INTRODUCTION:

The 1945 Constitution of the Republic of Indonesia, article 34, section 2 states that: "The State develops a social security system for all people and empowers the weak and incapable in accordance with human dignity." In this regard, the government and the People's Representative Council (DPR) of the Republic of Indonesia regulate the National Social Security System through Law No. 40 of 2004.

The National Health Insurance (JKN), as one of the 5 (five) National Social Security programs, is a concrete step taken by the government to protect all Indonesian people in health maintenance efforts. The benefits of JKN that can be enjoyed by the public include individual health services, which include promotive, preventive, curative, rehabilitative, drug services, and medical consumables in accordance with the necessary medical indications. In order for these benefits to be truly experienced by the public, the government established a separate agency specifically responsible for the implementation of the JKN, which is the Social Security Agency (BPJS), established under the Law of the Republic of Indonesia no. 24 of 2011 on the National Social Security Agency.

Every resident who has lived at least 6 (six) months in Indonesia are required to be registered as a participant of BPJS by paying dues regularly every month, so they will not be charged when sick or undergoing health maintenance. The premium payment system by participants consists of several categories, namely: 1. For the poor members of the public, premiums are borne by the government through the State Budget (APBN), and these recipients are called Subsidy Beneficiary (PBI); 2. For civil servants (PNS), members of the armed forces (TNI), and members of the police force (POLRI), premiums are deducted from their monthly salary; 3. For members of the public working in the private sector, premiums are paid by their employers; 4. For those who belong to none of the three former categories, the premiums are paid by themselves each month, and they are referred to as independent participants.

In performing health services, BPJS cooperates with First-Level Health Service Providers (PPK I) and Advanced Health Service Providers. BPJS Kesehatan makes payments to First-Level Health Service Providers on a pre-planned basis based on capitation of the number of participants registered at the First-Level Health Facilities (Presidential Regulation no. 12 of 2013 article 39). In addition, BPJS also develops referral system that is targeted to post-service patients in Advanced Health Service Providers, especially to people with chronic diseases. BPJS Kesehatan guarantees the need for drugs in the back-referral program through pharmacies or pharmacy departments of First-Level Health Service Facilities like Puskesmas and Clinics that are in cooperation with BPJS Kesehatan.

These drugs are paid for by BPJS Kesehatan, excluding capitation costs. Through this system, it is expected that chronic disease patients, whether poor or rich, are adherent in taking and using drugs, because the drugs have been provided by network pharmacies or back-referral pharmacies that can be accessed easily without having to spend more, considering that the cost can be a heavy burden for some poorer household¹¹.

The four major chronic diseases are cardiovascular diseases (coronary heart disease, heart failure, hypertension, stroke), cancer, chronic respiratory illnesses (asthma and chronic lung obstruction disease), and diabetes⁴.

Hypertension is a disease that has a very high incidence rate, doubling from 1995 to 2005, and is expected to increase by 24% from 2000 to 2025 in both developing and developed countries⁶.

Hypertension, as a chronic disease, requires continuous treatment in the long term. Hypertension becomes a serious problem globally because it is closely related to cardiovascular diseases, stroke, and renal disease. Early identification can prevent the occurrence of hypertension, especially in developing countries¹⁴. Hypertension is also a risk factor for DM, heart damage, and renal disease³.

The prevalence of hypertension increases from time to time, even estimated to reach 1.5 billion people worldwide by 2025¹⁰. Salt (NaCl) and Sodium Glutamate (NaC₅H₈NO₄), commonly used in everyday foods, have a major role in the occurrence of this disease if used excessively¹⁰, which can result in the emergence of other diseases such as cardiovascular diseases, resulting in many deaths around the world¹⁴. Failure of hypertension treatment is caused by several factors, including non-adherence of patients in using drugs as a result of their inability to purchase drugs¹¹. The existence of BPJS is a new hope for all Indonesian people, especially those with chronic diseases, because they can routinely conduct medical examinations and obtain drugs without getting money out of their pockets personally.

The purpose of this study was to analyze the effect of BPJS participation on therapeutic success in hypertension patients.

METHOD:

This research uses a cross-sectional observational design. Respondents are hypertension patients who performed routine checks at Community Health Centers throughout Pamekasan Regency with the following criteria:

Inclusion criteria:

1. Hypertension patient

2. Conducts routine checks at a Community Health Center in Pamekasan Regency

3. Able to read and write

4. Can speak Indonesian

5. Willing to be a research respondent.

6. Resides in Pamekasan Regency

Exclusion criteria:

1. Consumes traditional medicine, either obtained by buying or personally-made ingredients

2. Has complications outside of hypertension

The determination of sample size was done using the Slovin Formula:

S = ^{-----------------------------------}

1+ N.e ²

Note:

S = Sample = obtained 185.81 = 186

N = Population = 347

e = Tolerable error of 0.05

The number of hypertension patients who performed routine checks at Community Health Centers were 347 people, and after the calculation of samples with the formula above a sample of 186 people was obtained. Thus, the sample in this study was 186 people with hypertension.

Research variables:

The independent variables in this study are BPJS participation, body mass index, hospitalization history, type of drugs used, smoking habit, medication adherence, diet control, BPJS participation type, and exercise habits. The dependent variable is therapeutic success. Therapeutic success in this study was measured by blood pressure, which is categorized as controlled if the systolic blood pressure < 140 mmHg and diastolic < 90 mmHg and is regarded as uncontrolled pressure if the systolic blood ≥ 140 mmHg or diastolic blood ≥ 90 mmHg³.

Research Instruments:

The instrument used in this study is questionnaire. Prior to use, the questionnaire was first tested for validity and empirical reliability. The questionnaires were tested to hypertension patients other than the respondents. Then, the test results of the questionnaire were analyzed statistically to determine instrument validity and reliability. The instrument is declared valid if correlation coefficient > 0.3 and is declared reliable if its Cronbach Alpha value > 0.6¹². Reliability and validity test results indicated that the instrument is valid with a correlation value greater than 0.3, meaning that from the 12 question items, the lowest correlation value found was 0.370, while the highest was 0.593, with a Cronbach Alpha value of 0.893. The analysis of the research results was done through multiple logistic regression analysis.

RESULTS:

The respondents of this research were male and females with total respondents and ages can be seen in Table 1 and 2.

Table 1. Sex of respondents

Sex of respondents	N	%
Male	65	35
Female	121	65
Total	186	100

Table 2. Age of respondents

S. No	Age (years)	N	%
1	£ 40	23	12.4
2	41 - 50	48	25.8
3	51 - 60	59	31.7
4	61 - 70	38	20.4
5	³ 71	18	9.7
Total		186	100

The body mass index of respondents was recorded in Table 3. BMI is the division result of weight (kg) to height squared (m²), therefore weight is highly determined BMI value.

Table 3. BMI (body mass index)

S No	BMI	N	%
1	Overly underweight	3	1.6
2	Slightly underweight	12	6.5
3	Normal	106	56.9
4	Pre-obese	58	31.2
5	Obese	7	3.8
Total		186	100

The hospitalization history was shown in Table 4.

Table 4. Hospitalization history due to hypertension

S No	Hospitalization history	N	%
1	Yes	67	36.0
2	No	119	64.0
Total		186	100

The drugs used which consumed by respondents and smoking habits were showed in Table 5 and 6.

Table 5. Types of drug used

S No	Drug type	N	%
1	Amlodipine	46	24.7
2	Captopril	95	51.1
3	Lisinopril	6	3.2
4	Nifedipine	9	4.8
5	Captopril + Amlodipine	5	2.7
6	Captopril + HCT	9	4.8
7	Capopril + Furosemide	16	8.7
Total		186	100

Table 6. Smoking Habits

Smoking habits	N	%
Smoking	33	17.7
Not smoking	153	82.3
Total	186	100

Table 7 and 8 showed that the participation of respondents of BPJS and types of BPJS class.

Table 7. BPJS Participation

S No	BPJS	N	%
1	BPJS Participants	145	78
2	Non-BPJS Participant	41	22
Total		186	100

Table 8. BPJS participation types

S No	BPJS participation types	N	%
1	PBI	28	19.3
2	Civil servants	23	15.9
3	private employees	4	2.8
4	Independent participant	90	62.0
Total		145	100

Table 9 demonstrated exercise habits of respondents and table 10 showed drug consumption adherence.

Table 9. Exercise habits

No	Exercise habits	N	%
1	Routine exercises	86	46.2
2	Non-routine exercises	100	53.8
Total		186	100

Table 10. Drug consumption adherence

S No	Drug consumption adherence	N	%
1	Adherent	153	82.3
2	Nonadherent	33	17.7
Total		186	100.0

The diet habits and therapeutic success were shown at table 11 and 12.

Table 11. Diet habits

S No	Diet Habits	N	%
1	Diet	110	59.1
2	No diet	76	40.9
Total		186	100

Table 12. Therapeutic success

No	Blood pressure control	Total	Percentage
1	Controlled	107	57.5
2	Uncontrolled	79	42.5
Total		186	100

The results of the statistical test were showed in Table 13.

Table 13. Multiple Logistic Regression Statistic Test Results

Variable		P (Sig)
Dependent	Independent	P (Sig)
	BMI	0.600
	Hospitalization history due to hypertension	0.634
	Type of drug used	0.081
	Smoking habit	0.119
	BPJS Participation	0.053
	BPJS participation types	0.623
	Exercise habits	0.021
	Drug consumption adherence	0.000
	Diet habits	0.000

DISCUSSIONS:

Table 1 showed the majority of respondents were female (65%). Based on data at Community Health Centers, the number of patients is actually equal between males and females, each contributing about 50%. However, according to information provided by officers at Community Health Centers, female patients conduct more visits than the male ones.

Table 2 showed that the majority of respondents were aged 51-60 (31.8%). However, it should be noted that patients under age 40 were also significant at 12.4%. For BMI, table 3 showed the results value. Weight affected the quality of life, including the emergence of chronic diseases such as hypertension¹⁶. Weight reduction was a very important factor to prevent the occurrence of hypertension¹. The BMIs of respondents in this study were mostly normal (56.9%), as shown in Table 3. The BMI classified as being obese was used as a risk factor of hypertension⁸. After analysis with logistic regression, there was no significant effect to therapeutic success with p = 0.600, indicating that p > a. This was likely because most respondents have normal BMIs.

Definition of hospitalization history in this study was admission to hospital caused by hypertension. Table 4 showed that the majority of respondents did not have hospitalization history as a result of hypertension (64%). The more times a person is admitted to a hospital due to chronic illness, the more likely he/she is to have higher adherence to drug use, which affects therapeutic success. The results of statistical test on the effect of hospitalization history on therapeutic success showed no significant effect with p value = 0.634. This is likely because most respondents have never been hospitalized due to hypertension.

The most frequently consumed drug showed by table 5 was Captopril (51.1%).

For respondents’ gender, the majority of respondents did not smoke (82%) (Table 6). This was because most respondents were female. Smoking can increase the prevalence of hypertension and affect therapeutic success¹⁰. In this study, the results of statistical analysis showed no significant effect of smoking habits on therapeutic success, with a p value = 0.119. This happened because the majority of respondents did not smoke.

Table 7 showed that the majority of respondents were BPJS participants (78%). Among the BPJS participants, most are independent participants, i.e. participants who pay their own premiums to BPJS on a monthly basis (62%), as shown on table 8. Participants of BPJS were not charged when conducting medical checkup and drug purchase, unless when they request drugs/prescriptions outside the provisions (National Formulary). Thus, cost should no longer be a burden¹¹, so that patients can be adherent to conduct treatment and the success of therapy was more assured. The results of statistical analysis in this study found the p-value was 0.053, which means that BPJS participation did not significantly affect therapeutic success.

The majority of respondents in the study were independent BPJS participants (62%) as shown in table 8. The results of statistical multiple logistic regression analysis showed that the BPJS participation type did not yield significant effect on therapeutic success with p value = 0.623. Of the 186 respondents, only 46.2% regularly exercise as shown on Table 9. An exercise was said to be routine if performed twice or more in a week. Patients who routinely exercise had a more controlled blood pressure¹³. Physical activity can lowered blood pressure⁵ and can reduce the risk of cardiovascular disease². This study showed similar results with previous researchers, namely that exercise habits significantly influenced therapeutic success in patients with hypertension, with a p value = 0.021.

Drug consumption adherence is one of the keys to successful treatment in all patients with chronic diseases such as hypertension. This study, as shown in Table 10, found that most respondents were adherent in using drugs (82.3%). The regularity of control visits and adherence in taking medication by people with hypertension will reduce the prevalence and prevent the occurrence of hypertension complications. In addition, it also reduced the cost of treating hypertension¹⁷. This study showed that medication adherence significantly affected the success of therapy with p = 0.000.

Besides drug adherence, daily diet control also plays an important role in determining therapeutic success in patients with hypertension. In this study, the majority of respondents performed diet (59.1%). Diet control is an important factor in preventing and controlling hypertension¹. Many types of food consumption need to be reduced or controlled, such as reducing salt intake, increasing potassium intake, reducing alcohol use, and adoption of an overall healthy dietary pattern. The American Heart Association (2017) states that regular eating patterns, such as breakfast, lunch, dinner, and snacking habits also have an effect on increasing the prevalence of hypertension because diet has an effect on weight gain. Therefore, improved eating behaviour was essential to prevent the increasing prevalence of chronic diseases, such as hypertension and diabetes mellitus. Setting an eating pattern has a very significant effect on therapeutic success in patients with chronic diseases⁷. The results of this study were in accordance with the aforementioned study, namely that the habit of controlling the consumption/diet significantly affect therapeutic success in patients with hypertension with a statistical analysis results that yielded a p value = 0.000

A therapy is said to work if the patient's blood pressure is under control, i.e. below 140. The majority of respondents (57.5%) had a controlled blood pressure, as listed on Table 12.

The results of the statistical test to determine the influence of independent variables on the dependent variable showed that only exercise habits, diet control, and drug consumption adherence showed significant influence with p = 0.021 for exercise habits, p = 0.000 for diet control, and 0.000 for drug consumption adherence. The other variable, namely BPJS participation, had no significant effect. This showed that, although patients did not need to buy drugs, there was no guarantee that patients will consume drugs and use them in an adherent manner.

CONCLUSIONS:

BPJS participation did not yield a significant effect to therapeutic success as measured by the controlled blood pressure of patients. Other variables that also yield no effect on therapeutic success are: sex, age, body mass index, hospitalization history, type of drugs used, smoking habit, and BPJS participation type. Furthermore, exercise habit, diet control, and medication adherence affected therapeutic success.

Therefore, BPJS should be active or cooperate with health practitioners, such as Pharmacist at network pharmacies or back-referral pharmacies, as well as primary care physicians, either Community Health Center doctors, Clinical doctors, and self-employed doctors needed to provide education to BPJS participants, especially in advising to always exercise diligently, control the daily diet, being adherent to drug usage, and changed their lifestyle, because it was proven that education improved patient compliance.

CONFLICT OF INTEREST:

Authors report no conflict of interest.

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Received on 20.08.2018 Modified on 29.09.2018

Research J. Pharm. and Tech 2019; 12(1): 93-98.

DOI: 10.5958/0974-360X.2019.00018.0