Individual Determinant Factors of Patients with Hypertension and the Utilization of Chronic Disease Management Program (Prolanis) Services in First-Level Healthcare Facilities in Pesawaran District, Lampung, Indonesia

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INTRODUCTION
Hypertension is estimated to affect around 1.28 billion adults aged 30-79 years in the world, of which two-thirds are in low and middle-income countries.It is estimated that only 1 in 5 adults (21%) can control their hypertension.The global target is to reduce the prevalence of hypertension by 33% between 2010-2030 (1).While the prevalence of hypertension in Indonesia reached 34.1%, in Lampung Province, the prevalence of hypertension reached 15.10%, while in Pesawaran Regency, the prevalence of hypertension was 12.07% (2).
The trend of catastrophic diseases is also increasing and absorbing the highest costs in the National Health Insurance Program, the Healthy Indonesia Card (JKN-KIS).Efforts to treat hypertension at first-level healthcare facilities (FKTP) by the Indonesian Ministry of Health are carried out through an Integrated Development Post (Posbindu) for Non-Communicable Diseases (PTM) and the Integrated Service Post (Posyandu) for Elderly or Elderly Posyandu.The effort to treat hypertension in FKTP by BPJS Health is the Chronic Disease Management Program (Prolanis).In 2019, Prolanis beneficiaries were only 9.8% of the target, which decreased in 2020 to 7.3% and increased 2021 to 8.1% of participants (3).Even though there is an increase in utilization each year compared to the target of Prolanis, the total utilization of Prolanis has not met the national target of 50%.Pesawaran Regency is the third lowest district in the utilization of Prolanis in Lampung province (3).
The use of Prolanis by BPJS participants is essential because the Ratio of Prolanis Participants Routinely Visiting FKTP (RPPRB) indicates the continuity of chronic disease services.The target for fulfilling the RPPRB is at least 50%, and if it is not achieved, it will affect the amount of capitation received by FKTP (4).Factors that influence the utilization of health services are the determinants of society, individuals, and the health service system.Individual determinants consist of predisposing factors (drivers), including attitudes towards health facilities and knowledge about the disease, enabling (enabling) access, and illness level (disease level) (5).This study analyzes the relationship between individual determinants and utilization of Prolanis services at primary health facilities in Pesawaran, Lampung province, Indonesia.

DISCUSSION
This study analyzes the relationship between individual determinants and the utilization of Prolanis services at FKTP.This study found that there was a significant relationship between attitude and the use of Prolanis services at FKTP p-value <0.001, with an Odds Ratio (OR) of 2.4, so it can be said that respondents who have a positive attitude have 2.4 times higher chances of taking advantage of Prolanis services at FKTP Pesawaran Regency compared to respondents who have a negative attitude.The supporting theory is that attitude is a condition for the emergence of action, and attitude will determine a person's tendency to behave towards humans or something that is encountered.Memories will influence the views and feelings of these individuals, what is known, and impressions of what is being faced (6).A positive attitude will manifest good health behavior, so it is essential to measure attitudes (7).Attitude is a predisposition to respond to environmental stimuli that can initiate or guide the person's behavior influenced by personal experience and other people considered influential, culture, mass media, and emotional factors (8).The results of this study are similar to previous studies, which show a relationship between attitude and utilization of Prolanis services (9)(10)(11)(12)(13)(14)(15)(16).The researcher's analysis is based on the facts found in the field.However, most respondents have a positive attitude and utilize Prolanis services, and it is not yet known whether the attitude is permanent or temporary and will soon pass.It is hoped that the attitude that occurs is persistent and lasting so that it is automatically manifested in action.It is not yet known how the level of attitude of the respondents is whether they are only accepting (limited to receiving the given stimulus), responding (giving answers/responses), appreciating (giving positive value with actions), being responsible (taking risks with the actions taken).
This study also found that there was a significant relationship between knowledge and utilization of Prolanis services in FKTP with a p-value <0.001 and an Odds Ratio (OR) of 3.7, so it can be said that respondents who have high knowledge have the opportunity 3.7 times higher for utilizing Prolanis services at FKTP Pesawaran Regency compared to respondents who have insufficient knowledge.Behavior-based on knowledge will be more lasting than behavior that is not based on knowledge (8).Knowledge is influenced by memory, testimony, interest, curiosity, thought and reasoning, logic, language, and human needs.Factors influencing knowledge are education, information, culture, and experience (17).Knowledge is necessary for a person to have a basis for making decisions and acting on problems.Knowledge or cognitive domain is fundamental in shaping one's actions (over behavior) (18).This study's results are similar to those of previous studies, which show an influence between knowledge and utilization of Prolanis services (13)(14)(15)(19)(20)(21)(22)(23)(24)(25)(26)(27).Prolanis, as one of the preventive promotive programs, has not distributed the Prolanis participant health monitoring book, which contains much educational material and recording of Prolanis activities carried out, which the participants privately own.Bearing in mind that knowledge is a closed type of behavior that cannot be observed by other people clearly/covertly, the respondent's knowledge should be re-examined whether it is just knowing/recalling something specific (know), understanding (comprehension), explaining correctly about a known object, and can interpret the material correctly, Application uses material that has been studied in real (actual) situations or conditions, Analysis describes a material or an object into its components, Synthesis the ability to put or connect parts in a new whole.Evaluation of the ability to justify or evaluate a material or object and to realize knowledge at the highest level, health education/health education should still be provided using tools such as teaching aids and media through visual, audio, and audio-visual media using individual, group, or mass education methods.
The results of this study also found a significant relationship between access and utilization of Prolanis services in FKTP with a p-value of 0.010 and an Odds Ratio (OR) of 1.8, so it can be said that respondents who stated affordable access had 1.8 times higher chances to utilize Prolanis services at FKTP Pesawaran Regency compared to respondents who stated that access was not affordable.Primary health services are generalist services that can be accessed by all groups of people (28).Primary Healthcare Services are integrated and accessible health services managed by clinicians responsible for carrying out individual health efforts, developing ongoing relationships with patients, and carrying out their practice within the family and community of all groups of people ( 28).This study's results are similar to those of previous studies, which found a relationship between access/(geography, transportation) and service utilization (20,(29)(30)(31)(32)(33) Other research states that respondents who live in urban areas with affordable access are related to the use of Prolanis.There are accessibility gaps in visiting routines, treatment appropriateness, and disease control based on the type of FKTP and place of residence (34).The researcher's analysis is based on the facts found in the field.Even though more respondents answer that they are more unreachable, there is a relationship between access and utilization, so it is crucial to increase the number of Prolanis clubs with different locations to reach access to Prolanis participants better spread across 35 villages in 2 subdistricts.Road access is good, but in the field, it is not passed by public transportation, so Prolanis participants who cannot bring their vehicles need help from their families to access Prolanis services.
In addition, this study found that there was a significant relationship between the level of hypertension and the utilization of Prolanis services at FKTP with a p-value <0.001 and an Odds Ratio (OR) of 2.2 so that it can be said that respondents who had hypertension level 1 have a 2.2 times higher chance of utilizing Prolanis services at FKTP Pesawaran Regency compared to respondents with level 2 hypertension.One of the categories of health behavior is illness behavior and sick role behavior.Illness behavior is where everyone who feels sick carries out every activity to determine the state of health and find the appropriate medicine.Illness behavior is generally considered to be a person's actions after symptoms appear and are felt.Sick role behavior is any activity carried out by someone who considers himself sick, with the aim of recovering, including receiving treatment from health services, where the expected component is that someone is responsible for their illness.Illness gives individuals reasons to participate in the duties and obligations of people who are sick and are expected to realize that illness is an unwanted condition and that they must be motivated to recover.Recovering is assumed to be related to seeking health service assistance (18).The results of this study are similar to those of previous studies, which show that perceived severity is related to the use of the Prolanis program (22,35).The researcher's analysis is based on the facts found in the field.Most respondents with hypertension are at level 1 and utilize Prolanis services due to an emotional response due to chronic hypertension, making reasonable adjustments to the disease they are experiencing, and being able to adapt to changes in related habits.Pain is experienced as a management effort aimed at better quality long-term survival.Suggestions that researchers can give should have a positive role from the closest family as a form of social support to motivate sufferers to take advantage of Prolanis services because the level of illness will impact physical condition and affect work/family finances.Coping with chronic disease according to the level of illness is a lifelong challenge, so acceptance of hypertension and action for its prevention is significant.The more a person can manage a disease level, the greater the individual's potential to successfully overcome the disease and situation.
The results of the multivariate analysis showed that knowledge had the highest OR value = 3.380, so knowledge became the most dominant variable related to the use of Prolanis services at FKTP Pesawaran Regency.Hypertension is chronic or lasts long and is often not realized until the condition is already severe.The hope is that with Prolanis someone with hypertension or diabetes mellitus can manage and control the disease well so that Prolanis participants have a better quality of life than ordinary people and can prevent complications from the disease.Prolanis is a tertiary prevention program conducted at FKTP that focuses on Hypertension and DM., as well as the referral program/DRR as tertiary prevention, namely chronic drug services in FKTP.Monitoring Prolanis participants is very important so that doctors at the FKTP will provide consultations according to participants' complaints and provide recommendations according to participants' needs (36).
The results of this study are similar to the results of previous studies, which show that the knowledge variable is the dominant factor influencing Prolanis participation in FKTP (21) (37) (32).The results of this study follow the results of previous studies, which state that knowledge of health insurance is the dominant factor in the utilization of health services (38) Other studies have found a relationship between knowledge of health services and utilization of health services (39).Although low-and middleincome countries have seen improvements in all these areas, access to existing knowledge still needs to improve.Especially when compared to access in high-income countries.The results of this study are different from the results of other studies, which show that the quality of interaction and attitude is the most dominant factor with non-compliance in participating in Prolanis activities because researchers do not examine knowledge variables, only examine variables of understanding of instructions, interaction quality, family support, beliefs, attitudes) (10).The researcher's analysis based on the facts found in the field of knowledge is the most dominant variable related to the use of Prolanis because educational and gymnastic activities are the activities most often carried out, besides Prolanis activities for BPJS participants with hypertension preventive, rehabilitative promotive efforts have also been carried out by the Health Office Offering through community-based health enterprises (UKBM) in the area of each village in the region through Non-Communicable Diseases Posbindu and Elderly Posyandu so that people are exposed to hypertension education and have good knowledge.

CONCLUSION
A positive attitude, high knowledge, and having grade 1 hypertension are factors associated with this study's high utilization of Prolanis services.It is hoped that officers at the FKTP can optimize socialization regarding Prolanis services, especially for patients with hypertension, so that people's attitudes and knowledge can increase and ultimately impact reducing the level of illness due to hypertension.