FACTORS ASSOCIATED WITH THE UTILIZATION OF PUBLIC HEALTH CENTER IN CENTRAL JAVA

Background: The Public Health Center (PHC) is a gatekeeper to formal healthcare in Indonesia. PHCs in Central Java have met the basic health facility readiness standard, but there are still numerous challenges to increasing the utilization of PHCs. Aims: This study aimed to analyze the factors related to the utilization of PHC in Central Java. Methods: This cross-sectional study used secondary data from the 2018 Indonesia Basic Health Research, with 63,118 total samples. The independent variables were residence, age, gender, marital status, education, insurance, and socioeconomic, while the dependent variable was the utilization of PHC. The data were analyzed using a binary logistic regression. Results: The average rate of utilization of PHC in Central Java in 2018 was 5.7%. Those aged 46-65 and >65 years old, women, married and widowers, and those with health insurance had a higher possibility of utilizing PHC. Meanwhile, those who graduated from secondary and tertiary school, the employed and the wealthiest group had a lower possibility of utilizing PHC. Conclusion: The factors related to the utilization of PHC in Central Java are age group, gender, marital status, education level, working status


Public
Health Center (PHC/ Puskesmas) is the first-level health facility widely spread and easily accessible by the community for location and expense.According to the Regulation of the Minister of Health of the Republic of Indonesia Number 75 of 2014, the scope of PHC is at the subdistrict level and it focuses on community health development by prioritizing promotive and preventive efforts.
In the era of the National Health Insurance (NHI/JKN) system, PHC has a vital role as the gatekeeper to formal healthcare (Megatsari, Nandini and Laksono, 2023).PHC becomes the first contact and reference to the higher healthcare facilities using medical service standards (Wuri et al., 2021).Reinforcing the service by providing a comprehensive and qualified primary service (Sari, Zulfendri and Sanusi, 2020), followed by an increase in quality through an accreditation system, is taken to level up the utilization of PHC in the community.
The number of inpatients and outpatients of PHC in Central Java from 2017 to 2018 experienced significant growth (Central Java Provincial Health Office, 2018, 2019).This increasing trend can be seen today and is probably along with the government's efforts to optimally accelerate community health levels in the subdistrict area (Sulaiman, 2021).However, the increasing number of PHC patients does not necessarily indicate the achievement in the coverage of PHC utilization in Central Java.It is because, on the other hand, there were also more than two times increasing numbers of inpatients and outpatients in hospitals and other health facilities (Central Java Provincial Health Office, 2018, 2019).This data showed that people also choose to utilize other health services besides PHC.
In general, the Java region has become a benchmark for the distribution of good quality health services.Central Java meets the basic health facility readiness standard and has better knowledge scores than East Java, West Java, Sumatra, Sulawesi, and Lesser Sunda Islands (Haemmerli et al., 2021).However, this province still faces problems related to the disparity of public health facilities regarding the equitable distribution of PHCs in several districts (Wulandari et al., 2023).Furthermore, numerous obstacles and challenges have been observed in PHC utilization, such as in transportation, socioeconomic factors (Laksono, Nantabah and Wulandari, 2018), and a high number of dissatisfied patients with the service (Wulandari, Ridho, et al., 2019).Healthrelated utilization cannot be achieved only with high-quality primary services alone but is also related to the individual and the social environment factors (Chotchoungchatchai et al., 2020).
For this reason, this study aimed to analyze the factors related to the utilization of PHC in Central Java Province.Research on factors related to PHC utilization in Indonesia has been carried out many times before (Mulyanto, Kringos and Kunst, 2019;Wulandari and Laksono, 2019).Even so, this article can still provide new information and complement the previous research's findings regarding PHC utilization in Central Java.This article used secondary data from a national-scale survey to provide a more comprehensive representation of the conditions at the provincial level.Therefore, this article can contribute to enriching information concerning the utilization of PHC services in Central Java.

Independent Variable
This research used eight independent variables: residence, age group, gender, marital status, education level, working status, health insurance ownership, and socioeconomic status.The residence was classified into two categories: urban and rural, according to the Central Agency on Statistics.The age group was divided into ≤25 years old, 26-45 years old, 46-65 years old, and >65 years old.Gender consisted of two categories: men and women.Marital status was categorized into three: unmarried, married, and widowed.
This study defined the respondents' education as the admission of their last education certificate.There were four education levels: no school, primarymiddle, secondary, and tertiary.Working status was divided into two: unemployed and employed.This survey was also categorized into having and not having health insurance ownership.
The 2018 Basic Health Research used the wealth index pattern to identify socioeconomic status.It was accounted for using the average household outcome in total.It used the household outcome in the form of health insurance, food, and housing.Furthermore, it divided the income index into five categories of socioeconomic status: poorest, poor, middle, wealthy, and wealthiest (Wulandari, Qomarrudin, et al., 2019;Wulandari et al., 2022).

Data Analysis
The data were analyzed using the Chi-Square test to get a bivariate comparison.Moreover, it used the collinearity test to ensure the independent variables in the last regression model do not have any strong relations.The last point of the study used binary logistic regression to investigate the multivariate relationships among the independent variables and the utilization of PHC.This study used the IBM SPSS 26 application during the statistical analysis process.The utilization mapping of PHC in Central Java used ArcGIS 10.3 (ESRI Inc., Redlands, CA, USA).The Central Agency on Statistics provided an administrative border polygon shapefile for this study.

Results and Discussion
The analysis showed that the average rate of utilization of PHC in Central Java Province in 2018 was 5.7%.The first picture shows the distribution map of the utilization.It reported that this trend in the west side was lower than in any other area, while higher in the central areas.

Original Research
PHC.Based on gender, women tended to have two times higher than men.Table 1 informs that the widowed had the highest proportion of using PHC.Based on the education level, the higher the level, the smaller the chance to use PHC.For health insurance ownership, those who had one had two times the proportion of those who did not have any in utilizing PHC.Based on socioeconomic status, the higher the status, the lowest the proportion in utilizing PHC.
The result of the collinearity test showed that there was no strong relationship among free variables.The tolerant value for all variables was more significant than 0.10.The variance inflation factor (VIF) value was less than 10.00 for all factors.It can be concluded there were no signs of multicollinearity.Table 2 shows the binary logistic regression using PHC in Central Java Province.The analysis of the last step used it as the reference.

Original Research
Table 2 shows that the age group 46-65 had 1.587 times more probabilities than ≤25 years old (95% CI 1.365-1.844) in using PHC.The age group of >65 years old had a possibility of 1.494 times higher than ≤25 years old (95% CI 1.252-1.783) in using PHC.It was supported by the condition that most of society in Central Java was in the productive age (Central Java Provincial Health Office, 2021).In old age, physical function is impaired; therefore, a high health problem is possible.For diabetics, for instance, most patients were in the age range of 55-74 years old (Ministry of Health of the Republic of Indonesia, 2021).
The same result was found in East Java, showing that older people (>65 years old) used PHC service more than younger (Laksono, Megatsari and Zuardin, 2023).It was also in line with the research in North Carolina, which showed that the average rate of mental health check-up visits in health care every year was by the age group of 50 (Brathwaite et al., 2022).
Based on gender, women had 1.426 probabilities greater than men (95% CI 1.316-1.546)to utilize PHC.In developed countries, such as Indonesia, the health care program was mostly addressed to women, especially for increasing maternal health and decreasing maternal mortality (Chakhtoura et al., 2019).The priority programs for women that were included in the minimum health standard in PHC were as follows: the scope of implementation of early detection of cervical cancer and breast cancer, pregnancy check-ups, childbirth, and family planning programs, including lifestyle monitoring for noncommunicable disease control (Ministry of Health of the Republic of Indonesia, 2021).The national data also showed that diabetes prevalence in women was higher than in men (Ministry of Health of the Republic of Indonesia, 2019).
Based on marital status, those who were married and widowed had a higher probability of utilizing PHC than those who were unmarried.Previous research showed that married working women had more chances to finish four or more pregnancy checks (Denny et al., 2022).Some other health care can be used, such as maternity and postnatal services (Istifa et al., 2021), as well as maternal and child health services (Osaki et al., 2018).
According to the education level, people who graduated from secondary and tertiary school had a lower possibility of utilizing PHC than those who were not in school.This finding contradicted the previous study, where the higher the education that a person had, the higher the possibility of utilizing PHC or any health care (Mulyanto, Kringos and Kunst, 2019).
Several possibilities may explain the results of this study.Tertiary education is associated with better health conditions due to better health knowledge and awareness about health and better critical healthcare behavior.On the other hand, lower education is related to poor health (Raghupathi and Raghupathi, 2020).In addition, the education level influences people's choice to use health services.Those with higher education may choose not to use PHC facilities because they tend to consider the quality and service at PHC to be lower than secondary care (Mulyanto, Kringos and Kunst, 2019).
The employed group had 0.739 lower possibilities than the unemployed group (95% CI 0.681-0.803)to utilize PHC.Other research showed a similar case, stating that mothers and the unemployed community utilized PHC service in most places (Oktarianita, Sartika and Wati, 2021).Generally, outpatient service in PHC was not conducted in an emergency.Therefore, there is a possibility that the employed community will tend to find health services that can be accessed outside working hours.Other research showed that patient's loyalty to the health service correlated with working status.In terms of services provided by health workers, patients who were working have more expectations than those who did not work.Therefore, there is a possibility that those with working status will choose another health service place that can meet their expectations (Cahyani et al., 2021).
Those who owned health insurance had a 1.892 higher possibility of PHC utilization than those who did not have any Original Research (Wulandari, Laksono and Matahari, 2020), including PHC utilization (Ridwanah, Nugraheni and Laksono, 2022).The poor population with contribution assistance recipients of NHI in remote areas mostly use primary care facilities.In contrast, the population group without contribution assistance recipients of NHI in non-remote locations prefers to go directly to an advanced medical facility (Wenang et al., 2021).Insurance ownership can be a protective factor because it covers risk groups such as pregnant women and the elderly (Wulandari, Laksono and Matahari, 2020;Megatsari, Nandini and Laksono, 2023).
Based on socioeconomic status, the wealthiest group had 0.673 possibilities lower than any other group (95% CI 0.591-0.767)to utilize PHC.In line with the result, previous research informed that a society with a low socioeconomic level tended to have higher PHC utilization than the higher socioeconomic group (Wulandari et al., 2022).PHCs have advantages in terms of low or even no costs, and they can be found in almost every sub-district.Thus, transportation costs are more affordable for all, especially those with lower economic status (Johar et al., In comparison, the wealthiest group preferred to use secondary care health services (Mulyanto, Kringos and Kunst, 2019) due to better quality of service, good-quality equipment, and longer opening hours (Sokang, Westmaas and Kok, 2019).

Limitation of the Study
The study analyzed big data to represent information at the province level, but on the other hand, it analyzed secondary data.Thus, the accepted variables limited the analyzed factors.Several other characteristics related to the utilization of PHC found in previous studies, such as travel time, travel costs, and type of disease, could not be investigated (Wei et al., 2018;Laksono and Wulandari, 2020;Laksono, Wulandari and Efendi, 2020).

Conclusion
Seven factors related to PHC utilization in Central Java were observed, including age group, gender, marital status, education level, working status, health insurance ownership, and socioeconomic status.
The vulnerable groups dominated the utilization of PHC in Central Java.Insurance ownership has also become one of the factors related to PHC utilization.These results show that PHCs in Central Java have successfully provided an easily accessible health facility to vulnerable groups.However, this study's findings also indicate that the role of the PHC as a gatekeeper has not been maximized because it was only reaching certain groups.
PHC utilization can still be increased by reaching out to these groups: young people and adults, unmarried, male, highly educated, employed, and those at the wealthiest socioeconomic level.Efforts must be made to increase the trust of community groups who did not use the PHC facilities.Several strategies can be implemented, such as increasing the quality and completeness of PHC services and the adequacy of medical personnel at the PHC.It is also crucial to strengthen the PHC role, mainly in a promotive and preventive role.

Abbreviations
Figure 1.Distribution map of PHC utilization in Central Java 2018

Table 1 .
Descriptive statistics on the utilization of PHC and the respondent characteristics in Central Java2018 (n=63.118)

Indonesian Journal of Health Administration
Table1describes the descriptive statistics of the utilization.The result shows that the proportion in rural areas was less than in urban.While based on the age group, the older they were, the higher the utilization ofPurwoko, Sulasmi, Nursafingi   -ISSN 2303-3592, e-ISSN 2540-9301  10.20473/jaki.v11i2.2023.221-230 (Jurnal Administrasi Kesehatan Indonesia) p

Table 2 .
Result of binary logistic regression on the utilization of PHC in Central Java 2018 (Jurnal Administrasi Kesehatan Indonesia)p-ISSN2303 -3592, e-ISSN 2540 -9301  10.20473/jaki.v11i2.2023.221-230.221-230 KE.024/ 2018).Respondents have been informed about the objective of the research and signed the informed consent to participate in the study.All respondents' identities have been removed from the dataset.