in the vicinity are found with a dengue infection
9
or more than three people are suspected to have dengue—and if there are ≥ 5%
of larvae found in containers—fogging, education, larvae cleaning activities
should be undertaken (14,38).
Figure 4. Illustration of the Indonesian health system.

Source: The Republic of Indonesia Health System Review (2017) (52).
10
Integrated surveillance and outbreak preparedness
The WHO states that dengue surveillance can be conducted in passive and active
forms for both entomological and epidemiological surveillance (11). In order to
achieve the WHO goal of reducing the dengue burden by 50% by 2020, a robust
surveillance system for improving dengue reporting, prevention and control is
needed. The primary purpose of dengue surveillance is to identify early signs of
outbreaks and allow timely prevention measures to be applied. Surveillance is
closely related to effective and accurate dengue diagnostics in clinical care, as
mentioned in the previous section. A responsive surveillance system is able to
avoid disease outbreaks by recognizing occurring cases as early as possible. Case
surveillance is performed by recognizing fever and dengue haemorrhagic fever
cases and then reporting these cases to health authorities (53), while the objective
of vector surveillance is to observe the Aedes population (39) under the umbrella
of Indonesian regulation Kepmenkes No. 581 of the year 1992 (38).
Success of dengue surveillance depends on the active participation of many

different stakeholders, including health authorities, health facilities,
communities and individuals. In Indonesia, dengue surveillance is conducted in
a tiered mode, from the lowest to the highest levels. Community participation
means engaging people, both individuals and groups, so that they become
involved in decision-making as well as in practical activities that concern their
health and well-being (54). In disease control, community participation usually
implies that people are included in actions that have a positive impact on their
health (55).
Integrated vector management

In the current challenge of vaccine development (56), integrated vector control is
an effective and efficient approach for reducing the burden. Controlling dengue
vectors is approached by eliminating sources—such as containers that could
potentially be mosquito breeding places—by covering containers or, in some
cases, using insecticides to kill the mosquitoes in their aquatic stage of
development (11). All resources should be deployed, such as vector control
integration within the health system, adaptive management of vector control and
cooperation with other sectors (34).
11
In line with this, dengue vector control in Indonesia is developing in two ways—
through chemical treatment and environmental management. Chemical
treatment is effective for a short period of time (57), thus environmental
management—elimination of mosquito breeding sites—is the preferred option
(58). Community participation in dengue prevention is implemented through the
3M programme, as mentioned before. This programme was complemented with
the Jumantik programme, which employed cadres to monitor larvae presence in
communities. The cadres then report back to the village office and PHC
(Puskesmas) (21). Recently, this programme has been enhanced to ‘One-House,
One-Jumantik’ (‘Satu Rumah Satu Jumantik’) (59).
12
Study aim and objectives
Dengue is a severe global threat because transmission escalates quickly and
produces enormous costs, requiring many resources for its control. The WHO
encourages the reduction of the dengue burden through five technical elements,
four of which are implemented in Indonesia: diagnosis and case management,
integrated surveillance and outbreak preparedness, sustainable vector control
and implementation research. However, evidence regarding how these elements
are implemented and interact at the local level is lacking.
Overall aim
To provide in-depth understanding of dengue prevention and control in
Yogyakarta, Indonesia, in order to contribute to strengthening the country’s
health system and the implementation of standardized and well-accepted
dengue control strategies.
Specific objectives
1. To assess knowledge levels, attitudes and practices towards dengue and
vector control in Yogyakarta in order to support development and
implementation of vector control strategies;
2. To study the feasibility of using a control card to engage the community
in vector control activity;
3. To assess the implementation of the ‘Jumantik’ vector control
programme;
4. To investigate the hospital-based dengue surveillance system from the
perspective of clinical and administrative staff in order to explore
potential reasons for case underreporting.
13
Materials and methods
Study location
Yogyakarta, where the study was conducted, is a city on Java Island, which is
part of Indonesia. This city covers 32,5 Km² (60) and has 413,961 inhabitants (data
from 2018) (61) (Figure 5). Yogyakarta is a city with good quality of services,
consisting of 14 sub-districts and 45 village administrations. Health services in
this city are provided by 25 PHCs and 9 general hospitals.
The health system in Yogyakarta is tiered, from the DHO to the PHCs and then
the community. The DHO is the community’s advisor for disease prevention and
control programme. The PHCs execute the programme in collaboration with the
community.
Figure 5. City of Yogyakarta on Java Island in Indonesia.

Source: https://www.google.com/maps/place/Yogyakarta.
Study design
The research undertaken for this thesis employed multiple methods, including
quantitative, qualitative, and mixed-method approaches. First, a quantitative
study was performed to assess the knowledge, attitudes and practices of people
in relation to dengue (Objective 1). Second, a quasi-experimental study was
conducted to study the feasibility of using a control card (Objective 2). Third, a
14
mixed-method approach was employed to assess the opinions of various
stakeholders about the Jumantik programme (Objective 3). Finally, a qualitative
approach was applied to explore dengue case management and reporting
practices at local hospitals (Objective 4). The location of the objectives in relation
to the thesis framework is presented in Figure 6.
4 2 1
3
Figure 6. Positions of research objectives within the thesis framework.
Data collection and analysis
Community knowledge, attitudes and practices as a foundation for

intervention development (Objective 1)
A total of 521 households in two Yogyakarta villages—namely, Mantrijeron and
Demangan—participated in this study. Convenience sampling was applied to
select households due to resource limitations. Each household was represented
by one family member who was selected based on the following inclusion
criteria: (1) people of productive age (≥ 15 years of age) (62,63), having lived in
the study area for more than one year, (2) being able to communicate verbally
and in written form. People who had lived in the villages for less than one year
were excluded from the survey.
During the Knowledge, Attitude and Practice (KAP) survey, participants were
asked to answer a total of 29 questions, which were divided into four main
categories: 1) socio-demographics of respondents (sex, age, education,
occupation); 2) knowledge (disease, agents, symptoms, transmission, treatment);
15
3) attitudes (who's at risk, importance of container cleaning, seriousness of the
disease) and 4) precautionary practices (container cleaning, protective
behaviour). The questions related to knowledge and practices were designed as
multiple-choice items. The questions related to attitudes were designed as
statements and the responses were measured using a 4-point Likert scale, from
‘strongly disagree’ to ‘strongly agree’, which also included an optional ‘I do not
know’ answer. Correct answers on knowledge and practice questions were
scored with 1 point, except for one especially important practice question
addressing container cleaning practices. This item was scored from 0 to 3, with 3
representing the best practices and 0 the worst practices. Maximum possible
knowledge and practice scores were 8 and 11, respectively. Attitudes were scored
from 0 to 4, where the highest score represented the most proper or positive
attitude with respect to the topic. The lowest score (0) represented the least
proper or the most negative attitude. The maximum possible score for attitude
was 32.
The first analysis was descriptive, presenting total and mean scores for each
element—knowledge (K), attitudes (A) and practices (P)—according to the socio-
demographic characteristics of respondents. Bivariate logistic regression was
used to analyse the association between K, A and P scores and the socio-
demographic characteristics. The KAP total scores were divided into either poor
or good—it was considered good when participants obtained a score that was ≥
80% of the overall score and poor when their score was < 80% (64,65).
Executing the control card as a vector control intervention (Objective 2)

This vector control intervention was performed after the KAP survey. The trial
involved the same research area with the KAP survey, which was divided into
one intervention and one control site. Mantrijeron was selected as the
intervention location and Demangan as the control location. The control card
feasibility study began on June 1, 2014 and ran for eight consecutive weeks.
Prior to starting the study, 76 volunteer field workers—representing different

geographical sub-areas (called RW) within the Mantrijeron village region—were
informed about how the study should be monitored. Subsequently, they
distributed control cards to 2,440 households in their respective RW. Container
cleaning practices were regularly monitored by these field workers, who checked
16
the water containers and the card usage through random visits to 10 households
on a weekly basis. During the second month of the study, this monitoring was
executed every second week.
To evaluate whether control cards enhanced people’s cleaning practices, this

feasibility study had a pre-post intervention-control design. Pre and post the
number of larvae infested houses and containers were executed through random
sampling in both Mantrijeron and Demangan. All potential indoor and outdoor
mosquito breeding places were checked in the selected homes. The sample size
was calculated using Statcalc Epi Info 7.
The outcome of the feasibility study was evaluated by comparing the number of
positive containers/houses for larvae pre and post the intervention between the
intervention group and the control group using a Poisson regression model. This
analysis used time parameters (pre/post) and group parameters
(intervention/control) to estimate additional changes over the study period
resulting from the intervention by interacting the time variable with the group
variable longitudinally.
At the end of the control card study, a short survey was conducted among the
team of field workers who conducted the monitoring in order to assess their
experiences and opinions about control cards and their feasibility as a stand-
alone intervention.
Exploring the implementation of the ‘Jumantik’ vector control programme

(Objective 3)
This study originated from the previous study in which we identified weaknesses
in vector control engagement level in the community. This investigation was
directed to the working areas of the PHC (Puskesmas) Umbulharjo 1 (UH 1). This
centre is responsible for four villages: Warungboto, Pandean, Sorosutan and
Giwangan. According to Puskesmas UH 1 data, during the 2009–2017 period,
Sorosutan village had the highest average number of dengue cases, while
Giwangan had the lowest. Hence, the study was conducted in Giwangan village,
under the assumption that they were implementing good dengue vector control.
17
The study population consisted of 42 larva monitoring cadres in Giwangan. For
the quantitative approach, the study instrument was a questionnaire that
addressed the work of larva monitoring cadres—inspired by the Health Belief
Model perspective. This model predicts the health-related behaviour of people
through various constructs: perceived susceptibility, severity, motivation, benefit
and barrier (66,67). Our instrument used a 5-point Likert scale. Before data
collection began, the study instrument was tested with larva monitoring cadres
outside of the research area. After testing, 4 out of 20 questions were removed
and the overall Cronbach’s alpha for the 16 remaining items and the final
instrument was 0.81—and was thus considered to be reliable. SPSS Data Entry
Station release 24.0.0.1 was used to calculate data obtained from 35 larva
monitoring cadres participating in the survey. Data checks were performed for
consistency and descriptive statistics were calculated.
To complement the information gathered from survey answers, in-depth

interviews were conducted with the stakeholders involved in dengue vector
control—namely, 2 larva monitoring cadres, 2 community members, 1 head of a
community group and 1 surveillance officer from the Yogyakarta DHO. The
interviews aimed to further explore the opinions of people about the work of
larva monitoring cadres in order to identify potential weaknesses in the
programme. Interviews were transcribed verbatim, followed by familiarisation
with the material. Qualitative thematic analysis was used to analyse the data.
Manual coding was done by two researchers, grouping of codes into sub-themes,
re-coding iteratively and last was reporting the result.
Assessing the hospital dengue surveillance system: Case management and

reporting (Objective 4)
This study was based on in-depth interviews with a total of 16 informants: 4
paediatricians, 5 general practitioners, 3 internists and 4 medical record officers.
Purposive sampling was applied to select respondents, according to the
following criteria: 1) had worked in the hospital for more than 1 year, 2) was a
health professional and 3) was involved in dengue case management and
reporting. The sample consisted of respondents from both private and state
hospitals and aimed to obtain rich material about the current situation in
Yogyakarta. We sent invitations to 4 hospitals—asking potential respondents to
join the study—and ended up with a total of 16 participants that fulfilled the
18
necessary criteria—1 participant per profession and hospital. In the end, 1
participant could not participate because of lack of time and 1 hospital sent 2 GPs
to 1 interview.
Face-to-face interviews were conducted at the informants’ offices using a semi-

structured interview guide. The guide was developed on the basis of preliminary
results from a previous questionnaire study, conducted among GPs at private
and public hospitals in Yogyakarta (unpublished work). The preliminary results
indicated some potential weaknesses in dengue diagnostics, as well as reporting
routines and practices, at both system and individual levels. Hence, the guide
consisted of 20 open-ended questions that aimed to explore the informants’
experiences regarding all major processes that rule diagnostics, treatment and
reporting of confirmed dengue cases to the health authorities. The guide covered
the following themes: i) experience in dengue treatment, including raising the
alarm about dengue cases at the hospital, ii) procedures for diagnosing a dengue
patient, iii) efforts to improve and update their dengue knowledge, iv) case
reporting routines and practices (called Kewaspadaan Dini Rumah Sakit [KDRS] in
the local language) and v) how dengue management relates to health insurance
(financing). Written informed consent was requested from participants prior to
beginning the interviews. The interviews lasted for 30 to 60 minutes and were
audio-recorded and transcribed verbatim. Field notes were taken during the
interviews and were afterwards summarised to the participants. SS performed
the interviews in Bahasa, Indonesia. Follow-up questions were posed to further
probe for information that could increase the understanding of the system under
study. Saturation was reached after fifteen interviews were performed.
Qualitative content analysis was used to capture the manifest content in the data.
All transcripts were converted into rich text format and imported into the Open
Code software 4.03 for analysis. Open Code is an open-source software,
developed by Umeå University, Sweden (http://www.phmed.umu.se/enheter/
epidemiologi/forskning/open-code/). The analysis was conducted in four steps:
i) contextualization, ii) re-contextualization, iii) categorisation and iv)
compilation [18]. Four researchers, with a public health background, performed
the coding simultaneously to maintain trustworthiness during the data analysis.
As part of this process, the researchers met and held a discussion every second
week.
19
Ethical considerations
Participation in the research study was voluntary. Data collection took place at
participants’ houses or in their work settings.
Prior to the data collection, a written informed consent form was given to the
participants. The researcher verbally explained the research purpose before
signing. All participants were free to withdraw from participating in the research
at any time and without having to present a reason for doing so. All necessary
approval protocols followed and the consent forms were approved by the Ethical
Board of Universitas Ahmad Dahlan, Indonesia. Data were saved in a computer
that was protected by a password and only the research group could access them.
Data were presented so that no informants or their individual information could
be identified.
20
Results
This chapter presents the most critical findings, organized according to specific
aims.
Dengue and vector control knowledge, attitudes and practices in

Yogyakarta (Objective 1)
Community is an essential element of dengue prevention and control. A proper
understanding of dengue can increase the awareness of people about outbreak
prevention. In this study, low levels of knowledge and engagement were
reported.
In total, 521 individuals participated in the knowledge, attitudes and practices

survey (Table 1). More than half (50.7%) of the respondents were female. This
group obtained better knowledge, attitudes and practices scores than the male
respondents. More than 30% of the respondents were 45–59 years old. People 30–
44 years of age acquired the best mean score on knowledge, attitudes and
practices in comparison to other age groups. Almost 60% of our respondents had
graduated from secondary school. People who held a university degree had
better scores for knowledge, attitudes and practices than other education groups.
Many of the participants (36.1%) worked in the private sector. People who
worked in the government sector had better mean scores for knowledge and
attitudes than other occupations. Retired people and housewives obtained the
highest scores for practices.
21
Table 1. Participant characteristics and mean (SD) scores for dengue control knowledge, attitudes and practices.
Variable N (%) Mean Score

Knowledge (SD) Attitude (SD) Practice (SD)
All participants 521 (100%) 3.72 + 1.59 25.64 ± 3.55 9.18 + 1.25
Sex
Male 234 (44.9) 3.62 (1.47) 25.09 (4.10) 8.97 (1.41)
Female 287 (55.1) 3.80 (1.68) 26.12 (2.97) 9.36 (1.08)
Age group (years)
15–29 71 (13.6) 3.97 (1.43) 26.46 (2.71) 9.04 (1.35)
30–44 142 (27.3) 4.16 (1.59) 26.72 (3.80) 9.39 (1.16)
45–59 180 (34.5) 3.59 (1.64) 25.16 (3.40) 9.07 (1.36)
> 60 128 (24.6) 3.28 (1.47) 24.73 (3.53) 9.20 (1.12)
Occupation
Government sector 27 (5.2) 4.67 (1.17) 27.63 (2.73) 8.89 (1.71)
Private sector 188 (36.1) 3.74 (1.56) 25.96 (3.42) 9.13 (1.38)
Student 25 (4.8) 3.80 (1.47) 25.92 (2.87) 8.36 (1.18)
Seasonal worker 16 (3.1) 3.19 (1.97) 24.19 (1.60) 8.44 (1.93)
Retired 46 (8.8) 3.57 (1.53) 25.52 (2.69) 9.43 (0.95)
Housewife 160 (30.7) 3.83 (1.73) 25.94 (3.17) 9.42 (0.99)
Unemployed 59 (11.3) 3.15 (1.)20 23.41 (5.18) 9.20 (1.01)
Education
Primary 61 (11.7) 2.67 (1.54) 23.75 (3.82) 9.05 (1.62)
Secondary 311 (59.7) 3.79 (1.54) 25.80 (3.55) 9.24 (1.10)
University degree 126 (24.2) 4.25 (1.50) 26.59 (3.19) 9.15 (1.36)
Illiterate 23 (4.4) 2.74 (1.25) 23. 65 (2.01) 8.91 (1.47)
Table source: Sulistyawati et al. (2019) (44).
22
Knowledge questions had a low number of correct answers from respondents
regarding potential breeding places for Aedes and having prolonged fever as one
of the dengue symptoms. This is shown in Table 2.
Table 2. Knowledge regarding dengue agents, symptoms,

transmission and treatment.
Mantrijeron Demangan Total
Study Population
N = 257 N = 264 N = 521
Knowledge Item Correct Answer N (%)
Dengue agents, symptoms, transmission,
treatment
- DHF is an abbreviation for Dengue 93 (36.2) 109 (41.3) 202 (38.8)
Haemorrhagic Fever.
- Using repellent from morning until evening
72 (28.0) 71 (26.9) 143 (27.4)
is one way to prevent dengue.
- Having high and continuous fever for
71 (27.6) 72 (27.3) 143 (27.4)
several days is one dengue symptom.
- Paracetamol and sponging with tepid water
are types of first aid when infected with 72 (28.0) 65 (24.6) 137 (26.3)
dengue.
- Discarded material and bathtubs are
potential Aedes aegypti breeding sites inside 156 (60.7) 145 (54.9) 301 (57.8)
the house.
- Aedes aegypti biting time is from morning
99 (38.5) 96 (36.4) 195 (37.4)
until evening.
- Dengue cannot be transmitted by direct
210 (81.7) 216 (81.8) 426 (81.8)
contact with a dengue patient.
- Ditches are not potential breeding sites for
75 (29.2) 72 (27.3) 147 (28.2)
Aedes.
All questions related to attitudes received adequate responses, meaning that

most of the respondents had a positive attitude regarding dengue prevention and
treatment, such as reducing mosquito breeding places and treating family
members who have a fever (Table 3).
Table 3. Attitudes towards dengue fever (DF) prevention and

treatment.
Study Population
N = 257 N = 264 N = 521
Attitude Statement N (%)
I don’t bother with larvae in the indoor water container.
Strongly agree 7 (2.7) 6 (2.3) 13 (2.5)
Agree 4 (1.6) 11 (4.2) 15 (2.9)
Disagree 125 (48.6) 129 (48.9) 254 (48.8)
23
Study Population
N = 257 N = 264 N = 521
Strongly disagree 120 (46.7) 116 (43.9) 236 (45.3)
Don’t know 1 (0.4) 2 (0.8) 3 (0.6)
I need to take my family member to the hospital immediately if infected with DF.
Strongly agree 143 (55.6) 131 (49.6) 274 (52.6)
Agree 110 (42.8) 121 (45.8) 231 (44.3)
Disagree 1 (0.4) 6 (2.3) 7 (1.3)
Don’t know 1 (0.4) 2 (0.8) 3 (0.6)
It is not necessary to clean the bathtub routinely if it is not dirty.
Strongly agree 4 (1.6) 4 (1.5) 8 (1.5)
Agree 32 (12.5) 43 (16.3) 72 (14.4)
Disagree 164 (63.8) 166 (62.9) 330 (63.3)
Don’t know 1 (0.4) 2 (0.8) 3 (0.6)
It is necessary to brush bathtubs to eliminate mosquito eggs.
Strongly agree 108 (42.0) 112 (42.4) 220 (42.2)
Agree 133 (51.8) 138 (52.3) 271 (52.0)
Disagree 6 (2.3) 4 (1.5) 10 (1.9)
Don’t know 2 (0.8) 2 (0.8) 4 (0.8)
I leave unused plastic mineral water cans outside my house.
Strongly agree 4 (1.6) 5 (1.9) 9 (1.7)
Agree 9 (3.5) 14 (5.3) 23 (4.4)
Disagree 149 (58.0) 148 (56.1) 297 (57.0)
Don’t know 2 (0.8) 2 (0.8) 4 (0.8)
I don’t need to monitor larvae in my environment.
Strongly agree 3 (1.2) 3 (1.1) 6 (1.2)
Agree 22 (8.6) 31 (11.7) 53 (10.2)
Disagree 160 (62.3) 168 (63.6) 328 (63.0)
Don’t know 6 (2.3) 3 (1.1) 9 (1.7)
If I have a fever for three consecutive days without any other symptoms (influenza, cough,
diarrhoea), then I suspect that I have DF.
Strongly agree 46 (17.9) 49 (18.6) 95 (18.2)
Agree 182 (70.5) 174 (65.9) 356 (68.3)
Disagree 23 (8.9) 34 (12.9) 57 (10.9)
Don’t know 2 (0.8) 4 (1.5) 6 (1.2)
In my opinion, everyone has the same risk to get infected by DF.
Strongly agree 73 (28.4) 80 (30.3) 153 (29.4)
Agree 161 (62.6) 160 (60.6) 321 (61.6)
Disagree 19 (7.4) 14 (5.3) 33 (6.3)
Don’t know 2 (0.8) 4 (1.5) 6 (1.2)
24
Finally, different answers were provided by the respondents regarding dengue
prevention practices. For example, the usage of mosquito spray and coil received
the lowest response percentage from the participants (Table 4).
Table 4. Practices regarding DF prevention.

Study Population
N = 257 N = 264 N = 521
Practice Items Good Practice N (%)
- I pay attention to larvae
existing in indoor water 238 (92.2) 248 (93.2) 486 (92.7)
containers.
- I clean and brush water
containers if there are any 236 (91.5) 251 (94.4) 487 (92.9)
larvae inside.
- I clean my containers one to
239 (92.6) 242 (91.0) 481 (91.8)
three times a week.
- I always keep the water
174 (67.4) 166 (62.4) 340 (64.9)
containers at my house closed.
- I discard, cover or sell
discarded material outside the 255 (98.8) 258 (97.0) 513 (97.9)
house.
- All my family members are
responsible for cleaning water 254 (98.4) 262 (98.5) 516 (98.5)
containers.
- I clean water containers by
246 (95.3) 259 (97.4) 505 (96.4)
draining and brushing them.
- I use mosquito repellent. 161 (62.4) 160 (60.2) 321 (61.3)
- I use repellent, mosquito coil or
mosquito spray in mornings 60 (23.3) 53 (19.9) 113 (21.6)
and evenings.
Binary logistic regression analysis shows the factors that influence knowledge,
attitudes and practices towards dengue prevention, respectively. There was no
difference in knowledge between women and men (OR = 1.46, 95% CI: 0.33–6.44)
or between age groups (Table 5).
Regarding attitudes, women had a lower score on attitude (< 80% total score)
than men (OR = 0.45, 95% CI: 0.27–0.76). Age and attitude were also found to be
significantly associated. People aged 30–44 and 45–59 were 3.18 times (95% CI:
1.37–7.36) and 2.59 times (95% CI: 1.39–4.82), respectively, more likely to have a
higher score on attitude in comparison to the youngest age group (P = 0.05).
Those working in the private sector and housewives had 11.08 times and 2.50
25
times, respectively, higher score on attitude in comparison to people working in
the government sector (P = 0.05) (Table 6).
There was no difference in dengue practices by gender. However, those aged 45–
59 had two times better dengue prevention practices (P = 0.05). People who
worked in the private sector, seasonal workers and retirees had 72%, 82% and
78%, respectively, higher risk of worse practices than people who worked in the
government sector—the result was statistically significant (Table 7).
26
Table 5. Binary logistic regression analysis of factors associated to knowledge on dengue prevention
Knowledge category
Poor (<80%) Good(≥80%)
Socio-demographic characteristic Total response N OR (95%CI) P-value
N (%) N (%)
(%)
All Participant 521 (100) 507 (97.33) 14(2.67)
Sex
Male 234 (44.85) 228 (97.4) 6 (2.6) 1
Female 287 (55.15) 279 (97.2) 8 (2.8) 1.46(0.33-6.44) 0.61
Age
15 – 29 71 (13.55) 69 (97.2) 2 (2.8) 1
30 – 44 142 (27.29) 136 (95.8) 6 (4.2) 2.71(0.10-72.14) 0.55
45 – 59 180 (34.54) 175 (97.2) 5 (2.8) 5.69(0.38-84.57) 0.20
60 – 84 128 (24.62) 127 (99.2) 1 (0.8) 4.43(0.34-57.30) 0.25
Occupation
Government sector 27 (5.34) 27 (100.0) 0 (0.0) 1
Private sector 188 (2.67) 182 (96.8) 6 (3.2) *
Student 25 (4.77) 24 (96.0) 1 (4.0) *
Seasonal worker 16 (33.21) 15 (93.8) 1 (6.3) *
Retired 46 (3.05) 45 (97.8) 1 (2.2) *
Housewife 160 (3.78) 155 (96.9) 5 (3.1) *
Unemployed 59 (42.18) 59 (100.0) 0 (0.0) *
Education
Primary 61 (11.64) 60 (98.4) 1 (1.6) 1
Secondary 311 (59.64) 306 (98.4) 5 (1.6) *
Graduate /Post Graduate 126 (24.43) 118 (93.7) 8 (6.3) *
Illiterate 23 (4.39) 23 (100) 0 (0.0) *
*Not possible to estimate. OR: Odds ratio. CI: Confidence intervals
27
Table 6. Binary logistic regression analysis of factors associated to attitude on dengue prevention
Attitude category
Total response OR (95%CI) P-value
Poor (<80%) Good (≥80%)
Socio-demographic characteristic N (%)
N (%) N (%)
All Participant 521 (100) 263 (50.76) 258 (49.24)
Sex
Male 234 (44.85) 141 (60.3) 93 (39.7) 1
Female 287 (55.15) 122 (42.5) 165 (57.5) 0.45 (0.27-0.76) 0.00
Age
15 – 29 71 (13.55) 22 (31.0) 49 (69.0) 1
30 – 44 142 (27.29) 48 (33.8) 94 (66.2) 3.18 (1.37-7.36) 0.00
45 – 59 180 (34.54) 110 (61.1) 70 (38.9) 2.59 (1.39-4.82) 0.00
60 – 84 128 (24.62) 83 (64.8) 45 (35.2) 0.89 (0.50-1.60) 0.71
Occupation
Private sector 188 (2.67) 89 (47.3) 99 (52.7) 11.08 (2.89-42.34) 0.00
Student 25 (4.77) 9 (36.0) 16 (64.0) 1.97 (0.89-4.36) 0.09
Seasonal worker 16 (33.21) 12 (75.0) 4 (25.0) 1.36 (0.37-5.01) 0.64
Retired 46 (3.05) 24 (52.2) 22 (47.8) 1.03 (0.25-4.10) 0.96
Housewife 160(3.78) 78 (48.8) 82 (51.3) 2.50 (0.96-6.50) 0.05
Unemployed 59 (42.18) 47 (79.7) 12 (20.3) 1.35 (0.54-3.41) 0.51
Education
Primary 61 (11.64) 50 (82.0) 11 (18.0) 1
Secondary 311 (59.64) 149 (47.9) 162 (52.1) 0.62 (0.18-2.16) 0.46
Graduate /Post Graduate 126 (24.43) 46 (36.5) 80 (63.5) 1.93 (0.66-5.69) 0.22
Illiterate 23 (4.39) 18 (78.3) 5 (21.7) 2.52 (0.81-7.89) 0.11
OR: Odds ratio. CI: Confidence intervals

28
Table 7. Binary logistic regression analysis of factors associated to practice on dengue prevention
Practice category
Total response
Socio-demographic characteristic N (%) Poor (<80%) Good (≥80%) OR (95%CI) P-
value
N (%) N (%)
All 521 (100%) 130 (25.38) 391 (74.62)
Sex
Male 234 (44.85) 68 (29.1) 166 (70.9) 1
Female 287 (55.15) 62 (21.6) 225 (78.4) 0.66(0.38-1.13) 0.13
Age
15 – 29 71 (13.55) 23 (32.4) 48 (67.6) 1
30 – 44 142 (27.29) 26 (18.3) 116 (81.2) 1.37(0.57-3.33) 0.47
45 – 59 180 (34.54) 49 (27.2) 131 (72.8) 2.00(1.00-3.99) 0.04
60 – 84 128 (24.62) 32 (25.0) 96 (75.0) 1.19(0.65-2.18) 0.56
Occupation
Private sector 188 (2.67) 49 (26.1) 139 (73.0) 0.28(0.09-0.87) 0.02
Student 25 (4.77) 12 (48.0) 13 (52.0) 0.52(0.23-1.15) 0.11
Seasonal worker 16 (33.21) 8 (50.0) 8 (50.0) 0.18(0.05-0.66) 0.01
Retired 46 (3.05) 7 (15.2) 39 (84.8) 0.22(0.06-0.75) 0.01
Housewife 160 (3.78) 30 (18.8) 130 (81.3) 1.56(0.52-4.61) 0.42
Unemployed 59 (42.18) 13 (22.0) 46 (78.0) 0.63(0.24-1.64) 0.34
Education
Primary 61 (11.64) 14 (23.0) 47 (77.0) 1
Secondary 311 (59.64) 74 (23.8) 237 (76.2) 2.17(0.74-6.33) 0.15
Graduate /Post 126 (24.43) 33 (26.2) 93 (73.8) 1.91(0.74-4.92) 0.17
Graduate
Illiterate 23 (4.39) 9 (39.1) 14 (60.9) 1.63(0.58-4.57) 0.34
29
Control card feasibility study (Objective 2)
In total, 2,440 control cards were circulated—approximately 30 cards per sub-
area. We found that the level of community participation in the intervention was
insufficient. Our intervention using control cards to monitor community activity
in relation to cleaning action received low engagement from the community.
Following the intervention, the number of containers infested with larvae
significantly increased in the intervention group in comparison to the control
group (IRR = 1.71; 95% CI: 0.87–3.36). Correspondingly, the number of larvae-
positive houses increased in the intervention group (IRR = 1.42; 95% CI: 0.69–
2.92), although not significantly.
According to the community, some reasons given for low participation included
lack of time due to work as well as the opinion that larvae monitoring should be
done by cadres or the government and not by them.
Implementation of the ‘Jumantik’ vector control programme (Objective

3)
Most of the 35 respondents in the quantitative study survey were females,
generally 33 to 69 years of age—with more than half between 33 and 45 years of
age. More than half (51.4%) had graduated from senior high school and 30% had
graduated from junior high school. The majority (> 70%) of the respondents were
housewives. Most of the participants came from families with low- or medium-
income levels (Table 8).
30
Table 8. Larva monitoring cadre’s socio-demographic characteristics.
Demographic Characteristic Number of Participants

N (%)
Age Group (year)
- 33-45 18 (51.4)
- 46-50 6 (17.2)
- 51–69 11 (31.4)
Education Level
- Primary education 2 (5.7)
- Junior high school education 12 (34.3)
- Senior high school education 18 (51.4)
- Diploma education 1 (2.9)
- Bachelor/Master education 2 (5.7)
Occupation
- Labour/seasonal worker 1 (2.9)
- Housewife 25 (71.4)
- Entrepreneur 9 (25.7)
Income Level
- High-income level 8 (22.9)
- Medium-income level 12 (34.2)
- Low-income level 15 (42.9)
Table source: Sulistyawati et al (Manuscript).
Table 9 presents the characteristic of our qualitative informants. Of the 6

informants, five were female and one was male—all informants were more than
40 years old. Two informants were larva monitoring cadres and another two
informants represented the community. A community group leader also
participated in this study, who had graduated with a diploma in education. The
last informant was a DHO staff, with a bachelor’s degree, and was the person
responsible for the dengue programme in Yogyakarta City.
Table 9. Characteristics of qualitative phase informants.
Code Sex Age Education Occupation Subject

(year) Role
W01 Female 46 Senior high Not working LMC
school (housewife)
W02 Female 49 Senior high Private sector Community
school (clinic
administration
staff)
31
Code Sex Age Education Occupation Subject
(year) Role
W03 Female 62 Senior high Not working Community
school (housewife)
W04 Female 42 Primary Not working LMC
school (housewife)
W05 Female 57 Diploma Not working Community
(housewife) group
leader
D06 Male 54 Bachelor Civil servant DHO staff
From the survey, it was found that, generally, LMCs thought of dengue as a
dangerous illness that could infect everyone. Respondents answered that they
were able to take the time to exchange information and track larvae in their
habitat. More than 60% of LMCs agreed that everyone has a similar risk of
contracting dengue fever. Although more than half of the respondents indicated
that they agreed with the benefits of the Jumantik and PSN programmes, several
LMCs argued that dengue education did not increase community knowledge.
Approximately 11% of the LMC did not consider free levels of larvae (LFR)—a
proportion of houses without mosquito larvae—to be one of their job outputs.
Larva free rate is a measure that compares the number of houses without larvae
detected with the number of houses inspected. The Indonesian government is
setting the target for LFR to 95% in order to control dengue.
LMCs generally stated that they have not identified any barriers to performing
their duties in terms of time or salary. This was also reinforced by their
declarations of intent and willingness to perform their duties. The majority of the
respondents disagreed with the argument that limitations impaired their ability
to do their jobs. However, a limited number of LMCs shared having time
constrains for public education and routine LMC sessions. Approximately 70%
of LMCs indicated that they could develop dengue information to be shared with
the public. They also said that they could find the time to operate as LMCs. The
majority suggested that they could fulfil their duties as LMC even without being
paid. However, 14% of LMCs did not express their opinion or their neutrality
regarding this comment. In addition, LMCs claimed that they did not agree with
the argument that they do not recognize dengue, although 17% of LMCs also
indicated that they did not have adequate information to do so (Table 10).
32
Table 10. The opinions of larva monitoring cadres about their dengue vector
control tasks
Statements Strongly Disagree Neutral Agree Strongly

Disagree Agree
N (%)
Opinions regarding dengue
infection susceptibility.
Everyone, at any age—including 0 (0.0) 2 (5.7) 0 (0.0) 22 (62.9) 11 (31.4)
me—is susceptible to dengue
infection.
Opinions regarding benefits of
the vector control programme.
- Dengue counselling will 2 (5.7) 0 (0.0) 4 (11.4) 19 (54.3) 10 (28.6)
increase the community’s
knowledge about dengue.
- The higher the larva free rate, 1 (2.9) 4 (11.4) 1 (2.9) 22 (62.9) 7 (20.0)
the higher the possibility of
reducing dengue cases is.
- If everyone finds time to 0 (0.0) 0 (0.0) 0 (0.0) 19 (54.3) 16 (45.7)
conduct mosquito breeding
place elimination, dengue cases
could be reduced.
Understanding of the severity.
I think dengue is a deadly disease. 1 (2.9) 5 (14.3) 0 (0.0) 21 (60.0) 8 (22.9)
Opinions regarding LMC action
barriers.
- I do not have time to talk about 8 (22.9) 26 (74.3) 0 (0.0) 1 (2.9) 0 (0.0)
dengue with the community.
- I do not have time to monitor 14 (40.0) 19 (54.3) 1 (2.9) 0 (0.0) 1 (2.9)
larvae at the houses in my
community.
- I do not have enough time to 8 (22.9) 24 (68.6) 1 (2.9) 2 (5.7) 0 (0.0)
attend LMC meetings at the
village office regularly.
- LMC salary is small, so I will 10 (28.6) 22 (62.9) 1 (2.9) 2 (5.7) 0 (0.0)
work as I want.
Opinion regarding willingness to
act as an LMC.
- I frequently attend LMC routine 0 (0.0) 0 (0.0) 2 (5.7) 26 (74.3) 7 (20.0)
meetings to update my
knowledge.
- I share my knowledge about 0 (0.0) 0 (0.0) 0 (0.0) 27 (77.1) 8 (22.9)
dengue with the community to
remind them about dengue.
- I monitor larvae in the 0 (0.0) 0 (0.0) 0 (0.0) 28 (80.0) 7 (20.0)
community regularly.
Perception of self-efficacy.
33
Statements Strongly Disagree Neutral Agree Strongly
Disagree Agree
N (%)
- I am able to transfer my 0 (0.0) 1 (2.9) 0 (0.0) 28 (80.0) 6 (17.1)
knowledge about dengue to the
community.
- I am able to spare my time to 0 (0.0) 1 (2.9) 0 (0.0) 28 (80.0) 6 (17.1)
monitor larvae in the
community.
- I am able to fulfil my 0 (0.0) 0 (0.0) 5 (14.3) 24 (68.6) 6 (17.1)
responsibility as an LMC even
without any salary. 5 (14.3) 24 (68.6) 0 (0.0) 6 (17.1) 0 (0.0)
- I do not have enough
knowledge about dengue.
In the qualitative study, several sub-themes emerged from the data. These sub-
themes are perceived roles and responsibilities, people perception of dengue,
perceived benefits of the Jumantik and PSN programmes, perceived barriers of
the LMCs task, perceived willingness to participate in the ‘Jumantik’ programme,
perceived capacity and self-efficacy as well as possible improvements for vector
control in the future.
Perceived roles and responsibilities

The ‘perceived roles and responsibilities’ sub-theme defines the expectation of
respondents that success in vector control requires the support of partners, such
as LMCs, the government, the village office, the sub-district office, the primary
health centre, the sub-districts and the city health office. These stakeholders
highlight the complexities of the current vector control structure and the various
functions they perform, as stated by the DHO officer.
With respect to the position of LMCs, one LMC reported that one of their duties
was to provide health education for the community. This was reiterated by the
community group leader and the DHO officer, both of whom confirmed that, in
their area, LMCs carried out larvae checks and provided health education for the
general public on the basis of the awareness reports they obtained at LMC
meetings. The DHO officer expanded on the duties of an LMC related to
supporting the PSN programme. LMCs also act as data suppliers for the DHO,
34
in terms of reporting on larvae present in the population, which are, thus, a
variable for the measurement of the larva free rate.
From the interviews, we learned that this role had not properly been carried out
by LMCs. For example, larvae inspections should be carried out at least once a
week; however, in practice, there are those that perform them only once a
month—that is, before data reporting. This provision is conveyed by DHO
officers.
This study also revealed the role of the PHC—namely, as a community group
supervisor and providing knowledge updates to the LMC. What is very
important about the role of the PHC is that it becomes a mediator between LMCs
and the community when LMCs have difficulty conducting larvae inspections.
People´s perception of dengue

This sub-theme reflects people's views on the severity of dengue fever.
Participants were concerned about possible mortality as a result of infection.
Society and LMCs both agree that dengue is a serious disease. The LMC survey
shows that 60% claim that dengue can cause death. The community group leader
stated that, even though the community members were aware of the seriousness
of dengue, this was not fully reflected in the community level of concern because
the community stated that they were tired of hearing information related to
dengue. More than half of the respondents said that dengue can infect anyone.
However, LMCs expressed concern because the community ignores fever as a
symptom of dengue.
Perceived benefits of the ‘Jumantik’ and PSN programmes

This sub-theme focuses on the opinions of informants about the ‘Jumantik’ and
PSN programmes. In general, there was a consensus among respondents that
vector control through mosquito nest eradication (PSN) was the best approach
for controlling dengue spread. This was revealed by some participants in this
study, including the informant from DHO and members of the public.
The leader of the community group said that, until now, the ‘Jumantik’
programme has run less than optimally; however, the value of the ‘Jumantik’
35
programme in raising global understanding of dengue was reiterated. The
informant stressed that the effectiveness of the ‘Jumantik’ programme relied on
the multi-cooperation between all stakeholders, such as the government (DHO,
PHC) and the society. LMCs made the same point in the quantitative session,
where more than half of them (54.3%) claimed that vector management is
everyone's role and duty.
Perceived barriers to LMCs’ tasks

The survey results showed that more than 70% of respondents stated that they
did not experience problems in carrying out their duties as LMCs. However, a
few of them also stated that they did not have time to attend regular meetings
(5.7%) and conduct larvae inspections (2.9%). This was also raised in an interview
session with an LMC.
LMCs also stated that it was difficult to reach some members of the community
to carry out their duties and they reasoned that these members were embarrassed
by the condition of their bathroom so that they did not allow LMCs to enter and
carry out inspections.
From the survey results (Table 10), it can be concluded that LMCs have no
objection to continue working as LMCs without payment. This was also
conveyed during the in-depth interview sessions.
Perceived willingness to participate in the ‘Jumantik’ programme

This sub-theme defines the perceived willingness of each LMC and the entire
group to fulfil their duties. LMCs have the following duties, among others: to
conduct larvae inspections once a week, to update their knowledge and to attend
regular meetings. On the other hand, to support LMC performance, the public
needs to actively participate in mosquito nest eradication (PSN).
In the in-depth interviews it was reported that LMCs were compensated by the
redistribution of the village office budget. Even though LMCs were paid for their
work, getting someone to replace them was not easy because many people
refused to be LMCs. Hence, existing LMCs kept their role because no one else
was willing to take their position.
36
Perceived capacity and self-efficacy
In the interviews, the community group leader and community members shared
their opinion that LMCs had an adequate understanding of dengue because the
health authorities had educated them. The community group leader explained
that many LMCs had outstanding communication skills for coping with different
members of society and education—but some may fail to do that.
Possible improvements for vector control in the future

Community members and LMCs expressed their desire for dengue prevention
and vector control. They expected that the ‘Jumantik’ and PSN programmes
would perform well in the future. They expected to work together with all
stakeholders involved and did not feel like fighting dengue alone.
The community group leader underlined the importance of synergizing the

current ‘Jumantik’ programme with the new government policy—namely, ‘One-
House One-Jumantik’, which will be the foundation of dengue vector control in
the future.
Hospital-based dengue surveillance system: Case management and

reporting (Objective 4)
Generally, dengue prevention and control in Indonesia—including
Yogyakarta—is performed at two levels: the PHCs and the hospitals. The PHCs
are directly connected to the DHOs because the 2 institutions have the same
structure. The hospitals contribute to the success of dengue control and
prevention by reporting dengue positive cases within 24 hours of diagnosis to
the DHO. This acts as a starting point for conducting surveillance management
at the community level and, thus, for avoiding an outbreak.
Figure 7 shows how dengue case management in Yogyakarta, Indonesia is

conducted. Generally, prevention programmes use a syndromic surveillance
approach based on hospital and PHC reports. Patients with a fever can be
admitted to the health care facility (hospital or PHC) to get advice from a medical
doctor. Based on febrile phase symptoms, the doctor decides whether to use an
NS1 or a routine blood sample test. Platelets serve as an indicator for a suspected
dengue case to be hospitalised or sent home.
37
Figure 7. Dengue diagnostics, case management and reporting in Yogyakarta
Indonesia.
However, from this study, different challenges among the stakeholders involved
in dengue diagnosis and case reporting were observed. Some issues were related
to dengue diagnosis, including the low community awareness of dengue
symptoms—sometimes they could not explain the febrile phase history, which is
essential for clinicians to determine what tests to run and further treatment
course. Concerns about atypical symptoms and an increase in what they called
38
‘expanded dengue’ were raised, especially in children, among clinicians. The
rapid NS1 test was considered to support early and accurate dengue detection
and to, thus, reduce the risk of fatality. However, the use of the NS1 test was
arbitrary and considered to be an economic challenge.
Early warning reports (KDRS) from hospitals were not always submitted,
according to requirements, in the first 24 hours after diagnosis for various
reasons—including lack of regulation awareness, regulatory mismatches and
coordination challenges between hospitals and the local health authorities. There
were implications of a weak connection between hospitals and DHOs as
regulators of dengue prevention. In addition, inequalities in different hospitals’
prerequisites for dengue management, including updated knowledge about the
disease, were found.
The next section briefly describes the categories—and their sub-categories (in
bold)—that developed from the qualitative analysis and illustrates them with
certain selected quotations. Figure 8 shows the themes and categories of this
study.
Figure 8. Sub-categories and themes developed from the analysis.

Picture source: Sulistyawati et al. (2020) (68)
Challenging disease diagnostics

Challenges to disease diagnostics came from three sub-categories: ‘an ambiguous
and changing disease’, ‘varying prerequisites for NS1 utilisation’ and
39
‘inconsistent community attentiveness’. All three relate to the problem
concerning dengue diagnosis as a result of the changing dengue disease pattern,
which requires greater awareness about possible manifestations of this disease.
The following selected citations from the participants illustrate this case.
Currently, we are dealing with expanded dengue. Perhaps this

phenomenon makes it difficult for us to recognize dengue or we can say that
diagnosing dengue, without classic symptoms, is a challenge. So, in my
opinion, if we found a patient with classical dengue, it would be easy to
diagnose. (Ped-1)
If every single patient with suspected dengue was tested using NS1, it
would improve awareness because, nowadays, not every dengue patient
comes with classic dengue symptoms. However, the problem is the high
NS1 cost. Now, we use NS1 for patients because there is support from the
‘Eliminate Dengue Programme, which provides NS1 for free. Otherwise,
outpatients would have to pay IDR 300.000, which is expensive…. (Ped-
1)
…if I meet children, who have a fever, on the first day of the fever, but the
parents say that they don't have a thermometer, then I recommend for them
to go to the drugstore to buy a thermometer. Fever cannot be judged only
by feeling and by touching with the hand….’ (GPs-1)
Mismatch in regulatory frameworks and interplay with regulatory bodies

This category comprises several sub-categories: ‘immature insurance system’,
‘arbitrary documentation traditions and inappropriate workarounds’ and
‘friction between regulator and operator’. This category discusses the challenges
that dengue prevention and control face, specifically related to the regulation
discrepancy in several related agencies: hospitals, DHOs and national insurance
providers.
In BPJS, the NS1 antigen is covered but the result must be positive. If it is
negative—if negative—it is not covered. I do not know if this rule comes
from the BPJS or the hospital. I do not know. It's just that we are informed
that if NS1 is negative, it cannot be (covered). So, fortunately all patients
40
whom we have examined, the results of NS1 were positive so BPJS could
be claimed. (GPs-3)
NS1 is expensive. One, it is expensive, uh, and we will see the condition
first. Now, we have support from the ‘Eliminate Dengue’ programme. In
the past, there was no support. We do not have the heart. It is 300,000
(rupiah) for one patient. And for outpatients, this amount of money is a lot.
BPJS does not cover that. (Ped-1)
The DOH gives us, what do you call it, uh, a time period, if possible not
report it more than a week, but it is better to deliver it the first 24 hours.
(MRO-2)
What I dislike about them is that they schedule a meeting at the last minute;
for example, there is a meeting tomorrow and I am informed today. For
them, perhaps, three days is not the last minute for sending the invitation.
Yet, for us in the field, calling at night, ‘Doc, there will be a meeting
tomorrow…’. (Ped-1)
Unequal internal prerequisites for dengue management

This category represents the situation among hospitals at the research site. Two
sub-categories emerged from the interviews: ‘standard operating procedure not
standardised’ and ‘inconsistent conditions for knowledge updates’. We found
some variations among the hospitals in relation to dengue management as well
as regarding keeping staff informed and updated.
There is no SOP from [hospital name], but my guidelines are from the
WHO. Book, uh, WHO children service standard…. (GPs-3)
Also, about different SOP in different hospital. The GPs allows to practice
in three places. Something like that. If it happens here, we warn them. They
said, ‘Usually in hospital A, the patient is not hospitalised, Doc’. It turns
out that they also work at other hospitals and they have different
regulations there. (Ped-2)
41
Perhaps, most doctors, maybe, there are some who tend, uh, I know more
about the old ones. That’s number 1, number 2, perhaps too lazy to update.
(Ped-1)
I mean, my suggestion is that this hospital should support its doctors to

update their knowledge. We do not need to use, no need to send us to
seminars outside, we can use our internal doctors; for example, the
internists and the paediatricians…Not just the doctors, it can also be the
nurses, can be everyone. (GPs-3)
42
Discussion
This thesis studied dengue control and prevention in Yogyakarta, Indonesia. The
researcher assessed the status of dengue knowledge, the level of community
engagement and participation in vector control as well as dengue case
management and reporting routines in hospitals. The rationale behind this
research was that the community might play an essential role in reducing the
dengue burden because, through their participation and engagement, the dengue
prevention and control programme would be sustainable. Hospitals are a critical
pillar of surveillance because they generate the statistics about the actual dengue
burden, which is useful for health prevention authorities when planning the
dengue prevention and control programme. Likewise, it is beneficial for the
community to perform vector preventive measures. However, the system does
not support a control programme if it is not responsive.
This study explored the role played by the community in dengue vector control
and prevention. Some previous studies agreed that this approach was the
primary key to controlling dengue fever, as mentioned by the WHO in 2012—
namely, sustainable vector control. This activity is also part of surveillance and
outbreak preparedness. Larva monitoring cadres, as partners of the programme,
practically conformed to the current dengue guidelines, as did the hospitals in
their function as the vanguard for preventing dengue-related death resulting
from their responsibility to diagnose and manage cases. Hospitals, in addition,
were also part of the surveillance system by providing data input for the
prevention of transmission and dengue outbreak preparedness. Nevertheless, it
cannot be denied that there were weaknesses found in several aspects of dengue
prevention and control in Yogyakarta, Indonesia.
This discussion focuses on the most critical findings of this thesis, which are
presented in the following order. First, the consequences of insufficient
knowledge about dengue prevention and control that were identified among
various target groups during the studies are presented. Second, the complex
interplay between the stakeholders involved in dengue prevention and control is
elaborated because it threatens the effectiveness of community interventions as
well as the disease surveillance system. This is followed by a discussion on the
apparently inconsistent and incomplete standard operating procedures. Finally,
43
insufficient support for diagnosis and case management is touched upon,
followed by a look at the limitations and strengths of this study as well as
recommendations for future research and policy development directions.
Consequences of insufficient dengue prevention and control

knowledge
Knowledge is the foundation for people making decisions. Knowledge helps
someone understand and act to find a solution for a particular problem (69). It
was confirmed that the level of knowledge contributes to infectious disease
prevention behaviour (70). This thesis found knowledge gaps related to dengue
fever and control in all studied target groups—the community, LMCs and
hospital staff.
In the community, the overall knowledge, attitudes and practices related to

dengue were considered to be relatively adequate. However, we need to pay
attention to several aspects of vector control. First, awareness regarding the
mosquito outdoor breeding places and the importance of managing discarded
material outside the house were inadequate. In Indonesia, this might be the result
of ongoing dengue campaigns that are focused on mosquito breeding places
inside the house and seldom on those outside the house. On the other hand, the
waste disposal and recycling behaviour in Indonesia is still not sufficient in terms
of low knowledge levels about solid waste management (71,72). The link between
solid waste and dengue has widely been studied in the world, which has shown
that neglected solid waste has the potential to become a breeding site for Aedes
mosquitoes (73-75). The findings of this study are in line with those of some
previous research and reinforce that handling dengue vectors requires
multisectoral collaboration (11,76,77). The community needs to continuously be
accompanied, monitored and provided with good leadership in all sectors that
are involved in dengue prevention activities. In this manner, the community
would hopefully conduct dengue prevention through vector control voluntarily
because its members would realize that this is a shared need and responsibility.
Second, this study revealed that the community had low awareness when it came
to viewing fever as a dengue symptom. Doctors often received patients at late
stages of the disease because the community considered fever to be a common
disease symptom and delayed visiting a health care facility. Low awareness of
44
the community towards fever onset as a symptom prevents doctors from
establishing a timely diagnosis, thus posing a challenge. In the 2009 WHO
guidelines, it is written that fever onset is part of the general observations that
must be considered when accepting patients or suspected dengue persons (78).
This onset is used to calculate the estimated incubation period of the dengue
virus in the body of a patient and then to help determine further patient handling.
Our findings are supported by a study in Pakistan, which found that only 52% of
the respondents recognized that having prolonged fever could be a dengue
symptom (79). A similar study in Jamaica also reported that less than 50% of
people recognized this prominent symptom (80). In addition, the implication of
improper dengue symptom knowledge influences people’s health-seeking
behaviours (81) and many dengue cases can consequently be missed.
Knowledge gaps were also found among LMCs, particularly with respect to their
understanding of the larva free rate (LFR), which is an essential vector control
parameter. To the best of our knowledge, this thesis might constitute the first
study that elaborates on the challenges of that LMCs face in relation to vector
control as part of the ‘Jumantik’ programme. Previous studies have focused on
the effectivity of LMCs to improve the LFR (82,83) or on the level of LMCs’
knowledge regarding dengue (84). In this study, it was shown that LMCs did not
understand well the meaning and usefulness of the activities they carried out in
that role—even though having a good understanding of what one’s goal is can
motivate people to have higher job performance (85). In our study, it was
confirmed that some LMCs reported incorrect data about larvae inspections.
Lack of accurate data can contribute to a poor dengue integrated surveillance
system because wrong decisions could be made. Local authorities, in this case the
Yogyakarta District Health Office (YDHO), have tried to solve this issue. Thus,
to determine the LFR, the LMC larvae reports did not constitute all data but the
YDHO also utilized other data types, such as data obtained from epidemiology
investigation and periodic larva monitoring by a dengue operational working
group. Furthermore, in 2015, the central government launched the ‘One-House
One-Jumantik’ policy to strengthen existing programmes and to embrace
community involvement in monitoring the larvae in their respective homes,
aiming to reduce the central role of LMCs (86).
45
The gap between knowledge and practices that was found in the results of the
community-based KAP survey implies that people might be poorly motivated to
engage in vector control activities despite having good awareness of the practices
that health authorities recommend. Several studies have shown that knowledge
levels might directly influence dengue preventive practices (64,87). However,
there are other studies that have failed to establish a direct correlation between
knowledge and practices (70,88,89). Hence, we also need to look at people’s
motivation and not only at their knowledge levels. According to the so-called
Health Belief Model (HBM), people would not engage in healthy behaviour
unless they value the outcome related to that behaviour. Moreover, they need to
believe that that specific behaviour is likely to result in the desired outcome (90).
From the results of this study, it seems that people have learnt at least some
behaviours that can prevent the dengue disease—for example, how to get rid of
mosquito larvae. However, do they believe that their cleaning practices will
result in a mosquito larva decrease and, in the end, in a reduction of dengue
cases? Or do they feel that their work is meaningless? This depends on their level
of knowledge about the risks of getting dengue and how they perceive the risks
of not doing the work. This possibility is supported by a study by Wong et al.,
who found that people's perception of their susceptibility to dengue influenced
their dengue preventive behaviours (87). The motivation of people also depends
on whether they believe that their work has any effect—for example, that regular
cleaning will, indeed, result in a reduction in the larvae population and the
number of dengue cases. This requires feedback from the local authorities and,
therefore, it is essential to assess whether or not people have received any
feedback from them regarding their work. If the answer is yes, then how was this
information delivered and was it received as intended? Feedback from
authorities is valuable because the results of this study revealed that some people
often refused LMCs to conduct larvae inspections in their house.
Critical knowledge gaps were found among the doctors at the hospitals. The first
gap is related to the reports that should be sent to the DHO (KDRS), which is a
first step for preventing dengue transmissions and outbreaks. Some doctors did
not acknowledge the importance of this procedure for prevention activities in the
field. For example, one respondent said that the person in charge of this report
was the medical report officer and not themselves. The next gap is related to the
46
finding that not all doctors had updated knowledge about the current dengue
situation and management, which could influence their competence, capacity to
perform an accurate diagnosis and minimize the occurrence of infection in the
patient, as stated in an Ecuadorian study (91). There were additional differences
between the sampled hospitals, with some providing the opportunity for their
staff to update or share their knowledge both within the hospital—through
routine gatherings—or in external forums—through conferences and scientific
meetings. It is important to remember that strengthening the competency of
health workers, including doctors, is one of the mandates of the 2012 WHO
guidelines (11). To overcome the potential imbalance of knowledge possessed by
doctors, as mentioned, competencies can gradually be built with individual
certificates for those doctors who are allowed to treat dengue.
Dengue diagnosis has always been compared to other diseases that have almost
the same symptoms, such as influenza, typhus and leptospirosis. At the same
time, doctors are faced with changes in dengue virus strains in some Indonesian
cities that can confound dengue diagnosis (92-94). This might explain why some
doctors claim to encounter different symptoms in their patients. Again, doctors
must continuously update their knowledge about both the shifting dengue
disease itself and how patients are treated in order to avoid misdiagnosis.
Complex interplay of the stakeholders involved in dengue prevention

and control
Efforts to prevent and control dengue cannot be made separately by the parties
involved but a synergy between them is required. Sometimes, due to the
complexity of the party structure, communication is not smoothly delivered
between them and the aims of the dengue prevention and control programme
are not conveyed and understood correctly. The WHO clearly states that, to
establish a healthier future for people, effective, integrated and coordinated
communication between the parties involved is needed (95). Communication is
also an essential aspect of well-being, including disease prevention, health
promotion and quality of life (96). What people say influences their risk
perceptions (97), emotions (97,98) and uncertainties (99) about health behaviours.
Communication also aims to engage stakeholders from all decision-making
levels—from individual to organizational. For instance, a valuable experience
47
was given by the Ugandan government in relation to fighting malaria, where a
harmonized communication framework for malaria control was implemented
(100).
This thesis elaborated that communication challenges compromise the complex

interplay of the stakeholders involved in dengue prevention and control on
several levels. This includes the interplay between health authorities and
hospitals as well as between various stakeholders involved in the community-
based vector control initiatives.
Communication is a crucial aspect of delivering knowledge and understanding

to other people with the aim to engage them in behavioural change. Based on our
study, the ‘Jumantik’ programme did not run optimally partly due to
communication challenges that led to community resistance to programme
participation. The LMCs’ communication process with the community did not
seem to attract the audience’s attention and, as a consequence, a lack of
engagement in the ‘Jumantik’ programme and a low trust in the capability of
LMCs by the community may have been created.
According to the WHO, community engagement not only refers to involvement

or participation but also to ownership and action in a particular health
programme. This action requires many aspects of life to be addressed, such as
cultural, social, political and economic, with communication playing a vital role
in this process (101-103). The lack of ownership may reflect Indonesia’s policy
direction history, which largely uses a top-down approach that fails to capture
community opinions. Accordingly, urban communities’ voluntary participation
in vector control needs to be intensified, especially by promoting the
participation of all stakeholders.
Community refusal of LMC inspections also appeared to relate to the

community’s low trust in their working capacity. This situation is most likely
closely connected to the specific context mainly related to the economic and
educational status. In the urban area, most residents have higher education levels
and are at a higher economic level in comparison to LMCs themselves. Due to
these gaps, some community members did not respect LMCs and ignored their
message. Even though the goal of health communication is to generate change,
48
including health behaviour change (104), this may not be achieved unless the
receiver has an interest in and trusts the message sender—in this case, LMCs.
Increasing trust should be done from both sides: the community and LMCs. In
the community, the massive campaign about the importance of 3M and
‘Jumantik’ should be scaled up using proper media. Assessment of what popular
media should be chosen for this setting is needed, especially at this time when
social media has become a trend in health communication. Correspondingly,
social media could be an alternative tool for sending health messages and
information in real time (105). From the LMC side, capacity building to improve
the competence of LMCs is required, as mentioned earlier.
At the same time, the success of dengue prevention and control is not only
determined by communication at the bottom level but also at the top level.
Hospitals send dengue case information to DHOs, who are the entities
responsible for the community’s prevention policy. When this connection is not
working correctly, the prevention path is disturbed, which might lead to an
outbreak occurrence.
Communication challenges were also experienced between hospitals and health

authorities. The majority of the respondents said that they did not receive any
feedback from the DHO about dengue—even though these data were needed for
doctors to increase their awareness and for hospitals to be prepared logistically.
This weak link between the two sectors may illustrate the fragmented health
system of Yogyakarta. This situation might be not visible but it nevertheless
results in unintended consequences, such as inefficiency and ineffectiveness
(106,107). Indeed, the Indonesian government has implemented several reforms
in recent decades, including the move from a centralized to decentralized health
system, particularly in the budgetary aspect (108). After more than two decades
of implementation, some improvements in the performance of the health system
have been reported. However, there are also reports about structural challenges
that make overall management problematic (109).
Inconsistent and incomplete standard operating procedures

Standard operating procedure (SOP) refers to a document that defines current
operations to certify that procedures are performed correctly and with
consistency (110). Public health practice requires timeliness, consistency,
49
technical excellence and accountability (111). Accordingly, in the SOP, it is
important to avoid a misleading procedure. This thesis report that there were
challenges with the existence, implementation and compliance of various
standard operating procedures in the system under study.
At the community level, of which LMCs are a part, it was found that they did not
always provide accurate larva monitoring reports. This can be an indication of
low feelings of ownership of the programme or of a failure to understand the
long-term consequences that may arise from the false or inaccurate reports that
they provide, such as unknown priority DHF vector control areas due to poor
data (112). However, this should be recognized as a weakness of the existing
reporting system and not solely as an LMC failure. Monitoring and evaluating
the effectiveness, efficiency and acceptability of the ‘Jumantik’ programme is
suggested to be carried out by following the input, process, output and outcome
logic model (113,114). This logic model is commonly used in some countries
when a particular health programme is executed. For example, in Iran, this model
was used to assess the performance of the public health and primary care system
(115). According to the Indonesian Ministry of Health, every year the local
government must conduct an evaluation of the DHF control programme (116);
however, to what extent this is done and how this process impacts the
programme itself are areas that need to be explored further. Several studies in
Indonesia have assessed the ‘Jumantik’ programme (117-119). However, this is
not routinely done, so these studies cannot catch the inter-period problems due
to the community's dynamic.
The SOP challenge was also reported in the hospital setting. Two main problems
were identified regarding the KDRS SOP and patient-handling SOP. The
procedures for sending KDRS reports from the hospital to the DHO were not
always followed. Referring to Figures 2 and 3, the position between the health
office and the hospital is parallel. They have a partnership function, which
neither of them can force. A hypothesis is that this may be one main reason why
their collaboration is not functioning well. Indeed, they carry out different
functions—while the hospital carries out a curative function, the DHO carries out
tasks related to prevention and population education. However, this does not
mean that the two are separate; instead, they should support one another.
50
Some hospitals developed their own SOPs, while others did not have an SOP for
dengue in place. Indeed, the central government provides guides for the
treatment of patients, which some hospitals then translate into SOPs. This lack of
standardisation and synchronisation makes the system not function well, posing
serious risks for patients and reducing the quality of services. In fact, the presence
of SOPs for clinical practice is required in order to maintain a higher level of
patient treatment in critical circumstances (120). The competent authorities must
overcome this problem—namely, the non-standardization of SOPs in existing
hospitals. This SOP gap can potentially impact the opportunity for patients to
receive excellent, proper and safe services that follow the quality of care principle
established by the WHO, which states that quality of care must underlie
universal health coverage (121).
Considering that SOPs are either lacking or inconsistent at several levels,

reorientation between the actors involved is needed to achieve good
collaborative governance (122,123). The actors must have the motivation,
principles and capacities to carry out joint actions and have a positive impact on
the existing system.
Insufficient support for diagnosis and case management

Having an accurate diagnosis while in clinical care, followed by a proper
reporting system, is mandatory for achieving early detection, outbreak
prevention and adequate surveillance. To obtain an accurate diagnosis, a
combination of proper judgment—based on the patient’s medical history and a
valid test instrument—is required. Our results suggest that some doctors had
difficulties diagnosing dengue when a patient came with complications,
especially in paediatric patients. Moreover, the usage of NS1 as a rapid diagnostic
test is still limited by the national insurance system and is thus arbitrarily used
among clinics. The situation may get worse due to the community’s low
awareness of the fact that fever is one of dengue symptoms.
The NS1 antigen test is an instrument test that has been confirmed as useful in an
endemic setting for early dengue detection (124,125), which means that this tool
may also be beneficial in an Indonesian setting. However, the usage of NS1 faces
an important limitation—it is costly. In addition, doctors seem not to share the
same views regarding its value or which patient groups should have access to it.
51
Study limitations and strengths
Study limitations
In the KAP study, the validity test for the instrument was rather low (0.6), which
could lead to an underestimation of the knowledge score. But it was still in the
reliable category.
In the eight-week control card test, this was not enough time for a test that
involved behavioural changes. In addition, it was conducted during a
transitional period, when the number of dengue cases was not very high. Hence,
the community's awareness of dengue could still be low. In addition, after our
test was completed, we were informed that our control area had just finished
receiving treatment from other researchers. Thus, this could potentially bias the
results of our test.
In the ‘Jumantik’ programme study, we used the respondents’ self-reported

answers, which means that the answers cannot be confirmed. Second, there is a
risk of courtesy bias—on the part of LMCs—in selecting an answer on the basis
of an assumption and in order to have a positive response. Indonesia is a large
country with hundreds of districts/cities. Although, in general, they have the
same dengue programme, the achievements and problems that each face can be
different because each region has its own characteristics and differences. Hence,
it is necessary to be careful when generalizing the results of this study.
In the hospital-based study, neither respondents nor hospitals in the sample were
randomized. Hospitals were identified by the researcher and hospital
administration was named by the respondents. However, saturation was
attained and content was found to be rich in complexity, covering many essential
facets and viewpoints. Another possible drawback is that the content was
translated and interpreted in two distinct languages—thus, some essential
concepts could have been lost in translation.
52
Study strengths
This research contributes to the dengue programme in Indonesia, in general, and
in Yogyakarta, in particular. Thus far, there have been many studies about
dengue control but they are often conducted in relation to one aspect only.
Therefore, the fact that this study can provide a more comprehensive picture of
the public health context is considered to be its strength.
53
Conclusions and recommendations
This thesis presented several challenges related to dengue prevention and control
efforts in Yogyakarta, Indonesia, from the perspective of community
empowerment in vector control and hospital-based diagnosis and reporting.
These potential challenges include: insufficient knowledge, ineffective
communication due to the complexity of the system structure and absence of
SOPs at some levels. Given these challenges, the following recommendations are
given.
First, some weaknesses were found in the foundation of integrated dengue

prevention and control—such as community empowerment—and in the accurate
diagnosis and reporting system. Several stakeholders involved did not have
appropriate knowledge and motivation to achieve the programme’s goals.
Improving the knowledge of the community and LMCs through proper health
promotion media could be a good alternative. Community involvement through
the ‘One-House One-Jumantik’ program may strengthen community
empowerment and reduce dependency on current LMCs.
Second, at the hospital level, the hospital authorities need to standardize the
SOPs and certify doctors to treat dengue patients while maintaining
professionalism and securing the quality of health services. Finding a capacity
building mechanism that is easily accessible and up to date for physicians is
essential, given that they are very busy with service activities.
Future studies could further elaborate on the community’s desire to participate

in vector control. Also, simplifying the system structure to avoid a
communication gap—bidirectionally (cases from hospitals and disease burden
from health authorities to clinicians)—is recommended for decision-making
purposes.
Fourth, there was good support for vector control. But, it is important to establish
clear rules or SOP that LMCs must follow when reporting their activities. PHCs
and DHOs are recommended to assess LMCs performance regularly to monitor
their effectiveness.
54
Last, the potential for the NS1 test to be used as a first assessment for dengue
suspected cases is undeniable. Further studies could assess the effectiveness of
the NS1 test on reducing the number of hospitalized dengue patients and its cost
effectiveness.
55
Acknowledgements
This dissertation is the culmination of work and learning over a period of several
years. It would not have been possible to complete without the support of many
people. I am fortunate to have had a supervisory team whose members
complement one another. I am very thankful to them.
Åsa Holmner—my principal supervisor on this PhD journey. I am blessed and

lucky to have you as my mentor. Thank you for your time and for the motivation
and dedication you provided. Your feedback was always optimistic and positive
and you guided me to look at my research from different perspectives. You are
not only my supervisor but also my friend. Thank you!
Maria Nilsson—my first co-supervisor. I thank you for your support when I
found myself in tough situations. You always listened to me and helped as much
as you could, with your calm and expertise. Thank you for being like a second
mother to me when I was far away from my family.
Lutfan Lazuardi—my co-supervisor. It was a pleasure to work with and learn

from you when I began my PhD journey. Thank you for your thoughtful
feedback.
Miguel San Sebastian—my examiner. I am grateful for the time you dedicated
to listening to me and to discussing possible solutions when I was in a tough spot.
I will never forget all your valuable advice.
To my PhD colleagues at Epi (current and former)—thank you for your

friendship and support. Even though I cannot mention you all by name here,
believe me when I say that I enjoyed all the time we spent together during this
journey. I am fortunate to know you all both personally and professionally.
To my colleagues at UAD—Rahma, Yuni, Yanti and Tutik—thank you for your

friendship and support throughout our career development journeys.
To my family in Umeå—Nawi Ng, Ailiana Santosa and Septi Kurnia—thank

you for your kindness throughout the duration of my visit to Umeå.
56
Finally, to my family. First, to my husband—Suyanto—words will never be
enough to express my love for and gratitude to you. I thank you for always
supporting me in difficult situations. You always remind me that God—Allah—
is the greatest helper in all hardships. Thank you for taking care of our children
during my stay in Umeå, as well as during day-to-day activities when I was
focused on my writing. Second, to my children—Anindya Keisha Putri and M.
Bisma Hanindito—you are always in my heart. Thank you for being sweet kids
throughout my absence even though I was not always there to take care of you.
My prayers always accompany you. Third, to my parents—Sugimin and
Ramini—there are no words that can represent how grateful I am to have you. I
thank you for your constant prayers. I love you!
57
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Dengue Prevention and Control in Indonesia

A case study in Yogyakarta City

Department of Epidemiology and Global Health

(QS. Yunus, 57)

Also, for Suyanto, Cicha, Dito and my Parents…

with love and gratitude.

Study aim and objectives .................................................................................................... 13

Keywords: dengue, control and prevention, community empowerment, diagnostic and

Kata kunci: demam berdarah, kontrol dan pencegahan, pemberdayaan masyarakat,

I. Sulistyawati S, Astuti FD, Umniyati SR, Satoto TBT, Lazuardi L, Nilsson

Combatting dengue fever is challenging because of the complex interplay

The WHO encourages sustainable dengue control, considering it to be a low-cost

At the national level, Indonesia follows and implements the WHO’s

Note: Continues line: authority

Figure 2. Actors involved in vector control in Indonesia.

Current dengue fever situation in Indonesia

Dengue prevention and control in Indonesia

Figure 3. The Indonesian dengue vector control journey: 1968–2020.

In the 1970s, a dengue vector control strategy—called the ‘firefighting’ strategy—

In the 1980s, the use of larvicides was implemented on a massive scale to

In 2004, the government introduced the Communication for Behavioural Impact

The Indonesian government responded to the release of WHO guidelines in 2012

Dengue diagnostics workflow, case management and case reporting

According to Indonesian health regulations, once a patient is diagnosed as

Figure 4. Illustration of the Indonesian health system.

Success of dengue surveillance depends on the active participation of many

Integrated vector management

Figure 5. City of Yogyakarta on Java Island in Indonesia.

Figure 6. Positions of research objectives within the thesis framework.

Data collection and analysis

Community knowledge, attitudes and practices as a foundation for

Executing the control card as a vector control intervention (Objective 2)

Prior to starting the study, 76 volunteer field workers—representing different

To evaluate whether control cards enhanced people’s cleaning practices, this

Exploring the implementation of the ‘Jumantik’ vector control programme

To complement the information gathered from survey answers, in-depth

Assessing the hospital dengue surveillance system: Case management and

Face-to-face interviews were conducted at the informants’ offices using a semi-

Dengue and vector control knowledge, attitudes and practices in

In total, 521 individuals participated in the knowledge, attitudes and practices

Variable N (%) Mean Score

Table 2. Knowledge regarding dengue agents, symptoms,

All questions related to attitudes received adequate responses, meaning that

Table 3. Attitudes towards dengue fever (DF) prevention and

Table 4. Practices regarding DF prevention.

*Not possible to estimate. OR: Odds ratio. CI: Confidence intervals

OR: Odds ratio. CI: Confidence intervals

Implementation of the ‘Jumantik’ vector control programme (Objective

Demographic Characteristic Number of Participants

Table 9 presents the characteristic of our qualitative informants. Of the 6

Table 9. Characteristics of qualitative phase informants.

Code Sex Age Education Occupation Subject

Statements Strongly Disagree Neutral Agree Strongly

Perceived roles and responsibilities

People´s perception of dengue

Perceived benefits of the ‘Jumantik’ and PSN programmes

Perceived barriers to LMCs’ tasks

Perceived willingness to participate in the ‘Jumantik’ programme

Possible improvements for vector control in the future

The community group leader underlined the importance of synergizing the

Hospital-based dengue surveillance system: Case management and

Figure 7 shows how dengue case management in Yogyakarta, Indonesia is

Figure 8. Sub-categories and themes developed from the analysis.