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Abstrak :
ABSTRAK Keberhasilan Pemerintah dalam pembangunan, khususnya pembangunan kesehatan tidak diragukan lagi, hal ini terlihat dari semakin meratanya pelayanan kesehatan, dimana pada setiap kecamatan minimal ada 1 Puskesmas. Namun disamping itu ada hal yang menarik dalam pelayanan kesehatan, yaitu pengobatan tradisional sampai saat ini masih diakui keberadaannya oleh masyarakat. Hasil Survai Kesehatan Rumah Tangga (SKRT) menunjukkan data tentang masih adanya masyarakat yang menggunakan pengobatan tradisional, baik itu dilakukan sendiri dengan ramuan-ramuan ataupun dengan pertolongan pengobat tradisional. Kebijaksanaan Pemerintah tentang pengobatan tradisional telah digariskan dengan jelas dalam GBHN 1993, yaitu pengobatan tradisional yang secara medis dapat dipertanggung jawabkan perlu terus dibina untuk perluasan dan pemerataan pelayanan kesehatan. Disamping itu dalam Sistem Kesehatan Nasional (SKN) juga dinyatakan bahwa terhadap pengobatan tradisional yang terbukti berhasil guna dan berdaya guna terus dilakukan pembinaan dan bimbingan, sehingga dapat dimanfaatkan untuk meningkatkan pemerataan pelayanan kesehatan. Penelitian ini bertujuan untuk mendapatkan gambaran tentang bagaimana hubungan tingkat Sosial-Ekonomi masyarakat dengan pemanfaatan pengobatan tradisional di Kabupaten Subang, Pandeglang dan Kotmadya Bandung, Jawa Barat. Penelitian dilakukan ditempat-tempat ini oleh karena data-data menunjukkan bahwa masyarakatnya cukup banyak yang memanfaatkan pengobatan tradisional. Penelitian ini merupakan penelitian deskriptif analitik, dan data diambil secara "Kros seksional" dengan kepala keluarga sebagai responden. Jumlah sampel 301 yang dipilih secara random dari 10 desa di 5 Kecamatan. Hipotesis yang diajukan adalah : Tingkat Sosial-Ekonomi yang meliputi pendidikan, penghasilan dan jenis pekerjaan mempunyai hubungan negatip dengan pemanfaatan pengobatan tradisional, hubungan ini juga dipengaruhi oleh faktor jarak dari rumah ke tempat pelayanan kesehatan modern, umur, ketersediaan biaya kesehatan dan derajat sakit. Hasil penelitian membuktikan bahwa adanya hubungan negatip antara tingkat Sosial-Ekonomi dengan pemanfaatan pengobatan tradisional, dari hasil uji Chi-square didapatkan nilai p = 0.0481 untuk variabel pendidikan, p = 0.0036 untuk variabel penghasilan dan p = 0.0029 (nilai a = 0.05); hasil analisa logistik regresi juga menunjukkan bahwa hubungan negatip antara tingkat Sosial-Ekonomi dengan pemanfaatan pengobatan tradisional semakin lemah dengan semain dekatnya sarana pelayanan pengobatan modern dan semakin ringannya penyakit.

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ABSTRACT There have been so many development in health, resulted in the availability of health services, where in every sub district there is at least one "Public Health Center". However, according to a household surveys on health (SKRT) in 1988 and 1992, some people still use the traditional treatment to overcome their health problems. In this research, we want to know the relationship between economic and social status (education, income, job) and the use of traditional treatment. Furthermore, we also want to see how the distance of modern health services, age, degree of illness and cash availability affect the use of traditional treatment. This research was done in two districts of Subang and Pandeglang, and in one municipality of Bandung in West Java. It was a descriptive and analytical research using "cross sectional " data where the respondent was the head of the household. We take 301 respondents randomly from, .10 villages in 5 sub district. The hypothesis in this research is that social-economic factor, they are income, education and job have negative relationship with the use of traditional treatment. And the sub hypothesis is that the negative relationship will be weaker as the distance of modern health services becomes less, the degree of illness becomes higher, more money is available an the age becomes younger. Statistic analysis we use to prove this hypothesis was Chi-Square, we selected influential variables in traditional treatment by looking at "p" value. If "p" value is less than 0.05 the independent variables is significant. From the Chi-Square we get p value of education = 0.0481, p value of income = 0.0036 and p value of job = 0.0029. The regression logistic analysis we get different OR value before and after interaction with distances of modern health services and degree of illness, from that different value are proved that the distances of modern health services and degree of illness are influence the relationship between social-economic degree and the using of traditional treatment. From the result of analysis, hypothesis and sub hypothesis are proved, that the social-economic degree has a negative relationship with the using of traditional treatment and this relationship will be weaker as the distance of modern health services becomes less and the degree of illness becomes higher.

Abstrak :
Sebagian besar pasien dengan gangguan mental emosional pertama-tama belum berobat ke fasilitas pelayanan kesehatan jiwa. Pasien gangguan mental emosional yang berobat ke Puskesmas wilayah Jakarta Timur hanya 1,88 % dari kasus yang ada di masyarakat dengan rata-rata kunjungan 1,31 kali pada tahun 1994. Agar gangguan tersebut tidak menjadi berat atau menjadi penyakit lain, maka diperlukan pengobatan sedini mungkin. Untuk mencapai maksud tersebut, yang menjadi masalah penelitian ini adalah bagaimana pola perilaku pencarian pengobatan dari pasien gangguan mental emosional dan faktor-faktor apa yang berhubungan dengan perilaku tersebut. Jenis disain penelitian ini adalah crossectional, namun menggunakan analisis yang lazim digunakan pada studi case control pada penduduk dewasa (17 tahun ke atas) yang mengalami gangguan mental emosional. Gangguan mental emosional ditetapkan berdasarkan pengisian instrumen Self Reporting Questionnaire (SRQ) dengan cut-off points 6. Pengambilan sampel dilakukan secara systematic random sampling dengan sampling fraction 9. Unit sampel adalah rumah tangga dengan jumlah 650 KK yang meliputi 1950 penduduk dewasa sehat. Sampel pasien gangguan mental emosional yang diteliti berjumlah 446 kasus. Untuk mengetahui hubungan faktor dengan perilaku pengobatan dilakukan perhitungan Odds ratio melalui analisis regresi logistik multivariat. Hasil penelitian menunjukan bahwa pola perilaku pengobatan pertama pasien gangguan mental emmosional di Kelurahan Pulogadung adalah melakukan pengobatan sandhi 27,8 %, ke dokter umum 18,4 %, tidak mencari pengobatan 17,4 %, ke Puskesmas 13,2 %, ke pengobat tradisional 8,7 %, ke rumah sakit umum 6,1 %, ke spesialis penyakit dalarn 5,8 % dan ke psikiater 2,5 %. Pasien yang melakukan kegiatan rujukan adalah 23,6 %. Sebagian besar pasien yang melakukan rujukan dan pasien yang melakukan pengobatan selanjutnya tidak berobat ke fasilitas pelayanan kesehatan jiwa. Pasien gangguan mental emosional lebih mungkin tidak mencari pengobatan apabila pasien tidak merasa terganggu akibat gangguan mental emosional yang dialaminya (OR 0,01 ; 95% Cl 1,5E-03 - 0,02), kurang mendapatkan informasi pelayanan kesehatan jiwa (OR 0,49 ; 95% CI 0,25 - 0,95) dan apabila pasien malu berobat ke psikiater (OR 2,24 ; 95% 1,02 - 4,85). Pelayanan kesehatan jiwa di masyarakat diharapkan tidak hanya menunggu pasien datang berobat ke fasilitas kesehatan jiwa. Kegiatan pelayanan kesehatan jiwa di Puskesmas perlu dikembangkan dalam kegiatan Puskesmas lainnya (Taruna Husada, Sala Shakti Husada dan sebagainya). Pelayanan prevensi sekunder (mendorong pasien berobat) melalui peningkatan pengetahuan gangguan mental emosional dan fasilitas pengobatannya perlu lebih diprioritaskan. Penyegaran pengetahuan gangguan mental emosional terhadap dokter umum perlu dilakukan secara periodik. Peningkatan mutu pelayanan jiwa di Puskesmas dan pembinaan pengobat tradisional perlu lebih diperhatikan. Disamping itu perlu juga dipertimbangkan tentang perubahan konsep figur psikiater di masyarakat. ...... Most patients with mental emotional disorder didn't visit health facility with mental health service at the first treatment. There is only 1,8 % of people with mental emotional disorder who visited Puskesmas at East Jakarta with average 1.31 visit in 1994. To prevent the disturbance become more severe or to become another illness, early treatment is needed. To reach the purpose, the problem of this study is to identify health seeking treatment pattern of patient with mental emotional disturbance and to find factors which was associated with the behavior treatment. The study design is cross sectional study but method of analysis is case control. Sample of the study are adult (17 years or more) who experience mental emotional disorder. The criteria of mental emotional disorder is based on answers of Self Reporting Questionnaire (SRQ) with cut-off 6. Sampling method is systematic random sampling with sampling fraction of 9. Sampling unit is household with totally 650 household which include 1950 adult with good health. Sample of patient with mental emotional disorder are 446 cases. To identify relationship between factors with health seeking treatment, logistic regression with odds ratio is applied. The result showed that for the first treatment there is 27,8% of the mental emotional disorder patients performing self medication, 18,4% visit medical doctor, 17,4 % didn't seek any treatment, 13,2 % visit Puskesmas, 8,7 % going to traditional healer, 6,1% to general hospital, 5,8% visit internist and 2,5% visit psychiatrist. There where 23,6 patient who were given referral. Most of the patients who were referred or patient who continue the treatment didn't visit health facility with mental health service. Patients with mental emotional disorder probably not seek any treatment if they didn't feel uncomfortable with the disturbance they experienced (OR 0,01 ; 95% CI 1,5E-03 - 0,02), did not obtained enough information about mental health service (OR 0,49 ; 95% CI 0,25 - 0,95), or if the patient was ashamed to visit psichiatrist (OR 2,24 ; 95% CI 1,02 - 4,85). Patients with mental emotional disorder probably would performed self medication if their social economic status is low (OR moderat 0,52 ; 95% CI 0,06-0,83; OR high 0,45 ; 95% CI 0,04-0,62), if they were not bothered by the disturbance they experienced (OR 0,47; 95% CI 0,03-0,91), didn't consider the disturbance as severe (OR 0,54 ; 95% CI 0,07-0,91), didn't obtained enough information on the mental health service (OR 0,52 ; 95% CI 0,06-0,79), were not suggested to have treatment (OR 0,45 ; 95 % CI 0,04-0,57), they have no work (OR 0,35 ; 95 %CI 0,17-0,67) and if they are Askes member (OR 2,48 ; 95% CI 2,40-17,54). Patients with mental emotional disorder will probably visit traditional healer if they have expectation that the treatment not only give drug (OR 8,76 ; 95% CI 1,86 - 42,26), have supernatural believe (OR 7,53; 95% CI 3,15-40,22), and have enough knowledge on the traditional healer service (OR. 6,67; 95% CI 1.86-23,57), did not feel comfortable with the disturbance they experienced (OR 8,84; 95% CI 3,00 - 26,05), their knowledge on the mental emotional disorder was not good (OR 0,12;95% CI 0,03-0,56), and have no information on the mental emotional service (OR. 0,25; 95% CI 0,06-0,98). Patients with mental emotional disorder will probably visit mental health service if they felt disturbed (OR 4,43 ; 95% CI 1,76 - 11,13), did not have senior high school or more education (OR 0,36 ; 95% CI 0,16 - 0,81), expected to be given more than just drug (OR 5,93 ; 95% CI 1,93 - 18,17), feeling that the high cost of the treatment influence the effort to seek treatment (OR 7,17 ; 95 % CI 2,83 - 17,81), obtained enough information on the mental health service (OR 5,22 ; 95% CI 2,34 - 11,59), and did not feel ashamed to visit psychiatrist (OR 0,43; 95% CI 0,18 - 0,99). Patients with mental emotional disorder will probably visit Puskesmas if they feel bothered (OR 14,41 ; 95% CI 4,14 - 50,40), feeling the cost of the treatment influence the effort of seeking treatment (OR. 4,28 ; 95% CI 1,39 - 13,06), their social economic status is low (OR high 0,11 ; 95 % CI 0,03 - 0,37), lived near to Puskesmas (OR 0,21 ; 95% CI 0,06 - 0,77), realize that there is mental health service in the Puskesmas (OR 14,31 ; 95 % CI 4,09 - 49,89), did not know about traditional service (OR 0,05 ; 95 % CI 0,01 - 0,25), did not have knowledge about the general health service (OR 0,23; 95% CI 0,07 - 077), and the healer attitude did not influence the choice of treatment (OR 0,35 ; 95 % CI 0,14 - 0,88). Mental health service in the public is expected not only waited patients to visit the mental health service. Mental health service at the Puskesmas needs to be integrated and to be developed with the other Puskesmas activity (Taruna Husada, Bhakti Husada, Karang Werdha). Secondary prevention thru knowledge development on the mental emotional disorder, treatment facility and early detection should be give more priority. Knowledge refreshment on the mental emotional disorder to medical doctor needed to be in force periodically. Quality improvement of health service in Puskesmas' and education of traditional healer need to be given more attention. The figure of psychiatrist in the society need to changed as well.

Abstrak :
Masalah kesehatan maternal terutama masalah kematian ibu masih menjadi masalah prioritas Bangsa Indonesia dalam meningkatkan kualitas Sumber Daya Manusia (SDM). Angka kematian ibu yang tinggi sering dikaitkan dengan pemanfaatan layanan kesehatan ibu bersalin. Pemanfaatan pelayanan kesehatan ibu bersalin di Indonesia menunjukkan variasi antar wilayah regional, diduga berhubungan oleh faktor lingkungan dan perbedaan karakteristik dari populasi. Penelitian ini mengukur pemanfaatan pelayanan kesehatan ibu bersalin dan mempelajari besar hubungan lingkungan dan karakteristik populasi terhadap pemanfaatan pelayanan kesehatan ibu bersalin. Penelitian ini menggunakan data sekunder SDKI 2017 yang mencakup 3.586 wanita usia subur (15–49 tahun) yang pernah melahirkan dalam waktu satu tahun sebelum survei. Analisis regresi logistik multinomial digunakan untuk menguji hipotesis adanya perbedaan pemanfaatan pelayanan kesehatan ibu bersalin berdasarkan perbedaan kondisi lingkungan dan perbedaan karakteristik responden. Penelitian ini menunjukkan bahwa lingkungan dan karakteristik populasi berhubungan signifikan terhadap pemanfaatan pelayanan kesehatan ibu bersalin. Dari analisis multivariat wanita yang paling berpeluang bersalin di rumah dengan bukan tenaga kesehatan yaitu wanita dengan karakteristik suami bekerja di sektor pertanian / wirasuasta (aOR: 7,56 95% CI: 1,69-33,80), dan wanita yang paling berpeluang untuk bersalin di rumah dengan tenaga kesehatan yaitu wanita bertempat tinggal di Pulau Kalimantan (aOR: 11,43 95% CI: 6,13-21,28). Dari hasil analisis hubungan lingkungan dan karakteristik populasi pada penelitian ini disimpulkan bahwa adanya ketidakmerataan akses kesehatan maternal (inequitable access to maternal healthcare) khususnya pada pemanfaatan pelayanan kesehatan ibu bersalin di Indonesia. Untuk mewujudkan pemeratan akses kesehatan maternal perlu adanya komitmen pemerintah pusat dan daerah dengan memaksimalkan anggaran di daerah khususnya pada Pulau di luar Jawa-Bali.

Kata kunci: Pelayanan kesehatan Ibu bersalin, Lingkungan Wilayah Tempat Tinggal, dan Karakteristik Populasi, ketidakmerataan akses kesehatan maternal. ......Maternal health problems, specially maternal mortality, are one of the most important problems that need to be addressed for the Indonesian people in order to improve the quality of their human resources. Indonesia has a high mortality rate, which is often associated with the utilization of maternal health services. Utilization of maternal health services in Indonesia shows variations between regional areas, which might be influenced by environmental factors and differences in the characteristics of the population. This study examines the relationship between environmental factors and population characteristics with the utilization of maternal health services. This study used secondary data from the 2017 IDHS which included 3,586 women of childbearing age (15–49 years) who had given birth within one year prior to the survey. Multinomial logistic regression analysis was used to test the hypothesis of whether the use of maternal health services had significant differences between different environmental conditions and different respondent characteristics. This study showed that environmental factors and population characteristics are significantly associated with the utilization of maternal health services. Based on multivariate logistic regression analysis, women who are most likely to give birth at home with non-health workers are women whose husbands work in the agricultural sector / self-employed (aOR:7.56 95% CI: 1.69-33.80), and women who are most likely to give birth at home with health workers are women who live on the island of Borneo. (aOR: 11.43 95% CI: 6,13-21,28). Based on the analysis of the relationship between environmental factors and population characteristics in this study, it was concluded that inequality of access to maternal healthcare was evident, especially the utilization of maternal health services in Indonesia. To achieve equal / equitable access to maternal health services, commitment from the central and local governments to optimize their budget especially in provinces outside Java and Bali island is absolutely needed.

Abstrak :
Prevalensi karies gigi yang ditunjukkan dengan decayed, missing dan filled teeth (DMF-T) masih merupakan masalah kesehatan masyarakat, termasuk di Indonesia. Penelitian ini bertujuan untuk mengetahui peran faktor individu, rumahtangga dan kabupaten/kota terhadap kejadian karies gigi guna menyusun model pengendalian karies gigi di Kepulauan Bangka Belitung (provinsi dengan riwayat karies gigi tertinggi). Desain penelitian ini campuran (hybrid) antara ecological study dan cross-sectional. Pengumpulan data dilakukan dengan wawancara menggunakan kuesioner, pemeriksaan kesehatan gigi, pengambilan sampel air dan wawancara mendalam. Analisis data menggunakan regresi logistik multilevel (dengan mixed-effect model). Hasil penelitian menunjukkan faktorfaktor pada tingkat individu (frekuensi menggosok gigi, kebersihan gigi dan mulut dan kebiasaan makan makanan asam/bercuka), tingkat rumahtangga (jenis sumber dan keasaman air) dan tingkat kabupaten/kota (ketersediaan perawat gigi dan dokter gigi, angka gizi buruk dan besar anggaran kesehatan per kapita) berpengaruh terhadap prevalensi karies gigi berat pada penduduk dewasa, dimana secara keseluruhan dapat menjelaskan variasi risiko karies gigi sebesar 73,6%. Model pengendalian karies gigi yang sesuai dengan kondisi Kepulauan Bangka Belitung adalah menggabungkan pengendalian faktor pada tingkat individu, rumahtangga dan kabupaten/kota. ......Dental caries prevalence, indicated by decayed, missing and filled teeth (DMF-T), remains a global public health problem, including Indonesia. The objective of this research was to address the role of individual factors, households, and regency/municipality in explaining dental caries incidence, in order to formulate a model to control dental caries in Kepulauan Bangka Belitung—the province with the highest dental caries prevalence in Indonesia. This research was designed as a combination (hybrid) of cross-sectional and ecological studies. Quantitative and qualitative data were collected through interview, dental health examination by dentists, water sampling, and in-depth interviews. A multilevel logistic regression (mixed-effect) model was fitted to the data. The results show that the explanatory variables at individual (frequency of teeth brushing, dental and mouth hygiene, and acidic food consumption), household (main water source and acidity), and regency/municipality (availability of dentist and dental nurse, malnutrition, and per capita health budget) levels influenced the prevalence of severe dental caries among adults; they all explained 73.6% of the variation in risk of dental caries. The appropriate disease control model, given the local conditions of Kepulauan Bangka Belitung Province, is one that integrates control of risk factors at individual, household, and regency/municipality levels.

Abstrak :
Measles immunization has been introduced since 1960, thereby markedly reducing the number of cases in developed countries. However, measles epidemics still occur even in developed countries. In the United States, in 1988-1992 an increase in the number of measles cases reaching 50,000 cases was reported. Some of these cases occurred in previously immunized patients. This was thought to be caused by genetic mutation of the measles virus, aside from weaknesses of the vaccine and low immunization coverage. Since measles immunization was employed in Indonesia, the number of measles patients has decreased. However, epidemics are still frequently reported. About 15-30% of reported cases occurred in those previously immunized, raising the question of whether a genetic difference exists between the wild-type measles virus circulating in Indonesia and the vaccine virus being used. Such a difference may lead to the differences in the antigenicity of the wild-type and vaccine viruses, rendering the resulting antibody incapable of neutralizing the wild-type viruses. Based on the above, this study is aimed to demonstrate the extent of genetic and antigenic differences between the wild-type and vaccine measles viruses. We conducted an experimental laboratory study to sequence the N, H, and F genes of the wild-type measles viruses (G2, G3, and D9) and the CAM-70 vaccine virus. To show antigenic differences, the wild-type viruses (G2, G3, and D9) and the CAM-70 and Schwarz viruses were injected to BALB/c mice. Serum antibodies of the mice were analyzed using ELISA, cross-neutralization test, and immunoblotting using antigens from the respective viruses. Results of this study showed that the wild-type and the vaccine viruses differ in the sequence of the N gene by 73-79 nucleotides, resulting in amino acid substitution of 17-24 residues; the H gene by 60-99 nucleotides, resulting in amino acid substitution of 13-29 residues; the F gene by 71-88 nucleotides, resulting in amino acid substitution of 4-3 I residues. Differences between the wild-type and the CAM-70 and Schwarz vaccine viruses were also found in the epitope site of the CTL and antibodies, which are important to virus antigenicity. We conclude that a significant difference in antigenicity exists between the wild-type measles viruses circulating in Indonesia with the CAM-70 measles virus. We also found the immunogenicity of the CAM-70 and Schwarz vaccine viruses to be lower than that of the wild-type viruses.

Abstrak :
Measles immunization has been introduced since 1960, thereby markedly reducing the number of cases in developed countries. However, measles epidemics still occur even in developed countries. In the United States, in 1988-1992 an increase in the number of measles cases reaching 50,000 cases was reported. Some of these cases occurred in previously immunized patients. This was thought to be caused by genetic mutation of the measles virus, aside from weaknesses of the vaccine and low immunization coverage. Since measles immunization was employed in Indonesia, the number of measles patients has decreased. However, epidemics are still frequently reported. About 15-30% of reported cases occurred in those previously immunized, raising the question of whether a genetic difference exists between the wild-type measles virus circulating in Indonesia and the vaccine virus being used. Such a difference may lead to the differences in the antigenicity of the wild-type and vaccine viruses, rendering the resulting antibody incapable of neutralizing the wild-type viruses. Based on the above, this study is aimed to demonstrate the extent of genetic and antigenic differences between the wild-type and vaccine measles viruses. We conducted an experimental laboratory study to sequence the N, H, and F genes of the wild-type measles viruses (G2, G3, and D9) and the CAM-70 vaccine virus. To show antigenic differences, the wild-type viruses (G2, G3, and D9) and the CAM-70 and Schwarz viruses were injected to BALB/c mice. Serum antibodies of the mice were analyzed using ELISA, cross-neutralization test, and immunoblotting using antigens from the respective viruses. Results of this study showed that the wild-type and the vaccine viruses differ in the sequence of the N gene by 73-79 nucleotides, resulting in amino acid substitution of 17-24 residues; the H gene by 60-99 nucleotides, resulting in amino acid substitution of 13-29 residues; the F gene by 71-88 nucleotides, resulting in amino acid substitution of 4-3 I residues. Differences between the wild-type and the CAM-70 and Schwarz vaccine viruses were also found in the epitope site of the CTL and antibodies, which are important to virus antigenicity. We conclude that a significant difference in antigenicity exists between the wild-type measles viruses circulating in Indonesia with the CAM-70 measles virus. We also found the immunogenicity of the CAM-70 and Schwarz vaccine viruses to be lower than that of the wild-type viruses.

Abstrak :
Anemia is the main micronutrient deficiency problem among adolescent school girls in Indonesia. Anemia due to iron deficiency often coexists with zine deficiency. Iron and zinc have anlagonistic interaction. Therefore, it was appropriate ratio of iron-zinc supplementation. Objective The study was aimed to investigate the different ratios of iron-zinc supplementation Fe: Zn = 2: 1 and Fe: Zn = 4: 1 on improving the iron and zinc status and eventually reduction of the morbidity of anemic adolescent school girls compared to iron supplementation alone. Methodology A randomized, double blind community trial was conducted among anemic adolescent school girls (10-12 years old). Selection of subjects was conduted in two steps. Firstly, 238 girls (out of 1358 girls), with hemoglobin concentration level < 115 g/L using Hemocue were recruited and given antihelminthic drug (500 mg mebendazole as a single dose). Secondly, those who had hemoglobin concentration < 120 g/L using Cell Dyn from venous blood one week after deworming (n+133) were enrolled into the study. The 133 subjects were assigned randomly to one of the three groups for daily iron-zinc supplementation for 12 weeks with: Group 1 (n=45): iron (60 mg/day), Group 2 (n=45): iron and zinc (30 mg and 15 mg/day) or group 3 (n=43): iron and zinc (60 mg and 15 mg/day).Supplement intake was supervised at base line, weight and height were measured and the available iron and zinc intake from diet was estimated using a model modified from WHO/FAO and Murphy, based on the data 24-hour Food Recall and Food Frequency Questionnare. Iron (hemoglobin/Hb, serum ferritin/SF, serum transferrin receptor/TfR, zinc protoporphyrin/ZPP, Mean Corpuscular Volume/MCV, Red-cell Distribution Width/RDW, body iron/BI) and zinc (serum zinc/SZ) status and supplementation. Morbidity status of diarrhea and Acule Respiratory Infection (ARI) were recorded weekly. The phagocytes cell and Cell-Mediated Immunity were measured only for 50% of the subjects. Results and Discussion By the end of the supplementation, most indicators of iron status were increased significantly in all subjects both they took iron supplementation with or without zinc, and the proportion of iron deficiency anemia reduced. Iron supplementation alone or iron-zinc improved zinc status. The proportion of zinc deficiency was sinificantly reduced only among subjects who took iron-zinc supplementation with the ratio of Fe: Zn =2: 1. which was significantly lower compared to the other two groups at the end of supplementation. In iron/zinc 2 : 1 group, no subject had iron deficiency anemia and zinc deficiency after 12 weeks of supplementation, which suggested that iron-zinc supplementation with the ration of Fe: Zn = 2 : 1 had reduced both iron deficiency anemia and zinc deficiency. In this study, iron deficiency among anemic school girls was due to insufficiency of iron in red blood cell, and iron or iron-zinc supplementation for 12 weeks had less benefit to increase iron status. The possibility; of hemoglobinopathies such as thalassemia trait affecting adolescent girls in this study should be considered as several studies indicated that the prevalence of tlinlassemia trait among the same population in Indonesia is high. Iron deficiency also occurred at the storage level, which increased and reached the normal value with iron or iron-zinc supplementation. At the end of supplementation, the mean value of most indicators of iron status in all groups did not reach the normal value (such as Hb < 120 g/L, ZPP > 40 umol/mol heme, MCV <2 80 fL, RDW > l4%), perhaps the 12-weeks of iron supplementation was not long enough to fulfill iron for the 120 erythrocyte life cycle. lt seems, that the competition between iron and zinc occurred both at the storage level and the erythrocyte formation, and iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction as the improvement of both iron and zinc status was higher compared to the other groups. Most anemic adolescent school girls in this study had low available iron and zinc intake from the diet, with low intake of enhancers and high intake of inhibitors, which is not enough to promote either iron or zinc absorption from the supplements. The reduction of the proportion ol' subjects suffering from ARI was the highest among subjects who took either iron alone (3l.1% to 6.7%) compared to those who took iron- zinc supplement with ratio 2: 1 (1 7.3% to l1.l%) or iron-zinc supplement with ratio 4: 1(16.3 % to l4%), indicating that iron alone reduced morbidity status in tenn of Acute Respiratory Infection (ARI). However, adding zinc to iron supplements with ratio 2: 1 scents to improve the specific immune response of anemic adolescent school girls, as shown that the ratio of CD-4/CD-S was slightly increased among subjects who took iron-zinc supplement with the ratio of Fe: Zn= 2: 1. Conclusions and Recommendations lt was concluded, that both iron deficiency anemia (22%) and zinc deficiency (15.8%) were problems in the study area. Iron deficiency and hemoglobinopathies such as that assemia trait might be the causes of anemia among adolescent school girls. A daily 30 mg iron and 15 mg zinc supplementation among anemic adolescent schools girls for 12 weeks improved iron and zinc status and reduced iron deficiency anemia and zinc deficiency. Iron supplementation alone increased iron status, while adding zinc to iron supplementation protected the adverse effect of iron on decreasing zinc status. The competition between iron and zinc might occur in the role of both nutrients for erythrocytes formation as well-as at storage level, and supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction on improving bot.h iron and zinc status. As most of the anemic adolescent school girls had inadequate iron and zinc intake from the diet, the deficiencies of other micronutrients such as; vitamin A, folic acid and vitamin B12 should also be considered as the causes of anemia. Combined iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 was appropriate on reducing the risk of anemic adolescent school girls suffering from Acute Respiratory Infection, however the mechanism of both iron and zinc on enhancing immune system could not clearly be shown from the results of this study. It is recommended to establish an iron-zinc supplementation program with ratio of 2: 1 through the existing channel of school health program to alleviate iron de iciency anemia and zinc deficiency 'among adolescent girls. Research cum action prioritized is to explain the contribution of bioavailability iron and zinc intake from the diet including increase the enhancers and minimize the inhibitors to the absorption of iron-zinc supplementation with ratio of Fe: Zn = 2: 1. The possibility of hemoglobinopathies such as thalassemia trait, as the cause of anemia needs further investigations.

Abstrak :
Anemia is the main micronutrient deficiency problem among adolescent school girls in Indonesia. Anemia due to iron deficiency often coexists with zine deficiency. Iron and zinc have anlagonistic interaction. Therefore, it was appropriate ratio of iron-zinc supplementation. Objective The study was aimed to investigate the different ratios of iron-zinc supplementation Fe: Zn = 2: 1 and Fe: Zn = 4: 1 on improving the iron and zinc status and eventually reduction of the morbidity of anemic adolescent school girls compared to iron supplementation alone. Methodology randomized, double blind community trial was conducted among anemic adolescent school girls (10-12 years old). Selection of subjects was conduted in two steps. Firstly, 238 girls (out of 1358 girls), with hemoglobin concentration level < 115 g/L using Hemocue were recruited and given antihelminthic drug (500 mg mebendazole as a single dose). Secondly, those who had hemoglobin concentration < 120 g/L using Cell Dyn from venous blood one week after deworming (n+133) were enrolled into the study. The 133 subjects were assigned randomly to one of the three groups for daily iron-zinc supplementation for 12 weeks with: Group 1 (n=45): iron (60 mg/day), Group 2 (n=45): iron and zinc (30 mg and 15 mg/day) or group 3 (n=43): iron and zinc (60 mg and 15 mg/day).Supplement intake was supervised at base line, weight and height were measured and the available iron and zinc intake from diet was estimated using a model modified from WHO/FAO and Murphy, based on the data 24-hour Food Recall and Food Frequency Questionnare. Iron (hemoglobin/Hb, serum ferritin/SF, serum transferrin receptor/TfR, zinc protoporphyrin/ZPP, Mean Corpuscular Volume/MCV, Red-cell Distribution Width/RDW, body iron/BI) and zinc (serum zinc/SZ) status and supplementation. Morbidity status of diarrhea and Acule Respiratory Infection (ARI) were recorded weekly. The phagocytes cell and Cell-Mediated Immunity were measured only for 50% of the subjects. Results and Discussion By the end of the supplementation, most indicators of iron status were increased significantly in all subjects both they took iron supplementation with or without zinc, and the proportion of iron deficiency anemia reduced. Iron supplementation alone or iron-zinc improved zinc status. The proportion of zinc deficiency was sinificantly reduced only among subjects who took iron-zinc supplementation with the ratio of Fe: Zn =2: 1. which was significantly lower compared to the other two groups at the end of supplementation. In iron/zinc 2 : 1 group, no subject had iron deficiency anemia and zinc deficiency after 12 weeks of supplementation, which suggested that iron-zinc supplementation with the ration of Fe: Zn = 2 : 1 had reduced both iron deficiency anemia and zinc deficiency. In this study, iron deficiency among anemic school girls was due to insufficiency of iron in red blood cell, and iron or iron-zinc supplementation for 12 weeks had less benefit to increase iron status. The possibility; of hemoglobinopathies such as thalassemia trait affecting adolescent girls in this study should be considered as several studies indicated that the prevalence of tlinlassemia trait among the same population in Indonesia is high. Iron deficiency also occurred at the storage level, which increased and reached the normal value with iron or iron-zinc supplementation. At the end of supplementation, the mean value of most indicators of iron status in all groups did not reach the normal value (such as Hb < 120 g/L, ZPP > 40 umol/mol heme, MCV <2 80 fL, RDW > l4%), perhaps the 12-weeks of iron supplementation was not long enough to fulfill iron for the 120 erythrocyte life cycle. lt seems, that the competition between iron and zinc occurred both at the storage level and the erythrocyte formation, and iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction as the improvement of both iron and zinc status was higher compared to the other groups. Most anemic adolescent school girls in this study had low available iron and zinc intake from the diet, with low intake of enhancers and high intake of inhibitors, which is not enough to promote either iron or zinc absorption from the supplements. The reduction of the proportion ol' subjects suffering from ARI was the highest among subjects who took either iron alone (3l.1% to 6.7%) compared to those who took iron- zinc supplement with ratio 2: 1 (1 7.3% to l1.l%) or iron-zinc supplement with ratio 4: 1(16.3 % to l4%), indicating that iron alone reduced morbidity status in tenn of Acute Respiratory Infection (ARI). However, adding zinc to iron supplements with ratio 2: 1 scents to improve the specific immune response of anemic adolescent school girls, as shown that the ratio of CD-4/CD-S was slightly increased among subjects who took iron- zinc supplement with the ratio of Fe: Zn= 2: 1 Conclusions and Recommendations lt was concluded, that both iron deficiency anemia (22%) and zinc deficiency (15.8%) were problems in the study area. Iron deficiency and hemoglobinopathies such as that assemia trait might be the causes of anemia among adolescent school girls. A daily 30 mg iron and 15 mg zinc supplementation among anemic adolescent schools girls for 12 weeks improved iron and zinc status and reduced iron deficiency anemia and zinc deficiency. Iron supplementation alone increased iron status, while adding zinc to iron supplementation protected the adverse effect of iron on decreasing zinc status. The competition between iron and zinc might occur in the role of both nutrients for erythrocytes formation as well-as at storage level, and supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction on improving bot.h iron and zinc status. As most of the anemic adolescent school girls had inadequate iron and zinc intake from the diet, the deficiencies of other micronutrients such as; vitamin A, folic acid and vitamin B12 should also be considered as the causes of anemia. Combined iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 was appropriate on reducing the risk of anemic adolescent school girls suffering from Acute Respiratory Infection, however the mechanism of both iron and zinc on enhancing immune system could not clearly be shown from the results of this study. It is recommended to establish an iron-zinc supplementation program with ratio of 2: 1 through the existing channel of school health program to alleviate iron de iciency anemia and zinc deficiency 'among adolescent girls. Research cum action prioritized is to explain the contribution of bioavailability iron and zinc intake from the diet including increase the enhancers and minimize the inhibitors to the absorption of iron-zinc supplementation with ratio of Fe: Zn = 2: 1. The possibility of hemoglobinopathies such as thalassemia trait, as the cause of anemia needs further investigations.