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Community Medicine and Education Journal
Published by HM Publisher
ISSN : -     EISSN : 27742962     DOI : https://doi.org/10.37275/cmej
Core Subject : Humanities, Health, Education,
Humanities Education Health Professions Languange, Linguistic, Communication & Media Public Health
CMEJ covers all subjects regarding community medicine and education. The covered research areas as follows community medicine, public health, epidemiology and biostatistics, health policy and administration, public health nutrition, environmental health, occupational health and safety, health promotion, reproductive health, maternal and child health, quality of life, health literacy and communication and their role in developing new healthcare programs, Arts of teaching, Case studies from schools around the world, Change management and education quality, Citizenship education, Classroom management, Computers in educational administration, Differing cultural perceptions of management in education, Distance education and multimedia environments, Early Childhood Education, Economics of education, Educational administration, Education environments (political, social, legal, cultural), Educational leadership, Educational policy and management, Educational systems planning/strategic planning, E-education / E-learning, Entrepreneurial development, Equity and education, Finance and accountability in education, Globalization and education, Human resources management, Individual professional learning portfolio, Information Communication Technologies (ICT) in Education, Special Education and Theories of educational management.
Arjuna Subject : Ilmu Sosial - Pendidikan
Articles 112 Documents
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The Impact of Health Policy on Community-Based Palliative Care Services: A Mixed-Methods Evaluation in Bandung, Indonesia Dea Albertina; Istiqomah Putri; Nazeera Hamid; Cindy Susanti
Community Medicine and Education Journal Vol. 6 No. 1 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i1.697

Abstract

Palliative care is a crucial component of comprehensive healthcare, yet access to community-based palliative care services remains limited in many low- and middle-income countries, including Indonesia. This study aimed to evaluate the impact of existing health policies on community-based palliative care in Bandung, Indonesia. A mixed-methods approach was employed, combining quantitative and qualitative data collection and analysis. Quantitative data included a retrospective analysis of patient records (n=350) from three community-based palliative care providers in Bandung from 2018-2023, assessing referral patterns, service utilization, and patient demographics. Qualitative data were gathered through semi-structured interviews with policymakers (n=10), healthcare providers (n=15), and patients/caregivers (n=20) to explore their perspectives on policy implementation and its impact. Data were analyzed using descriptive statistics, thematic analysis, and a framework approach guided by the WHO Health Systems Framework. The study found that while national health policies acknowledge the importance of palliative care, significant gaps exist in implementation at the local level. The number of patients accessing community-based palliative care increased modestly from 45 in 2018 to 78 in 2023, but this represents a small fraction of the estimated need. Key policy-related barriers identified included: limited funding allocated specifically for community-based palliative care , inadequate training and workforce capacity in palliative care, lack of standardized referral pathways from hospitals to community-based services and limited public awareness of palliative care. In conclusion, health policies in Indonesia have not yet translated into widespread access to quality community-based palliative care in Bandung. Strengthened policy implementation, increased funding, workforce development, improved referral systems, and enhanced public awareness are crucial to address this gap and improve the quality of life for patients with life-limiting illnesses and their families.
Integrating Social Prescribing into Primary Care: Policy Implications and Educational Needs in Medan, Indonesia Ni Made Nova Indriyani; Lisye Tiur Simanjuntak; Badrool Nizham; Ramakhrisnand Ramakhrisnand
Community Medicine and Education Journal Vol. 6 No. 1 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i1.699

Abstract

Social prescribing (SP) is a growing approach to address the social determinants of health by linking patients in primary care with non-clinical community resources. Indonesia, with its diverse population and rapidly evolving healthcare system, presents a unique context for exploring SP implementation. This study investigated the feasibility, policy implications, and educational needs for integrating SP into primary care in Medan, Indonesia. A mixed-methods approach was employed. This included a policy review of relevant Indonesian healthcare regulations and guidelines (national and local), semi-structured interviews with primary care physicians (n=20), community health workers (n=15), and representatives from local non-governmental organizations (NGOs) (n=10), and a cross-sectional survey of primary care physicians in Medan (n=150) to assess their knowledge, attitudes, and perceived barriers to SP. Quantitative data was generated based on literature review and publicly available demographic and health data for Medan. Thematic analysis was used for qualitative data, and descriptive and inferential statistics were used for quantitative data. The policy review revealed a fragmented healthcare landscape with limited explicit support for SP. Interviews highlighted potential benefits of SP, including reduced physician workload and improved patient well-being, but also significant challenges: lack of awareness of SP, limited inter-sectoral collaboration, and insufficient resources for community-based services. The survey indicated that only 25% of physicians were familiar with the concept of SP. Significant predictors of willingness to implement SP included perceived patient benefit (p<0.001) and availability of referral pathways (p<0.01). Thematic analysis revealed key educational needs, including training on identifying social needs, building referral networks, and understanding the roles of various community actors. In conclusion, integrating SP into primary care in Medan holds promise for addressing complex health needs, but requires significant policy and educational interventions. Key recommendations include developing a national SP framework, strengthening inter-sectoral partnerships, investing in community-based resources, and incorporating SP into medical and healthcare professional curricula.
Building Community Resilience to Climate Change in Jakarta: A Public Health Approach Integrating Policy, Practice, and Education Jonah Abraham; Andi Fatihah Syahrir; Neva Dian Permana; Matilda Munoz; Sarah Armalia
Community Medicine and Education Journal Vol. 6 No. 1 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i1.700

Abstract

Climate change poses significant and escalating threats to public health in Jakarta, Indonesia, including increased risks of vector-borne diseases, heat-related illnesses, and mental health impacts exacerbated by flooding and displacement. This study examined the current state of community resilience to these climate-related health threats and evaluated the effectiveness of existing policies and educational interventions. A mixed-methods approach was employed, combining a cross-sectional survey of Jakarta residents (n= 850), semi-structured interviews with key stakeholders (n= 25) from government agencies, NGOs, and community organizations, and a policy review of relevant Indonesian and Jakarta-specific regulations and strategic plans. The survey assessed climate change awareness, perceived health risks, adaptive capacity, and access to resources. Interviews explored policy implementation challenges, inter-sectoral collaboration, and community engagement strategies. The policy review analyzed alignment with international best practices and identified gaps. The survey revealed moderate levels of climate change awareness but significant gaps in understanding of specific health risks (62% aware of general climate change, but only 38% aware of the link to dengue fever increase). Perceived adaptive capacity was low, particularly among vulnerable populations (low-income households, those living in flood-prone areas). 75% of respondents in flood-prone areas reported lacking adequate resources to cope with flooding events. Interviews highlighted challenges in inter-sectoral coordination, limited funding for community-based programs, and a lack of culturally appropriate health education materials. The policy review found that while national-level policies exist, Jakarta-specific implementation lags, particularly in integrating health considerations into urban planning and disaster preparedness. In conclusion, building community resilience to climate change in Jakarta requires a multi-pronged approach. This includes strengthening health system preparedness, developing targeted and culturally appropriate health education programs, improving inter-sectoral collaboration, enhancing community engagement, and integrating health considerations into all relevant policies. Specific recommendations include strengthening early warning systems for heat waves and floods, expanding access to clean water and sanitation, promoting climate-resilient housing, and investing in community-based adaptation projects.
Tele-ophthalmology versus Traditional Fundus Photography for Diabetic Retinopathy Screening: A Comparative Meta-analysis of Diagnostic Accuracy, Cost-Effectiveness, and Health Policy Uptake Ramzi Amin; Dio Asgira Rizky
Community Medicine and Education Journal Vol. 5 No. 2 (2024): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v5i2.729

Abstract

Diabetic retinopathy (DR) remains a leading cause of preventable blindness globally, imposing a significant public health burden. Effective screening is paramount for early detection and timely intervention. Traditional fundus photography (TFP), often requiring specialized equipment and personnel, faces access challenges. Tele-ophthalmology (TO) has emerged as a potential solution to improve screening coverage. However, rigorous comparative evidence regarding its diagnostic accuracy relative to established TFP methods, its economic viability, and factors influencing its adoption into health policy and routine practice remains fragmented. This systematic review and meta-analysis aimed to synthesize the evidence comparing TO and TFP for DR screening across these critical domains. We conducted a systematic literature search adhering to PRISMA guidelines across PubMed, EMBASE, and Web of Science databases for studies published between January 1st, 2013, and December 31st, 2023. Keywords included "diabetic retinopathy," "screening," "teleophthalmology," "telemedicine," "fundus photography," "digital imaging," "diagnostic accuracy," "cost-effectiveness," and "policy." Inclusion criteria mandated studies directly comparing TO (any modality involving remote image grading) with TFP (in-person acquisition and grading or local grading) for detecting any DR or referable DR (RDR) in diabetic populations. Outcomes of interest were diagnostic accuracy (sensitivity, specificity), cost-effectiveness metrics (e.g., ICER), and reported health policy uptake or implementation factors. Study quality was assessed using adapted QUADAS-2 criteria for accuracy studies and relevant checklists for economic evaluations. 6 studies met the full inclusion criteria for this meta-analysis. Pooled sensitivity for detecting RDR using TO was 0.90 (95% CI: 0.87-0.93), compared to 0.92 (95% CI: 0.89-0.95) for TFP. Pooled specificity for TO was 0.91 (95% CI: 0.88-0.94) versus 0.93 (95% CI: 0.90-0.95) for TFP. Moderate heterogeneity was observed (I² > 50%). Health policy uptake varied significantly, influenced by factors such as established reimbursement frameworks, governmental support, integration with electronic health records, availability of trained non-ophthalmic personnel, and robust quality assurance protocols. In conclusion, tele-ophthalmology demonstrates high diagnostic accuracy for DR screening, comparable, albeit potentially slightly lower on average, to traditional fundus photography. Economic evaluations largely favor TO, suggesting significant potential for efficient resource allocation in DR screening programs. However, successful translation into widespread, effective public health policy requires addressing implementation barriers related to infrastructure, workforce training, reimbursement parity, and quality assurance.
Health System Factors Influencing the Adoption and Sustainability of Evidence-Based Retinal Care Guidelines: A Systematic Review and Meta-Synthesis Ramzi Amin; Rafika
Community Medicine and Education Journal Vol. 6 No. 1 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i1.730

Abstract

Evidence-based guidelines (EBGs) are crucial for optimizing care and outcomes for highly prevalent retinal diseases like diabetic retinopathy (DR), age-related macular degeneration (AMD), and retinopathy of prematurity (ROP). However, their translation into routine clinical practice remains inconsistent. Understanding the health system factors that facilitate or impede the adoption and long-term sustainability of these guidelines is critical for improving population eye health. This systematic review and meta-synthesis aimed to identify and synthesize qualitative evidence on health system-level determinants influencing the implementation of retinal care EBGs. We conducted a systematic review following PRISMA guidelines. Major biomedical databases (PubMed, Scopus, Embase, Web of Science) and grey literature sources were searched from January 2013 to December 2024 using keywords related to retinal diseases, guidelines, implementation, adoption, sustainability, and health systems. Inclusion criteria focused on qualitative or mixed-methods studies exploring factors influencing the uptake or continued use of formal retinal care guidelines within clinical settings. Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed study quality using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist. A thematic synthesis approach, following Noblit and Hare's methodology for meta-ethnography, was employed to synthesize findings across studies, involving familiarization, coding, theme generation, and synthesizing translations between studies. 7 studies met the inclusion criteria. These studies originated from diverse healthcare systems and focused primarily on DR and AMD guidelines. Quality assessment indicated moderate to high methodological rigor across the included studies. The meta-synthesis identified six interconnected key themes representing health system factors influencing guideline adoption and sustainability: leadership engagement and organizational culture prioritizing evidence-based practice; resource allocation and infrastructure adequacy, including staffing, funding, and integrated IT systems; inter-professional collaboration and streamlined communication pathways across disciplines and care settings; alignment with external policy levers and financial incentives; perceived guideline characteristics and adaptability within local workflows; and robust feedback mechanisms and continuous quality improvement cycles integrated into the system. Lack of resources, fragmented communication, conflicting financial incentives, and inadequate leadership support emerged as primary barriers. In conclusion, the successful adoption and sustainability of evidence-based retinal care guidelines are profoundly influenced by a complex interplay of health system factors. Effective implementation requires more than guideline dissemination. Addressing these system-level determinants is paramount for bridging the evidence-practice gap and reducing preventable vision loss from retinal diseases globally. Policymakers and healthcare administrators must consider these multifaceted factors when designing and implementing strategies to enhance retinal care quality.
Deconstructing Self-Medication: The Dominance of Attitude and Social Norms over Perceived Control in Non-Prescription Amoxicillin Use Maria Regina Lusiana Kya; Titien Siwi Hartayu
Community Medicine and Education Journal Vol. 6 No. 2 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i2.778

Abstract

The global escalation of antimicrobial resistance (AMR) is profoundly exacerbated by the irrational self-medication of antibiotics. This study was conducted in the Ende Tengah District, a community within an Indonesian province where non-prescription antibiotic acquisition is highly prevalent. The primary objective was to deconstruct the psychosocial determinants of the intention to self-medicate with amoxicillin, framing the analysis within the context of a recent regulatory change designed to limit antibiotic access. A quantitative, cross-sectional study was undertaken between April and May 2025. Using a purposive sampling strategy, 109 community members aged 18-60 who had used amoxicillin without a prescription were recruited from public-access areas. Data were gathered using a structured, pilot-tested questionnaire based on the Theory of Planned Behavior (TPB), which demonstrated good internal consistency (Cronbach’s α: 0.78-0.85). The instrument measured attitude, subjective norms, perceived behavioral control (PBC), and behavioral intention. Multiple linear regression was used for the primary analysis after all statistical assumptions were confirmed. The regression model was statistically significant (F(3, 105) = 21.267, p < .001) and accounted for 37.8% of the variance in self-medication intention (R² = 0.378). Attitude emerged as the most powerful predictor of intention (β = 0.341, p = .001), followed by subjective norms (β = 0.276, p = .015). Strikingly, perceived behavioral control, the construct most related to access, was not a significant predictor of intention (β = 0.081, p = .459). In conclusion, among the study participants, the intention to self-medicate with amoxicillin is overwhelmingly a psychosocial phenomenon, driven by favorable personal attitudes and deeply ingrained social norms rather than by perceptions of access. This suggests that top-down regulatory policies focused solely on restricting antibiotic supply may be insufficient without parallel, community-focused strategies designed to reshape the beliefs and behaviors that sustain demand.
Patient Cognition Over Social Context: A Theory of Planned Behavior Analysis Reveals Attitude as the Dominant Predictor of Primaquine Adherence Intention for Plasmodium vivax Radical Cure in Hyperendemic Papua, Indonesia Dewi Wijayanti; Titien Siwi Hartayu
Community Medicine and Education Journal Vol. 6 No. 2 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i2.803

Abstract

Relapsing Plasmodium vivax malaria remains a major obstacle to malaria elimination, with its treatment critically dependent on patient adherence to a 14-day primaquine regimen for radical cure. In hyperendemic regions like Papua, Indonesia, non-adherence is a primary cause of treatment failure. This study applied the Theory of Planned Behavior (TPB) to identify the key psychosocial determinants of adherence intention in this population to inform targeted public health interventions. A descriptive analytical study with a cross-sectional design was conducted in the East Sentani District of Papua, Indonesia, from February to April 2024. A total of 100 adult patients diagnosed with P. vivax malaria were recruited via consecutive sampling. A culturally adapted, validated questionnaire was used to measure the TPB constructs: attitude, subjective norms, and perceived behavioral control (PBC), alongside behavioral intention. Initial data analysis revealed quasi-complete separation, necessitating the use of a penalized logistic regression model (Firth's method) to generate stable and reliable estimates of association. The penalized logistic regression model was statistically significant and explained a considerable portion of the variance in adherence intention (Nagelkerke R² = 0.482). After controlling for other variables, a patient's personal attitude toward the treatment was the only significant predictor of their intention to complete the primaquine regimen. A more positive attitude was strongly associated with a higher intention to adhere (Odds Ratio [OR] = 5.21, 95% Confidence Interval [CI]: 2.15 - 12.67; p < 0.001). In contrast, neither subjective norms (OR = 1.12, 95% CI: 0.88 - 1.43; p = 0.354) nor perceived behavioral control (OR = 1.35, 95% CI: 0.91 - 2.01; p = 0.138) demonstrated a significant independent influence on behavioral intention. In conclusion, patient attitude—the individual's cognitive and affective evaluation of the treatment—is the primary driver of the intention to adhere to the 14-day primaquine regimen in this Papuan cohort. While social context and perceived barriers should not be disregarded, these findings strongly suggest that public health strategies must prioritize patient-centered educational interventions that cultivate a deep understanding of the biological necessity of radical cure to foster positive, resilient attitudes towards treatment completion.
Synergistic Undernutrition: The Metabolic Nexus Between Chronic Energy Deficiency and Anemia in Rural Balinese Pregnant Women I Putu Adigama; I Nyoman Sayang; Gusti Ngurah Nyoman Yuliastina; I Made Pasek Soma Gauthama
Community Medicine and Education Journal Vol. 6 No. 2 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i2.828

Abstract

Despite the widespread implementation of Iron-Folic Acid (IFA) supplementation programs, the prevalence of maternal anemia in Indonesia remains stagnant, suggesting a multifactorial etiology beyond simple micronutrient deficiency. In rural agrarian settings, macronutrient adequacy—specifically protein-energy balance—may play a critical, yet overlooked, role in hematopoiesis. This study investigates the "Synergistic Undernutrition" hypothesis, positing that chronic energy deficiency (CED) acts as a metabolic rate-limiting factor for hemoglobin synthesis among pregnant women in the highlands of Bangli, Bali. A retrospective cross-sectional study was conducted using medical records from the Susut 1 Primary Health Center from January to September 2025. A total of 155 pregnant women were selected via total sampling of eligible records. Anthropometric measurements (Mid-Upper Arm Circumference/MUAC) and hemoglobin levels were extracted from the first antenatal care (ANC) visit to establish temporal precedence. The sample size was initially determined using the Slovin formula for prevalence estimation (n = 157), though post-hoc analysis reveals this is underpowered for hypothesis testing. Multivariate logistic regression was employed to calculate Adjusted Odds Ratios (aOR) controlling for parity and age. The prevalence of CED (MUAC <23.5 cm) was 37.4%, and anemia (Hb <11 g/dL) was 41.9%. In the multivariate model, CED was associated with an Adjusted Odds Ratio (aOR) of 1.88 (95% CI: 0.97–3.67). While the p-value (0.063) indicated a marginal association rather than statistical significance at the 5% level, the effect size suggests a clinically substantial doubling of risk. A post-hoc power analysis indicated the study operated with approximately 52% power, explaining the wide confidence intervals. Multiparity also showed a similar marginal association (aOR 1.88; p=0.066). In conclusion, pregnant women in rural Bali face a dual burden where energy deficits likely exacerbate anemic states. Although statistical significance was limited by sample size, the magnitude of the Odds Ratio supports a "Protein-Iron Nexus" mechanism. Interventions should transition from isolated iron supplementation to comprehensive nutritional rehabilitation, addressing the underlying macronutrient deficits. Future research requires larger cohorts to overcome the statistical power limitations identified in this study.
Maternal Oxygen Transport Capacity and Nutritional Reserves: Anemia and Mid-Upper Arm Circumference (MUAC) as Independent Predictors of Low Birth Weight in the Indonesian Highlands I Putu Adigama; I Nyoman Sayang; Gusti Ngurah Nyoman Yuliastina; I Made Pasek Soma Gauthama
Community Medicine and Education Journal Vol. 7 No. 1 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v7i1.832

Abstract

Low birth weight (LBW) remains a critical determinant of neonatal mortality and long-term metabolic syndrome, particularly in agrarian transition zones. While demographic factors are often studied, the specific impact of maternal oxygen transport capacity (hemoglobin) and somatic nutritional reserves (Mid-Upper Arm Circumference/MUAC) remains under-characterized in highland populations where the paradox of food security versus nutritional insecurity exists. A retrospective case-control study was conducted in the highland region of Bangli, Indonesia, covering all deliveries in 2024. To maximize statistical power within the available clinical population, a total sampling technique was employed for the case group (n=20 mothers delivering infants <2,500g), matched 1:2 with randomly selected controls (n=40 mothers delivering infants ≥2,500g). Data were analyzed using independent t-tests and binary logistic regression. The multivariate model was restricted to biological predictors to maintain statistical stability given the sample size. The prevalence of anemia and Chronic Energy Deficiency (CED) was significantly higher in the case group (p<0.001). Bivariate analysis indicated profound risks associated with anemia (OR=9.00) and CED (OR=6.93). In the adjusted multivariate model, maternal anemia (aOR=11.45; 95% CI: 2.50–52.40) and CED (aOR=9.80; 95% CI: 2.15–44.60) remained dominant, independent predictors. The wide confidence intervals reflect the small sample size inherent to the facility-based dataset. ROC analysis demonstrated that MUAC <23.5 cm offers excellent diagnostic accuracy (AUC=0.845). In conclusion, clinical markers of oxygen transport and nutritional substrate availability are superior predictors of LBW compared to maternal age or parity in this cohort. The findings advocate for a biological-first approach to antenatal risk stratification.
The Post-Pandemic Plateau: A Provincial-Level Longitudinal Analysis of Tuberculosis Stagnation in Indonesia (2021–2023) Adhika Rahman; Punik Mumpuni Wijayanti; Vita Widyasari
Community Medicine and Education Journal Vol. 6 No. 2 (2025): Community Medicine and Education Journal
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/cmej.v6i2.858

Abstract

The COVID-19 pandemic caused profound disruptions to global tuberculosis (TB) control, particularly in high-burden nations. Indonesia, ranking second globally in TB burden, faces a critical recovery period. This study aims to characterize the epidemiological trajectory of TB in Indonesia during the post-pandemic phase (2021–2023), testing the hypothesis of stagnation versus recovery. We conducted a longitudinal ecological study utilizing Global Burden of Disease (GBD) estimates and national registry data. The dataset comprised 102 observations, representing a balanced panel of Indonesia’s 34 provinces across three years (2021, 2022, 2023). Variables included age-standardized prevalence per 100,000 population, mortality rates, and Human Development Index (HDI). Normality was assessed via the Shapiro-Wilk test. Correlations were analyzed using Spearman’s rank test for non-normal distributions. To account for unobserved spatial heterogeneity and provincial clustering, we employed a Fixed Effects Within-Group Panel Regression model to determine the independent effect of time on disease burden. The mean TB prevalence across the 34 provinces was 645.2 per 100,000 population (Standard Deviation 120.5), with a mean mortality rate of 38.4 per 100,000. Regional disparities were pronounced; Papua reported prevalence rates exceeding 1,000 per 100,000, while Bali remained below 350. The Fixed Effects regression model revealed that, after controlling for provincial heterogeneity, the passage of time from 2021 to 2023 was not significantly associated with a reduction in prevalence (beta = -1.24; p = 0.68) or mortality (beta = -0.05; p = 0.81). The model confirmed a Post-Pandemic Plateau, where metrics remained statistically unchanged despite the resumption of health services. In conclusion, TB control in Indonesia has entered a critical period of stagnation. The lack of a significant downward trend in the fixed-effects model suggests that post-pandemic recovery efforts have yet to neutralize the accumulated burden of missed diagnoses. Structural interventions targeting high-incidence provinces are urgently required to restart the decline.

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