How Do the System Determinants Differ Between Regions with Regional Health Insurance (ASKESDA) and the One Without?

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 Evidence Summit for Reducing Maternal and Neonatal Mortality in Indonesia

How the system determinants differ between regions with regional health insurance (ASKESDA) and the one without?

Implementation of UHC including increased utilization of MNH services and improved financial protection of the poorest and most vulnerable

Table of contents

Table of contents

1. Introduction

A. Rationale

B. Focal questions

2. Methods

A. Eligibility Criteria

Type of studies

Type of population

Type of interventions

Type of comparators

Type of outcome measures

B. Evidence Gathering

Evidence resources

Search strategy

C. Evidence Selection

Selection of studies

D. Evidence Review

Assessment of risk of bias in included studies

Data extraction and management

3. Results

Study Selection

Study Characteristics

Quality assessment

4. Discussion

Study limitation

5. Conclusion

6. Recommendations

References

Appendix

Appendix 1. List of institutions

Appendix 2. Search strategy

Appendix 3. Quality assessment tools

Appendix 4. Results of individual qualitative studies

List of Tables

Table 1.  The description of population, intervention, comparator and outcome

Table 2. Characteristic of Quantitative Study

Table 3.Characteristic of qualitative study

Table 4. Risk of Bias – quantitative studies

Table 5. Results of individual quantitative studies

List of figures

Figure 1. PRISMA Flowchart: Summary of searching activity for selected studies

1.    Introduction

A.    Rationale

Since 2004, according to act no 40 regarding national social security system, Indonesian government introduce national health insurance (Jaminan kesehatan nasional – JKN) for families with lower socio-economic levels.(1) In addition, since 2014, most social insurance schemes (including Askes, Jamsostek, and Jamkesmas) have been merged under a single-payer umbrella – JKN – and Jampersal (Jaminan persalinan – a special program financed by the central government that provided a comprehensive maternal health benefit package) has been dismantled.(1, 2) JKN was slightly over 156.8 million people covered in the year 2015 and increased to around 171.7 million people in 2016. Due to limited national health budget, the inclusion criteria used might not cover everybody who need subsidy, or vice versa. In this case, the local governments are required to subsidize more people using local budget, called ASKESDA (asuransi kesehatan daerah or JAMKESDA (jaminan kesehatan daerah) – the local government-financed social insurance programs that complement Jamkesmas in several districts and provinces).   The aim of both JKN and ASKESDA are to improve access to health care for the poor and the poorest Indonesian.(1, 2)

The ASKESDA/Jamkesda was implemented with various procedures based on capacity of the local government. The first provinces that implemented this program was Aceh and Bali. Data at the national  level  shows that ASKESDA/ Jamkesda covers 13.5% of the population (in year of 2012). (2) In addition, based on estimates from SUSENAS 2011-the magnitude of the extent of insurance coverage is similar to that found in IDHS (Indonesia Demographic and Health Survey) 2012- Jamkesda/ASKESDA and Jamkesmas/JKN together cover about 21% of population in terms of maternal health. Based on the report of the BPJS 2017, for the integration of ASKESDA/Jamkesda into the Program JKN, up to 6 January 2017 there are 433 Districts/cities that have done the integration and there are still 81 counties that have yet to implement the integration. As for the number of participants who were paid by local governments was 15,779,685 inhabitants.

It is assumed that the local governments who have commitment to provide local health insurance subsidy are those who are also committed to other effort to improve the health care facilities and services in their areas, including for maternal and neonatal care.  For example, applying better budget allocation for maternal and neonatal health, better fee scheme for certain health providers, better scheme to improve health providers’ competence, distribution policy of health providers, better provision of drugs and equipment in health facilities, recruitment of specialists for district hospital to ensure the availability of 24/7 days emergency care, better health information system, having MoU with neighbor district/city, having MoU with private hospital, clear and effective referral system, etc. However, information about beneficiaries of the local health insurance are not available, hence it is difficult to assess whether Jamkesda provides additional benefits and their beneficiaries do not overlap with those of Jamkesnas/JKN.(2)

We performed this review to evaluate whether there are differences on system determinants (the availability (coverage) and the utility (access) of health care facilities, as well as the quality of health services and human resources (health workers)) between regions with regional health insurance (ASKESDA/ Jamkesda) and those without ASKESDA/ Jamkesda.

B.    Focal questions

We addressed the question: “How the system determinants differ between region with regional health insurance (ASKESDA) and the one without?” (Bagaimanakah perbedaan sistem determinan antara daerah yang memiliki jaminan kesehatan daerah dengan daerah yang tidak?).

Provide an explicit statement of the question(s) this protocol will address, including the scope of the focal question.

In this protocol, we will address the question: “How does the health system determinants differ between regions with the regional health insurance and not ?” (Bagaimanakah perbedaan sistem determinan pada daerah yang memiliki jaminan kesehatan daerah dengan daerah yang tidak?). This focal question was derived from the question on how does the different governance system (delivery system and financial system) in each district relate to the maternal and neonatal health. Since the topic area 3 discuss the implementation of universal health care, in this protocol, we will focus on health system sub-determinants of health financing.

The description of PICO are listed in Table 1, while search term are listed in appendix 2.

Table 1.  The description of population, intervention, comparator and outcome

P Region (province, district, city or municipality)
I Regional or local health insurance (jaminan kesehatan daerah -JAMKESDA)
C Non-regional health insurance
O System determinant, includes the availability (coverage) and the utility (access) of health care facilities; quality of health services and human resources (health workers)

2.    Methods

A.    Eligibility Criteria

Type of studies

Since the objective of evidence summit is to assemble all existing evidence relevant to maternal and neonatal mortality in Indonesia including to identify evidence gaps, all type of literature, including published or unpublished, in form of scientific articles or government/institution reports were eligible for review. No publication date or publication status restrictions were implied, but we limited to articles that was written in English of Bahasa Indonesia. For study reports, we did not limit study design, but only included those that were conducted in Indonesia.

Type of populationThe diseases or conditions of interest should be described here, including any restrictions such as diagnoses criteria, age groups and settings.

The articles were eligible if involving regions in Indonesia, either province, district, city, or municipality.

Type of interventions

Interventions should be defined here. Restrictions on dose, frequency, intensity or duration should be stated. If the intervention is not available, this section can be omitted.

In this review, we included articles that discuss health insurance scheme that was organized as regional or provincial governmental programs in Indonesia (ASKESDA/Jamkesda).  The scheme must have a sufficient legal basis, for example approved by regional legislators.

Type of comparators

Comparators should be defined here. Restrictions on dose, frequency, intensity or duration should be stated. If the comparator is not available, this section can be omitted.

The articles were included if comparing the regional or provincial health insurance to non-regional health insurance schemes. These included Nationally organized health service (compulsory universal coverage, national general revenue, financing, and national ownership of health sector inputs; JKN/Jampersal), any national social insurance (compulsory universal (or employment group–targeted) coverage under a social security (publicly mandated) system financed by employee and employer contributions to nonprofit insurance funds, with public and private ownership of sector inputs), private insurance( employer-based or individual purchase of private health insurance and private ownership of health sector inputs)4, or no implementation of health insurance.

Type of outcome measuresThe measures of outcomes or situations should be defined here. It is normally expected that the conclusions of the review will be based in large part on these outcomes

We included articles that evaluated system determinant as the outcome. This included human resources (health workers: doctors, nurses, and midwives), quality of services (maternal and neonatal morbidity and mortality, patient’s satisfaction), and  health facilities (the availability, the number, access to and level of health facilities: primary health centres, hospitals)

B.    Evidence Gathering

Evidence resources

In this review, we searched bibliographic sources i.e. MEDLINE and Google Scholar. Additionally, hand searching for dissertations, theses, conference abstracts/proceedings, government or non-government organizations program or project reports or documents, were also performed to the institutions listed in appendix 1. We also searched the reference lists of retrieved studies.

Search strategy

Two ERTs (RT and IK) defined the keywords based on the PICO and used the keywords to conduct the searching. No years of publication and language restriction placed on the search strategy.  All  search results were put on EndNote library and were uploaded to COVIDENCE

(Note: if there are any years of publication or language restriction, please justify the reasons for restriction)

C.     Evidence Selection

Selection of studies

Two ERTs independently screened the titles and abstracts identified from evidence gathering process. We discarded studies not meeting the eligibility criteria. For studies appearing to meet the eligibility criteria, or where there was insufficient information to make a clear decision, we obtained the full report and two ERTs independently assessed the full text articles to establish whether the studies meet the eligibility criteria. We conducted both process in COVIDENCE. Any discrepancies resolved by discussion within two ERTs.

D.    Evidence Review

Assessment of risk of bias in included studies

ERTs independently assessed risk of bias for each eligible study using modified quality assessment tools from Effective Public Health Practice Project (EPHPP) (Appendix 3). The domains that assessed were including selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, and global rating. We judged the studies to be at either strong, moderate, or weak quality which translated to low risk, low risk*, or high risk of bias. Any disagreements were resolved by discussion between two ERTs.

Data extraction and management

A standard extraction form designed in Excel by ER. For eligible study, the ERTS independently extracted the data using the data extraction form. If reported, information collected on:

  1. Article characteristics: Title, first author, journal name
  2. Methods: study design
  3. Population characteristics (specific necessary details)
  4. Outcomes: Coverage, Utilization and Quality

Any discrepancies resolved by discussion referring to the relevant study paper.

3.    Results

Study Selection

Figure 1 shows the number of and results of articles from the searching, selection and screening process. We identified 523 articles from Medline database and 293 articles from Google scholar. We first screened the articles based on the title and abstracts. We identified two studies compared health care utilization and satisfaction, before and after the implementation of regional health insurance in one region (3, 4)  Finally, we excluded these studies because did not have comparison between regions with and without regional health insurance. Therefore, we did not find any studies to be reviewed to answer the focal question.

Fig. I. Summary of searching process for selected articles (modified from PRISMA flowchart covidence)

4.     Discussion

Jaminan kesehatan daerah (JAMKESDA), the health insurance provided by local government, was initiated in 2009 because of limited national budget to cover health insurance for all Indonesian citizens. It is assumed that the health cares and system determinants in regions with both Jamkesmas and JAMKESDA are better compared to those without JAMKESDA. We aimed to perform a systematic review on this issue, however we did not find any studies or articles reporting comparison between regions with and without regional health insurance.  This might because of our literature searching was limited to published articles and limited data bases. We found two studies from Aceh comparing health care utilization and patients’ satisfaction, before and after the implementation of local health insurance. Aceh was the first province in Indonesia where people could attain universal health coverage and had implemented  its own universal coverage scheme called Jaminan Kesehatan Aceh (JKA) since 2010. The studies may provide information on the difference situation between those with and without JAMKESDA.

In general there was no difference in types of services provided by JAMKESDA and other health insurance, as the JAMKESDA program referred to standardize national MNH program. (3-7) With regard to maternal and neonatal health, JAMKESDA covers fully all maternal health care provided in government health care facilities. Delivery care was free and it was covered under all health insurance schemes in Indonesia. However, a study from East Java reported that in some regions Jamkesmas utilization was better than JAMKESDA. (8) The problem of the utilization was also coming from the issue of lacking of baseline data on poor population, thus sometimes the insurance did not delivered to the appropriate target. The local schemes may suffer from a lack of financial and human resources, and limited administrative capacity and technical expertise.

The health care utilization after JAMKESDA implementation was varied between regions. Two studies reported that JAMKESDA increased maternal services utilization.(4, 9) These findings were similar to that reported from Ghana (10) and China (11), where regional health insurance improve access to maternal care. The increase rate of ANC in Ghana after introduction of regional health care is even higher than Indonesia i.e, 15 %.(10) In Aceh, the regional health insurance is called Jaminan Kesehatan Aceh (JKA). After the implementation of JKA, the utilization of family planning services increased sharply to more than 80% in all insurance scheme groups.  (3) Also, there was an increase in caesarean sections among women in the wealthiest quartile, but no effect on the number of births attended by a trained professional. This is in line with the finding in China that identified more than 80 % increase rate of maternal care utilization was due to increase rate of caesarean section.(11)

Patients’ satisfaction has been increasingly recognized as an important outcome for health‑care delivery systems including in maternal and neonatal service. A study in Aceh showed that after JKA implementation, the satisfaction on of maternal health‑care services among women was increased. (4) This perhaps through the fact that receiving the new health insurance from the government makes the poor more satisfied with and grateful for the new service. For women who were covered by Askes and Jamkesmas, they may not have felt so impressed anymore because they had been covered by their insurance schemes for a long time. Improvements in ANC were also observed in terms of the depth of antenatal services provided. On the contrary, there were evidences from other studies that found that there was no different in services quality, in some aspects Jamkesmas was better than JAMKESDA (not specified which one)(5, 8) The client satisfaction on JAMKESDA were also captures in one qualitative studies conducted in Central Java. (12) In contrary, some qualitative studies reported a dissatisfaction of clients and also health providers on JAMKESDA. (7, 13) These warrant a further investigation on the real reason of satisfaction among clients and health care provider under the JAMKESDA insurance scheme, and whether it was influenced by specific regional characteristics.

5.    Conclusion

There was no evidence to evaluate the difference of system determinants between the region with regional health insurance (JAMKESDA) and the one without. However, it is good to keep in mind that regional schemes might be better in terms identifying and addressing regional needs of the population, also contribute to an increase in antenatal care visits and the probability of receiving basic recommended antenatal care services, and a decrease in home births/ lower percentage of mothers help by traditional birth attendance, especially for households that fall outside the target group of the national health insurance programs.

 

6.    Recommendations

  1. Improvement of publication and published report on JAMKESDA, esp. from the eastern region of Indonesia.
  2. Improvement of the quality of the studies that evaluate JAMKESDA. The study should have at minimum a bivariate analysis or comparison, not merely descriptive.
  3. Capacity building for researcher in maternal and neonatal health evaluation research, so they can locally and regularly evaluate the implementation of JAMKESDA and also JKN in their region. Several researches in this study showed good examples in their research method.
  4. Advocacy to the local government, so they can customize the MNH program according to their own region characteristics

Bibliographic of Included Studies

None


References

Referrence

1.  UU RI No 40/2004 tentang Sistem Jaminan Sosial Nasional., (2004).

2. International Labour Organization. Jamkesda – Regional Health Insurance for the Poor and Near Poor. 2012. .

3. Kesuma ZM, Chongsuvivatwong V. Utilization of the Local Government Health Insurance Scheme (JKA) for Maternal Health Services Among Women Living in Underdeveloped Areas of Aceh Province, Indonesia. Asia-Pacific journal of public health. 2015;27(3):348-59.

4. Kesuma ZM, Chongsuvivatwong V. Comparison of satisfaction with maternal health-care services using different health insurance schemes in aceh province, Indonesia. Indian journal of public health. 2016;60(3):195-202.

5. Ernawati T. Studi pelaksanaan kebijakan peraturan daerah jaminan kesehatan daerah sumatera barat sakato dalam menghadapi undang-undang sistem jaminan sosial nasional dan undangundang badan penyelenggara jaminan sosial tahun 2013. . J Kebijak Kesehat Indones 2013;2(3).

6. Yuniyati B, Sukini T, Kriswoyo P. Hubungan Program Jampersal dengan Cakupan K4 pada Ibu Hamil LINK. 2015;11(1).

7. Ariandini A, Warsito, Turtiantoro. Evaluasi Kebijakan Jaminan Kesehatan Daerah di Kabupaten Semarang Journal of Politic and Government Studies. 2015;4(3).

8. Budiarto W, Ristrini. Komparasi Implementasi Program Jamkesmas dan Jamkesda  di tiga Kab/Kota di Jawa TImur. Buletin Penelitian Sistem Kesehatan 2013;16(2):194-202.

9. Hartwig R, Sparrow R, Yumna A, Warda N, Suryahadi A, Redi A. Effects of decentralized health care financing on maternal care in Indonesia. . Institute of Health Policy and Management, Erasmus Universiteit Rotterdam, 2015.

10. Mensah J, Oppong JR, Schmidt CM. Ghana’s National Health Insurance Scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health economics. 2010;19 Suppl:95-106.

11. Long Q, Zhang T, Xu L, Tang S, Hemminki E. Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co-operative Medical System). Tropical medicine & international health : TM & IH. 2010;15(10):1210-7.

12. Subiyantara DA, Widayati W, Taufiq A. Kualtas Pelayanan Program Jamkesmas dan Jamkesda di RSUD Prof. Dr. Margono Soekarjo Purwokerto Kabupaten Banyumas. Journal of Politic and Government Studies. 2013;2(2).

13. Pipa F, Lengkong D, Rorong A. Efektivitas Program Pelayanan Jaminan Kesehatan Daerah (JAMKESDA) Di Rumah Sakit Umum Kota Bitung. Jurnal Administrasi Publik. 2015;2(30).

Appendix

Appendix 1. List of institutions

A.  Kementerian:

Kementerian Kesehatan:

  1. Sekretaris Jenderal
  2. Direktur Jenderal Pelayanan Kesehatan
  3. Direktur Jenderal Kesehatan Masyarakat
  4. Kepala Badan Pengembangan dan Pemberdayaan SDM Kesehatan (BPPSDM Kesehatan)
  5. Kepala Badan Penelitian dan Pengembangan Kesehatan (Balitbangkes)
  6. Sekretaris BPPSDM Kesehatan
  7. Kepala Pusat Perencanaan dan Pembangunan SDM Kesehatan
  8. Direktur Pelayanan Kesehatan Rujukan
  9. Direktur Pelayanan Kesehatan Primer
  10. Direktur Kesehatan Keluarga
  11. Direktur Promosi Kesehatan dan Pemberdayaan Masyarakat

 

Kementerian Riset, Teknologi, dan Pendidikan Tinggi:

  1. Sekretaris Jenderal
  2. Direktur Jenderal Sumber Daya IPTEK dan Dikti
  3. Direktur Jenderal Pembelajaran dan Kemahasiswaan
  4. Direktur Jenderal Riset dan Pengembangan

Bappenas:

  1. Kepala Bappenas
  2. Deputi Menteri PPN/Kepala Bappenas Bidang Pembangunan Manusia, Masyarakat, dan Kebudayaan
  3. Direktur Kesehatan dan Gizi Masyarakat
  4. Direktur Keluarga, Perempuan, Anak, Pemuda dan Olahraga

 

B.  Dekan Fakultas Kedokteran dan Fakultas Kesehatan Masyarakat:

  1. Universitas Indonesia (UI)
  2. Universitas Gadjah Mada (UGM)
  3. Universitas Padjajaran (UNPAD)
  4. Universitas Airlangga (UA)
  5. Universitas Hasanuddin (UNHAS)
  6. Universitas Diponegoro (UNDIP)
  7. `swUniversitas Sumatera Utara (USU)
  8. Universitas Andalas (UNAND)
  9. Universitas Sriwajaya (UNSRI)
  10. Universitas Sebelas Maret (UNS)
  11. Universitas Brawijaya (UB)
  12. Universitas Udayana (UNUD)
  13. Universitas Syiah Kuala(UNSYIAH)
  14. Universitas Katolik Atmajaya Jakarta (UAJ)
  15. Universitas Lampung (UNILA)
  16. Universitas Tarumanegara (UNTAR)
  17. Universitas Jenderal Soediman (UNSOED)
  18. Universitas Islam Indonesia (UII)
  19. Universitas Muhammadiyah Yogyakarta (UMY)

 

C.  Stakeholders bidang Kesehatan

  1. Asosiasi Institusi Pendidikan Kedokteran Indonesia (AIPKI)
  2. Asosiasi Institusi Pendidikan Ners Indonesia (AIPNI)
  3. Asosiasi Institusi Pendidikan Kebidanan Indonesia (AIPKIND)
  4. Asosiasi Institusi Pendidikan Tinggi Kesehatan Masyarakat Indonesia (AIPTKMI)
  5. Ikatan Dokter Indonesia (IDI)
  6. Ikatan Bidan Indonesia (IBI)
  7. Perhimpunan Perawat Nasional Indonesia (PPNI)
  8. Ikatan Ahli Kesehatan Masyarakat Indonesia (IAKMI)
  9. Perkumpulan Obstetri dan Ginekologi Indonesia (POGI)
  10. Ikatan Dokter Anak Indonesia (IDAI)

D.  Mitra AIPI

  1. Lembaga Ilmu Pengetahuan Indonesia (LIPI)
  2. USAID Indonesia
  3. World Health Organization (WHO) Indonesia
  4. United Nations Children’s Emergency Fund (UNICEF) Indonesia
  5. World Bank Indonesia
  6. UNDP Office Indonesia
  7. United Nations Population Fund (UNFPA)
  8. AUSAID Indonesia
  9. Center for Indonesia’s Strategic Development Initiatives (CISDI)
  10. The Summit International Development (SID)
  11. Gerakan Kesehatan Ibu dan Anak (GKIA)
  12. Yayasan Kesehatan Perempuan (YKP)
  13. Centre of Women and Gender Studies UI (PKWJ)
  14. Centre of Women Studies UGM (PSW)
  15. Pusat Studi Wanita (PSW) Unika Soegijapranata Semarang
  16. Pusat Studi Wanita & Gender – Samarinda
  17. Pusat Studi Wanita dan Gender (Pusdi W/G) LPPM UNY (PSW IKIP Yogya)
  18. Pusat Studi Gender dan Anak (PSGA) UIN Jakarta
  19. Pusat Studi Wanita Universitas Airlangga (PSW UNAIR)
  20. Women research institute (WRI)

Appendix 2. Search strategy

Present draft of search terms (in Bahasa and in English) to be used for at least one electronic database, including planned limits, such that it could be repeated. List the synonyms for each components of PICO, based on the scope of focal questions describe on the list of focal questions. The use of matrix is encouraged.

Example:

P I C O
Region JAMKESDA Non – JAMKESDA Human resources
Province* Jaminan kesehatan daerah Asuransi kesehatan nasional Doctor*
District* JAMKESDA Asuransi perusahaan Nurse*
municipality Sistem Jaminan Kesehatan Daerah/ SJKD Asuransi swasta Midwife
City Local health insurance Out of pocket health services
Kabupaten Regional health insurance ASKES Morbidity
Jampersal Mortality
Tabulin Health facilities
Jamkesos hospital
Jamkesmas primary health centre
Kartu Indonesia Sehat access
Private insurance Tenaga kesehatan
Social insurance Dokter
National insurance Perawat
Bidan
Rumah Sakit
Puskesmas
Akses
Fasilitas

Appendix 3. Quality assessment tools

QUALITY ASSESSMENT TOOLS FOR QUANTITATIVE STUDIES

Evidence Summit on Reducing Maternal and Neonatal Mortality in Indonesia

Adapted from Effective Public Health Practice Project.

Thomas BH, Ciliska D, Dobbins M, Micucci S. A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs. 2004;1(3):176-84.

 

  1. Selection Bias

(Q1)  Are the individuals selected to participate in the study likely to be representative of the target population?

  1. Very likely
  2. Somewhat likely
  3. Not likely
  4. Can’t tell

(Q2)  What percentage of selected individuals agreed to participate?

  1. 80 – 100% agreement
  2. 60 – 79% agreement
  3. less than 60% agreement
  4. Not applicable
  5. Can’t tell
SELECTION BIAS RATE THIS SECTION

See dictionary

STRONG

1

MODERATE

2

WEAK

3

In Covidence Low Risk Low Risk* High Risk

*Tuliskan “Moderate” pada kotak judgement comment

  1. Study Design

(Q1) Indicate the study design

  1. Randomized controlled trial
  2. Controlled clinical trial
  3. Cohort analytic (two group pre + post)
  4. Case-control
  5. Cohort (one group pre + post (before and after))
  6. Interrupted time series
  7. Other specify ____________________________
  8. Can’t tell

(Q2) Was the study described as randomized? If NO, go to the next domain:

 No  Yes

(Q3) If Yes, was the method of randomization described? (See dictionary)

 No  Yes

(Q4) If Yes, was the method appropriate? (See dictionary)

 No  Yes

STUDY DESIGN RATE THIS SECTION

See dictionary

STRONG

1

MODERATE

2

WEAK

3

In Covidence Low Risk Low Risk* High Risk

*Tuliskan “Moderate” pada kotak judgement comment

 

 

  1. Confounders

(Q1)  Were there important differences between groups prior to the intervention?

  1. Yes
  2. No
  3. Can’t tell

The following are examples of confounders:

  1. Race
  2. Sex
  3. Marital status/family
  4. Age
  5. SES (income or class)
  6. Education
  7. Health status
  8. Pre-intervention score on outcome measure

(Q2)  If yes, indicate the percentage of relevant confounders that were controlled (either in the design (e.g. stratification, matching) or analysis)?

  1. 80 – 100% (most)
  2. 60 – 79% (some)
  3. Less than 60% (few or none)
  4. Can’t Tell
CONFOUNDERS RATE THIS SECTION

See dictionary

STRONG

1

MODERATE

2

WEAK

3

In Covidence Low Risk Low Risk* High Risk

*Tuliskan “Moderate” pada kotak judgement comment

  1. Blinding

(Q1)   Was (were) the outcome assessor(s) aware of the intervention or exposure status of participants?

  1. Yes
  2. No
  3. Can’t tell

(Q2) Were the study participants aware of the research question?

  1. Yes
  2. No
  3. Can’t tell
BLINDING RATE THIS SECTION

See dictionary

STRONG

1

MODERATE

2

WEAK

3

In Covidence Low Risk Low Risk* High Risk

*Tuliskan “Moderate” pada kotak judgement comment

 

  1. Data Collection Methods

(Q1)   Were data collection tools shown to be valid?

  1. Yes
  2. No
  3. Can’t tell

(Q2) Were data collection tools shown to be reliable?

  1. Yes
  2. No
  3. Can’t tell
DATA COLLECTION METHODS RATE THIS SECTION

See dictionary

STRONG

1

MODERATE

2

WEAK

3

In Covidence Low Risk Low Risk* High Risk

*Tuliskan “Moderate” pada kotak judgement comment

  1. Withdrawals and Dropouts

(Q1) Were withdrawals and drop-outs reported in terms of numbers and/or reasons per group?

  1. Yes
  2. No
  3. Can’t tell
  4. Not Applicable (i.e. one time surveys or interviews)

(Q2) Indicate the percentage of participants completing the study. (If the percentage differs by groups, record the lowest).

  1. 80 – 100%
  2. 60 – 79%
  3. less than 60%
  4. Can’t tell
  5. Not Applicable (i.e. Retrospective case-control)
WITHDRAWAL AND

DROP-OUTS

RATE THIS SECTION

See dictionary

STRONG

1

MODERATE

2

WEAK

3

Not applicable
In Covidence Low Risk Low Risk* High Risk Unclear

*Tuliskan “Moderate” pada kotak judgement comment

  1. Global Rating

 

Please transcribe the information from the gray boxes on pages 1-3 onto this page.

See dictionary on how to rate this section.

 

A Selection Bias STRONG

1

MODERATE

2

WEAK

3

In covidence Low Risk Low Risk High Risk
B Study Design STRONG

1

MODERATE

2

WEAK

3

In covidence Low Risk Low Risk High Risk
C Confounders STRONG

1

MODERATE

2

WEAK

3

In covidence Low Risk Low Risk High Risk
D Blinding STRONG

1

MODERATE

2

WEAK

3

In covidence Low Risk Low Risk High Risk
E Data Collection Method STRONG

1

MODERATE

2

WEAK

3

In covidence Low Risk Low Risk High Risk
F Withdrawals and Dropout STRONG

1

MODERATE

2

WEAK

3

Not applicable
In covidence Low Risk Low Risk High Risk Unclear
G GLOBAL RATING STRONG

1

NO WEAK ratings

MODERATE

2

ONE WEAK ratings

WEAK

3

TWO OR MORE WEAK ratings

In covidence Low Risk Low Risk* High Risk

*Tuliskan “Moderate” pada kotak judgement comment

 

Appendix 4. Results of individual qualitative studies

None

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