Case Study 7 “Together Picket”: Community Activities in Dengue Source Reduction in Purwokerto City, Central Java, Indonesia Rita Kusriastuti*#, Thomas Suroso* Sustriayu Nalim** and Wibowo Kusumadi*** *Directorate General Communicable Disease Control and Environmental Health, Ministry of Health, Jalan Percetakan Negara No. 29, Jakarta, 10560, Indonesia **Vector Control Research Unit, Ngawen, Salatiga, Central Java, Indonesia ***Hospital Elisabeth, Purwokerto, Central Java, Indonesia Abstract This paper looks at how dengue prevention and control in Indonesia has evolved from a vertical, government-controlled programme to a more horizontal, community-based approach. The authors illustrate how social mobilization has improved Aedes source reduction by drawing upon recent experiences in Purwokerto City, Central Java. Keywords: Dengue, prevention and control, community-based, social mobilization, source reduction, Indonesia. Country setting and humidity favour mosquito populations with a peak in mosquito abundance in the rainy background season. The major dengue vector in urban The Indonesian archipelago consists of five areas is Aedes aegypti but Aedes albopticus large islands – Java, Sumatra, Kalimantan, is also present. The majority of houses in Sulawesi, and Papua – and thousands of Indonesia have a cement water container smaller islands. Approximately 60% of located in the bathroom to store water for Indonesia’s 210 million people live on Java bathing, and a smaller container in the island. There are 370 ethnic groups with 67 water closet (WC). Water containers made languages, but Bahasa Indonesia unites all from clay or plastic barrels/jars are also kept citizens. The national economy is based on in the kitchen for cooking or drinking agriculture and industrial production of the purposes. Additional water containers may country’s natural resources. act as potential breeding sites both inside and outside houses. The rainy season lasts from October to March and the dry season from April to The first reported dengue fever and September. High temperatures and dengue haemorrhagic fever (DHF) epidemic #E-mail: [email protected] Dengue Bulletin – Vol 28, 2004 (Suppl.) 35 Community Activities in Dengue Source Reduction in Indonesia in Indonesia occurred in 1968, with 24 messages communicated through various fatalities and a high Case Fatality Rate (CFR) media. Voluntary cadres, mostly women of 41.3%[1]. Since then, dengue fever has from the “PKK” (Family Welfare become endemic in most areas of Indonesia Empowerment Organization) were mobilized with year-round transmission. DHF affects to conduct regular house-to-house children under the age of 14 years but an inspections of potential Aedes breeding sites. increasing number of cases are being Staff from health centres and district health reported in older age groups. For example, offices also carried out inspections of public 47% of all cases reported in 2000 were places every three months. patients over 14 years of age. Several Knowledge, Attitude and The approach to DHF control in Practice Surveys (KAP) conducted in the Indonesia has evolved considerably in the mid-1990s, however, showed that while the last 30 years. From 1968 to 1979, the general public possessed knowledge of the Health Department operated a vertical 3M messages, few people were taking programme that emphasized perifocal appropriate action. A social mobilization chemical spraying to reduce mosquito approach was needed that could achieve density in areas where cases of DHF were and sustain behavioural results. This new reported. A mass larviciding programme (1% initiative, known as Piket Bersama temephos sand granules applied to (“Together Picket”), was first piloted in mosquito breeding sites) was established Purwokerto, Central Java. This paper focuses between 1980 and 1985 but was effective on “Together Picket” experiences in only for three months of each year[2]. From Purwokerto City (population of 220,000). 1986 to 1991, decreasing programme resources resulted in a shift to selective larviciding. An intensive physician training Planning innovation for programme in clinical diagnosis and dengue prevention and management of DHF has been in place since the 1970s. This programme has control helped to reduce the CFR to 2%. The initiative commenced with a pilot study From 1992 until the late 1990s, attention in a hamlet in Purwokerto in 1996. This was given to larval source reduction through study suggested that Pemberantasan Sarang increased community participation, health Nyamuk and Bulan Gerakan 3M education and intersectoral coordination[3]. programmes should continue but a new An inter-sectoral DHF Working Group (DHF- focus for community action was required. WG) was established at all administrative The study recommended the formation of levels, from villages to sub-district, district, dasawisma (dasa means “ten” and wisma province and national level, in order to means “house”). Each dasawisma was to implement source reduction strategies under have a leader, preferably a PKK the guidance of local health personnel. Two representative, who would receive DHF programmes – Pemberantasan Sarang training. Depending on their size, each Nyamuk (DHF source reduction) and Bulan urban neighbourhood was to organize Gerakan 3M (Menguras = Cleaning; approximately 1-5 dasawisma. Householders Menutup = Covering; and Mengubur = within each dasawisma were to be Burying) – were established with key health organized by their local leader to take turns 36 Dengue Bulletin – Vol 28, 2004 (Suppl.) Community Activities in Dengue Source Reduction in Indonesia inspecting each others premises for larval were held with the heads of various DHF habitats (Figure 1). Working Groups, the PKK, and key stakeholders from government departments Figure 1: Monthly meeting of a dasawisma to gain their support. in Purwokerto City, in which they discuss Supported by their local PKK the results of their activity and make a plan for the next month representative, dasawisma then arranged a roster whereby each house took turns to inspect the other nine houses for potential larval habitats (Figure 2). Figure 2: Dasawisma’s activity, weekly checking for larvae in a bathroom of one member of a dasawisma in Purwokerto City Additional planning in Purwokerto involved the establishment of partnerships between the local government, the Rotary Club, the PKK, and municipal health services. The “head” DHF Working Group, chaired by the mayor and consisting of members of the health, education and economic sectors, PKK representatives, village development units, Each dasawisma was provided with a and Rotary Club members, agreed to “source reduction” kit containing flashlights disseminate information and monitor source to check the presence of larva, forms to reduction activities. The Rotary Club acted as record basic information, and education a funding agency for materials procurement booklets containing information on the and training. “3Ms” (cleaning, covering, and burying). Dasawisma leaders were asked to monitor and supervise the implementation of Implementing the new “Together Picket” in their areas and to approach report results to the district office. Inspections of public places such as The new approach officially began in traditional markets, public gardens, places of November 1997 with several meetings worship, and offices were also carried out to inform and encourage several by health centre staff and district health neighbourhoods in Purwokerto to undertake officers every three months. Based on initial source reduction. Then, all members of the indications that the new approach was local Rotary Club received education on having a higher level of behavioural impact, “Together Picket”. Rotary members became social mobilization and communication role models for others by carrying out their activities were expanded to other areas of own household inspections. Next, meetings the city between 1998 and 1999. Dengue Bulletin – Vol 28, 2004 (Suppl.) 37 Community Activities in Dengue Source Reduction in Indonesia Monitoring and evaluating throughout Indonesia (e.g. Palembang, Cirebon, Solo, Kudus, Surabaya, and Bali). the new approach “Together Picket” is ongoing in Purwokerto. Lessons learned Dasawisma activity reports are classified into three categories (active, less active, not Compared to previous efforts in Indonesia, active) at monthly PKK sub-district meetings the “Together Picket” approach has shown in a process known as the “Dasawisma early signs of success in reducing larval Participation Map”. The leaders of PKK indices mainly because a few, critical neighbourhoods and hamlets attending these behaviours have been emphasized by meetings are informed of the activity level of mobilizing very local social networks (the each dasawisma. Less active or inactive dasawisma), supported by key stakeholders dasawisma are encouraged to improve and including government and nongovernmental receive closer supervision. A local sociologist organizations, community leaders and also monitors all dasawisma group activity in experts. The Purwokerto experience Purwokerto through random visits to demonstrates the advantages gained when neighbourhoods. Larval surveys are programmes establish effective partnerships with existing organizations such as PKK. conducted every three months by local Monitoring and evaluation of such health staff and DHF hospital cases are community-based efforts, however, need to tracked. Pertinent larval survey results and be carefully planned and