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Background: Integrated efforts that involve many public health sectors are required to combatdengue in any setting. Hospitals are responsible for providing accurate diagnosis and reportingconfirmed dengue cases to the health authorities, which serves as an alarm for increasingpreventive measures. Community participation in dengue vector control is essential becauseit affects sustainability and cost-effectiveness of preventive and control. This thesis aimed toprovide an in-depth understanding of dengue prevention and control in Yogyakarta, Indonesia,in order to contribute to strengthening the country’s health system and the implementation ofstandardized and well-accepted dengue control strategies. Several aspects have been studiedin term of dengue prevention and control (case management and reporting, surveillance andvector control) in a dengue-endemic region of Indonesia – namely, Yogyakarta.

Methods: This thesis comprises four individual research studies: Knowledge, Attitude andPractice (KAP) survey, control card intervention, implementation of the Jumantik programmeand dengue case management and reporting in hospital. A descriptive analysis, followed by apre-post assessment, was performed in the community. A mixed-method approach was usedfor assessing the Jumantik programme and qualitative approach was conducted for the hospitalstudy.

Results: The findings indicated that: (i) KAP regarding dengue vector control were sufficient butcertain aspects still had weaknesses; (ii) level of community participation in vector control wasnot satisfactory for several reasons, including lacking time, being busy with work and memberof the community feel that vector control was not their responsibility; (iii) the Jumantikprogramme dealt with various obstacles, especially those related to public acceptance; (iv)coordination between the district health office and hospitals for early dengue detection didnot run optimally. We also found that standard operating procedures for dengue managementdiffered between hospitals.

Conclusions: The results clearly show that dengue prevention and control efforts in Yogyakartaface certain challenges that must be addressed. While many World Health Organizationrecommendations are being followed, the weaknesses found in some aspects of theimplementation, as well as the lack of integration for various dengue prevention and controlelements, need to be promptly addressed.

The incidence and geographical distribution of dengue fever has increased in recent decades. The actual disease burden is unknown owing to frequent underreporting and misclassification of cases. A well-functioning system for diagnosing, treating, and reporting cases is of prime importance as disease statistics is the foundation for decisions aiming to control the disease. This study aimed to explore the hospital-based disease surveillance system in Yogyakarta, a dengue-endemic region on Java, Indonesia. Semi-structured interviews were performed with 16 informants from four hospitals, including five general practitioners, three internists, four pediatricians, and four administrative staff working with administration relating to dengue diagnostics and reporting. Data were analyzed using content analysis. A theme arose from the analysis "Dengue surveillance stands and falls by the rigor of the health system." The theme, and underlying categories and subcategories, describes a surveillance system that in the best-case scenario works well and is likely to produce reliable dengue case data. However, there is a lack of synchronization between regulations and guidelines in different hospitals and some friction between regulatory bodies and the care provider. Knowledge among the staff appears to vary, and many clinical and financial decisions are made rather arbitrarily, which ultimately might lead to unequal health service delivery. In conclusion, the dengue surveillance system under study could improve further, particularly by ensuring that all regulations and recommended procedures are standardized and that all staff are given the best opportunity to stay updated on dengue-related matters, clinical as well as regulatory, on a regular basis.

Effort to control dengue transmission requires community participation to ensure its sustainability. We carried out a knowledge attitude and practice (KAP) survey of dengue prevention to inform the design of a vector control intervention. A cross-sectional survey was conducted in June⁻August 2014 among 521 households in two villages of Yogyakarta, Indonesia. Demographic characteristics and KAP questions were asked using a self-managed questionnaire. Knowledge, attitudes and practice scores were summarized for the population according to sex, age, occupation and education. The average knowledge score was rather poor-3.7 out of 8-although both attitude and practice scores were good: 25.5 out of 32 and 9.2 out of 11 respectively. The best knowledge within the different groups were found among women, the age group 30⁻44 years, people with a university degree and government employees. Best practice scores were found among retired people and housewives. There were several significant gaps in knowledge with respect to basic dengue symptoms, preventive practices and biting and breeding habits of the Aedes mosquito. In contrast, people's practices were considered good, although many respondents failed to recognize outdoor containers as mosquito breeding sites. Accordingly, we developed a vector control card to support people's container cleaning practices. The card was assessed for eight consecutive weeks in 2015, with pre-post larvae positive houses and containers as primary outcome measures. The use of control cards reached a low engagement of the community. Despite ongoing campaigns aiming to engage the community in dengue prevention, knowledge levels were meagre and adherence to taught routines poor in many societal groups. To increase motivation levels, bottom-up strategies are needed to involve all community members in dengue control, not only those that already comply with best practices.

In the year of 2016, there were more than 24 million Indonesian twitter users sharing news, events, as well as personal feelings and experiences on Twitter. This study seeks to validate a search protocol of health-related terms using real-time Twitter data which can later be used to understand if, and how, twitter can reveal information on the current health situation in Indonesia. In this validation study of mining protocols, we extracted geo-located conversations related to health and disease postings on Twitter using a set of pre-defined keywords, assessed the prevalence, frequency and timing of such content in these conversations, and validated how this search protocol was able to detect relevant disease tweets.

Groups of words and phrases relevant to disease symptoms and health outcomes were used in a protocol developed in the Indonesian language in order to extract relevant content from geo-tagged Twitter feeds. A supervised learning algorithm using Classification and Regression Trees was used to validate search protocols of disease and health hits comparing to those identified by a team of human experts. The experts categorized tweets as positive or negative in respect to health events. The model fit was evaluated based on prediction performance.

We observed 390 tweets from historical Twitter feeds and 1,145,649 tweets from Twitter stream feeds during the period July 26th to August 1st, 2016. Only twitter hits with health related keywords in the Indonesian language were obtained. The accuracy of predictions of mined hits versus expert validated hits using the CART algorithm showed good validity with AUC beyond 0.8.

Our study shows that monitoring of public sentiment on Twitter, combined with contextual knowledge about the disease, can detect health and disease tweets and potentially be used as a valuable real-time proxy for health events over space and time.