Introduction
Disasters are serious disruptions to the functioning of a community that are beyond its capacity to cope, using its own resources. Disasters and the emergencies they entail occur in diverse situations in both sparsely populated rural and densely populated urban regions, as well as in situations involving natural and manmade hazards. Apart from the ongoing coronavirus disease 2019 (COVID-19) pandemic, natural disasters are a common threat in Indonesia, owing to its geographical position on the Ring of Fire and location at the boundaries of 3 tectonic plates. 1 During disasters, pharmacists may function as first-line responders at the site of the event. They are expected to assist in emergency care for displaced victims in the health system, as observed during the COVID-19 pandemic. Reference Aburas and Alshammari2,Reference Hamid, Masood, Khalid, Saqlain, Tariq and Munir3 Several studies have mentioned the need to increase the number of pharmacists who are prepared to deal with disaster situations by exposing pharmacy students to emergency preparedness concepts through education and training. Reference McCourt, Singleton, Tippett and Nissen4–Reference Hannings, von Waldner, McEwen and White8 Evaluation based on the learning module on the role of pharmacists in disaster management has indicated the need for mass triage simulation programs for emergency situations. Reference Hannings, von Waldner, McEwen and White8,Reference Montana, Mathias, Rathelot, Lacroix and Vanelle9 Students equipped with the knowledge and skills required for disaster management can show superior responses in disaster situations. Therefore, it is necessary to investigate the opinions of academic and professional pharmacists regarding what pharmacy students need to prepare for future efforts in disaster management based on their experience.
Methods
Setting
The study was conducted online using the Zoom video meeting platform with academic and professional pharmacists in Indonesia. The interviews were scheduled according to the participants’ preferences.
Design and reporting
This exploratory study adopted a qualitative design to gain insight into the research objective. To follow a standard reporting process, COREQ statements were used. Reference Tong, Sainsbury and Craig10
Participants
The participants were academic or practicing pharmacists who had played active roles in disaster management situations, either as resource persons at disaster-related scientific forums or had been involved in handling disasters at disaster sites. Participants were selected via purposive sampling to achieve maximum variability. Key informants were initially identified by teams of resource persons known to be competent in the topic and who had played active roles in various disaster management activities. Of the identified informants, 3 were academic lecturers with whom the research team had worked prior to the commencement of the study. Snowball sampling was then used to reach other individuals with experience in disaster response. Unwillingness to participate in the study was considered an exclusionary criterion. Participants were invited through private WhatsApp messages or emails to the institutions, and subsequently, they were informed of the study’s objectives.
Interview methods
Individual semi-structured interviews were conducted in June 2021. The interview questions were developed following a comprehensive literature review to determine the relevant themes targeted during the interviews. Participants shared with researchers their experiences and knowledge about disaster management. Considering the impact of the COVID-19 pandemic, some interview questions were related to the Indonesian government’s response toward COVID-19 disaster prevention. Each Zoom interview session included only a single participant and the research team. The interviews involved open-ended questions to obtain in-depth information related to the research objectives. The interviews lasted approximately 60 – 90 minutes and were recorded. The research team comprised 1 professor, 1 associate professor, and 2 assistant professors of pharmacy studies with prior experience in qualitative research during their careers as academic lecturers. The research team evaluated results of interview before continuing to the next interview to ascertain whether enough data had been collected to draw conclusions, and any further data collection will not produce value-added insights All researchers took turns as interviewers and facilitators during each interview session.
Validity and reliability of research findings
To support the study’s confirmability and credibility, all transcripts and findings were shown to participants to check whether they were consistent with their actual experiences and opinions. The findings then were discussed within the research team who brought different perspectives of data interpretation. The research team members mutually agreed on the themes obtained from the interviews.
Data analysis
A combination of manual and software (NVivo) techniques were used in data analysis. The research assistant listened to the recordings and transcribed them verbatim. The transcripts were imported in NVivo12® software (QSR International, Burlington, MA, USA). The transcripts were then read through several times by the first author (CW) to identify the meaning units from the text. Other researchers (NNW, SDP, AKN) and CW then condensed the meaning units and gave names with codes sorting the data into categories; The whole organizing process was supported and facilitated by NVivo12® software (QSR International, Burlington, MA, USA). Content analysis was performed on the data in Indonesian before the data was translated to English. The process of synthesizing theme was inductive and depended on the judgement of the authors through many discussions. Each theme presented in the results was supported by quotations. The quotations were not literally translated word-for-word, but parts of the quotations that were unnecessary or repetitious were excluded and indicated with an /…/. Additions to words were placed in square brackets to facilitate understanding of the quotation.
Results
Of the 11 selected participants, 2 refused to participate. 2 men and 7 women between the ages of 35 and 59 years participated in individual interviews (Table 1). All 9 participants had graduated, namely: 2 professors, 2 PhD holders, 4 masters, and 1 pharmacist. The undergraduate was chosen because he had already fulfilled a critical and complementary role during various disaster situations in affiliation with various institutions. 7 participants had experienced and held strategic and operational positions in disaster management, while the other 2 were involved as resource persons in various scientific meetings related to disaster management.
Participant characteristics
6 main themes related to what pharmacy students needed to prepare for disaster management were identified, namely: (1) knowledge of health and disaster management, (2) specific skills in disaster management, (3) positive attitudes toward involvement in disaster management, (4) appropriate behavior in the face of a disaster, (5) personal readiness, and (6) training to achieve competence and readiness. The 4 themes of knowledge, skills, attitudes, and behaviors form the competency framework. In addition to competencies, the study demonstrated that personal readiness is required to prepare students in disaster management. Training was also a theme identified in this study; training is a strategic program required to achieve the desired competencies and readiness. The 6 themes, main categories, and their sub-categories are shown in Table 2. Knowledge of disasters, specific drug management, communication, and problem solving are themes that are often conveyed in interviews. Illustrative quotations from participants are shown under each of the main themes, categories, and sub-categories to help explain these findings.
Themes, main categories, and sub-categories
Theme 1: Knowledge of health and disaster management
The theme knowledge of health and disaster management was a principal theme identified from data analysis. It included 4 main categories: (1) Concepts and practices of disaster management, (2) Medicine and health care during disasters, (3) Specific theoretical knowledge of pharmacy, and (4) Applied knowledge of pharmacy. According to participant experiences, pharmacy students involved in disaster management should already understand the basic concepts pertaining to disasters and the disaster management guidelines of the Ministry of Health. Furthermore, they stated that pharmacy students must equip themselves with knowledge of medications and their management. This is the foundational competence of pharmacists. During a disaster, this knowledge must be adapted to disaster conditions.
Concepts and practices of disaster management
‘The important thing, of course, is to have an understanding about the disaster itself” [Participant 4]
‘Know the terrain first because there are so many types of disasters.’ [Participant 8]
‘The terms pre-, during, and post-disaster/…/ also need to be understood.’ [Participant 2; 7]
Medicines and health care during disasters
‘Ministry of Health guidelines related to disaster management contain details about the disaster types and the possibilities of emerging diseases and existing drug packages.’ [Participant 7]
‘Triage is not only for earthquakes or Mount Merapi eruptions. Even for COVID-19, triage is important to sort out which patients [COVID-19 patients] can be in the village shelter, which need to be taken to the hospital, or to the ICU, for example.’ [Participant 1]
Specific theoretical knowledge of pharmacy
‘Pharmacists are like that; they are mainly involved in drug handling, storage, delivery to patients, counseling, and so on.’ [Participant 4]
‘So, the SOP (standard operating procedure) for students was to prepare medicines and logistics and then report on drugs that will be held or those that have been given to the community.’ [Participant 8]
‘Here, we are dealing with logistics, so how to ensure in terms of logistics that the pharmacy is sufficient to provide all health services.’ [Participant 9]
Applied knowledge of pharmacy
‘If we receive medication aid, we have to observe carefully which drugs can be accepted and which drugs cannot.’ [Participant 7]
‘Counseling during a disaster situation may be a little different in terms of the points that must be emphasized.’ [Participant 4]
Theme 2: Specific skills in disaster management
The participants emphasized the importance of soft skills, including communication, problem-solving skills, open-mindedness, knowledgeability, organizational skills, and survival skills. Learning soft skills was the most widely mentioned competency among interviewees. Communication and various issues related to problem-solving were the skills most frequently discussed by participants. Although students have completed courses related to soft skills, their practice of these skills appears to be limited.
Communication
‘Communication skills come first. Communication/…/so we must also be smart to listen, to map out what they ask for, and provide solutions.’ [Participant 6]
‘Communication skills refer not only to counseling but also communication with people outside our field.’ [Participant 1]
Problem-solving skills
‘Keep them (drugs) from getting wet (during a flood disaster) and choose drugs that really won’t get wet or protect them from getting wet.’ [Participant 8]
‘Sometimes, we feel confused when there is inadequate medical equipment and supplies. For example, medicine bottles, etc., so we must be creative, /…/. That’s part of the challenge too.’ [Participant 2]
‘For poisoning, there is no antidote/…/ modification was required/…/to solve the poisoning problem.’ [Participant 3]
‘Students can also invite speakers and work with resource person(s) to create podcasts or other news dissemination programs.’ [Participant 4]
Open-mindedness
‘We should be open-minded, but we (pharmacy students) are too afraid of doing something wrong, to go out of the corridor, or to think out of the box.’ [Participant 3]
Knowledgeability
‘Update knowledge and also actively follow the development of problems and their solutions.’ [Participant 7]
‘Before I go, I usually google the health problems related to the disaster first, about what words they (based on culture) often say.’ [Participant 6]
Organizational skills
‘We have to be able to play teamwork roles, it is also important apart from the initial provisions.’ [Participant 3]
‘COVID-19 is the most visible; leaders should be healthy individuals.’ [Participant 1]
Survival skills
‘Yes…. knowledge of survival skills.’ [Participant 8]
‘Volunteers must be able to survive in any condition.’ [Participant 7]
Theme 3: Positive attitude toward involvement in disaster management
Participants stated that a positive attitude toward disaster management should be actively encouraged among students. In addition to the need for training related to disasters, the involvement in community programs is crucial for pharmacy students to build a positive attitude and appropriate behavior in their disaster responses. Some statements by participant on the issues related to Theme 3 are as follows:
Empathy
‘Empathy is required. How one can increase one’s empathy cannot be taught but rather it happens through exposure.’ [Participant 1]
‘We must look for gaps for which we can provide help, but empathy is number 1.’ [Participant 3]
‘Hopefully there will be a sense of empathy/…/he is willing to carry out service and share in any form.’ [Participant 2]
Altruism
‘This means that we need to make students aware that service is purely human (altruism) and not for anything specific.’ [Participant 1]
‘The souls of such (altruists) might complement each other.’ [Participant 2]
Passion
‘At least someone has that passion/…/. He has the spirit of disaster response/…/. If there is a disaster, he will come.’ [Participant 4]
‘It’s because of passion from the beginning.’ [Participant 5]
Theme 4: Appropriate behavior in the face of disaster
Disasters can cause fatalities and sudden escalations in individuals who require care from medical professionals. In addition to the positive attitude needed during disaster management, in the recovery phase, when the victim has the burden of an incurable health condition, health professionals must exhibit responsible behavior. Responsible and caring behavior is the main category found in this theme.
Responsible behavior
‘We serve the community and the hospital; we must work sincerely. We work so that all people can be served.’ [Participant 9]
‘We guarantee that the medicine is stored safely and will not be lost.’ [Participant 5]
Caring behavior
‘For example, students need to know not (should behave) to throw chemicals into the sink. That’s also part of their care for the environment.’ [Participant 3]
Theme 5: Personal readiness
Pharmacy students must be primed for the challenges associated with disaster management. Thus, their readiness to effectively function is critical. Personal readiness means being ready for emergencies or disasters at anywhere and anytime. Personal readiness needed to be able to optimize performance and be fit at any disasters site. The participants emphasized the importance of personal readiness, including physical, mental, and family readiness.
Physical readiness
‘So, the first aspect is physical, yes, for sure, because in a disaster, usually everything is not perfect, right?’ [Participant 7]
‘Maybe that’s what drained a lot of our energy there.’ [Participant 2]
Mental readiness
‘The condition is stressful, right, stressed, so/…/have to be ready for that.’ [Participant 7]
‘They must be mentally prepared and ready for any kind of location because it will be different.’ [Participant 8]
Family readiness
‘My mama said, ‘do what you can to help as many people as possible.’ [Participant 5]
‘My mother is paranoid if my father is not there.’ [Participant 8]
Theme 6: Training to achieve competence and personal readiness
Even though students have received courses related to soft skills, some participants stated that the practice of skills still appears to be limited. The results emphasize that apart from basic knowledge of pharmacy, training was needed to achieve competence and personal readiness. Training through participation in various organizations can familiarize pharmacy students with understanding different cultures and educational backgrounds, as well as the boundaries and responsibilities thereof. Participants believed that getting used to problem-solving in professional and extracurricular student organizations could be a learning tool for acquiring a comprehensive range of skills and how to behave in disaster management. This theme comprised 3 main categories: professional organizations, study club/ student university organizations, and community service programs. Some participant statements on the issues related to Theme 6 are as follows:
Professional organizations
‘The Mer-C organization is already clearly established, /…/ just put them into Mer-C or any agency that makes them collaborate.’ [Participant 1]
‘The American soldier came with 4 sacks of medicine, give or take, filled with medicine and medical devices. Then, the Chinese also brought aid, though the instructions were written in Kanji and couldn’t be read.’ [Participant 6]
‘If you have never been exposed to or involved in an organization, it is rather difficult to interact.’ [Participant 3]
‘From IAI (Indonesian Pharmacist Association), we have ATB (Disaster Response Pharmacists), who have a forum that collaborates with BNPB (National Board for Disaster Management).’ [Participant 2]
Study clubs/ university student organizations
‘Usually accompanied by existing lecturers and often carried out by Piogama or Klinika (a kind of faculty study club), I think such action is quite useful.’ [Participant 4]
‘At the student level, there is something called ISMAFARSI (a kind of faculty study club). I think they also have programs related to it all.’ [Participant 2]
‘Being involved in a group of studies or student organizations will speed up the adaptation process.’ [Participant 3]
Community service programs
‘They must be exposed to certain rules and ideas. For example, that participating in the service program is mandatory for students.’ [Participant 3]
‘Must be exposed, for example… to service/ community services/is mandatory for students, for example.’ [Participant 1]
Discussion
The participants of the study believed that students should have knowledge of health and disaster management, including disaster concepts, disaster health management, and knowledge of topics in pharmacy studies. Notably, this study shows that pharmacy students must gain proficiency in triage, as a field of knowledge. In the event of an incident with mass casualties, the health professions must implement effective triage as critical care resources become scarce. The accuracy and efficiency of triage contribute to timely medical treatment and superior patient outcomes. Reference Timbie, Ringel and Fox11 Therefore, appropriate knowledge and training for triage in disaster situations is essential and should be prepared for by pharmacy students.
All participants agreed that specific knowledge of pharmacy management is an essential competency, such as drug storage to prevent damage by fire, flood, or unsafe water, and the use of temperature-sensitive drugs when refrigeration is temporarily unavailable. Activities related to the logistics of medicines, including data entry and the listing and distribution of medicines to disaster victims and their documentation, require volunteers who understand or have backgrounds in pharmacy. Drug handling, storage, and delivery to patients in the form of packages, and counseling on the use of drugs are pharmacist activities that are regularly conducted during disasters. A participant stated that when distributing medicines during the 2006 Yogyakarta earthquake, the process was made more difficult and, at times, had to be done again when she was assisted by non-pharmaceutical personnel. Therefore, acquiring knowledge is an effective way to manage disaster effects.
This study provides insight into the importance of pharmacy undergraduate education to develop students’ knowledge, considering the fundamental values and principles of drug management in disaster areas. Therefore, despite all the advancements in pharmacy curricula, certain knowledge areas still need to be explored further. This is also indicated by Rajesh et al., who highlighted the need for curriculum changes for effective integration of various sectors for disaster management, particularly in developing nations, which exhibit a definite scarcity of resources. Reference Rajesh, Binnal, Pai, Nayak, Shenoy and Rao12 Furthermore, a study conducted by Santos et al. also suggested that health and nursing schools should provide students with diversified education, enhancing their knowledge in multiple fields. Reference Santos, Rabiais, Berenguer and Amendoeira13
This qualitative study has described the importance of improving soft skills for students in disaster management. Extracted categories highlight communication and problem-solving skills as important aspects of these skills. Communication skills usually draw limited attention in university syllabi. Reference Cavaco14 According to participant interviews, communication is a key soft skill that requires frequent application and review during campus classes. Communication ability is required not only for fellow health professionals but also for other professions and society. The skills needed to care for patients in disaster situations can be different than in routine settings. Students should participate in patient counseling, interviewing, and educational sessions, as well as collaborative work with other health care providers. Reference McDonough and Bennett15
During the COVID-19 pandemic, much misleading information, especially medical news, has been deliberately spread through social media without fact verification. Some people have difficulty finding reliable sources and guidance when they need it. Therefore, various efforts are needed to ensure that everyone has access to accurate information. Reference Nasir, Baequni and Nurmansyah16 Since engagement in medical volunteering during the COVID-19 pandemic can be regarded as a risk-taking activity. Therefore, a participant suggested that in handling the COVID-19 disaster, pharmacy students could play a role in straightening information on social media. Students can help deal with problems related to misinformation by making podcasts and other broadcasts with a trusted source under the guidance of their educators. The present study shows that problem-solving training is essential.
As future healthcare professionals, pharmacy students should possess appropriate knowledge, skills, behavior, and positive attitudes in response to emergencies or disasters. Various factors could affect health professionals and students’ willingness to respond to disasters. The factors that influenced Australasian emergency nurses to attend to their workplace during a disaster were the type of disaster, individual demographic factors, family factors, and the workplace itself. Reference Arbon, Ranse and Cusack17
A study of 169 Korean nurses found that respondents expressed the highest willingness to work in response to a landslide disaster. Reference Choi and Lee18 In contrast, they reported the lowest willingness and competency for human-caused radioactive terrorism. The current study found that a positive attitude toward disaster management should be actively encouraged among pharmacy students. According to Choi and Lee, Reference Choi and Lee18 the provision of well-organized disaster preparedness and response training programs could enhance a positive attitude in terms of willingness to respond during a disaster. A positive attitude toward people affected by a disaster is useful in bringing about positive changes in behavior.
Participants acknowledged that pharmacy students must have specific personal readiness, including physical, mental, and family readiness. Readiness is willing to do something and ready to go, because of preparedness to act immediately. Work without adequate rest and changes in eating and sleeping habits are common during disasters and emergencies. Many people find it extremely difficult to tolerate work pressures and stress, work in harsh conditions, and have the physical ability to deal with disaster victims. Thus, students must be mentally prepared and highly willing to be involved, take risks, and be ready for all kinds of disaster situations because these are usually extraordinary circumstances. Several studies about disaster medicine preparedness and readiness among health care profession students. Reference Pate, Bratberg, Robertson and Smith7,Reference Gillani, Mohamed Ibrahim, Akbar and Fang19–Reference Kim, Kim and Kim21 A study in Pakistan among healthcare profession students found that students’ levels of readiness to practice were moderate. Reference Gillani, Mohamed Ibrahim, Akbar and Fang19 Kang et al. Reference Kang, Lv and Hao22 realized that additional mental health services and training should be available to at-risk medical rescuers and groups to ensure that they are adequately prepared for relief efforts and to maintain their mental health after assistance in disaster relief. Certain traits, such as adaptability and flexibility, are important because these traits increase students’ adaptability in chaotic situations and when experiencing a high level of stress. Thus, being prepared can reduce fear, anxiety, and losses that accompany disasters. Providing this preparation before disasters occur can promote the ability and willingness of pharmacy students to work during disasters.
Pharmacy students need to be prepared to overcome the complexity of health problems caused by a disaster. They are obligated to have the requisite knowledge, positive attitude, and practice towards disaster to be ready and prepared. Study results emphasize that apart from basic knowledge of pharmacy, training was needed to develop and increase specific knowledge and skills that relate to specific competency. To fulfil their role in dealing with disasters, pharmacists must attain and maintain essential competencies to population health needs. Thus, it is very important to identify the competencies required for pharmacy students to enable them to work effectively in disaster management. Competence is perceived as the capacity of individuals to perform specific tasks and roles to the expected standards in a given context or profession. Reference Biemans, Nieuwenhuis, Poell, Mulder and Wesselink23,Reference Weigel, Mulder and Collins24 Thus, it involves the integration of practical and theoretical knowledge, as well as personal, and social qualities within a broadly defined occupational field. Reference Brockmann, Clarke, Méhaut and Winch25 Competencies embrace knowledge, skills, attitude, and behaviors in order to support their effective and persistent performance. 26,Reference Boahin and Hofman27 Competency frameworks for training or education is widely used in the health professions, including pharmacy. Reference Gruppen, Mangrulkar and Kolars28–Reference Batt, Tavares and Williams30 In the context of the ever-changing roles of pharmacists, the use of competency frameworks could aid in ensuring consistent quality pharmacy training. Since in emergency situations during disaster, pharmacist played a critical role in the effective use of medicine provided for disasters, drug dispensing, and consultation as well as good teamwork. Reference Nakura31 Communication skills and coordinates care among members of the healthcare team are also the basic competencies needed for optimal care. Reference Ayuba, Danjuma, Nassa, Joseph, Matthew and Micheal32 WHO also emphasized that all hospital personnel, including volunteers must have the knowledge, positive attitude, and readiness to practice towards disaster. 33 Thus, acquiring competency and personal preparedness through training are effective means to manage the effects of disasters. By training, pharmacy students could become qualified and proficient in doing specific purpose relate to disaster managements.
Selection of learning methods is important in increasing competence and personal readiness to deal with disaster situations. A wide range of training models have been developed. Reference Kim, Kim and Kim21–Reference Biemans, Nieuwenhuis, Poell, Mulder and Wesselink23 According to the participants, pharmacy students deployed in disaster areas, could be expected to have more opportunities to be involved in various organizations activities. Student membership within professional organizations are key components to advancing the profession of pharmacy. Engaging students in professional organizations during school may contribute to the establishment of professional traits. Reference Bradford, Watmore, Hammer and Warholak34 Student organizations foster the acquisition of knowledge and the application of soft skills such as problem solving, time management, and communication. Students who experience participating in extracurricular activities led to more positive self-perceptions of leadership traits including confidence, honesty, optimism, persistence, and responsibility than for students who were not involved in those organizations. Reference Smith and Chenoweth35 Community-based training is a strategy that gives students an opportunity to deal with real health problems in natural settings. Students who willingly contribute to community service learning programs may acquire several benefits, including enhanced social skills, improved community consciousness and a greater desire to help others. The training based community engagement has given an opportunity for the students to get close to the local community and increase in the level of academic performance, life skills, civic, and social responsibility and personal development of the students. Reference Selvaratnam36 Furthermore, exposing students to community engagement can help to intentionally integrate theory and practice. Reference Nuuyoma, Munangatire and Nghiweni37 Service learning, which integrates community services into coursework, can promote the civic growth of students in unique and powerful ways. Reference Bringle and Steinberg38 Therefore, having experience in professional and university organizations, as well as community services, will speed up the process of pharmacy students’ blending, coordinating, and collaborating with health volunteers, and other team members in disaster management.
Limitations
This study collates the results of studies conducted in specific cultural and educational contexts. Although 2 of the research team members had previously completed a disaster management course, the presence of the other interviewers helped with detecting the risk of bias and enhancing the rigor of the data. A problem with snowball sampling is that participants’ social networks are not random. Initial subjects tend to nominate people they know well. Therefore, the use of this technique can result in biased samples. The relatively small sample size limits the general applicability of the results. However, selection of participants having various types of disaster experience assisted in ensuring the broad applicability of the findings to the context of preparing pharmacy students for involvement in disaster management in Indonesia and other countries.
Conclusion
Health professionals’ involvement in disaster management requires careful preparation according to their competencies. Students should be trained and prepared long before they join a disaster management team. The current study explores the preparation that pharmacy students need for improving their contributions to disaster situations. The research findings show that knowledge of health and disaster management, specific skills in disaster management, positive attitudes toward involvement in disaster management, and appropriate behavior in the face of a disaster are essential aspects of disaster-specific competencies required in pharmacy students assisting in disaster management in addition to personal preparedness. Students should improve their soft skills to effectively provide disaster care. Involvement in various organizations could help students achieve competence and personal readiness. These findings can serve as a guide for designing courses to prepare pharmacy students for disaster management.
Acknowledgements
This work was supported by the Faculty of Pharmacy, Universitas Gadjah Mada. The authors are grateful to all research participants for sharing their knowledge and experiences, and to Chintya Gilang Ghaisani for her valuable verbatim transcripts.
Authors contribution
Chairun Wiedyaningsih conceived the idea for the study. Akhmad Kharis Nugroho provided professional advice in the field of research policy. Chairun Wiedyaningsih, Niken Nur Widyakusuma, and Septimawanto Dwi Prasetyo developed the protocol. All authors carried out the study and analyzed the results. Chairun Wiedyaningsih produced the first draft of the paper, and all the other authors read and contributed to the manuscript.
Ethical considerations
Ethical approval was obtained from the Medical and Health Research Ethics Committee (MHREC), Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada-DR Sardjito General Hospital, Indonesia, (Reference number: KE/FK/0305/EC/2021) on April 14, 2021. All participants were informed about the aims and methods of the study. They were guaranteed that their names would remain confidential in any reports of the study.
