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. 2023 Jan 14;23(1):103.
doi: 10.1186/s12889-023-15015-0.

Geographical variations and district-level factors associated with COVID-19 mortality in Indonesia: a nationwide ecological study

Henry Surendra  1   2 , Danarastri Paramita  3   4 , Nora N Arista  4 , Annisa I Putri  3   5 , Akbar A Siregar  3   5 , Evelyn Puspaningrum  6 , Leni Rosylin  3 , Dida Gardera  3 , Montty Girianna  3 , Iqbal R F Elyazar  6
Affiliations

Geographical variations and district-level factors associated with COVID-19 mortality in Indonesia: a nationwide ecological study

Henry Surendra et al. BMC Public Health. .

Abstract

Background: Ensuring health equity, especially for vulnerable populations in less developed settings with poor health system is essential for the current and future global health threats. This study examined geographical variations of COVID-19 mortality and its association with population health characteristics, health care capacity in responding pandemic, and socio-economic characteristics across 514 districts in Indonesia.

Methods: This nationwide ecological study included aggregated data of COVID-19 cases and deaths from all 514 districts in Indonesia, recorded in the National COVID-19 Task Force database, during the first two years of the epidemic, from 1 March 2020 to 27 February 2022. The dependent variable was district-level COVID-19 mortality rate per 100,000 populations. The independent variables include district-level COVID-19 incidence rate, population health, health care capacity, and socio-demographics data from government official sources. We used multivariable ordinal logistic regression to examine factors associated with higher mortality rate.

Results: Of total 5,539,333 reported COVID-19 cases, 148,034 (2.7%) died, and 5,391,299 (97.4%) were recovered. The district-level mortality rate ranged from 0 to 284 deaths per 100,000 populations. The top five districts with the highest mortality rate were Balikpapan (284 deaths per 100,000 populations), Semarang (263), Madiun (254), Magelang (250), and Yogyakarta (247). A higher COVID-19 incidence (coefficient 1.64, 95% CI 1.22 to 1.75), a higher proportion of ≥ 60 years old population (coefficient 0.26, 95% CI 0.06 to 0.46), a higher prevalence of diabetes mellitus (coefficient 0.60, 95% CI 0.37 to 0.84), a lower prevalence of obesity (coefficient -0.32, 95% CI -0.56 to -0.08), a lower number of nurses per population (coefficient -0.27, 95% CI -0.50 to -0.04), a higher number of midwives per population (coefficient 0.32, 95% CI 0.13 to 0.50), and a higher expenditure (coefficient 0.34, 95% CI 0.10 to 0.57) was associated with a higher COVID-19 mortality rate.

Conclusion: COVID-19 mortality rate in Indonesia was highly heterogeneous and associated with higher COVID-19 incidence, different prevalence of pre-existing comorbidity, healthcare capacity in responding the pandemic, and socio-economic characteristics. This study revealed the need of controlling both COVID-19 and those known comorbidities, health capacity strengthening, and better resource allocation to ensure optimal health outcomes for vulnerable population.

Keywords: COVID-19; Coronavirus; Epidemiology; Indonesia; Mortality; Pandemic.

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Conflict of interest statement

The authors declare no competing interests.

We declare no competing interests.

Figures

Fig. 1
Fig. 1
COVID-19 incidence and mortality over the first three epidemic waves in Indonesia between March 2020 to February 2022
Fig. 2
Fig. 2
Heatmaps of weekly incidence rate per 100,000 population (A) and mortality rate per 100,000 population by province (B)
Fig. 3
Fig. 3
District-level mortality rate (A), and incidence rate (B) in Indonesia between March 2020 and February 2022
Fig. 4
Fig. 4
Correlation matrix of COVID-19 burden, prevalence of health-related conditions, vaccine coverage for > 60 years old population, health care capacity, and socio-economic characteristics. Significance level of the correlation can be seen in Supplementary Table 4
See this image and copyright information in PMC

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