Darajat Health Promotion & Competition Program

Muhyidin SKM at IIGCE 2018
Penyerahan plakat dan sertifikat dari panitia IIGCE 2018

Framingham’s Score Improvement of Geothermal Employees at Darajat Through Health Promotion and Health Competition Program

Muhyidin, SKM and dr.Indra Rohim

Star Energy Geothermal Darajat II, Limited

Sentral Senayan II, 25th floor. Jl.Asia Afrika No.8, Jakarta 10270. Indonesia

Note: this paper has been presented and submitted at The 6th Indonesia International Geothermal Convention & Exhibition 2018


In 2015, Star Energy Geothermal Darajat II, Limited initiated worksite wellness program to promote healthy lifestyle through voluntary health competition program for their employees. The baseline data based on previous Medical Check Up (MCU) result showed the average of Framingham’s Score (FS) was 6.36%. It means in average, the estimation of 10-year of employees at Darajat to get cardiovascular risk (coronary heart disease) was 6.36 %.

Some improvement plans taken during the activity such as conducted training & coaching from the health expert; health promotion through sport competition & aerobic, one day healthy menu within a week during lunch time at the workplace, and sharing healthy tips to participants.

Total 106 employees participated in this voluntary program within consecutive 6 months program period. Monthly measurement was conducted to all partipants by company doctor. All participants are reviewed on their body weight to calculate body mass index (BMI), exercise / sport program implementation, ratio cholesterol and HDL (high density lipoprotein), fasting blood sugar, waist to hip ratio, blood pressure, and smoking behavior.

Result of this program showed FS decreased from 6.36% to 5.71% by the end of program. The FS criteria was divided into 4 namely very low risk (<1%), low risk (1-<10%), intermediate risk (10-20%) and high risk (>20%). High risk employees reduced 2% to intermediate risk and 25% shifting of FS from low risk to very low risk.


Cardiovascular diseases (CVD) currently become a big problem globally. It become the leading cause of death worldwide and resulted in 17.6 million deaths in 2015 or 31.3% of total deaths. CVD is the leading of noncommunicable disease (NCD); nearly half of the 39 million deaths due to NCDs are caused by CVDs.  (WHO, 2016).  

The cause of death due to CVD is increasing from 14,4 million (27,7%)  in 2000 to 17,6 million (31,3%) in 2015 and become  number one cause of death worldwide (WHO, 2016). Global health estimates death by cause summary is shown in the Table 1 below.

Tabel 1. Global health estimates death by cause

The different types of CVDs are listed below.

  1. CVDs due to artherosclerosis. Arherosclerosis is the underlying disease process in the blood vessel that result in coronary heart disease (heart attack) and cerebrovascular disease (stroke): ischaemic heart disease or coronary artery disease, cerebrovascular disease, and disease of the aorta and arteries including hypertension and peripeheral vascular disease.
  2. Other CVDs such as disorders of the heart muscle, disorder of the electrical conduction system of the heart and heart valve disease: congenital heart disease, rheumatic heart disease, cardiomyopathies, and cardiac arrhythmias (WHO, 2011).

A large percentage of CVD is preventable through the reduction of behavioral risk factors. Prevention of artherosclerosis involves improving risk factors through: healthy eating, exercise, avoidance of tobacco smoke and limiting alcohol intake. Treating risk factors, such as high blood pressure, blood lipids and diabetes is also beneficial. Unhealthy behavior lead to metabolic changes: raised blood sugar (hypertension); overweight/obesity; raised blood sugar (diabetes); and raised blood lipids. In terms of attributable deaths, the leading cardiovascular risk factor globally is high blood pressure result in 13% of CVD death, while tobacco result in 9%, diabetes 6%, lack of exercise 6% and obesity 5% (WHO, 2011).

In USA, heart disease is the leading cause of death, costing the country about $200 billion each year in health care services, medications, and lost productivity (CDC, 2017). In Indonesia, CVD is contributing 37% and become the number one leading cause of death  (WHO, 2014).

Cardiovascular risk can be predicted with scientific prediction models that been developed to estimate the risk of developing CVD such as Framingham Risk Score (FRS) model. The FRS is a gender-specific algorithm used to estimate the 10-year cardiovascular risk of an individual. It was first developed based on data obtained from the Framingham Heart Study, to estimate the 10-year risk of developing CVD (P.W., Wilson, 1998). The FRS has been validated in the USA, both in men and women, both in European Americans and African Americans (D’Agostino RB Sr, 2001).

The first FRS included age, sex, LDL (low density lipoprotein) cholesterol, HDL cholesterol, blood pressure (and also whether the patient is treated or not for his/her hypertension), diabetes and smoking. The updated version include dyslipidemia, age range, hypertension treatment, smoking and total cholesterol. It excluded diabetes because Type 2 diabetes meanwhile was considered to be a corronary heart disease (CHD) Risk Equivalent, having the same 10-year risk as individuals with prior CHD. (NIH, 2002).

At the workplace, cardiovascular risk can be prevented through health promotion program. According to the American Journal of Health Promotion (2009), health promotion defined as “the science and art of helping people discover the synergies between their core passion and optimal health, enhancing their motivation to strive for optimal health and supporting them in changing their lifestyle to move toward a state of optimal health. Optimal health is a dynamic balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of learning experiences that enhance awareness, increase motivation, and build skills ad, most important, through the creation of opportunities that open access to environments that make positive health practices the easiest choice”

The health promotion through competetition program among employees at geothermal company at Darajat is a voluntary basis. Company, through Fight to Fit committees consist of some departments, collaborated in planning & organizing this program within 6 months period from April – October 2015. The purpose & objective of this programs are to improve healthy lifestyle, improve team building within Darajat employees and change paradigm from curative to preventive, and reduce the cardiovasular risk. Previous year, the initial program was launched, but in 2015 there are some improvements taken with more systematic approach and measurement.

The program was run by Health & Medical (HM) department and Health, Safety and Environment (SHE) department with sharing budget. The committee consist of several departments and management team to support the program. HM department absorbed the cost related to MCU, laboratory analysis and health talk. SHE absorbed the cost related to prizes, souvenir, and meals during the program.

This health promotion program also involved family & their spouse especially during supporting activities such as health talk about nutrition, sport, and medical sport topic from the experts. The spouse’s involvement during health cooking competition & aerobic dance for all families are  made to make the program more attractive and support the employees who involved in this program. Support from spouse is very important especially in serving health menu at home and keep healthy life style both at the workplace and at home. Spouse verified the implementation of employee health program by signing the form before submission to committee.

The health competition at Darajat was divided into some teams. Each team consist of 4 employees. There are 24 teams and 10 employees with individual categories as per company doctor recommendation. Total 106 of 127 employees or 83% of total employees involved in this program.

Baseline Framingham score data from participants was taken from 2014 MCU record. Medical team has divided the Framingham score into 4 criteria as shown in Table 2.

Tabel 2. Baseline Framingham score criteria

Framingham Score CriteriaTotal Participants
Very low risk (<1%)0
Low risk (1 – <10%)82
Intermediate risk (1- 20%)21
High risk (>20%) 3

Baseline average body mass index (BMI), cholesterol/HDL, and fasting sugar is shown in Figure 1. Total participants of men are 103 and women are 3 persons. The average of fasting sugar and BMI of women participants were higher compare to men participants.

Figure 1. Baseline average BMI, cholesterol/HDL and fasting sugar

Baseline average BMI, Cholesterol, HDL


The FS baseline data of the Darajat employees are taken from previous MCU data on year 2014. Company doctor compile some employees’ MCU data to calculate the FS such as age, sex, LDL cholesterol, HDL cholesterol, blood pressure, Body Mass Index (BMI), and smoking behavior.     

The monthly measurement is conducted to all participants to monitor their BMI progress and waist to hip circumference ratio. Laboratory analysis on cholesterol and HDL cholesterol and fasting blood sugar were conducted every three months. Participants have to attend the approved laboratory based on the schedule. All the result from laboratory then sent to medical team.

The last measurement is conducted during annual MCU that conducted on October 2015 which is the last period of the program. Medical team will collect all the required data to count Framingham score of all participants.

The scoring criteria to select the winner of this competition program based on the program and implementation of healthy life style program (exercise, healthy food and rest time), BMI improvement result, cholesterol total and HDL ratio, fasting blood sugar, waist to hip circumference ratio, blood pressure, smoking behavior, and team compliance in submiting program & mothly report and measurement.

The weighting of scoring was 25% from healthy life style, 15% from BMI result (target BMI is 23 kg/m2), 15% from cholesterol total and HDL ratio, 10% from fasting blood sugar, 10% from waist to hip circumference ratio, 10% from blood pressure, 5% from smoking behavior, and 10% from team compliance report.

On the beginning of competition, each team are required to present to committees on their specific program. Every month, each team shall submitted their program implementation evidences through report and pictures as part of scoring criteria.

Every team will have their own program based on their commitment. They will have their own exercise program such as play table tennis or badminton together and personnal exercise program such as daily push up / sit up, jogging and running. Team have to submit the implementation and it’s evidence to Medical team to be reviewed and verified.


During the program, committee conducted some monitoring & measurement. Interim complete measurement was conducted after 3 months program while monthly measurement such as body weight and team exercise program implementation  keep monitored periodically. Medical team reminded all participants to conduct the measurement as per schedule.

The interim result of the program is shown in Figure 2. There is a shifting participants’ FS criteria from low risk to very low risk, from intermediate risk to low risk and from high risk to intermediate risk. Very low risk criteria increased to 26% (28 of 106 participants), low risk criteria reduced to 13%, intermediate risk criteria reduce to 11% and high risk criteria reduce to 2%

Figure 2. Interim result of Framingham score per category

Framingham score baseline & interim

Comparison of Framingham score baseline and interim result from can be seen clearly through box and whisker plot (box plot) below in Figure 3. There are changes of data distribution such as median, Q1, Q3 and min and max data of Framingham score. The result showed improvement of Framing score, the lower score the lower possible risk of getting cardiovascular disease.

Figure 3. Box Plot Framingham score baseline & interim result

Boxplot Framingham score

The detail data showed there was reduction of total cholesterol per HDL with mean from 4.87 to 4.73. In the baseline data, there are 53 participants with total cholesterol per HDL >5. Total cholesterols are a measure of HDL, LDL and other lipoproteins that present in the blood. HDL often referred as good cholesterol while LDL known as bad cholesterol. The desired level of total cholesterol is 200 mg/dl or below. Since HDL protects the heart and vessel, increasing the HDL might be as important as decreasing of the total cholesterol. HDL may protect the body against narrowing blood vessel (AHA, 2018).

On October 2015, annual MCU was conducted for all employees (include participants). The parameters to count Framingham score already included in the MCU package. The final result comparison of FS baseline and FS after 6 months program is shown in the Table 3. It showed the reduction of FS from participants.

In this study we found that 3 of 106 (2,8%) total participants have high risk to get CVD. It was common for employees to have the condition or other risk factors to get CVD due to tobacco use, unhealthy weight (obesity) and lack of exercise. During the program, these high risk employees was implementing their specific team healthy program. Each participants has their own specific exercise program, diet program and specific team program that they need to implement. From the high risk participants, 2 of 3 (66,7%) improved their Framingham score and become intermediate risk.

On the other criteria, we found that 13 of 21 (61.9%) participants categorized as intermediate risk employees was shifted to low risk criteria. Total 37 of 82 (45.1%) was shifted to very low risk criteria. Detail data shown in the Table 3.

Tabel 3. Comparison of baseline Framingham score and after 6 months of program

Framingham Score CriteriaBaselineAfter Program
Very low risk (<1%)026
Low risk (1 – <10%)8245
Intermediate risk (1- 20%)2134
High risk (>20%) 31

The impact of workplace health promotion and competition at Darajat has led to change at both the employee and the organization levels. For employees, this program has impact to their health such as Framingham score and for organization this program has impact to reduction of medical cost. Average of Framingham score was reduced from 6.36% (year 2014) to 5.71% (during the program in year 2015).

The medical cost saving during this program was USD 7.430 from total participants or reduced 21% from total medical cost from previous year. There are 68 of 106 (64.15 %) of participants have reduced their medical cost. This comparison was conducted to the same participants on their medical cost.

The health promotion and competition program at Darajat was run through lean sigma approach which is divided into several stages:

  • Define phase

During this phase, lean sigma project contract and team was established. All team member from several departments, project champion and sponsor from management signed the contract as a commitment to succeed the program.  Team committed to contributing to the successful completion of the project by using kaizen technique and contributing process knowledge, ideas and experiences, give time and priority in join meeting, do action items on time and communicating project progress to the champion and sponsor. Champion committed in coordinating available resources and conducting frequent review of the team progress. Sponsor as management representative committed to ensure that the project was aligned with overall organization goals and regularly asking for project progress and help remove the barrier including in providing required resources.

Problem/opportunity statement, objective and scope was explored during this phase. Timeline and resources of the project was also defined to make it well planned.

  • Measure phase

In measure phase, team measured the as-is performance which is Framingham score of Fight to Fit participants at Darajat from MCU previous year data. Team from medical department measuring this data and divided into 4 criteria which are very low risk, low risk, intermediate risk and high risk. Due to confidentiality of the MCU data, medical team only provided the Framingham score and required data without showing detail data of each participants.

Medical team also provided medical cost of participants from previous year as baseline and then it will be compared after the program completed. Team targeted the medical cost reduction to 20% from this program.

  • Analyze phase

Causes and effect diagram was established during analyze phase. From brainstorming result, team divided into 4 aspects which are supporting program, people, method and monitoring.

Possible solution from the causes was explored and some recommendation actions were formed. Alternative solution of the causes was also generated in case any barrier during the implementation. Some of recommendation actions during this phase such as conduct monthly formal review of participants’ progress update and coaching to participants especially who did not meet the target. The face to face coaching was delivered by medical team.

  • Improve phase

During improve phase, some detail improvement plans were made with person in charge and due date included in the plan. Here are the improvement plans during this phase:

  • Monthly review of measurement result

Each month, all participants are required to measure their body weight, waist to hip ratio, and blood pressure. If the participants did not conduct the monthly measurement, medical team will deduct the total score. The participants also submit their team program implementation with its evidences to get score. The incomplete of measurement data and program implementation will reduce their score. That’s why, the participants remind each other of their team to ensure all members did it in timely manner.

  • Training and coaching from the health expert

During the program, committee provided special training and coaching from the health expert. The training was scheduled every 2 months with the topics on exercise specialist, nutrition specialist, and cardiologist. This event was conducted at Garut office and attended by participants and their spouse. The purpose in involving spouse due to family is very important in the implementation of healthy life style at home and to get support from their spouse.

  • Health promotion

Some health promotion program such as sport competition (table tennis and badminton), aerobic, health cooking competition for spouse, and one-day healthy menu in weekly at canteen. Table tennis and badminton competition was conducted per department team. The competition attended by most of the participants during the program period.

Aerobic and health cooking competition involving spouse. The spouse of participants’ team competed in cooking and serving healthy food. Committee conducted assessment on this competition as per guidelines in healthy food cooking criteria and its hygiene process.

At Darajat, all employees were provided with lunch. To align this program, committee asked canteen personnel to have healthy menu in a week. During healthy menu, there was no fried food (only steam food processed). Participants who took healthy menu with certain portion as per nutritionist advice will have additional score. The amount of food was also controlled so participants cannot eat more.


       The risk of CVD can be reduced through integrated health promotion and competition. The risk reduction can be seen from Framingham score improvement of all participants from baseline and end of the program. The improvement of Framingham score could lead the reduction of medical reimbursement cost as one of the result of participants wellbeing improvement.

       The health promotion and competition at Darajat can be adopted by other geothermal company. The detail program can be modified based on the organization culture and specific goal. Support from top management is one key of successes of this program.


American Heart Association (2018): What Your Cholesterol Level Means.

Michael P. O’Donnell (2009). Definition of Health Promotion 2.0: Embracing Passion, Enhancing Motivation, Recognizing Dynamic Balance, and Creating Opportunities. American Journal of Health Promotion: September/October 2009, Vol. 24, No. 1, pp. iv-iv, updated from Michael P. O’Donnell (1986), Definition of Health Promotion, American Journal of Health Promotion, June 1986; vol. 1, 1: pp. 4-5.

National Institute of Health (2002): Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. NIH Publication No.02-5215. September 2002.

P.W., Wilson; D’Agostino, R.B.; Levy, D.; Belanger, A.M.; Silbershatz, H.; Kannel, W.B. (12 May 1998). “Prediction of coronary heart disease using risk factor categories.”. Circulation97 (18): 1837–1847.

World Health Organization (2014): Noncommunicable Disease (NCD) Country Profiles.

World Health Organization (2016): Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva.

World Health Organization (2011): Global Atlas on Cardiovascular Disease Prevention and Control. pg.3-18.

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