clinical research centre

Health System Research Difference

2006

- 2

009

Perak

July 2013

Health System Research

Research To make a

DifferencePerak

2006

- 2

009

Health System Research (HSR) in Perak 2006-2009Using Research to Make a Difference

© July 2013, Clinical Research Centre Perak, Level 4, Ambulatory Care Centre, Raja Permaisuri Bainun Hospital, Jalan Hospital, 30990 Ipoh, Perak, Malaysia.

Editorial Committee

Amar-Singh HSSOoi Qing XiLionel Chia Dick HuaLim Wei YinLina HashimArvinder Singh Harbaksh Singh

Advisors

Datin Dr Ranjit Kaur Praim SinghDeputy Director of Perak State Health Department (Public Health)

Sondi SararaksHead Health Outcomes Research Division, Institute for Health Systems Research (IHSR)

Dr Asmah Zainal AbidinHead of Assistant Director of Public Health Division (Non-Communicable Disease Centre, NCDC)Perak State Health Department

Disclaimer

The views, interpretations, implications, conclusions, and recommendations expressed in this book are those of the authors of individual reports and do not necessarily represent the opinions, the views or policy of the Ministry of Health Malaysia.

Acknowledgement

The authors wish to thank the Director-General of Health Malaysia for giving permission to publishthese reports.

ContentsHome Safety Practices for Prevention of Poisoning in Young Children

1

Effective Implementation of a Structured Psychoeducation Programme Among Caregivers of Schizophrenia Patients in the Community

41

Improving Asthma Care in Ministry of Health Primary Care Clinics

89

The Involvement of Lay Educators in Diabetic Control of Type 2 Diabetic Patients

123

Improving Knowledge of Type 2 Diabetes Mellitus Patients on Oral Hypoglycaemic Agents

163

Health Seeking Behaviour Towards Communicable Diseases Among Foreign Workers in Industrial & Agriculture Sectors of Selected Districts in Perak, Malaysia

205

Improving Blood Pressure Controls in Primary Care Settings

249

An Intervention Programme Among Overweight Primary School Children

281

Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting

321

1

Home Safety Practices for Prevention of Poisoning in Young ChildrenHealth Systems Research 2008/2009

Authors

Shoba PathmanathanPaediatric Department, Hospital Raja Permaisuri Bainun Ipoh, Perak

Lina HashimClinical Research Centre Perak

Affendi YusufManjung District Health Office

Vishanthri KulasingamGreentown Health Clinic

Hooi-Meng PuahKinta District Health Office

Amar-Singh HSSClinical Research Centre Perak, Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak

Sondi SararaksInstitute for Health Systems Research

Ranjit Kaur Praim SinghPerak State Health Department

Asmah Zainal AbidinPerak State Health Department

Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Shoba Pathmanathan, Lina Hashim, Affendi Yusuf, Vishanthri Kulasingam, Hooi-Meng Puah, Amar-Singh HSS, Sondi Sararaks, Ranjit Kaur Praim Singh, Asmah Zainal Abidin. ”Home Safety Practices for Prevention of Poisoning in Young Children” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 1. (ISBN: 9789671063422)

ISBN

9789671063422

2 Home Safety Practices for Prevention of Poisoning in Young Children

Contents of Report page

Abstract 3

1. 0 Introduction 5

1.1 Problem statement

1.2 Problem analysis

2.0 Objective 9

2.1 General objective

2.2 Specific objectives

3.0 Methodology 9

3.1 Overview of research design

3.2 Intervention package

3.3 Study type

3.4 Ethical considerations

3.5 Variables

3.6 Sampling

3.7 Techniques for data collection & pre-testing

3.8 Plan for Data Analysis and Interpretation (Include Dummy Tables)

4.0 Results 17

4.1 Results of Evaluation of Safety Device

4.2 Socio-demographic data

5.0 Discussion 24

5.1 Statement of principal findings

5.2 Strengths and weaknesses of the study

5.3 Strengths and weaknesses in relation to other studies

5.4 Meaning of the Study (Possible Mechanism and Implication for Clinicians/Policymakers)

5.5 Unanswered questions and future research

6.0 Conclusion & Recommendations 27

References 28

Appendices 31

3Home Safety Practices for Prevention of Poisoning in Young Children

ABSTRACT

Home Safety Practices for Prevention of Poisoning in Young Children

Shoba Pathmanathan¹, Lina Hashim², Affendi Yusuf³, Vishanthri Kulasingam4, Hooi-Meng Puah5, Amar-Singh HSS¹,², Sondi Sararaks6, Ranjit Kaur Praim Singh7, Asmah Zainal Abidin7

1 Paediatric Department, Hospital Raja Permaisuri Bainun Ipoh2 Clinical Research Centre Perak3 Manjung District Health Office4 Greentown Health Clinic5 Kinta District Health Office6 Institute for Health Systems Research7 Perak State Health Department

Introduction and Objectives

Poisoning in young children is defined as unintentional ingestion of medication(s) and common household products or chemicals. Poisoning in young children is a preventable cause of mortality and morbidity. Poisoning accounts for 2% of the accidental deaths in developed countries and for 5% in developing countries. Most poisoning accidents occur in children aged between 1 to 4 years old. The objective of the study was to evaluate and improve home poison safety practices to prevent poisoning in homes with children aged 1-4 years in the Kinta and the Manjung Districts.

Methodology

The study was a non-controlled community trial conducted at urban and semi-urban areas in Perak state to assess home safety practices and effectiveness of an intervention programme in home setting. Initial validation of a safety device involved 100 children and 100 adults (parents/caregivers accompanying the child) who attended Ministry of Health (MOH) health clinics and were recruited to test two home safety devices. In both urban and semi-urban areas, 300 households with children aged 1-4 years were randomly selected. They were audited at baseline. Two post-intervention audits were conducted at 3 and 6 months post-baseline audit using the same tools as in the first audit. The households were divided into two intervention arms. Caregivers in the first arm received Intervention Package 1 which consists of an immediate post-audit feedback, an educational pamphlet and a home safety device while caregivers in the second arm received Intervention Package 2 which consists of an immediate post-audit feedback and an educational pamphlet.

Results

At baseline, 60-71% of urban and semi-urban households in Perak had unsafe home safety practices to prevent poisoning in young children. Only 30 (20.4%) households in the Kinta District compared to 79 (52.7%) households in the Manjung District had good


knowledge. Good knowledge does not ensure a safe household. At the end of the study there was a statistically significant increase in the percentage of safe households in both districts with Kinta District doing better. Kinta District had an incarese from 48.6% (CI 40.4-56.8) to 93.9% (CI 89.7-98.0) while in the Manjung District, the increase was from 21.3% (CI 14.7-28.0) to 67.7% (CI 59.7-75.6).

Conclusion

The intervention package notably the Home Safety Practices Audit checklist, which was developed by the researchers for the study, significantly improved home poisoning safety practices. 75.7-85.3% of urban and semi-urban households in Perak had a safe home to prevent poisoning in children at the end of the study. Addition of the safety device to the home safety practices audit further improves home poisoning safety practices. Knowledge and perception does not ensure a safe household in prevention of poisoning in young children.

Keywords

poisoning in children, home poisoning safety practices, safe households, home safety practices audit checklist, safety device


1.0 INTRODUCTION

Poisoning in young children is defined as unintentional ingestion of medication and common household products (J. Nixon et al. 2004).

Poisoning in young children is a preventable cause of mortality and morbidity (Laffoy M., 1997). Poisonings account for 2% of the accidental deaths in developed countries and for 5% in developing countries (Nadarajah P., 2004).

Most poisoning accidents occur in children aged between 1 to 4 years (48.5% in the study by Sibel E. and Sukran S. (2006) and 60.3% according to FDA’s Poisoning Surveillance and Epidemiology Branch 1981.

Around 80-85% poisoning accidents occur in the home (B. Jacobson et al. 1989).

Children under the age of 5 are in a stage of development where they constantly explore their home environment. This is a normal characteristic and should not be restricted. Unfortunately they usually put whatever they see or reach in their mouth (A. W. Craft, 1990).

Most of the poisoning accidents (49.5%) stemmed from storing of drugs within the reach of children. Out of these accidents, 49.5% were due to drugs, 17.5% due to cleaning agents and 16.5% due to insecticides/pesticides (Sibel E. et al. 2006).

In a study on home safety in the United States, although most families reported locked storage of medications, 77% had unlocked storage of medication documented during home observation (Kimberly E. et al. 2007).

Medications involved in suspected poisoning were most frequently packed in containers without Child Resistant Containers (CRC) (63%) or transparent blisters (20%). However safe packaging cannot compensate for unsafe storage. Bathroom and kitchen cabinets and drawers are the safest place to store medication (H. M. Wiseman et al. 1987).

The concept of CRC is widely supported by parents as an important mechanism for protecting children from toxic products. However the support for CRCs was often based on the notion that they were childproof rather than child resistant. As a result some parents were more likely to store products unsafely if they were in CRCs (L. Gibbs et al. 2005).

CRC is defined by the Poison prevention Packaging Act to be packaging that is “difficult for children under age of 5 years to open” but “not difficult for normal adults to use properly”. US Consumer Product Safety Commission (CPSC) regulations require that certain drugs be packaged in special containers that would prevent at least 80% of those children younger than 5 years old from opening the container within 10 minutes (CPSC Federal Register 1983). Oral prescription drugs became subject to Child Resistant Packaging requirements since 1974 in the US. Introduction of CRC resulted in 47% reduction in the incidence of


paraffin poisoning in the study community compared to the control community (Krug et al. 1994).

Safe storage of toxic products should be in a locked cabinet or cupboard out of reach if possible in the kitchen or bathroom (L. Gibbs et al. 2005). Safe disposal according to the National Drug Control Policy Federal Guidelines Washington DC for unneeded or expired prescription drug should be taken out of their original container and thrown into the trash, returned to a community pharmaceutical take back program or flush down the toilet if the label instructs so.

Other implementation measure, besides safe storage and disposal practices and CRC, is parental education and improved supervision by parents. In rendering the child’s environment safe, the family’s education especially that of the mother is vital (Stewart J., 2001). 67% of the children involved in a poisoning accident were under the supervision of their mothers at the time of the accident (Sibel E. et al. 2006). 69% of mothers claimed to have taken measures to prevent future poisoning accidents in their homes however there was no mention at all of basic precautions such as storage in locked cupboards which are out of reach of children. This proves the necessity for educational measures in the families (Sibel E. et al. 2006).

In summary, a combination and not a single home poison safety strategy is needed to reduce accidental poisoning in young children. The strategies are:

1. Safe storage practices.2. Efficacious CRC and Child Safety Devices.3. Safe disposal practices.4. Parent education.5. Responsible supervision of children by caregiver at all times.

1.1 Problem Statement

The number of cases of accidental poisoning admitted to government hospital is static with no reduction over the years. There are no available local studies assessing the knowledge of caregivers or home poison safety practices. There is also no CRC or Child Safety Device in regular use in our local setting.

Based on international data, only 20% of homes are safe in terms of preventing an accidental poisoning and we assume this is the case in our setting as well.

Here is a table showing the number of admissions to government hospitals in Malaysia due to poisoning by drugs, medicaments and biological substances in the 1-4 years age group. (Data was obtained from Admissions and Deaths in Government Hospitals due to Injury in Malaysia 1999-2002.)


Table 1. Number of deaths in government hospital due to poisoning by drugs, medicaments and biological substances.

Age (years) 1999 2000 2001 2002

<1 0 0 0 1

1-4 1 3 0 2

5-11 1 0 0 1

Table 2. Number of admissions in government hospital in Malaysia due to poisoning by drugs, medicaments and biological substances.

Age (years) 1999 2000 2001 2002

<1 101 96 104 67

1-4 446 481 466 459

5-11 132 137 163 130

The above local statistics are comparable with international data such that the common age group involved in accidental poisoning is 1-4 years old. The local statistics available are only from those cases of accidental poisoning admitted to hospital and we are unable to capture data on children who seek treatment from health clinics and private clinic and hospital. So the actual number of cases of accidental poisoning is most likely to be 100 times the numbers projected in the table above.

Table 3. Number of admissions in government hospitals in Perak due to poisoning by drugs, medicaments and biological substances for those in the 1-4 years old age group.

Year Number of poisoning cases

2003 66

2004 72

2005 nil

2006 37

2007 65

Based on the 1-4 years old population size in Perak of 171 853, the incidence of accidental poisoning in this age group in Perak is about 3% in keeping with international data for developing countries (5%).

1.2 Problem Analysis

Accidental poisoning rates in children aged 1-4 years old has not reduced over the years because of the absence of an intervention program which include:


1. Educational program for parents2. No audit of home poison safety practices to determine number of safe

households3. No CRCs or child home safety device in use regularly.

8

1.2 Problem Analysis Accidental poisoning rates in children aged 1-4 years old has not reduced over the years because of the absence of an intervention program which include:

1) Educational program for parents 2) No audit of home poison safety practices to determine number of safe households 3) No CRCs or child home safety device in use regularly.

Figure 1: Bubble chart of problem analysis

Figure 1. Bubble chart of problem analysis


2.0 OBJECTIVES

2.1 General Objective

To evaluate and improve home poison safety practices to prevent poisoning in homes with children aged 1-4 years in the Kinta and Manjung districts.

2.2 Specific Objectives

1. To assess the home safety practices for poisons in homes with young children with respect to:a. Knowledge of caregivers on safe practices.b. Safe storage of medications and household products.c. Safe disposal of poisons.

2. To develop an intervention programme to improve poison safety measures at home by:a. Immediate audit feedback and recommendations to caregivers.b. Education of caregivers.c. A home safety device for safe medication and household product

storage.

3. To evaluate the effectiveness of the intervention programme for poison safety in:a. Improving knowledge of caregivers on safe practices.b. Improving safe storage of medications and household products.c. Improving safe disposal of medications and household products.d. The value of a home safety device for safe medication and household

product storage.

4. To make recommendation on the use of the intervention package to improve home poison safety practices for poisons in homes with young children in Malaysian communities.

3.0 METHODOLOGY

3.1 Overview of Research Design

A non-controlled community trial was conducted in the Kinta and Manjung Districts in Perak State evaluating and improving home poison safety practices to prevent poisoning. The researchers intervened using an audit checklist and give immediate feedback to caregivers, provide an educational pamphlet and a home safety device/product.


Phase 0: Validation of Home Safety Device

In order to ensure that the home safety device used in this study works effectively, the researchers performed a sub-study to test the efficacy of two different children home safety devices prior to its implementation in the study. The most efficacious device was then chosen.

In this sub-study, 100 children and 100 adult parents/caregivers accompanying the child to attend the MOH health clinics were recruited to test the home safety devices. Parents/caregivers accompanying a child aged between 12 to 60 months to a MOH clinic were approached about the study and a written consent was obtained if he or she agreed to be involved. 100 children and 100 of their parents/caregivers were asked to test on Device A and Device B.

The inclusion criteria for the children recruited for the study were:i) Seeking treatment at MOH health clinic.ii) Aged 12-60 months.

The exclusion criteria for the children recruited for the study was:i) Suffering from any physical or mental disabilities.

The inclusion criteria for the adults recruited for the study were:i) Parent/caregiver for the child recruited for the study.ii) Ability to communicate in English or Malay.

The exclusion criteria for the adults recruited for the study were:i) Suffering from any physical or mental disabilities.

There were three activities in the study:i) The first activity involved the child operating Device A or Device B without

guidance. The child was given 5 minutes to operate the device. The method used by the children to successfully operate the device was documented.

ii) The second activity phase involved the child operating Device A or Device B without guidance, following a demonstration by a researcher. The child was given 5 minutes to operate the device. The method used by the children to successfully operate the device was documented.

iii) The third activity involved the accompanying parent/caregiver operating Device A or Device B without guidance, following a demonstration by a researcher. The adult were given 5 minutes to operate the device.

Table 4 describes the criteria to determine the efficacy of the home safety device. The results were analysed to decide on the most efficacious device to be utilized in the study.


Table 4. Criteria for efficacy of home safety device

Activity Criteria for Efficacy

Activity 1Child operates device without guidance

At least 85% of the children must fail to operate the device within 5 minutes of attempting

Activity 2Child operates device without guidance, following a demonstration by a researcher

At least 80% of the children must fail to operate the device within 5 minutes of attempting

Activity 3Adult operates device without guidance, following a demonstration by a researcher

At least 85% of adults must be able to successfully operate the device within 5 minutes of attempting

Phase 1: Identification, Baseline Audit and Intervention

Phase 1 involved the identification of households with children aged 1-4 years, a baseline audit of the households and the implementation of an intervention package which include an immediate post audit feedback, an educational pamphlet and a home safety device.

The samples were randomly chosen from the Birth Registration Book from Year 2004 till Year 2007. The homes identified were sampled into two intervention arms. Caregivers in Group 1 received intervention package which consists of an immediate post audit feedback, an educational pamphlet and a home safety device while caregivers in Group 2 received intervention package which consists of an immediate post audit feedback and an educational pamphlet.

Public health nurses from district health clinics were identified as research assistants as they are well versed with the demographics of the study areas. They were trained to administer a knowledge questionnaire (refer to Appendix A), to conduct a home safety audit using a checklist (refer to Appendix B), to give immediate feedback, recommendations to caregivers after the audit, to explain an educational material (refer to Appendix D) and to explain the use of a home safety device to caregivers based on an instruction leaflet (refer to Appendix E).

During the first audit, public health nurses visited the homes identified, administered the knowledge questionnaire to caregivers; conducted a home safety audit using a checklist and gave immediate feedback to caregivers after the audit. A copy of the audit checklist signed by the respondent and public health nurse (include the nurse’s phone number for respondent to call if there is any problem) were given


13

Figure 2: Flow chart of study design

Inclusion criteria: 1. All households with

children aged 1-4 2. Respondents consented

to participate 3. Respondents able to

converse in English or Malay

Exclusion criteria: 1. Households where only the maid and children are present during the visit

Identification of households with children age 1 -4 (n = 300)

Group 2 (Manjung) (n=150) Households to receive intervention package 2

1. Immediate post audit feedback & Education

Group 1 (Kinta) (n=150) Households to receive intervention package 1

1. Immediate post audit feedback & Education

2. Home safety device

Training of public health

Audit 1 Nurses administered questionnaire, carried out 1st audit and implemented intervention package 1.

Audit 1 Nurses administered questionnaire, carried out 1st audit and implemented intervention package

Evaluation of the effectiveness of intervention package in terms of

1. Safe storage 2. Home safety device 3. New changes by parents eg

use child resistant device


1. Safe storage 2. New changes by parents eg

use child resistant device

Nurses administered questionnaire


1. Safe storage 2. New changes by parents

Evaluation of the effectiveness of the intervention package in terms of

1. Safe storage 2. New changes by parents 3. Home safety device

Phase 0: Sub-study to validate the home safety device

Two home safety devices will be tested on children and adults. The most cost-efficient and effective device was chosen based on the following criteria:

i) At least 85% of children fail to operate the device after 5 minutes without guidance ii) At least 80% of children fail to operate the device after 5 minutes without guidance, following

demonstration by the researcher iii) At least 85% of adults successfully operate the device after 5 minutes without guidance, following

demonstration by the researcher

The most cost-efficient and effective home safety device was chosen and used for the study

Phase 1: Identification of households, baseline audit and intervention implementation

Nurses administered questionnaire

Phase 2: 3 months post intervention audit

Phase 3: 6 months post intervention

Figure 2. Flow chart of study design


to the respondent. An educational material were provided to both intervention groups but the home safety device with instruction leaflet and demonstration of the device by the nurse were provided only to homes in Group 1.

Phase 2

The second audit was conducted after 3 months from the first audit. The same tools as in the first audit were used. Improvements in home poison safety practices were evaluated in both intervention arms. Additional changes made by parents to improve home poison safety practices were assessed in both intervention arms.

Phase 3

The third audit was conducted after 6 months from the first audit. The same tools as in the first audit were used. Improvements in home poison safety practices were evaluated in both intervention arms. Additional changes made by parents to improve home poison safety practices were also assessed in both intervention arms.

Fidelity testing was also done for the audit to monitor the quality of the intervention implementation. This was carried out by telephone calls to the audited respondents based on a Fidelity Test Form (Appendix C). In both intervention arms of each audit, 30 different samples were chosen for fidelity testing each time.

3.2 Intervention Package

1. Immediate post audit feedback and recommendations:

a. Store medication and household products in locked cabinet.b. Keep medication and household products out of reach of children.c. Keep medication in CRCs.d. The safe places to store medication and household products are the

kitchen, bathroom and the storeroom. e. Safe disposal of medication by removing from the original container and

throwing in the trash bin, flush down the toilet if the labels says so and return medication to the pharmacy.

f. Store household products in their original containers.

2. An educational material will be prepared in three languages (Malay language, Mandarin and Tamil) to educate caregivers about safe storage and disposal of medication and household products and home safety practices to avoid poisoning in young children.

3. An instruction leaflet on the use of the home safety device will be provided to respondents in Group 1 (intervention package 1).


3.3 Study Type

This study is an interventional study (non-controlled community trial) conducted in 2 districts with similar demographic distribution in Perak. There was no control group as the researchers feel that it is unethical not to intervene as most children in a household are at risk of poisoning.

3.4 Ethical Considerations

The researchers had obtained approval from the national ethics committee prior to implementing the study. All the information from the questionnaire and audit checklist was kept confidential. No identification data were captured. Verbal consent was obtained and documented before the respondent’s participation in the study. Caregivers were allowed to refuse consent to participate in the study.

3.5 Variables

Table 5. Variables definition

No Variables Operational Definitions Scale of Measurement

1Relationship of caregiver to child/ children

Relationship between respondent and young children at home as obtained by a direct question to the respondent

1. Father2. Mother3. Grandmother4. Grandfather5. Others

2Age of the caregiver

Age in complete years is obtained from respondent to a direct question to the respondent

Years

3Ethnicity of caregiver

Ethnicity of respondent Obtained from respondent to a direct question to the respondent

1. Malay2. Chinese3. India4. Others

4Education level of caregiver

Highest education level achieved by respondent as obtained by direct questioning to respondent

1. No education2. Primary3. Secondary4. Tertiary

5No. of children aged 1-4 years in household

Respondent own children aged 1-4 obtained from direct question to the respondent

Number



6No. of other children in household

Respondent other children obtained from direct question to the respondent

Number

7No. of adults in household

Number of adult persons who stay in the house obtained from direct question to the respondent

Number

8Furniture availability

Cabinets and drawers available obtained by direct observation by research assistant during home visit

Yes

9Self reported practice of medication storage

Reported practice of medication storage obtained from direct question to the respondent

Conclusion on safe storage based on criteria*:1. Safe2. Partially safe3. Partially dangerous4. Dangerous

10

Self reported practice of household chemicals storage

Reported practice of household chemicals storage obtained from direct question to the respondent

Conclusion on safe storage based on criteria:1. Safe2. Partially safe3. Partially dangerous4. Dangerous

11

Self reported practice of safe disposal of medication

Reported practice of disposal of medication obtained from direct question to the respondent

CorrectIncorrect(Based on criteria#)

12

Knowledge on specific medication/household chemicals poisoning

Specific question on medication poisoning/household chemicals to young children posed to the respondent

Percentage of respondents aware of risk



13

Possible rate of poisoning in household of young child

Specific question on prior experience of poisoning in the past year in young children in the family

Rate per 1000 children per year

14

Possible poisoning in young child of household or relatives

Specific question on any experience of poisoning in the past year in young children in the family or relatives

Yes or No

15

Knowledge on specific young child behaviour toward medication/household chemicals

Specific question on young child behaviour toward medication/household chemicals to young children posed to the respondent

Percentage of respondents aware of risk

16

Additional knowledge on safe storage on medication/household product

Specific question to determine additional knowledge on safe storage of medication poisoning/household chemicals to young children posed to the respondent

Open ended

3.6 Sampling

The sample size for the study was calculated using the Epicalc 2000 software. A similar study carried out shows that about 20% of homes have good home poison safety measures in place (Kimberly E, et al Home Safety in Inner Cities: Prevalence and Feasibility of Home Safety Product Use in Inner City Housing Pediatrics 2007). Setting the significance level at 0.05 with a study power of 90% and assuming an improvement in home poison safety practices level from 20% to 40%, the calculated sample size was 108 for each intervention arm. After considering an estimated 30% attrition rate, the sample size was set at 150 for each intervention arm.

Random quota sampling of households which fulfil the inclusion and exclusion criteria was carried out.

The following are the inclusion criteria for houses selected for the study:1. Households with children aged 1 to 4 years2. The respondents have consented to participate


3. The respondents are able to converse in either English or Malay

The following are the exclusion criteria for houses selected for the study:1. Households where only the maid/babysitter is present during the visit

The samples were randomly chosen from the Birth Registration Book from Year 2004 till Year 2007. The homes identified were sampled into two intervention arms. Caregivers in Group 1 received intervention package which consists of an immediate post audit feedback, an educational pamphlet and a home safety device while caregivers in Group 2 received intervention package which consists of an immediate post audit feedback and an educational pamphlet.

3.7 Techniques for Data Collection & Pre-Testing

Baseline data collection and data collection during each of the subsequent audits were carried out by trained public health nurses using a questionnaire (refer Appendix A) and an audit checklist (refer Appendix B). The questionnaire is used to determine the level of knowledge of caregivers on home poison safety practices including safe storage and safe disposal to prevent accidental poisoning in young children.


SPSS version 15.0 and Epicalc 2000 were used to analyse the results of the study.

4.0 RESULTS


A total of 133 children and their accompanying caregivers were involved in a sub-study to decide which safety device was more efficacious to be used in the intervention package of the main study. Safety Device 1 is the Patrull Drawer/Cabinet Lock and Safety Device 2 is the Patrull Multilock.

Some of child-caregiver teams were tested on Safety Device 1 only (66), some on Safety Device 2 (104) and some were tested on both devices.

This sub-study, to validate the home safety device, showed only Safety Device 2 (Patrull Multilock) to be efficacious which was then used in the intervention package for Kinta District in the main study. A total of 100 (96.2%) out of 104 children failed to open Safety Device 2 on their first try and 89 (89.0%) out of 100 children failed to open Safety Device 2 on their second try. All 104 (100%) accompanying caregivers/adults successfully opened Safety Device 2 (Table 6).

Safety Device 1 was found to be unsuitable as although 62 (93.9%) out of 66 children failed to open Safety Device 1 on their first try, only 45 (72.6%) out of 62 children


failed to open Safety Device 1 on their second try. For the device to be considered efficacious, 85% of children tested should fail to open the Safety Device within the 5 minutes allocated on their first try and 80% of children should fail on their second try after the investigator demonstrates how to open the lock. We did not continue our study on Safety Device 1 after we found out that Safety Device 1 was no longer available for purchase in this country. Hence only 66 instead of the planned 100 children were tested on Safety Device 1 (Table 6).

The mean age of the participating children was 39.24 months (SD 9.42). The minimum age was 18 months and the maximum 68 months. A total of 61 (45.9%) children were male and 72 (54.1%) were female. Their accompanying caregiver was mainly mothers (75.9%), followed by fathers (14.3%), grandmothers (6.8%), grandfathers (1.5%) and others (1.5%). The accompanying caregivers’ mean age was 34.77 years (SD ± 9.09 years). The accompanying caregivers’ minimum age was 21 years old and the maximum 62 years old. Most of the caregivers (69.9%) of them had up to secondary level education.

Out of the 4 children who could open safety Device 1 on their first try, 3 were males. On their second try eleven out of 18 children who successfully opened Safety Device 1 were males. The same trend was seen with Safety Device 2 whereby 3 out of 4 children who were successful on their first try were males and 8 out of 11 children successful on their second try were males.

4.2 Socio-demographic Data

For the first audit, 146 households were evaluated from the Kinta District and 150 from the Manjung District. 8 (6.1%) households dropped out in the Kinta District for the second audit and 12 (8.0%) from Manjung. For the third audit another 8 households dropped out in Kinta District and another two (1.4%) households dropped out from Manjung (Table 7).

Socio-demographic data comparing both the districts at baseline is shown in Table 8. There was no significant difference in terms of relationships of the caregivers to the child, age, ethnicity and education level of the caregivers.

To say that the household assessed has good knowledge on safe medication & chemicals storage & disposal we put together a score whereby one correct answer from each of the following aspect i.e. how to safely store medication, how to safely store household chemicals, how to safely dispose medication and all three correct answers on identifying possible household substances that can cause poisoning in children were considered to have good knowledge. Any household not fulfilling the above criteria was considered to not have good knowledge. Knowledge level was only assessed during the pre-intervention visit.


Only 30 (20.4%) households in Kinta District (Group 1) compared to 79 (52.7%) households in Manjung District (Group 2) had good knowledge (Table 9).

Most caregivers in Kinta District (Group 1) perceived their children to be safe from poisoning at home with 113 (77.4%) households safe from medication poisoning and 120 (81.6%) from chemical poisoning. The same results were seen in Manjung (Group 2) with 122 (81.3%) households perceiving their children to be safe from medication poisoning and 121 (80.7%) households safe from chemical poisoning (Table 9).

Good knowledge and high perception did not ensure a safe home in prevention of poisoning in children as the data from Manjung (Group 2) revealed that although they had better scores in knowledge and perception, only 21.3% of households were safe when audited as compared to 48.6% in Kinta District (Audit 1) as shown in Figure 3 and Figure 4.

Number of poisoning in children in the past year was 4 (0.91%) in the Kinta District and 6 (1.26%) in the Manjung District. (The incidence of accidental poisoning in this age group in Perak is about 3% and international data for developing countries is 5%.) The incidence of poisoning per 1000 children per year in the Kinta District was 9.11 compared to 12.55 in the Manjung District. (p-value 0.85).

Table 7. Number of respondents for each audit visit by district

Audit Kinta District Manjung District

1st Audit 146 150

2nd Audit 138 138

3rd Audit 130 136

Table 6. Validity of safety device by ability of child and caregiver to open a drawer/cabinet

Safety Device 1(Patrull Drawer/

Cabinet Lock) n = 66

Safety Device 2 (Patrull Multilock)

n = 104

Child Attempt 1 (Inability of child to open the drawer with safety device)

62 (93.9%) 100 (96.2%)

Child Attempt 2 (Inability of child to open the drawer with safety device after a demonstration)

45 (72.6%) 89 (89.0%)

Parent Attempt (Ability of parent to open the drawer with safety device after a demonstration)

66 (100%) 104 (100%)


Table 8. Socio-demographic characteristics comparing both the districts at baseline

Socio-demographic characteristics

Group 1(n=147)

Group 2(n=150)

p-value

Relationship to the child

Father 4 7

0.25 comparing mother with others

Mother 118 112

Grandfather 1 1

Grandmother 16 25

others 8 5

Age ( years)

<20 0 1

0.8 comparing age 40 and less with age 40 and above

20-30 37 40

31-40 66 66

41-50 24 21

>50 19 22

missing 1 0

Socio-demographic characteristics

Group 1 (n=147)

Group 2(n=150)

p-value

Number of children in households

Total number 439 478 -

Mean number (SD) 2.99 (1.49) 3.19 (1.82) -

Ethnicity

Malay 93 920.72 comparing Malays with non-Malays

Chinese 26 21

Indian 21 34

Others 6 3

Education level

Lower education 29 33 0.67 comparing lower and higher education levelHigher education 116 117


Table 9. Knowledge on safe medication, chemical storage, disposal, poisoning numbers & rates and perception of caregivers

Pre-intervention (Audit 1)

Group 1(n=147)

Group 2(n=150)

p-value

Knowledge on safe medication & chemical storage & disposal

30(20.4%)

79(52.7%)

–

Poisoning Numbers & Rates

Number of poisoning in household in past year4

(2.8%)6

(4.0%)–

Number of poisoning in children in past year4

(0.91%)6

(1.26%)–

Rate per 1000 children per year 9.11 12.55 0.85

Possible poisoning in young child of household or relative in the past (excluding above)

6(4.1%)

4(2.8%)

–

Perception of Caregivers

No access of young child to medication in household

113(77.4%)

122(81.3%)

0.40

No access of young child to chemical in household

120(81.6%)

121(80.7%)

0.83

Table 10: Safety of household for pre and post intervention audits by district

Safety of household

Pre-intervention Post-intervention

Audit1 Audit 2 Audit 3

Group 1(n=146)

% (95%CI)

Group 2(n=150)

% (95%CI)

Group 1(n=138)

% (95%CI)

Group 2(n=138)

% (95%CI)

Group 1(n=130)

% (95%CI)

Group 2(n=136)

% (95%CI)

Safe household overall

48.6(40.4-56.8)

21.3(14.7-28.0)

68.1(60.2-76.0)

60.9(52.6-69.1)

93.9(89.7-98.0)

67.7(59.7-75.6)

Safe household for medications

52.1(43.9-60.3)

36.0(28.2-43.8)

73.9(66.5-81.3)

65.2(57.2-73.3)

95.4(91.7-99.0)

73.5(66.0-81.0)

Safe household for chemicals

74.0(66.8-81.2)

41.3(33.4-49.3)

82.6(76.2-89.0)

84.8(78.7-90.0)

97.0(94.0-99.9)

88.2(82.8-93.7)


Figure 3. Pre-intervention knowledge assessment compared with households’ safety practices (Audit 1) by district

Figure 4. Knowledge and perception compared with households’ safety practices (Audit 1) by district


Figure 5. Overall household safety for pre- and post-intervention audits by district showing 95% CI

Figure 6. Household safety for Medication pre- and post-intervention audits by district showing 95% CI


Table 10 above and Figure 5 below show the key outcomes of the three audits by district. The initial overall safe households were higher in Kinta (Group 1) than in Manjung (Group 2). It can be clearly seen that there was a statistical significant increase in the percentage of safe households in both districts. Kinta (Group 1) had an increase from 48.6% to 93.9%, while in Manjung (Group 2) the increase was from 21.3 to 67.7% over 7 months. The significant increase of safe households continued in Kinta from audit 2 and 3, however in Manjung the increase plateaued after audit 2.

Households within Manjung (Group 2) had lower rates of safe homes for both medication and chemicals when compared to Kinta (Group 1) households. The increase in safe households in both districts was similar for medication and chemicals as shown in Figure 4 and Figure 5.

5.0 DISCUSSION

5.1 Statement of Principal Finding

At baseline (Audit 1) between 29.3-40.3% of urban and semi-urban households in Perak have safe home safety practices to prevent poisoning in young children.

Figure 7. Household safety for Chemical pre- and post-intervention audits by district showing 95% CI


At baseline (Audit 1), 40.4-56.8% of households in the Kinta District were found to be safe in prevention of poisoning compared to 14.7-28.0% in the Manjung District. In Kinta, more households (66.8-81.2%) were safe for prevention of household chemicals poisoning compared to medication poisoning (43.9-60.3%). In Manjung, the rates for safety from household chemicals poisoning and medication poisoning did not differ much at 28.2-43.8% and 33.4-49.3%, respectively.

However only 30 (20.4%) households in the Kinta District compared to 79 (52.7%) households in the Manjung District had good knowledge when assessed at audit 1. Households in Kinta and Manjung had similar high rates in perceiving their children to have no access to medication and household chemicals, 77.4% and 81.6% respectively in Kinta and 81.3% and 80.7% in Manjung.

The percentage of safe households in the Kinta District improved significantly to between 60.2-76.0% after Audit 2 and further to between 89.7-98.0% after Audit 3. Manjung also showed significant improvement to between 52.6 – 69.1% after Audit 2 but plateaued at 59.7-75.6% at Audit 3. The sustained improvement in Kinta District may be attributed to the Safety Device.

Knowledge does not affect practice as demonstrated by the findings from the Manjung District.

Number of poisoning in children in the past year was 4 (0.91%) in the Kinta District and 6 (1.26%) in the Manjung District. The incidence of poisoning per 1000 children per year in the Kinta District was 9.11 compared to 12.55 in the Manjung District.

In Audit 2, 88.4% households were satisfied with the device and this was sustained in Audit 3. However, satisfaction or dissatisfaction with the device did not affect safety practices in the household.

5.2 Strengths and Weaknesses of the Study

This study did not assess post intervention knowledge at Audit 2 and Audit 3 as it was considered that the audit conducted with carers was superior to conventional health education using leaflets.

There was no control group as it will be unethical not to intervene in those households at risk. The Manjung district was used as a “partial control” as no safety device was provided in the intervention package.

The population studied only represented urban and semi-urban households and not the rural population. Spoken language use was limited to Bahasa Malaysia and English. Chinese and Tamil was not included although around 34% of households used either one of these languages. However the safety educational material was made available in 4 languages Bahasa Malaysia, English, Chinese and Tamil.


This study did not evaluate the use of the safety device. Instead, the study focused on evaluating the satisfaction of caregiver with the device. The majority of caregiver involved in the study was female and this may have contributed to the success of the intervention.

5.3 Strengths and Weakness in Relation to Other Studies

Rate of Unsafe Households

This study shows 60-71% of urban and semi-urban households in Perak have unsafe homes. The figure is comparable to a study done in urban lower income households in the USA where 77% of homes were not safe in preventing poisoning in children (Kimberly E. et al. 2007).

Improvement Rate of Safe Household

In this study, good knowledge and high perception did not affect practice. This is similar to finding in other studies. A study in Turkey shows that 69% of mothers claimed to have taken preventive measures after their child had a poisoning accident at home but they did not even mention at all basic precautions such as storage of poisonous agents on different shelves and storage of medication and household chemicals in locked cabinets (Sibel E. et al. 2006). 76.1% of mothers only mentioned keeping the medication out of the reach of children.

The study in the USA also shows that caregiver reports of poison safety/storage (71%) were falsely higher than if evaluated by a home safety checklist/audit (17%) (Kimberly E. et al. 2007). This strongly suggests that home audit rather than conventional education or questionnaire alone is a more powerful tool to identify unsafe home as well as to make significant changes in practices. The audit not only gathers information but also educates the respondents and ensures that correct practices are adhered to.

The use of the safety device may have contributed to further improvement but this needs to be studied further.

Community-based prevention educational programmes are an important component in preventing poisonings and have been shown to change parental poison storage habits (Maiesl G. et al. 1967 as quoted by John T. Arokiasamy in an editorial Accidental Poisoning: Selected Aspects of its Epidemiology and Prevention Med. J. Malaysia June 1994).

The rate of poisoning in household participating in this study was 1.1% over a one year period. This is lower than the average calculated from accidental poisoning in Perak for children aged 1-4 years which was 3% (HMIS data, MOH 2003-2007) and international data for developing countries (5%) (Kimberly E. et al. 2007). The rate is


lower in this study as the denominator includes all children in the household aged 0-12 years of age.

5.4 Meaning of the Study (Possible Mechanism and Implication for Clinicians/Policymakers)

The high rate of unsafe households i.e. between 60-71% of urban and semi-urban households calls for some intervention to improve the situation. The single most powerful means of change is the Home Safety Audit Tool.

5.5 Unanswered Questions and Future Research

One concern is whether parents will sustain good home poison safety practices after this study is over. The fact that caregiver were aware that health personnel were returning for an audit may have contributed to them maintaining safe home practices. This could be answered by an unannounced audit one year after the 3rd Audit.

It was uncertain from the study what impacts the use of a safety device had in changing the household behaviour to prevent poisoning. Finally, the rate of unsafe household in rural communities is not known and needs to be investigated.

6.0 CONCLUSION & RECOMMENDATIONS

This study shows between 60-71% of urban and semi-urban households in Perak have unsafe home safety practices to prevent poisoning in young children.

The intervention package, mainly the Home Safety Practices Audit developed by the researchers for this study, significantly improved home poisoning safety practices. 75.7-85.3% of urban and semi-urban households in Perak had a safe home to prevent poisoning in children at the end of the study.

Addition of the safety device with the Home Safety Practices Audit further improves home poisoning safety practices.

Knowledge and perception does not ensure a safe household in preventing poisoning in young children.

Recommendation:

1. There is a need to support parents to make their home poison safe.

2. The Audit Mechanism and Package used in this study should be used by the Family Health Development Division of the Ministry Of Health Malaysia so that public health nurses can enable caregivers to improve poison safety practices in homes.


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ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper.


APPENDIX

41ISBN

9789671063477

Effective Implementation of a Structured Psychoeducation Programme among Caregivers of Schizophrenia Patients in the CommunityHealth Systems Research 2008/2009

Authors

Paranthaman VengadasalamJelapang Health Clinic

Satnam Kaur Harbhajan SinghBahagia Ulu Kinta Hospital

Jean-Li LimSlim River Health Clinic


Sondi SararaksInstitute of Health Systems Research

Nafiza Mat NasirTanjung Malim Health Clinic



Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Paranthaman Vengadasalam, Satnam Kaur Harbhajan Singh, Jean-Li Lim, Amar-Singh HSS, Sondi Sararaks, Nafiza Mat Nasir, Ranjit Kaur Praim Singh, Asmah Zainal Abidin. ”Effective Implementation of a Structured Psychoeducation Programme among Caregivers of Schizophrenia Patients in the Community” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 41. (ISBN: 9789671063477)

42 Effective Implementation of a Structured Psychoeducation Programme among Caregivers of Schizophrenia Patients in the Community


Abstract 43

1.0 Introduction 48

2.0 Objectives 48



3.0 Methodology 49


3.2 Study type


3.4 Variables

3.5 Sample size and sampling method

3.6 Data collection tools and techniques

3.7 Data analysis and interpretation

4.0 Results 55

4.1 Socio-demography of caregivers

4.2 Socio-demography of patients

4.3 Knowledge of caregivers on schizophrenia

4.4 Outcomes of patients with schizophrenia

4.5 FBIS/SF score of caregivers

4.6 Feasibility of the psychoeducation programme

5.0 Discussion 64

5.1 Key findings

5.2 Comparison with other studies

5.3 Limitations of the study


Acknowledgement 68

References 68

Appendices 69

43Effective Implementation of a Structured Psychoeducation Programme among Caregivers of Schizophrenia Patients in the Community

ABSTRACT

Effective Implementation of a Structured Psychoeducation Programme among Caregivers of Schizophrenia Patients in the Community

Paranthaman Vengadasalam1, Satnam Kaur Harbhajan Singh2, Jean-Li Lim3, Amar-Singh HSS4,7, Sondi Sararaks5, Nafizah Mat Nasir6, Ranjit Kaur Praim Singh8, Asmah Zainal Abidin8

1 Jelapang Health Clinic, Perak.2 Bahagia Ulu Kinta Hospital, Perak.3 Slim River Health Clinic, Perak.4 Clinical Research Centre Perak.5 Institute of Health Systems Research.6 Tanjung Malim Health Clinic, Perak.7 Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak8 Perak State Health Department.

Introduction & Objectives

Psychoeducation has shown promising benefits in managing patients with schizophrenia. In Malaysia, the use of psychoeducation is rather limited and its impact indeterminate. This study was to assess the effectiveness of a structured psychoeducation programme for the community in improving caregiver knowledge, decreasing caregivers’ burden, reducing patients’ readmission and defaulter follow-up rates.

Methodology

This was a controlled interventional study involving caregivers of adults with schizophrenia. Subjects for the interventional and control group were selected from seven separate community clinics. All respondents identified were given the demographic survey, pre-test questionnaire and The Family Burden Interview Schedule - Short Form (FBIS/SF) prior to intervention. The respondents in the interventional group went through a structured psychoeducational program followed by an immediate post-test questionnaire after the completion of the modules. Caregivers were assessed at baseline, 3 and 6 months post-intervention for knowledge and burden using the knowledge questionnaire and FBIS/SF. Patients were monitored for relapse and defaulting treatment. The staff was also required to complete a survey form regarding their opinion of the whole psychoeducation program 3 months into the programme.

Results

109 caregivers were included, with 54 and 55 in the intervention and control groups respectively. Baseline demography of the caregivers showed that mean age (53.1 vs. 53.9 years) and ethnicity was not significantly different in both groups. However, there were more males in the intervention group (50.0% vs. 27.3%, p=0.025), duration as a caregiver was significantly shorter in the intervention group (caring for less than 5 years: 37.0%


vs. 18.2%, p=0.047), and mean duration of illness was shorter in the intervention group (below 10 years: 48.1 vs. 28.8%, p=0.04). Caregivers in the intervention group showed significant improvement in knowledge scores (18.65 vs. 14.93, p<0.001), reduction in burden of assistance in daily living (severity, p<0.001) and reduced patient defaulter rate. All staffs involved in the psychoeducation program were satisfied in giving the program and 90% agreed that the program had been beneficial to the patient.

Conclusion

The findings support the use of a structured psychoeducation program among caregivers of patient with schizophrenia in the community.

Keywords

schizophrenia, psychoeducation, community, caregiver


1.0 INTRODUCTION

1.1 Background

Worldwide, mental health problems present as the fifth most common cause of disability and are associated with a significant burden of morbidity. In Malaysia, schizophrenia presents as the main mental health problem. The burden of this disease has increased over the years. The National Mental Health Registry in Schizophrenia showed a 8.07% increase in registered cases in the year 2004 with 2436 cases to the 2254 cases in 2003 (Aziz SA, 2006).

1.2 Benefits of psychoeducation

Aside from the usual pharmacological treatment, psychoeducation has shown great promise in the management of schizophrenia. Psychoeducational approaches have been developed to increase patients’ and their carers’ knowledge of, and insight into, their illness and treatment. A review of more than 30 randomised clinical trials have shown that family psychoeducation reduces the rate of relapses, encourages recovery of patients as well as improves family dynamics among participants (McFarlane WR et al., 2003). A recent study showed a significant reduction in patient rehospitalisation rates and improved compliance over a period of 2 years after patients and their families attended a psychoeducational programme consisting of 8 sessions (Pitschel-Walz G et al., 2006). In the Asian setting, similar results were observed among Chinese patients in Hong Kong (Chien WT et al., 2007).

Family psychoeducation is a method of working in partnership with families to impart current information about mental illness and to help them develop coping skills for managing problems posed by mental illness in their family. This approach respects and incorporates the individual, family, as well as cultural realities and perspectives. It almost always fosters hope in place of desperation and demoralisation.

Increasingly, mental health facilities are pressured to meet the demands of service and productivity. Mental health program leaders find they need to direct services that will satisfy these demands without sacrificing the quality of care being offered. At the same time, program leaders are concerned about practitioners’ level of satisfaction. The American Psychiatric Association and the Agency for Health Care Policy and Research cite family psychoeducation as one of the most effective ways to manage schizophrenia (APA, 2004). Research has shown that there is a significant reduction in relapse rates (by at least 50% of previous rates) when family intervention, multi-family groups, and medications are used concurrently.

What is the benefit of psychoeducation for practitioners? Research has shown that psychoeducation provides practitioners with an opportunity to (Implementation Resource Kit, Draft Version, 2003):


1. Promote improved clinical outcomes, satisfaction, and higher rates of recovery amongst their clients

2. Feel more supported in their efforts to manage the effects of illness 3. Build relationships with families 4. Experience improved cost-benefit ratios

For consumers, the practice of family psychoeducation: 1. Helps build a support network for recovery 2. Provides hope 3. Reduces relapse and hospitalisation 4. Improves symptom management 5. Reduces medication dosages 6. Improves social skills and community participation 7. Increases employment, earnings, and career options 8. Strengthens family ties 9. Reduces family conflicts

1.3 Rationale of study

However, the application of family psychoeducation in Malaysia has been rather limited and very recent. In June 2004, the Bahagia Ulu Kinta Hospital Psychoeducation Team (HBUK-PET) was initiated to conduct courses to train facilitators who will provide education to clients and their caregivers.

The HBUK-PET programme consists of 5 modules as below:1. Understanding your illness2. Understanding your treatment3. Helping yourself prevent relapses4. Avoiding and handling crisis5. Healthy lifestyle – diet and exercise

Following the initiation of this programme, there was encouraging results from both the client as well as their caregivers. Notably, there was an increase in the quality of life in both the client as well as their caregivers. Relapse rates were also lower as they were able to recognise the early warning signs of possible relapse (Ghaus Z, 2006).

With the success of the HBUK-PET programme, the researchers have decided to adapt the 5 modules into a community care setting. As this is a pioneering initiative, the researchers have decided to study the effectiveness of the structured psychoeducation programme among caregivers of schizophrenics in the community. The researchers hope to be able to make recommendations with regards to a uniformed national psychoeducation programme for schizophrenia patients.



The main aim of this study is to assess if a structured psychoeducation programme can be effectively implemented among schizophrenia patients in the community (please refer to Figure 1). However, the researchers foresee some possible problems with implementation of this study.

Similar programmes have been implemented in many psychiatric institutions in Malaysia. The HBUK-PET programme has been shown to be successful in the short term, but the long term sustainability has yet to be studied locally. There is a need to ensure that the delivery of the psychoeducation programme is standardised and less operator dependent. To ensure success of the programme, adequate trainers must be available to impart the knowledge needed. With this, the issue of time, budget, and suitable infrastructure and resources is crucial.

Issues with staff are inseparable from the success of the programme. Adequate staff is needed for the programme to be carried out so that the existing staff is not over-burdened, considering the ever-widening scope of the primary healthcare. Staffs need to have the correct attitude to run the programme. Incentives (allowance, promotional prospects) should be considered to motivate and drive the staff.

Can we effectively implement a structured psychoeducation

programme among caregivers of schizophrenia patients in the

community?

Lack of Infrastructure &

Resources

Unsure oflong term

sustainability

Defaulters/ dropout rates

Programmeimplementation

Lack of budget

Delivery of a standardized programme

Lack of qualified trainers

Extended time factor needed for

programme

Staff factors

Poor attitude

Lack of staff

Increased burden of

work

Patient/ care-giver factors

Poor insight about

disease

Poor knowledge

about disease

Lack of motivation &

Incentive

Figure 1. Problem analysis chart


Finally, the final outcome of the programme will depend largely on patient and caregiver factors. Defaulter and drop-out rates will largely depend on the patients’ insight and existing knowledge and understanding about the illness. Thus, this programme aims to increase both the insight and knowledge of disease through a structured psychoeducation programme.

With all these issues in mind, our study will perhaps shed some light on improving system of care for schizophrenia patients and ultimately improve the health outcome for these patients and their families.

1.5 Potential utilisation of research

This study hopes to describe the effectiveness of family psychoeducation in terms of increasing the knowledge of schizophrenia among caregivers and its sustainability. The study will also describe the feasibility of the programme in the community setting. Since many studies showed that the psychoeducation programme has impact on patient care, therefore with this study it may change our care of patient with schizophrenia especially in community setting. Ultimately it is hoped that the study will help to improve the current health status and outcome of psychiatric patients currently on follow up in the community.

2.0 OBJECTIVES


To compare the effectiveness of a structured versus non-structured psychoeducation programme among caregivers of patients with schizophrenia in the community of an administrative region.


1. To determine if the use of a structured psychoeducation programme will significantly:a. improve the knowledge about schizophrenia among caregiversb. decrease patient readmission rates c. improve compliance to follow up d. decrease the burden of caregivers

2. To determine the feasibility of the structured psychoeducation programme among the staff implementing it.

3. To make recommendations regarding the implementation of a structured psychoeducation programme in the community.


3.0 METHODOLOGY


An interventional study was conducted among caregivers of schizophrenic patients in the community of Perak. This study involved 7 health clinics in the state, of which 3 and 4 were allocated into the intervention and control groups respectively. The intervention used was the introduction of a structured psychoeducation programme. Specific health staffs in the interventional group were trained in the structured psychoeducation module, after which gave structured psychoeducation to the caregivers. The control group included caregivers of patients who followed the standard treatment without any structured intervention. The study was conducted in 3 phases. Please see Figure 2 for the diagrammatic description of the study.

Phase 1

Health clinics and patients/caregivers were identified for inclusion into the study and allocated to the intervention and control groups respectively, according to the researchers’ convenience of access to these clinics.

Phase 2

Specifically identified health staffs in the intervention group from the respective clinics were trained in the use of the Structured Psychoeducation Programme Module (Appendix A). Following this, a baseline audit was conducted. All respondents identified in both groups were given the demographic survey, the knowledge questionnaire form, and The Family Burden Interview Schedule-Short Form (FBIS/SF) prior to the intervention.

Phase 3 (psychoeducation module)

Respondents in the intervention group went through the structured psychoeducational programme. To ensure the modules were taught adequately and in a standard manner, all staffs involved in giving the psychoeducation programme were required to complete a checklist. The caregivers were given psychoeducation using 5 modules as used in the PET programme. The patients in the intervention groups were given psychoeducation mainly in the clinics. Methods of teaching included audio visual aids, e.g. LCD projectors with power point presentations, charts, and also one to one teaching. Those who were unable to come to the clinic were taught at their homes. The teaching materials that were provided to the trainers during the training sessions were used during the teaching. All the 5 modules were completed within 2 weeks. The knowledge questionnaire form was done immediately after completion of the modules to assess the quality of the training.


Figure 2. Methodology flow chart

Effective implementation of a structured psychoeducation programme among caregivers of schizophrenia patients in the community 9

Phase 1

Phase 3 3 months -------------------------------------------------------------------------------------------------- 6 months -------------------------------------------------------------------------------------------------

Intervention study to assess the effectiveness of a structured versus non-structured psychoeducation programme among caregivers of schizophrenics in the community

Phase 2 Training of trainers

HBUK 13-14 Nov 2006

Identification of clinics & caregivers & patients for inclusion

Control group (55 patients)

KK Simee KK Tg Rambutan

KK Slim River KK Manjoi

Intervention group (54 patients) KK Jelapang

KK Tg Malim

1. Demographic Survey (caregiver & patient) 2. Knowledge Pretest (before psychoeducation) 3. FBIS/SF Survey I

Non-structured psychoeducation

Structured psychoeducation

1. Knowledge test result III 2. Burden FBIS/SF Survey III 3. Readmission rates and compliance to f/u

Post intervention Knowledge test result I

1. Knowledge test result II 2. Burden FBIS/SF Survey II 3. Readmission rates and compliance to f/u 4. Staff evaluation of programme


In the post-intervention phase, the knowledge questionnaire form and the FBIS/SF were conducted further after 3 and 6 months for both groups. The staffs were also required to complete a survey form regarding their opinions of the whole psychoeducation programme 3 months into the programme.

After completion of the 6-month study period, patients’ treatment cards were screened to trace follow-up default or readmission. The caregivers might be interviewed to get this information. The information gained was recorded in the initial demographic survey form.

3.2 Study type

This was a community interventional trial using a quasi-experimental design. The intervention was the introduction of a structured psychoeducation programme. The study design included an interventional and a control group, but there was no randomisation as this was not possible to be done (contamination of respondents and availability of clinics were limited).


The researchers requested approval from the national ethics committee prior to implementing the study via the National Medical Research Register (NMRR). All information from the questionnaire was kept confidential. Written informed consent was taken before the respondents’ involvement in the study. Caregivers were allowed to refuse consent to participate in the study.

3.4 Variables

Variables Operational Definition Scale of Measurement

Age of staff Age of staff as of completed year Years

Age of caregiverAge of caregiver as of completed year

Years

Age of patient Age of patient as of completed year Years

Working experience of medical personnel

Duration of working experience of the medical personnel in the Ministry of Health

Years

Sex of caregiver Answer provided to specific question in questionnaire

Male/Female

Sex of patientAnswer provided to specific question in questionnaire

Male/Female

Ethnicity of caregiver

Ethnic of the caregiver based on paternal side

Malay/Chinese/Indian/Others


Ethnicity of patient

Ethnic of the patient based on paternal side

Malay/Chinese/Indian/Others

Marital status of caregiver

Current marital status of the caregiver

Single/Married/Divorced/Widow/Widower

Marital status of patient

Current marital status of the patientSingle/Married/Divorced/Widow/Widower

Household income

Total income of all members in the household

Ringgit Malaysia per month

Occupational status of caregiver

As obtained from caregiver in response to specific question in questionnaire

Organised by social class

Occupational status of patient

As obtained from caregiver in response to specific question in questionnaire

Organised by social class

Duration as caregiver status

Number of years taking care of the patient as the primary caregiver

Years

Educational statusFormal education received by respondent

No Education/Primary/Secondary/Tertiary

PretestStandard designed test regarding knowledge about schizophrenia

Marks obtained: 0-20 marks

Post testStandard designed test regarding knowledge about schizophrenia

Marks obtained: 0-20 marks

Family Burden Interview Schedule

A toolkit for evaluating family experiences with severe mental illness. As obtained form caregiver in response to specific question in standardised FBIS questionnaire

Marks obtained:§7-63 in daily living

assistance module (section A)

§5-45 in supervision module (section B)

§1-5 in financial expenditures module (section C)

§4-20 in impact on daily routines module (section D)

§5-35 in worry module (section E)


ReadmissionNumber of admissions to a psychiatric unit due to a psychiatric condition

Total number of readmission events

Default follow upAny incidence of default in follow-up (within one month of appointment)

Total number of default in follow up


The minimum sample size required in each arm (intervention & control group) is 46. This figure was arrived at by using the EpiCalc 2000 software. Setting the significance level at 0.05 with a power of 90% and assuming a change in knowledge level from 55% to 85%. To allow for loss to follow up, the researchers will sample 60 respondents in both the intervention and control groups.

A total of 7 health clinics in Perak which offered care to patients with schizophrenia were selected conveniently – 3 in the intervention group and 4 in the control group. 120 respondents were selected randomly from these 6 clinics, with 20 from each clinic.

3.5.1 Inclusion criteria

1. The caregivers of patients with schizophrenia diagnosed according to DSM-IV.

2. The caregiver should be agreeable to be involved in the psychoeducation programme.

3. The caregiver should be able to understand either the Malay or English language.

3.5.2 Exclusion criteria

1. Those caregivers of patients who have co-morbidity of substance abuse.

2. Those caregivers of patients with uncontrolled or unstable medical illness requiring admission, i.e. uncontrolled hypertension, ischaemic heart disease, cerebrovascular accident, or uncontrolled diabetes mellitus.

3. Caregivers who had already undergone a structured psychoeducation programme.

Based on the criteria above, the following clinics were chosen as they were conveniently accessed by the researchers.


The interventional group with structured psychoeducation programme:1. Jelapang Health Clinic2. Tanjung Malim Health Clinic (with Psychosocial Rehabilitation Unit)3. Tapah Hospital

The control (non-intervention) group with standard treatment:1. Slim River Health Clinic2. Tanjung Rambutan Health Clinic3. Simee Health Clinic (with Psychosocial Rehabilitation Unit)4. Manjoi Health Clinic

Of the 2 clinics with Psychosocial Rehabilitation Unit, caregivers of patients from Tanjung Malim health clinic were chosen to be in the intervention group whereby those from Simee health clinic were in the control group.

3.6 Data collection tools and techniques

1. Data on demography of caregiver, patient, and staff were recorded in the Caregiver Demographic Data Form (Appendix B), Patient Demographic Data Form (Appendix C), and Staff Demographic Data Form.

2. Evaluation of the understanding of schizophrenia illness was done using the Knowledge Questionnaire Form (Appendix D) based on existing HBUK questionnaire module.

3. Data on the burden of the patient to the caregiver were scored using The Family Burden Interview Schedule- Short Form (FBIS/SF) (Appendix E) which was self-administered by the caregiver with the help of the interviewer. The FBIS/SF is a toolkit for evaluating family experiences with severe mental illness prepared by Richard Tessler and Gail Gamache from the Department of Sociology, Social and Demographic Research Institute, University of Massachusetts. The FBIS/SF has 5 sections. Responses are rated on a 5-point Likert scale.

a. Section A: Assistance in daily living moduleb. Section B: Supervision modulec. Section C: Financial expenditures moduled. Section D: Impact on daily routines modulee. Section E: Worry

4. Questionnaire on the Feasibility of the Psychoeducation Programme (Appendix F) was used to assess the opinion of staff conducting the psychoeducation modules.

5. Data on pretest and post test results were recorded using the Pre & Post Test Report Form (Appendix G).


6. Data on readmission rate and default on follow up was recorded at the end of the study using the Patient Demographic Data Form, which was filled up by the staff.

7. Staff involved in the training used the Psychoeducation Programme Registration Form (Appendix H) to keep track of all caregivers and patients who participated in the study. Clinic appointments were made using the Appointment Form (Appendix I).


The raw data were processed and entered for data analysis according to the different phases, starting as soon as the patients were recruited, until the end of the study. Data collected were sorted out and processed on a weekly basis. Data entry, utilising codes, was done using the SPSS programme. Computer assisted analysis was carried out at the end of the study. Chi-square tests and T-tests were used in the statistical analysis of the data.

4.0 RESULTS

4.1 Socio-demography of caregivers

A total of 114 caregivers of patients with schizophrenia were selected from 7 clinics. 58 were recruited into the intervention group and 56 into the control group. However, only 54 patients in the intervention group and 55 in the control group were included in the data analysis. The following caregivers were excluded and the reasons for the exclusion are below.

a. Intervention group– 1 patient from Tanjung Malim health clinic passed away during the study,

and the respective caregiver was dropped from the study.– 1 caregiver from the same clinic developed a stroke midway through the

study and was thus unable to care for the patient and was subsequently excluded.

– 2 caregivers from the same clinic did not undergo the baseline audit and were therefore excluded.

b. Control group– 1 caregiver from Simee health clinic was not traceable during the 6th

month follow-up period and was thus excluded from the study.


Table 1. Socio-demography of caregivers in intervention and control groupsa

Characteristic Intervention Group(n=54)

Control Group(n=55) p-valueb

Age, years 53.1 (SD=13.5) 53.9 (SD=17.09) 0.797c

Age category< 30 years30-39 years40-49 years> 50 years

4 (7.4)3 (5.6)

15 (27.8)32 (59.3)

6 (10.9)8 (14.5)8 (14.)

33 (60.0)

0.7630.2150.1440.907

GenderMaleFemale

27 (50.0)27 (50.0)

15 (27.3)40 (72.7) 0.025

EthnicityMalayChineseIndianOthers

25 (46.3)13 (24.1)8 (14.8)8 (14.8)

31 (56.4)17 (30.9)6 (10.9)1 (1.8)

0.3890.5580.7470.034

Marital statusMarriedSingleWidow/widowed

8 (14.8)39 (72.2)7 (13.0)

13 (23.6)31 (56.4)11 (20.0)

0.3550.1270.465

Household income< RM 500RM 500-RM 999RM1,000-RM 1,499> RM 1,500 No response

13 (24.1)16 (29.6)6 (11.1)

17 (31.5)2 (3.7)

15 (27.3)16 (29.1)

4 (7.3)7 (12.7)

13 (23.6)

0.8700.8810.7170.0330.006

Education level No formal educationPrimarySecondary & above

9 (16.6)14 (25.9)31 (57.4)

8 (14.5)15 (27.3)32 (58.2)

0.9670.9540.912

Duration as a caregiver< 5 years5-10 years11-20 years> 20 years

20 (37.0)17 (31.5)10 (18.5)7 (13.0)

10 (18.2)17 (30.9)13 (23.6)15 (27.3)

0.0470.8870.6750.105

a Data are presented as number (percentage).b All statistical analysis were performed using the Chi-square test.c Statistical analyses using the Independent samples T-test.


The socio-demographic characteristics of caregivers are shown in Table 1. The mean age of caregivers were similar in both the intervention and control groups (53.1 vs. 53.9 years, p=0.797). Majority of them were more than 50 years old (59.3% vs. 60.0%, p=0.884). There were significantly more male caregivers in the intervention group compared to the control group (50.0% vs. 27.3%, p=0.025). The distribution of Malay, Chinese, and Indian caregivers were similar in both groups, but there were significantly more caregivers of other ethnicity in the intervention group (14.8% vs. 1.8%, p=0.034). The duration as a caregiver was significantly shorter in the intervention group, where there were more caregivers who worked less than 5 years (37.0% vs. 18.2%, p=0.047). Significantly more caregivers in the intervention group had a monthly household income of more than RM 1,500 (31.5% vs. 12.7%, p= 0.033). A significant number of caregivers in the control group chose not to reveal their income status (23.6%). Marital status and education level did not differ significantly between both groups.

4.2 Socio-demography of schizophrenic patients

There were 54 patients in the intervention group and 55 in the control group (see Table 2). Their mean age were similar (41.5 vs. 46.0 years, p=0.060). There was an equal distribution of male patients in both groups (46.3% vs. 41.8%, p=0.781). Similar to caregivers, there was no significant difference in the distribution of Malays, Chinese, and Indian patients in both groups, but a significantly higher number of patients of other ethnicity in the intervention group (9% vs. 1%, p=0.019). The duration of illness was statistically different between the groups. Patients in the intervention group had a shorter duration of illness (below 9 years: 48.1% vs. 28.8%, p=0.04). Marital status was not statistically different between the groups. However, most patients in both groups were single (62.1% vs. 62.5% respectively). Education level and household income category did not differ significantly between both groups.

4.3 Knowledge of caregivers on schizophrenia

Caregivers were subjected to a test on the understanding of schizophrenia illness using the Knowledge Questionnaire Form before and after the psychoeducation, and knowledge scores were calculated (Table 3). In the intervention group, there was a highly significant improvement in the knowledge scores immediately after psychoeducation was provided (baseline vs. immediate post-intervention: 13.78 vs. 15.87, p<0.001). Knowledge assessment at 3-months post-intervention also showed a highly significant improvement in the knowledge scores from 15.87 to 18.15 (p<0.001). However, the change in knowledge score from 3-months to 6-months post-intervention was not statistically significant. In the control group receiving the usual care, their knowledge score at 3-months improved compared to baseline but the increment was not statistically significant (13.47 vs. 14.33, p=0.083).


Table 2. Socio-demography of schizophrenic patients in intervention and control groupsa

Characteristic Intervention Group(n=54)

Control Group(n=55) p-valueb

Age, years 41.5 (SD=14.2) 46.3 (SD=11.8) 0.060c

GenderMaleFemale

25 (46.3)29 (53.7)

23 (41.8)32 (58.2) 0.781

EthnicityMalayChineseIndian Others

25 (46.3)12 (22.2)8 (14.8)9 (16.7)

31 (56.4)17 (30.9)6 (10.9)1 (1.8)

0.3400.4180.7470.019

Marital statusSingle Married DivorcedWidow/widowed

33 (61.1)17 (31.5)

1 (1.9)3 (5.6)

34 (61.8)16 (29.1)

1 (1.8)4 (7.3)

0.9040.9500.4840.980

Household income< RM500RM 500- RM 999RM 1,000-RM 1,499> RM1,500No response

7 (13.0)11 (20.4)

4 (7.4)10(18.5)22 (40.7)

10 (18.1)8 (14.5)3 (5.5)4 (7.3)

30(54.5)

0.6260.5830.9800.1420.211

Education level No formal educationPrimarySecondary & above

6 (11.1)15 (27.8)33 (61.1)

6 (10.9)13 (23.6)36 (65.5)

0.7850.7830.786

Duration of illness< 9 years10-19 years> 20 years

26 (48.1)13 (24.1)15 (27.8)

15 (28.8)18 (34.6)19 (36.5)

0.0400.4300.464

a Data are presented as number (percentage).b All statistical analysis were performed using the Chi-square test.c Statistical analyses using the Independent samples T-test.


Similarly, there was no significant improvement in their knowledge when comparing knowledge scores at 3-months and 6-months (p=0.208).

Table 4 details the overall percentage score of all caregivers for individual questions in the Knowledge Questionnaire Form. From the summarised percentage scores, the particular area of the illness of which patients did not answer correctly can therefore be identified.

4.4 Outcome of patients with schizophrenia

Patient outcomes were measured by the rate of readmission and default to follow-up (Table 5). The readmission rate in the intervention group was lower compared to the control group, but the difference was not statistically significant (5.6% vs. 9.1%, p=0.479). However, a significantly higher number of patients in the control group defaulted their follow-up (11.1% vs. 25.5%, p=0.032).

Table 3. Knowledge scores of caregivers on schizophrenia in intervention and control groups at baseline and 3 & 6 months audita

Mean Knowledge Scores of Intervention Group

Baseline Post-Test P1b 3 Months P2c 6 Months P3d

13.78 15.87 <0.001 18.15 <0.001 18.65 0.156

Mean Knowledge Scores of Control Group

Baseline 3 Months P4e 6 Months P5f

13.47 14.33 0.083 14.93 0.208

a Statistical analyses using the paired samples T-test.b Comparison between baseline and immediate post-intervention.c Comparison between immediate and 3-months post-intervention.d Comparison between 3-months and 6-months post-intervention.e Comparison between baseline and 3-months audit.f Comparison between 3- and 6-months audit.


Table 4. Overall percentage score for each question in the Knowledge Questionnaire Form

Question Number

BaselineImmediate

Post Test3/12

Post Test6/12

Post Test

1 94.5 98.1 98.2 98.2

2 67.9 96.3 86.2 91.7

3 86.2 94.4 91.7 94.5

4 24.8 18.5 46.8 55.0

5 26.6 37.0 52.3 56.0

6 29.4 38.9 60.6 64.2

7 58.7 75.9 75.2 76.1

8 95.4 96.3 93.6 96.3

9 94.5 92.6 99.1 97.2

10 86.2 88.9 93.6 97.2

11 86.2 90.7 94.5 92.7

12 95.4 94.4 99.1 97.2

13 54.1 74.1 79.8 84.4

14 80.7 96.3 86.2 94.5

15 42.2 57.4 55.0 58.7

16 55.0 68.5 70.6 69.7

17 50.5 74.1 73.4 71.6

18 78.0 87.0 89.9 87.2

19 82.6 94.4 89.9 93.6

20 82.6 94.4 89.0 93.6

Table 5. Outcome of patients with schizophrenia in intervention and control groups at 6 monthsa

Outcome MeasureIntervention Group

(n=54)Control Group

(n=55)p-valueb

Readmission rate 3 (5.6%) 5 (9.1%) 0.479

Default follow-up 6 (11.1%) 14 (25.5%) 0.032

a Data are presented as number (percentage).b Statistical analyses using the Independent samples T-test.


Table 6. FBIS/SF scores of caregivers in the intervention and control groups

Module

Intervention Group Control Group

BaselineAt

3/12p-

valueAt

6/12p-

valueBaseline

At 3/12

p-value

At 6/12

p-value

Section A: Assistance in Daily Living Module (severity)(7-35)

14.26 11.24 0.012 10.69 0.581 13.44 12.06 0.251 9.86 0.235

Section A: Assistance in Daily Living Module (burden)(7-28)

11.89 9.42 0.018 9.41 0.991 9.98 10.35 0.691 8.93 0.118

Section B: Supervision Module (severity)

6.30 6.15 0.805 5.83 0.609 6.58 6.36 0.664 5.80 0.191

Section B: Supervision Module (burden)

5.96 5.69 0.620 5.56 0.796 6.11 6.00 0.783 5.69 0.358

Section C: Financial Expenditures Module (severe debt & financial burden)

3.43 3.85 0.108 4.00 0.528 4.04 4.22 0.457 4.20 0.927

Section D: Impact on Daily Routines Module (Past 1 month)

5.06 4.72 0.337 4.22 0.035 5.16 4.82 0.352 4.44 0.215

Section E: Worry 25.87 26.74 0.399 26.39 0.739 22.71 22.89 0.903 23.53 0.674

4.5 FBIS/SF score of caregivers

Table 6 summarises the FBIS/SF of caregivers in the intervention and control groups at baseline, 3 & 6 months post-psychoeducation.


Table 7. Opinions of staff regarding the feasibility of the psychoeducation programme

Question Agreen (%)

Disagree/Unsure

n (%)

1. In your opinion, is this psychoeducation programme beneficial to the patient?

9 (90) 1 (10)

2. Do you find the programme a burden? 6 (60) 4 (40)

3. Do you find it easy to implement the module? 8 (80) 2 (20)

4. Do you have support from the other staff in implementing this programme?

9 (90) 1 (10)

5. Are you satisfied in giving the psychoeducation to the patient/caregiver?

10 (100) 0 (0)

6. Do you find the programme too time consuming? 8 (80) 2 (20)

7. Would you like incentives to be given such as time off/extra allowance?

10 (100) 0 (0)

8. Should this programme be continued? 10 (100) 0 (0)

4.5.1 FBIS/SF scores of caregivers in the intervention group

In section A, which included questions on assistance in daily living in terms of severity, a significant reduction in severity scores were observed at baseline and 3 months post-intervention (14.26 vs. 11.24, p=0.012), but no significant change in severity scores was observed at 3 and 6 months post-intervention (11.24 vs. 10.69, p=0.581). Similarly, in relation to the burden of assistance in daily living, there was a statistically significant improvement in burden at baseline and 3 months (11.89 vs. 9.42, p=0.018). However, no significant change in burden was observed at 3 and 6 months (9.42 vs. 9.41, p=0.991).

Section B interviewed caregivers regarding assistance during troublesome behaviours of patients in terms of severity. There was a slight improvement in the severity score comparing baseline and 3 months (6.30 vs. 6.15, p=0.805), and this further improved at 6 months (6.15 vs. 5.83, p=0.609). However, both improvements were not statistically significant. In terms of supervision burden, improvement was observed at 3 months and 6 months, but the reduction in burden scores were not statistically significant.

Regarding the financial expenditures module (section C), caregivers rated their debt severity and financial burden. Improvements were noted when


scores were compared between baseline and 3 months (3.43 vs. 3.85, p=0.108) and between 3 months and 6 months (3.85 vs. 4.0, p=0.528), but the difference was not statistically significant.

In section D, caregivers rated the impact on daily routines due to the involvement in caring for the schizophrenic patient in the past 1 month (Section D). No significant change in the impact score was observed between baseline and 3 months (5.06 vs. 4.72, p=0.337) but there was a significant reduction in the impact on daily routines at 6 months (4.72 vs. 4.22, p=0.035).

Caregivers were asked of their concerns and worries about the schizophrenic patient under their care (Section E). There was a reduction in worry at 3 months (25.87 vs. 26.74, p=0.174) and 6 months (26.39 vs. 26.74, p= 0.739) post-intervention. However, the change in worry scores was not statistically significant.

4.5.2 FBIS/SF scores of caregivers in the control group

There was no significant improvement in the assistance in daily living in terms of severity at 3 months (13.44 vs. 12.06, p=0.251) and 6 months (12.06 vs. 9.86, p=0.235). In terms of assistance burden, similar observations were noted at 3 months and 6 months.

Regarding the supervision of schizophrenic patient, there were slight improvements in the severity scores between baseline and 3 months (6.58 vs. 6.36, p=0.664) and between 3 & 6 months (6.36 vs. 5.80, p=0.191). However both differences were not statistically significant. Similarly, on the burden of supervision, there was lesser burden at 3 months and 6 months, but the reduction in burden was not statistically significant.

Under the financial expenditures module, an improvement in debt severity and financial burden was observed between baseline and 3 months (4.04 vs. 4.22, p=0.457), but worsened at 6 months (4.22 vs. 4.20, p=0.927).

In terms of the impact on daily routines in the past 1 month, caregivers reported an improvement at 3 months (5.16 vs. 4.82, p=0.352) and 6 months (4.82 vs. 4.44, p=0.215). However, the differences of impact scores were not statistically significant.

Although caregivers reported a reduction in worry at 3 months (22.71 vs. 22.89, p=0.903) and 6 months (22.89 vs. 23.53, p=0.674), this observed difference was not statistically significant.



4.6.1 Duration in service of staff

There were a total of 10 staffs involved in the teaching of the psychoeducation module to caregivers. They consisted of medical assistants and staff nurses working in the respective health clinics. 8 (80%) of them had been working for more than 10 years and the remaining worked for 6-10 years.

4.6.2 Opinions of staff regarding the psychoeducation programme

Staffs involved in the teaching of the psychoeducation module were asked regarding the feasibility of the programme (Table 7). All 10 were satisfied in giving the psychoeducation programme. All agreed that the programme should be continued and that they would like to be given incentives. Almost all of them (90%) agreed that the psychoeducation programme is beneficial to the patient and they had support from the other staff in implementing the programme. 80% agreed that the module was easy to implement but admitted that it was too time consuming. However, more than half of them (60%) found the program a burden.

5.0 DISCUSSION

5.1 Key findings

5.1.1 Socio-demographics of respondents

In our study, there were more male caregivers in the intervention group as compared to the control group. We postulate that male caregivers were more likely to be able to come for follow-up. Further analysis needs to be done to find out the reason for this observation. The distribution of Malay, Chinese, and Indian caregivers were similar in the intervention and control groups. However, there were significantly more caregivers of other ethnicity in the intervention group. This was perhaps due to the small sample size of other ethnicity.

The duration as a caregiver was significantly shorter in the intervention group as compared to the control group. One possible reason could be that the caregivers are more receptive to the patients’ illness in the initial period of their illness. More caregivers in the interventional group have a household income of more than RM 1,500 as compared to the control group. One possible reason for this was a significant number (23.6%) of caregivers in the control group did not divulge their household income.


Schizophrenic patients in the intervention group have a shorter duration of illness. This is reflected in the profile of the caregivers in the intervention group, who had shorter duration as a caregiver. It is possible that this group of patients and their caregivers are more keen to learn about the disease in the earlier years.

5.1.2 Knowledge of caregivers on schizophrenia

There was a significant increase in the knowledge of the caregivers in the intervention group after the psychoeducation module was given, and the knowledge increment was sustained after 3 months. At 6 months there was no further knowledge increment but the score did not drop. This was the result of the continuous structured psychoeducation given to the caregivers. Furthermore, the staffs gave consistent attention to the caregiver and their patients and helped contribute to the increase in knowledge. During the study period, any uncertainties and doubts could be clarified as and when needed.

In the control group, there was modest but insignificant improvement in the knowledge scores of caregivers. The slight initial improvement observed was probably due to the extra attention given by the staff during the study period. This gave rise to increase in awareness and interest among caregivers and patients, thus leading to improved scores even though no psychoeducation given. This observation is explained by the Hawthorne effect.

Among the questions, knowledge on the following questions were poorly answered and understood: definition of symptoms such as hallucinations and delusions, the belief that medication is only necessary if the patient is not well, early warning signs and symptoms indicating relapse, and the interference of alcohol and drugs in the illness.


5.2.1 Readmission rates

Overall, there was no significant difference in the readmission rates between both groups. One possible reason for this is the short study duration of 6 months. A similar study by Chien & Wong (Chien WT et al., 2007) showed that readmission rates were reduced when patients were followed up over a period of 12 months. Two recent systematic reviews (Pekkala E et al., 2002; Pharoah FM et al., 2003) reported that patients whose families received psychoeducation had reduced relapse rates of 4-fold after 1 year, and 2-fold the subsequent year. Another study by Aguglia and colleagues (Aguglia E


et al., 2007) showed similar results when patients were followed up over a period of a year. Perhaps if our study were to be extended to a minimum of a year, there might be a significant reduction in the readmission rates.

5.2.2 Defaulter rates

There was a significant decrease in defaulter rates when the intervention group was compared to the control group. This observation could be due to the increase in social contacts and support between the caregivers and the staffs providing training in the intervention group. One such study which looked at family interventions (Carrà G et al., 2007) showed improved compliance at 12 months of a support program.

5.2.3 Family burden

There was a significant reduction in terms of severity and burden of assistance in daily living in the intervention group at 3 months from baseline. Generally, the FBIS/SF scores in other sections also improved in the intervention group, although the improvement was not statistically different. This tool include sections that evaluated the need for assistance in daily living, need for supervision, debt and financial burden, impact on daily routines, and worry. According to Chien & Wong (Chien WT et al., 2007), who used a similar assessment, there was a significant improvement in the caregiver burden and functioning, especially in terms of communication and their attitude towards the patient during the study period of 12 months. They also noted reduced rehospitalisation and relapse rates as a result of better family functioning and health after psychoeducation.

Similar but insignificant improvement was also noted in the control group in terms of improved impact on daily routines, assistance in daily living, the need for supervision, debt and financial burden, impact on daily routines, and worry. This improvement could be due to the external environmental influence during the time between the 3rd and 6th month post-test. During this period, the WHO celebrated the annual World Mental Health Day in

October. Part of the programme included awareness of good mental health published by the mass media as well as health camps at the community level.


Overall, almost all staffs (80-90%) found that the programme was beneficial, easy to implement, and should be continued. During the study, these staff had adequate support from their colleagues. However, more than half of them found the programme a burden as they had multiple health programmes to run concurrently


on top of their daily responsibilities. All staffs responded that they would like to be given an incentive, whether financially or by time off.

5.4 Limitations of the study

The small sample size of the study limited the analysis of the mediating variables to identify therapeutic mechanisms of the psychoeducation group programme. In addition, the study had a relatively short period of follow-up of 6 months. This short follow-up period limited further assessment of the impact of the intervention on outcomes such as relapse and defaulter rates.

Despite the success of the psychoeducation programme, it was not standardised in every clinic. In some clinics, it was done in small groups and in others, it was done one-to-one. The equipments to deliver the modules also varied among the clinics. These variations might affect the knowledge received by the caregivers. The researchers also acknowledged the fact that the staffs had difficulty carrying out the programme because they had other work responsibilities.


6.1 Conclusion

The study showed that a structured psychoeducation programme among caregivers of patient with schizophrenia can be effectively implemented in the community. The programme significantly improved and sustained the knowledge about schizophrenia, decreased the caregivers’ burden in daily living assistance and improved compliance to follow up. Staff involved in the program found that the programme was feasible and are keen for its implementation. The small sample size and the short duration of this study limit the achievement of the study objectives. These findings warrant further evaluation of this type of intervention and its therapeutic mechanisms.

6.2 Recommendations

Based on the study findings, the researchers would like to make the following recommendations:

1. To introduce and implement a psychoeducation programme in all primary health centres. To ensure success, the module needs to be revised and its delivery standardised prior to implementation. It is suggested that the module be taught for every newly diagnosed schizophrenia patient and the caregiver. The module should be repeated after the first 2 years and then every 5 years.

2. If the need arises to repeat the study it should be carried out for a longer duration and with a larger sample.


REFERENCES

1. Aguglia E, Pascolo-Fabrici E, Bertossi F, Bassi M. Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the Italian community psychiatric network. Clin Pract Epidemiol Ment Health 2007;3:7.

2. American Psychiatric Association. Guidelines for treatment of schizophrenia. Washington, DC: American Psychiatric Association; 2004.

3. Aziz SA. Lecture on Schizophrenia epidemiology and outcome in Malaysia, HBUK, August 2006.

4. Carrà G, Montomoli C, Clerici M, Cazzullo CL. Family interventions for schizophrenia in Italy: randomized controlled trial. Eur Arch Psychiatry Clin Neurosci 2007; 257(1):23-30.

5. Chien WT, Wong KF. A family psychoeducation group program for chinese people with schizophrenia in Hong Kong. Psychiatr Serv 2007;58(7):1003-6.

6. Ghaus Z. Lecture on Psychoeducation, HBUK, August 2006. 7. Implementation Resource Kit. Family Psychoeducation. Evidence Based Practices,

Shaping Mental Health Services Toward Recovery Draft Version, 2003.8. McFarlane WR, Dixon L, Lukens E, Lucksted A. Family psychoeducation and

schizophrenia: a review of the literature. J Marital Fam Ther 2003;29(2):223-45.9. Pekkala E, Merinder L. Psychoeducation for schizophrenia. Cochrane Database Syst

Rev 2002;(2):CD002831.10. Pharoah FM, Rathbone J, Mari JJ, Streiner D. Family Intervention for schizophrenia.

Cochrane Database Syst Rev 2003;(4):CD000088.11. Pitschel-Walz G, Bäuml J, Bender W, Engel RR, Wagner M, Kissling W. Psychoeducation

and compliance in the treatment of schizophrenia: results of the Munich Psychosis Information Project Study. J Clin Psychiatry 2006;67(3):443-52.

ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper.

Our deepest gratitude and indebtedness to Dato’ Dr. Amar-Singh HSS, who has been invaluable in the conduct of the study. He has been a constant source of encouragement and his untiring willingness to contribute ideas towards the study design and report writing has kept us amazed. It would not have been possible to complete this study due to the complexity of issues involved without the statistical input and support of Dr. Sondi Sararaks. We would also like to thank Datin Dr. Ranjit Kaur Praim Singh for her constant encouragement and technical support for this study.

Lastly, we thank all staff of the various clinics who were directly involved in this study, especially those who had spent hours giving psychoeducation to caregivers of patients with schizophrenia in the community.


APPENDICES

Appendix A: Structured psychoeducation programme module

Effective implementation of a structured psychoeducation programme among caregivers of schizophrenia patients in the community

Appendices Appendix A: Structured psychoeducation programme module Slide 1

Modul ProgramPsychoeducation

Di HBUK

Slide 2

PSYCHOEDUCATION

MODUL 1Memahami Penyakit Anda

Slide 3

Skizofrenia

Sejenis Penyakit Mental serius yangMelibatkan

a) Gangguan Tingkah Lakub) Gangguan Pemikiranc) Gangguan Emosid) Kemerosotan Dalam Fungsi

Sosial, akademik dan Pekerjaan




Di HBUK

Slide 2

PSYCHOEDUCATION


Slide 3

Skizofrenia







Di HBUK

Slide 2

PSYCHOEDUCATION


Slide 3

Skizofrenia




Slide 1

Slide 4

Slide 2

Slide 5

Slide 7

Slide 3

Slide 6

Slide 8 Slide 9


Slide 4 Penyebab Skizofrenia

a) Bahan kimia dalam otak tidak seimbang

b) Keturunanc) Persekitaran d) Sosial

Slide 5 Memahami PenyakitAnda

Mungkin disebabkan oleha) perasaan takut danb) tekanan

contohnya tidak boleh duduk diam

Marah dankegelisahan/libang libu

Pemikiran yang berserabut/bercelaru

contohnyaa) Delusi: Sesuatu yang anda percayai

benar tetapi sebenarnyasalah

Cth: Gerak geri saya diintip oleh polis

b) Pemikiran yang tidak rasionalCth: saya boleh terbang tanpa sayap

GanguanPemikiran

melihat, mendengar, terbau, sentuhan dan merasa sesuatu yangtidak wujud

Berlaku dalam keadaan sedar

Halusinasi

MaknaGejala

Slide 6

Patuhi semua arahan rawatanyang diberikan

Berbincang dengan keluarga/stafftentang gejala yang dialami

Belajar teknik mengawalperasaan dan menenangkan diri

Pastikan dapat rehat, senamanyang mencukupi dan makananseimbang

Cara-cara Mengatasi














GanguanPemikiran



Halusinasi

MaknaGejala

Slide 6





Cara-cara Mengatasi


Slide 7

Penyakit Skizofreniaa) boleh di ubatib) tidak berjangkit

Perlu mendapat rawatansecepat mungkin untukmengelak kemerosotan

Sokongan keluarga danmasyarakat amat di perlukanbagi proses penyembuhan

Fakta-fakta Yang PerluDiketahui Tentang

Skizofrenia

Slide 8 Cara Rawatan Penyakit

Skizofrenia: Pengambilan ubat-ubatan Sesi kaunseling Psychoeducation (bagi meningkatkan

pengetahuan tentang penyakit) Rehabilitasi (mengembalikan fungsi

kehidupan harian)

Penyakit Ini Juga Boleh Berulang.Lakukan Segala Yang Termampu Bagi

Mengelakkannya

Makan ubat secara teratur Jumpa doktor ikut temujanji Kenalpasti tanda awal gejala penyakit

JIKA KEADAAN BERTAMBAH TERUK, HUBUNGI DOKTOR

DENGAN SEGERA!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Slide 9

PSYCHOEDUCATION

MODUL 2Memahami Rawatan

Anda


Slide 7





Skizofrenia




kehidupan harian)


Mengelakkannya



DENGAN SEGERA!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Slide 9

PSYCHOEDUCATION


Anda


Slide 7





Skizofrenia




kehidupan harian)


Mengelakkannya



DENGAN SEGERA!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Slide 9

PSYCHOEDUCATION


Anda














GanguanPemikiran



Halusinasi

MaknaGejala

Slide 6





Cara-cara Mengatasi



Slide 10 Jenis Rawatan Yang Ada

Ubat-ubatan- Paling penting- Mengurangkan gejala

Rehabilitasi- Mengembalikan kemahiran hidup

Kaunseling- Memberikan sokongan emosisecara berterusan

Slide 11 Samb…..

Pendidikan- Memberi pengetahuan tentang

penyakit dan semua masalahyang berkaitan

Rekreasi Terapeutik- Melakukan rekreasi untuk

mengurangkan gejala

Electro Convulsive Therapy- Hanya untuk penyakit dan

keadaan tertentu

Slide 12 Fungsi Ubat-ubatan

untuk menstabilkan bahan kimiayang tidak seimbang di dalamotak

Jenis-jenis UbatAntipsikotik (untuk fikiran celaru)Antidepressant ( untuk kemurungan)Antianxiety ( untuk perasaan cemas)Antiepilepsy ( untuk sawan) Sleep Inducer ( ubat untuk sukar tidur)Mood stabilizer (mengawal emosi)Dan lain - lain






Slide 11 Samb…..




mengurangkan gejala


keadaan tertentu









Slide 11 Samb…..




mengurangkan gejala


keadaan tertentu




Slide 10

Slide 13

Slide 16

Slide 11

Slide 14

Slide 17

Slide 12

Slide 15

Slide 18


Slide 13 Kesan Sampingan

Ubat

Adalah kesan ubat yang tidakdiperlukanSemua ubat mempunyai kesan

sampingan yang boleh dikawalJangan bimbang sekiranya

terdapat kesan sampingan. Doktor boleh menukar ataumemberi ubat untukmengurangkan kesansampingan

Slide 14 Tanda-tanda Kesan

Sampingan UbatKeresahanPergerakan perlahan

( rasa kaku otot)Terketar-ketarPening/mualMengantukMulut keringSembelitMasalah seks dan lain-lain

Slide 15 Fakta - Fakta Yang Perlu

Di Ingat Apabila MendapatRawatan

Sentiasa patuhi arahan yang diberikan oleh doktorBekerjasama dan berbincang

dengan Doktor dan staf yang berkaitanJangan berhenti ubat tanpa

arahan kerana ini akanmenyebabkan penyakitberulang(relapse)Rawatan ubat-ubatan tidak

semestinya sepanjang hayat



Ubat















Ubat














Slide 16

PSYCHOEDUCATION

MODUL 3PENCEGAHAN PENYAKIT

BERULANG /Relapse

Slide 17

Definisi

Gejala lama muncul semula atauyang sedia ada bertambah teruk. Gejala berbeza antara setiap

individu.Pencegahan relapse lebih mudah

daripada merawatnya.

Relapse – Boleh dicegah!

Slide 18 Sebab-sebab Penyakit

BerulangTidak makan ubat atau makan tidak

ikut aturanKrisis yang tidak ditangani dengan

cepat.Mengalami tekanan berterusanTidak cukup rehat dan tidurMenghidapi penyakit fizikal yang

lain cth: demam kuat/radang paru-paru

dllMinum arak dan salah guna dadah.


Slide 16

PSYCHOEDUCATION


BERULANG /Relapse

Slide 17

Definisi












Slide 16

PSYCHOEDUCATION


BERULANG /Relapse

Slide 17

Definisi













Slide 19 Langkah untuk

menangani Relapse /Sakit Berulang

Makan ubat berterusan – ikutaturan. Elak tekanan berterusan. Kenali gejala awal.Hubungi/berjumpa Doktor,

Jururawat/ pembantu perubatanuntuk berbincang keadaan anda.

Slide 20 Kenapa ArahanPengambilan Ubat TidakDipatuhi Dengan Betul?Tidak faham tindakan ubat dalam

membantu penyembuhan. Tidak faham mengenai penyakit. Mengalami gangguan dari kesan

sampingan. Tiada pengawasan daripada

penjaga.Perasaan sudah sembuh.Pengaruh rawatan tradisional.Tidak tahu bahawa arak dan

salahguna dadah boleh ganggurawatan.

Slide 21 Apakah Itu Gejala

Amaran Awal?

Gejala yang mula-mula timbuldipermulaan penyakit berulang. Perkara-perkara ganjil yang anda

alami bila mula sakit. Perubahan yang anda mula alami

ketika pertama kali sakit. Perubahan tingkahlaku anda yang

dapat dilihat orang dipermulaanpenyakit berulang.












Amaran Awal?
















Amaran Awal?





Slide 19

Slide 22

Slide 25

Slide 20

Slide 23

Slide 26

Slide 21

Slide 24

Slide 27


Slide 22 Contoh Perubahan:

a) Tingkah lakucth: berbogel/menyendiri.

b) Pemikiran bercelaru.

c) Emosi tidak terkawalcth: menjerit-jeritberterusan.

Slide 23 Bagaimana MengawasiGejala Amaran Awal?Senaraikan gejala amaran awalPerhatikan perkembangan gejala

amaran awal – tulis dalamdairi/buku nota. Berjumpa/beritahu doktor atau

paramedik sekiranya gejalaamaran awal menganggu anda.

Cara Menjaga Kesihatan Yang Baik

Jaga kesihatan fizikal, mental, sosial dan rohani

Slide 24

PSYCHOEDUCATION

MODUL 4

Cara Mengelakkan Dan Mengendalikan Krisis











Slide 24

PSYCHOEDUCATION

MODUL 4












Slide 24

PSYCHOEDUCATION

MODUL 4



Slide 25 Kenali Faktor Risiko

Krisis

Berhenti makan ubatTekanan di tempat kerjaTerlalu letihBertengkar dengan orangMasalah tidurGejala penyakit muncul semula Penyalahgunaan dadah atau

alkohol

Slide 26 Peringkat Krisis

Peringkat 1: Perubahan Kelakuanmerungut apabila disuruh makan

ubatmerokok secara berlebihantidak hadir sesi temu janji rawatan

Peringkat 2: Gejala-Gejala Awalmasalah tidurgejala penyakit muncul kembaliberhenti makan ubat

Slide 27 Samb…..

Peringkat 3: Krisismelakukan perkara-perkara

merbahayabercakap dengan kelam-kabutprasangka terhadap keluarga / rakan

Peringkat 4: Kecemasanancaman verbalberkelakuan agresifcuba mencederakan diri / bunuh diri



Krisis


alkohol





Slide 27 Samb…..






Krisis


alkohol





Slide 27 Samb…..





Appendix B: Demographic survey of caregiver

SOAL SELIDIK MENGENAI PENJAGA

DEMOGRAPHIC SURVEY OF CAREGIVER

Tandakan (√) dalam petak berkenaan. Please tick (√) in the appropriate box.

A. DEMOGRAFI/DEMOGRAPHY1. Umur/Age

……………………… tahun/years

2. Jantina/Sex Lelaki/Male Perempuan/Female 3. Bangsa/Race Melayu/Malay Cina/Chinese India/Indian Lain-lain/Others Nyatakan/specify …………………………………

4. Taraf Perkahwinan/Marital status Bujang/Single Kahwin/Married Cerai/Divorced Janda/Duda/Widow/Widower

5. Pekerjaan/Occupation

…………………………………..(nyatakan/specify)

6. Pendapatan keluarga/household income

RM$……………………………..bulan/month (nyatakan/specify)

7. Taraf pendidikan/educational level Tidak bersekolah/no formal education Rendah/Primary Menengah/Secondary Diploma/Teknikal Universiti/Tertiary

8. Tempoh menjadi penjaga pesakit /Duration as a care giver ............. tahun/years


Appendix C: Demographic survey of patient

SOAL SELIDIK MENGENAI PESAKIT SKIZOFRENIA

DEMOGRAPHIC SURVEY OF PATIENT WITH SCHIZOFRENIA

Tandakan (√) dalam petak berkenaan. Please tick (√) in the appropriate box.

A.DEMOGRAFI/DEMOGRAPHY1. Umur/Age

……………………… tahun/years

2. Tempoh mengidapi penyakit skizofrenia/Duration of ilness ......................... tahun/years.

3. Jantina/Sex Lelaki/Male Perempuan/Female 4. Bangsa/Race Melayu/Malay Cina/Chinese India/Indian Lain-lain/Others Nyatakan/specify …………………………………

5. Taraf Perkahwinan/Marital status Bujang/Single Kahwin/Married Cerai/Divorced Janda/Duda/Widow/Widower

6. Pekerjaan/Occupation

………………………………….. (nyatakan/specify)

7. Pendapatan keluarga/household income

RM$…………………………….. bulan/month (nyatakan/specify) 8. Taraf pendidikan/educational level Tidak bersekolah/no formal education Rendah/Primary Menengah/Secondary Diploma/Teknikal Universiti/Tertiary

Untuk kegunaan penyelidik sahaja.

Bilangan kemasukan ke hospital:

Bilangan ketidakhadiran (non-compliance) temujanji:


Appendix D: Knowledge questionnaire form

PENILAIAN KEFAHAMAN

(Pre-test / Post-test 1 / Post-test 2 / Post-test 3)

Untuk menilai sejauh mana anda memahami tentang penyakit skizofrenia dan memahami program Psychoeducation, sila jawab soalan-soalan di bawah.

Bulatkan jawapan yang betul.

1. Skizofrenia adalah sejenis penyakit jiwa yang merangkumi gangguan pemikiran, emosi dan tingkahlaku serta kemerosotan fungsi kerja, pergaulan dan pembelajaran.

A: Benar B: Salah 2. Penyebab penyakit skizofrenia ialah ketidak seimbangan bahan kimia dalam otak A: Benar B: Salah

3. Mendengar suara-suara ghaib adalah contoh gejala psikosis. A: Benar B: Salah

4. Delusi adalah melihat, mendengar, terbau, sentuhan dan merasa sesuatu yang tidak wujud.

A: Benar B: Salah

5. Halusinasi adalah sesuatu yang anda percayai benar tetapi sebenarnya salah A: Benar B: Salah

6. Ubat anti-psikotik hanya perlu diambil sehingga pesakit merasa lebih baik. A: Benar B: Salah

7. Penyakit skizofrenia tidak boleh diubati. A: Benar B: Salah

8. Pesakit skizofrenia perlu mendapat rawatan secepat mungkin untuk mengelak kemerosotan

A: Benar B: Salah

9. Mengambil ubat secara berkala seperti yang diarahkan oleh doktor boleh menghalang gejala penyakit dari berulang.

A: Benar B: Salah

10. Rasa kaku otot, mulut kering dan mengantuk adalah kesan samping ubat. A: Benar B: Salah


11. Salah satu langkah penting untuk membantu pesakit merasa lebih baik ialah mengenalpasti masalah dan gejala yang mengganggu mereka.

A: Benar B: Salah

12. Terlupa atau berhenti mengambil ubat boleh meningkatkan risiko pesakit untuk mendapat serangan semula penyakit

A: Benar B: Salah

13. Rawatan ubat-ubatan tidak semestinya sepanjang hayat. A: Benar B: Salah

14. Gejala amaran awal ialah gejala yang muncul secara tiba-tiba atau gejala sedia ada bertambah teruk yang menandakan pesakit akan mendapat serangan semula penyakit.

A: Benar B: Salah

15. Gangguan tidur, fikiran yang tidak jelas dan mendengar suara-suara ghaib bukan merupakan gejala amaran awal yang perlu diambil perhatian.

A: Benar B: Salah

16. Pengambilan minuman keras dan penyalah-gunaan dadah TIDAK akan memberi kesan ke atas pengambilan ubat-ubatan dan TIDAK akan membuatkan gejala penyakit bertambah teruk.

A: Benar B: Salah

17. Sokongan keluarga dan masayarakat tidak diperlukan bagi proses penyembuhan penyakit skizofrenia.

A: Benar B: Salah

18. Faktor yang boleh mencetuskan krisis walaupun pesakit merasa dirinya sihat adalah mengalami perubahan dalam kehidupan yang menyebabkan tekanan.

A: Benar B: Salah

19. Untuk mendapatkan faedah maksima dari senaman yang dilakukan, masa terbaik yang patut diambil semasa melakukan senaman ialah antara 20 hingga 30 minit, tiga kali seminggu.

A: Benar B: Salah

20. Garis panduan pemakanan yang betul ialah dengan memilih makanan dari jenis lemak, minyak dan gula dalam jumlah yang kecil.

A: Benar B: Salah


Appendix E: Family Burden Interview Schedule-Short Form (FBIS-SF)


Appendix E: Family Burden Interview Schedule-Short Form (FBIS-SF)

THE FAMILY BURDEN INTERVIEW SCHEDULE-SHORT FORM FBIS/SF

adapted from the

Toolkit for Evaluating Family Experiences with Severe Mental Illness

Prepared for the Evaluation Center@HSRI

by

By Richard Tessler, Ph.D.

and

Gail Gamache, Ph. D.

1994

Department of Sociology Social and Demographic Research Institute

Machmer Hall University OF Massachusetts

Amherst, Ma 01003-4830



SECTION A: ASSISTANCE IN DAILY LIVING MODULE It frequently happens that persons who have a mental illness need help or need help or need to be reminded to do everyday things. The next questions are about that. All of them may not apply to (Name), but please try to answer them to the best of your knowledge. A1a. During the past 30 days, how often did you help (Name) with, or remind (Name) to do things like grooming, bathing or dressing? Was it? 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO A2a.) a week a week a week A1b. How much did you mind helping (Name) with or reminding about these things? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot A2a. During the past 30 days, how often did you help, remind or encourage (Name) to take (his/her) medicine? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO A3a.) a week a week a week A2b. How much did you mind helping, reminding or encourage (NAME) to take (his/her) medicine? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot A3a. During the past 30 days, how often did you help (Name) with, or remind (name) to do (his/her) housework or laundry? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times everyday? (GO TO A4a) a week a week a week A3b. How much did you mind helping (Name) with or reminding him/her about these things? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot A4a. During the past 30 days, how often did you help NAME WIETH, OR REMING (name) to do shopping for groceries, clothes and other things? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times everyday? (GO TO A5a) a week a week a week



A4b. How much did you mind helping (NAME) with or reminding (him/her) about these things? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot A5a. During the past 30 days, how often did you cook for (NAME) or help (him/ her) prepare meals)? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times everyday? (GO TO A6a) a week a week a week A5b. How much did you mind cooking for (Name) or helping (him/her) prepare meals? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot A6a. During the past 30 days, how often did you give (Name) a ride, help (him/her) to use public transportation? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO A7a.) a week a week a week A1b. How much did you mind helping (Name) with (his/her) transportation needs? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot A7a. During the past 30 days, how often did you help (Name) to manage (his/her) time such as going to work or school or aftercare or visiting with friends? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B1a.) a week a week a week A1b. How much did you mind helping (Name) make use of (his/her) time? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot



SECTION B. SUPERVISION MODULE Less frequently, persons with mental illness can require some assistance when certain troublesome behaviors occur. Te next questions may not apply to (NAME) but please try to answer them to the best of your knowledge. B1a. During the past 30 days, how often did you try to prevent or stop (Name) from doing something embarrassing? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B2a.) a week a week a week B1b. How much did you mind dealing with (Name)’s embarrassing behaviour? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot B2a. During the past 30 days, how often did you try to prevent or stop (Name) from doing excessive demands for attention? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B3a.) a week a week a week B2b. How much did you mind dealing with (Name)’s attention-seeking behavior? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot B3a. During the past 30 days, how often did you try to prevent or stop (Name) from keeping anyone up at night? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B4a.) a week a week a week B3b. How much did you mind dealing with (Name)’s disturbing behavior? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot



B4a. During the past 30 days, how often did you try to prevent or stop (Name) from injuring or threatening to injure anyone? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B5a.) a week a week a week B4b. How much did you mind doing that? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot B5a. During the past 30 days, how often did you try to prevent or stop (Name) from talking about, threatening or attempting suicide? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B6a.) a week a week a week B5b. How much did you mind dealing with (Name)’s suicidal (talk/threats/attempts)? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot B6a. During the past 30 days, how often did you try to prevent or stop (Name) from drinking too much? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B7a.) a week a week a week B6b. How much did you mind dealing with (Name)’s drinking? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot B7a. During the past 30 days, how often did you try to prevent or stop (Name) from using drugs? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? (GO TO B6a.) a week a week a week B5b. How much did you mind dealing with (Name)’s using drugs? Was it: 1 2 3 4 __________ ___________ __________ __________ not at all very little some a lot



SECTION C. FINANCIAL EXPENDITURES MODULE C1. During the past 30 days, have you personally paid for, or given (NAME) money for any of the following for which (NAME) has not paid you back? (IF YES, IMMEDIATELY ASK Q. C2) C2. How much money was that? Q. C1 Q. C2 YES NO AMOUNT IN PAST 30 DAYS

a. transportation expenses, carfare, gas, taxi, etc. 1 2 $____________ b. clothing? 1 2 $____________ c. Pocket money? 1 2 $____________ d. Food? (IF (NAME) LIVES WITH R ASK R TO ESTIMATE (NAME)’S SHARE OF GROCERY BILL) 1 2 $____________ e. Shelter (rent, mortgage)? (IF (NAME) LIVES WITH R ASK R TO ESTIMATE (NAME)’S SHARE OF RENT/ MORTGAGE ) 1 2 $____________ f. medication? 1 2 $____________ g. mental health treatment? 1 2 $____________ h. other medical expenses? 1 2 $____________ i. cigarettes? 1 2 $____________ j. personal items? 1 2 $____________ k. other expenses (SPECIFY) 1 2 $____________

C3. Was (NAME) a financial burden to you during the past 12 months? Was it: Constantly or almost constantly, 1 Often, 2 Sometimes, 3 Seldom, or 4 Never? 5



SECTION D. IMPACT ON DAILY ROUTINES MODULE D1a. During the past 30 days, how often did you miss, or were you late for (school/[and] work) because of your involvement with (NAME)? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? a week a week a week D1b. During the past 30 days, how often were your social and leisure activities changed or disrupted because of (NAME)? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? a week a week a week D1c. During the past 30 days, how often was your usual housework or domestic routine disrupted or changed because of (NAME)? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? a week a week a week D1d. During the past 30 days, how often did taking care of (NAME) prevent you from giving other family members as much time and attention as they needed? Was it: 1 2 3 4 5 __________ ___________ __________ __________ _________ not at all less than once 1 or 2 times 3 to 6 times every day? a week a week a week D2. Has (NAME)’s illness caused you to make more of less permanent changes in you daily routine, work, or social life such as:

(YOU MAY CIRCLE MORE THAN ONE RESPONSE)

working less or quitting job 1 retiring earlier than you planned 2 having no social life, 3 losing friendships, or 4 not taking vacations? 5



SECTION E: WORRY

E1. (Even when people have not seen each other for a period of time, sometimes they worry anyway about the other person.). I would like to ask you about concerns or worries you may have about (NAME). a. Do you worry about (NAME)’s safety: 1 2 3 4 5 __________ ___________ __________ __________ _________ constantly often sometimes seldom never? Or almost constantly b. Do you worry the kind of help and treatment (NAME) is receiving: 1 2 3 4 5 __________ ___________ __________ __________ _________ constantly often sometimes seldom never? Or almost constantly c. Do you worry about (NAME)’s social life: 1 2 3 4 5 __________ ___________ __________ __________ _________ constantly often sometimes seldom never? Or almost constantly d. Do you worry about (NAME)’s physical health: 1 2 3 4 5 __________ ___________ __________ __________ _________ constantly often sometimes seldom never? Or almost constantly e. Do you worry about (NAME)’s current living arrangements: 1 2 3 4 5 __________ ___________ __________ __________ _________ constantly often sometimes seldom never? Or almost constantly



f. Do you worry about (NAME) would manage financially if you were not there to help (him/her) safety: 1 2 3 4 5 __________ ___________ __________ __________ _________ constantly often sometimes seldom never? Or almost constantly g. Do you worry about (NAME)’s future prospects: 1 2 3 4 5 __________ ___________ __________ __________ _________ constantly often sometimes seldom never? Or almost constantly


Appendix F: Questionnaire on the feasibility of the psychoeducation programme

QUESTIONNAIRE ON THE FEASIBILITY OF THE PSYCHOEDUCATION PROGRAMME

Please answer this questions below as truthfully as possible and will be kept strictly confidential. Your cooperation is greatly appreciated.

OCCUPATION: _________________________________________________________

DURATION IN SERVICE (Please tick): < 1 year 1-5 years 6-10 years >10 years

Please circle the best answer that applies to you

1 2 3 4 5Strongly disagree Disagree Unsure Agree Strongly agree

1. In your opinion, is this psychoeducation program beneficial to the patient?

1 2 3 4 5

2. Do you find the program a burden?

1 2 3 4 5

3. Do you find it easy to implement the module

1 2 3 4 5

4. Do you have support from the other staff in implementing this program?

1 2 3 4 5

5. Are you satisfied in giving the psychoeducation to the patient/ caregiver?

1 2 3 4 5

6. Do you find the program too time consuming?

1 2 3 4 5

7. Would you like incentives to be given such as time off/ extra allowance?

1 2 3 4 5

8. Should this program be continued?

1 2 3 4 5

9. Any suggestion to improve this program

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________


Appendix G: Pre- and post-report form

BORANG LAPORAN PENILAIAN MARKAH PRE DAN POSTEST PESERTA PROGRAM PSYCHOEDUCATION

Nama Fasilitator yg mengendalikan

Pretest: _________________________________

Postest: _________________________________

BIL. NAMA PESAKIT NO KPMARKAH

PRETEST POSTESTImmediate

POSTEST1 mth

POSTEST3 mths


Appendix H: Psychoeducation programme registration form

BORANG PENDAFTARAN PROGRAM PSYCHOEDUCATION

Nama __________________________________

No. KP (baru) : __________________________________

Tarikh daftar : __________________________________ Verbal consent taken Modul untuk Psycoeducation1. Memahami penyakit anda2. Memahami rawatan anda3. Membantu mencegah ‘Relapse’ (penyakit berulang)4. Cara mengelakkan dan mengendalikan krisis5. Cara hidup sihat (Pemakanan, Senaman dan lain-lain)

Tarikh Jangkaan modul diberi Modul Nama Fasilitator

Tandatangan Fasilitator & Tarikh

selepas modul diberi

Jika modul tidak diberikan Sila beri

alasan

1.

2.

3.

4.

5.

Tarikh pre test dijalankan: _____________________ (Markah:__________/ 25)

Tarikh post testdijalankan: _____________________ (Markah:__________/ 25)


Appendix I: Appointment form

BORANG TEMUJANJI

Nama Peserta __________________________________________________________

No. KP (baru) __________________________________________________________

Nama Fasilitator __________________________________________________________

Tarikh Temujanji Test / Modul

Pre-test

Modul 1

Modul 2

Modul 3

Modul 4

Modul 5

Immediate Post-test

Post-test 1 month

Post-test 3 month

89ISBN

9789671063453

Improving Asthma Care in Ministry of Health Primary Care ClinicsHealth Systems Research 2008/2009

Authors

Shahnul Kamal SidekTanjung Malim Health Clinic

Siti Khadijah HawariGunung Rapat Health Clinic

Kok-Seng TengTaiping Hospital

Normah Mohd ZinPerak State Health Department

Zainab NoordinKampar Health Clinic

Paranthaman VengadasalamJelapang Health Clinic





Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Shahnul Kamal Sidek, Siti Khadijah Hawari, Kok-Seng Teng, Normah Mohd Zin, Zainab Noordin, Paranthaman Vengadasalam, Amar-Singh HSS, Sondi Sararaks, Ranjit Kaur Praim Singh, Asmah Zainal Abidin. ”Improving Asthma Care in Ministry of Health Primary Care Clinics” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 89. (ISBN: 9789671063477)

90 Improving Asthma Care in Ministry of Health Primary Care Clinics


Abstract 91

1.0 Introduction 93

2.0 Objective 97



3.0 Methodology 97

3.1 Study type and design

3.2 Ethical consideration

3.3 Sampling

3.4 Variables

3.5 Technique of data collection

4.0 Results 102

4.1 Sociodemographic characteristics

4.2 Key outcomes

4.3 Comparison of change in asthma control based on ACT in the post intervention cohort

5.0 Discussion 109

5.1 Statement of principal findings

5.2 Strengths and weaknesses of the study

5.3 Strengths and weaknesses in relation to other studies

5.4 Meanings of the study


References 113

Acknowledgement 115

Appendices 116

91Improving Asthma Care in Ministry of Health Primary Care Clinics

ABSTRACT

Improving Asthma Care in Ministry of Health Primary Care Clinics

Shahnul Kamal Sidek¹, Siti Khadijah Hawari², Kok-Seng Teng³, Normah Mohd Zin4, Zainab Noordin5, Paranthaman Vengadasalam6, Amar-Singh HSS7,8, Sondi Sararaks10, Ranjit Kaur Praim Singh9, Asmah Zainal Abidin9

1 Tanjung Malim Health Clinic2 Gunung Rapat Health Clinic3 Taiping Hospital4 Ministry of Health (MOH)5 Kampar Health Clinic6 Jelapang Health Clinic7 Clinical Research Centre Perak8 Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak9 Perak State Health Department10 Institute for Health System Research


The goal of asthma treatment should be optimum asthma control. This study was carried out to improve asthma management among adolescents and adults attending Ministry of Health Primary Health Care clinics, in the Kinta and Batang Padang Districts by using the Asthma Control Test (ACT) as part of the asthma plan and asthma handbook to educate patient for self-empowerment.

Methodology

It was a non-controlled convenient quota sampling community trial from August 2008 to February 2009 in 6 government health clinics. Asthma patients who fulfilled the criteria and received treatment during the study period were sampled. Interventions included giving patients a self-administrated test card using the ACT, assistance by a trained healthcare provider and measurement of peak flow rate (PEFR) at every clinic visit. Healthcare providers were given revised GINA guidelines and were educated about ACT and PEFR use. To reinforce education to the patient, Asthma Action Plan which includes ACT scoring for self-assessment, Asthma Control Handbook and Asthma Treatment Records were introduced.

Results

Of the total 634 respondents, 516 (77.1%) completed the study. 118 respondents were dropped due to default in follow up and non-availability of outcomes. Comparing the baseline and post intervention sociodemographic characteristics, there is no significant difference between gender, ethnicity and age group between those that completed and those failed to complete the study. Majority of them were Malays, female and aged


between 40 to 50 years old. At baseline 35.8% of asthmatics were controlled, 35.6% had a Peak Expiratory Flow Rate less than 60% (of best predicted value) and 67.5% were on preventer medication. Post intervention data have shown that the proportion of those with asthma controlled significantly increased to 52.9%, those with a Peak Expiratory Flow less than 60% (of best predicted value) decreased to 26.8% and those on preventer medication increased to 85.9%. The proportion of patients with uncontrolled asthma reduced from 25.6% (95%CI 22-29) to 13.8% (95%CI 11-17). After the intervention, the asthmatic control among those of Indian ethnicity significantly improved from 25% (95%CI 18-31) to 42% (95%CI 35-50). Those aged 41-50 years also show a significant degree of improvement from 41% (95%CI 33-49) to 59% (95%CI 51-67).

Conclusion

This study has shown that only one third of the asthmatics were controlled at baseline. The overall rate of asthmatic control for those patients who complete the intervention improved from 39.7% to 52.9%. The intervention package used in this study is effective in improving asthma control.

Keywords

Asthma, control, ACT-asthma control test, intervention, asthma action plan, preventer medication, PEFR


1.0 INTRODUCTION

Asthma is a reversible inflammatory and hyper responsiveness of the airways, which results in recurrent episodes of coughing, wheezing, chest tightness and breathlessness, particularly at night or in the early morning. Asthma is a significant burden, not only in terms of healthcare costs but also lost productivity and reduced participation in family life (Vincent et al. 2006). Clinical manifestations of asthma can be controlled with appropriate treatment. When asthma is under controlled, there should not be more than occasional flare ups and severe exacerbations should be rare (GINA 2000). If uncontrolled it can lead to severe limitations on daily life and may be fatal. Overall, one in every 250 deaths is due to asthma and they are mostly preventable.

It has been shown that the prevalence of asthma is increasing throughout the world, and it is estimated that there may be an additional 100 million persons living with asthma by 2025 (ISAAC Committee 1998). In Western countries, 4 to 6 % of the adult population has a physician-confirmed diagnosis of bronchial asthma (Tjard R.S. et al., 2002) while it is estimated that 4.4 million in East Asia and Pacific region have asthma. In South East Asia, it was reported that there are 17.5 million cases with a prevalence of 3.3% (Goh et al., 1994) and the highest rates are seen in Thailand, Philippines and Singapore.

From the National Health Morbidity Survey (NHMS) III 2006, the prevalence of adult asthma was 4.5% in Malaysia, and in Perak, 3.8% respectively. The highest prevalence was among the Malays (67%) followed by Indians (12.9%), other Bumis (10.05) and Chinese (7.3%). 74.2% of adult asthmatics have intermittent asthma, while 25.8% have persistent asthma. More than 73% of outpatient attendances in health clinics were for respiratory symptoms, and asthma is one of the common conditions noted. It is also shown that 67.8% of asthmatic patients had exacerbations, with 7.98% of them had more than 12 attacks per year, 17.79% with 4-12 exacerbations per year, while the rest suffered less than 3 attacks per year. National average for respiratory illness admitted into government hospitals was about 5.8%, and asthma cases made up to about 27.1% of the respiratory cases admitted.

A local study of 93 asthmatics from two government health clinics and a state hospital in Negeri Sembilan shows that fewer than 50% achieved minimum day or night symptoms and no restriction in daily activities. However, among the severe asthmatics, only 19.4% were on inhaled corticosteroids, and only 36.1% of adult asthmatics ever had their peak flow measured (Malaysian Adult Asthma CPG revised 2002). It is also found that Malaysian and other Asian patients had poor understanding of their condition and role of ICS, with:

1. only 23.2% realized that inflammation is the underlying cause of asthma2. 17.5% thought the underlying condition could be treated3. 12.9% claimed to be familiar with ICS4. 29.2% had heard of peak flow meter, 7.1% reported owning one, 2/3 would not buy

and use a peak flow meter because they could not afford it ( Partridge et al. 2006)


The findings of AIRIAP1 and 2 studies establish the fact that asthmatics in Malaysia live in a compromised life and expectation of control is low. The approach used in managing asthma is mainly symptom based i.e. reactive and short term, with low usage of preventer medications, low compliance to long term management leading to poor control. There is a need for new treatment approach that would encourage doctor-patient partnership, leading to better patients’ compliance and encourage doctors to treat asthma with control as the goal through appropriate assessment, adequate treatment and regular monitoring.

The primary goal in treating asthma is to achieve and maintain good control, enabling them to participate in school, work and other normal daily activities including exercise, maintain pulmonary function as close to normal level as possible, prevent asthma exacerbations, avoidance of adverse effect from asthma medications and to prevent mortality.

Assessment and monitoring asthma severity and asthma control is one of the important elements to achieve a better asthma control. The asthma control test (ACT) is a validated tool, recommended by Global Initiative for Asthma (GINA) guidelines and can be used for this purpose. It’s not only a form of objective assessment of asthma control but also a self monitoring questionnaire for the patient to assess and guide them in managing their asthma accordingly. It presents a clear goal of asthma treatment besides allows smooth doctor-patient communication on goals and encourages a patient to actively participate in treatment.

In this study ACT is introduced as an objective way of assessing asthma control besides Peak Expiratory Flow Rate (PEFR) measurement as part of the intervention package to improve asthma status among patients attending the outpatient clinic.

Literature Review

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms. Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs. The choice of treatment should be guided by level of asthma control, current treatment, pharmacological properties and availability of the various forms of asthma treatment and economic considerations. In addition cultural preferences and differing health care systems need to be considered. Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient / family most often results in the achievement of control.

Asthma has been classified by severity into intermittent and persistent based on frequency of daytime symptoms, nocturnal symptoms limitations of daily activities, need for reliever treatment and results of lung function tests (Malaysian Adult Asthma CPG revised 2002). However asthma severity may change over time and there is now good evidence that the clinical manifestations of asthma—symptoms, sleep disturbances, limitations of daily


activity, impairment of lung function, and use of rescue medications—can be controlled with appropriate treatment. Instead, the document now recommends a classification of asthma by level of control: controlled, partially controlled, or uncontrolled.

A good asthma control is defined as:

1. No (twice or less/week) daytime symptoms2. No limitations of daily activities, including exercise3. No nocturnal symptoms or awakening because of asthma4. No (twice or less/week) need for reliever treatment5. Normal or near-normal lung function results6. No exacerbations

According to National Asthma Education and Prevention Program (NAEPP) achieving and maintaining asthma control requires four components of care namely,

1. Assessment and monitoring asthma severity and asthma control2. Education for a partnership in care3. Control of environmental factors and co morbid conditions that affect asthma4. Medications

A systematic review including 23 trials concludes that self-management programmes are able to improve health outcomes in adult asthma if they include self-monitoring and are accompanied with written action plans and regular medical professional review (Gibson et al. 2003).

The National Asthma Education and Prevention Program (NAEPP) Expert Panel 2 Report (ERP-2) published 1997 emphasise the importance of providing patients with a written asthma action plan based on sign and symptoms and / or peak flow monitoring especially important for patients with moderate to severe asthma or history of exacerbations.

In view of assessment of asthmatic control, recommendation to use peak flow meters in the home management of asthma has been made in the most recent asthma guidelines but only some minimal studies specifically addressing its usefulness. Two community based studies found no difference between using Peak Flow Meter (PFM) or monitoring symptoms and another comparing Peak Expiratory Flow (PEF) self-management with regular review found similar results (Jones et al. 1995). Regular follow up and action plan are effective in improving asthma control and quality of life and the routine use of PFM to guide interventions is not the only way to achieve better control of asthma (Turner et al. 1998).

Lung function testing by spirometry or PEF continues to be recommended as an aid to diagnosis and monitoring of asthma. It provides an assessment of severity, reversibility, variability of airflow limitation and helps to confirm diagnosis of asthma. Long or short term


daily PEFR monitoring can provide the patient and clinics with objective data upon which therapeutic decisions were made. However, adherence to long term PEFR monitoring is difficult to maintain (Gibson et al. 2000). Some reports adherence with home PEF recording is satisfactory in the short term but falls off considerably after several months suggesting a significant limitation to this form of monitoring. The most conservative approach is to have patients monitor their condition using both objective and subjective measures and this can be accomplished by monitoring their PEFR reading and asthma symptoms. PEFR provide an objective measurement of airflow obstruction and can be performed accurately by most adults and children older than five years of age. While patients’ adherence to PEFR monitoring is highly variable, connecting its use to the data relevant to concrete self management activities may increase adherence (Caress et al. 2002).

In a busy out patient practice physician often needs a quick, reliable and quantifiable way to help assess a patient’s level of asthma control with or without the use of lung function testing. The ACT gives patients a simple way to help monitor their asthma control between office visits and serves as a validated tool that researchers can use to help measure the level of asthma control within a population (National Institutes of health; National Heart, Lung and Blood Institute, 1997). ACT was pioneered and developed in USA and now adopted throughout the world. The test intended to provide a brief patient-based assessment of asthma control with or without the use of lung function test. The questionnaire has been designed to reflect the multidimensional nature of asthma control and to be completed easily by patients in either primary care or specialist setting. It is a validated 5-item self administered questionnaire that covers the following variables: Activity limitations, shortness of breath, night-time awakenings, rescue medication use and patient rating of control. The questionnaire incorporates 5-point rating scale for each variable and patients are asked to recall events from the past 4 weeks. In practice, responses to each of the 5 items in the ACT are summed to give a score ranging from 5 (poor control) to 25 (total control). A cut off score of 19 was optimal for differentiating between well controlled and uncontrolled asthma. The Asthma Control test is recommended by GINA as a validated tool for assessing asthma control. This represents one of the tools cited by GINA as having ‘the potential to improve the assessment of asthma control, providing a reproducible objective, measure that may be charted over time and representing an improvement in communication between patient and health care professional’ (GINA 2006).

Asthma education should begin in the physician’s office and must include a written action plan. Education about asthma should aim at altering patient’s behavior besides providing knowledge and according to theory, intervention involving multiple educational methods may be most effective. Asthma self management education is essential to provide patients with skills necessary to control asthma and improve outcomes. On the other hand, healthcare provider should also have the basic skill and knowledge necessary to transmit current principle of asthma management. This is important but often neglected aspect in management of asthma. Patient education should include nature of


asthma, preventive measures/avoidance of triggers, drugs used and their side effects, proper technique of using inhaled drugs, peak flow monitoring, recognition of features of worsening asthma, knowledge of the difference between relieving and preventive medications and self management plan.

Poor compliance with prescribed inhaled treatment is an important cause of uncontrolled disease and it is likely that by improving compliance with treatment will lead to improvement s in asthma control (Thoonen et al. 2003). Furthermore compliance with prophylactic inhaled corticosteroid treatment is poor in many patients with asthma, thus limiting its effectiveness (Van der P.J. et al. 1997). In Malaysia, just as other Asia pacific region use of inhaled corticosteroid is low. In AIRIAP study, use of inhaled corticosteroid was reported by only 13.6% while 56.3% use quick relief short acting bronchodilators. In short, improvement in care of asthmatic actually requires greater commitment and involvement by healthcare providers and patients.

Many studies have shown that by using a comprehensive approach generally consisting of education and training, written action plans, and periodic supervision, improve knowledge, practical skills, decision-making responsibility, ultimately, disease control in patients with asthma should be achieved (Tjard R.S. et al. 2002).

2.0 OBJECTIVES


To improve asthma management among adolescents and adults attending MOH primary healthcare clinics, in Kinta and Batang Padang districts.


1. To determine the level and proportion of asthma control among the asthmatic patient by sociodemographic characteristic among adolescents and adults with asthma attending the primary healthcare clinic.

2. To implement an intervention package and evaluate the effectiveness of the intervention package in improving asthma control.

3. To make recommendations on improving asthma management in primary care.

3.0 METHODOLOGY

3.1 Study type and design

It is a non-controlled community trial and was carried out in 3 phases. Data collection was done from August 2008 to February 2009. 6 health clinics in Kinta and Batang Padang districts were selected based on clinics with the highest anticipated number


of asthmatic patients. All asthma patients who fulfilled the criteria and received treatment at the selected health clinics during the study period were involved and sampled using convenient quota sampling.

Phase 1 – Planning the intervention package

In this phase, an intervention package was designed:

1. Flow Chart of Chronic Asthma Management in Adult based on GINA revised 2006 (see Appendix A)

2. Modified Management Approach Based on Asthma Control (see Appendix B)3. Peak Expiratory Flow Rate (PEFR) monitoring to determine level of asthma

control, and use of Peak Flow Chart during clinic visit. (see Appendix C)4. Asthma Action Plan for patient (see Appendix D)5. Asthma Control Handbook and Asthma Treatment Record for patient.

Two weeks before starting the baseline audit (Phase 2), all healthcare providers involved directly in asthma management were briefed and trained based on above interventional package, over one day session (see Appendix F1). The target group of healthcare providers was:

1. Medical officers2. Assistant medical officers3. Nurses (sister, staff nurse, community nurse)

Each new staff who was to get involved in the asthma management in selected clinics was trained by the existing trained healthcare providers in the clinic.

These interventional package and peak flow meters were distributed and made available in all treatment and consultation rooms, where they were used to improve the asthma control. By using these tools, the healthcare providers were reminded on the steps that need to be taken if patients have partially controlled or uncontrolled asthma, and that management should be adjusted according to their level of control.

Phase 2 – Baseline Audit with Simultaneous Ongoing Intervention

Data collection on 500 asthmatic patients was collected from all the participating clinics. Patient attending the clinic for continuation of asthma care were selected by quota sampling, with their card stamped at the screening room (see Appendix E).

Age, gender, medications, and asthma symptoms as stated in ACT were self-reported by the patients using the Asthma Action Plan (AAP) leaflet (Appendix D), assisted by the trained healthcare provider, who was responsible to measure their height and PEFR. The medical officers or assistant medical officers in the treatment or


Phase 1: Planning intervention package (June – August 2008)

Design and preparing of intervention package, followed by empowerment of health care providers on:1. Flow Chart of Asthma Management2. Modified Management Approach Based on Asthma Control3. Peak Expiratory Flow Rate (PEFR) monitoring4. Asthma Action Plan for patient (including ACT)5. Asthma Control Handbook / Treatment Record

Phase 2: Baseline audit with simultaneous ongoing intervention (August 2008 – February 2009)

Pre-intervention data collection on age, gender, medication, asthma control level and PEFR (500 quota samples from 6 intervention clinics)

Implementation of the intervention package simultaneously:1. Flow Chart of Asthma Management2. Modified Management Approach Based on Asthma Control3. Peak Expiratory Flow Rate (PEFR) monitoring during clinic visit4. Asthma Action Plan for patient (including ACT)5. Asthma Control Handbook / Treatment Record

Phase 3: Post-intervention audit (March 2009)

Post-intervention data on age, gender, medication, asthma control level and PEFR will be collected at 6 months post-implementation (n=500)

Figure 1. Flow chart of methodology


consultation rooms were required to review the AAP leaflet and management of patient were then be based on the Modified Management Approach (Appendix B). This intervention was implemented throughout the 6 months study period (August 2008 – February 2009). For each clinic visit, the patients were given a new AAP leaflet for them to keep record, to reinforce education and empowering.

Phase 3 – Post-intervention Audit (March 2009)

In this phase, the same 500 asthmatic patients from the selected clinics were reviewed using the AAP leaflet, at 6 months post-implementation.

Post-intervention audit data were provided to the selected health clinics involved, with feedbacks and outcome measures.

3.2 Ethical Consideration

Verbal consent was obtained prior to the patient self-assessment for data on disease severity. No identifiable particulars were collected. There was no control group in this study, as the researchers considered it unethical not to intervene in partially controlled and uncontrolled asthmatics, when encountered during the study period.

3.3 Sampling

Sample size was calculated using EpiCalc 2000, using two proportions with the power of 0.8 at a significant level of 0.05, with a change from the asthma uncontrolled from 25% to 15%, the calculated sample size is 411. For this study, at least 500 samples were targetted to allow for dropout rate of 20% from the 6 clinics within the 2 districts. Sampling was done by quota sampling. Each patient was selected as respondent and was tagged (stamp on treatment card), and intervened.

Inclusion criteria:

All asthmatic patients:

1. Aged between 13 to 60 years old. 2. Diagnosed by a medical personnel (doctors & medical assistants).3. Currently attending MOH health clinics regularly in Kinta or Batang Padang

district.

Exclusion criteria:

1. Presenting with status asthmaticus, as such patients will be stabilised and admitted immediately.

2. Other diseases which influence bronchial symptoms and/or lung function such as heart failure, chronic obstructive airway disease (COAD).


3.4 Variables

Variables Operational Definition Measuring scale

Age of patientAge of patient in completed years obtained from self reporting in the asthma action plan leaflet

Years

GenderSex of patient obtained from self reporting in the asthma action plan leaflet

MaleFemale

Height

Height of patient in centimeters obtained by staff measurement of patients at time of clinic visit, using a Seca scale

Centimeter (cm)

Current Patient Medication(s)

Drugs used for asthma management by the patient at the time of current visit as obtained from self reporting in the asthma action plan leaflet

Short-acting beta2-agonist (Salbutamol / Terbutaline)Inhaled corticosteroids (Budesonide/ Beclomethasone)Sustained release theophyllineOral prednisoloneLong-acting beta2-agonist (Symbicort / Seretide) Leukotrienes modifier (Singulair)

PEFR

Lung function of patient obtained from staff measurement of patients at time of clinic visit using an adult peak flow meter – best of 3 attempts

Litre/minute (L/min)

Asthma Control

Control of asthma of the patient as assessed using the GINA Revised 2006 Guidelines conducted at the time of clinic visit, by the healthcare provider

UncontrolledPartially controlledControlled

Asthma Control Test (ACT)

A validated self-reported questionnaire to assess asthma control of the patient, conducted at the time of clinic visit with staff assistance before seeing the healthcare provider

5-14 – Uncontrolled15-19 – Partially controlled20-25 – Controlled

Status asthmaticus

Any life-threatening form of asthma that needs immediate referral to hospital.

Number of patient


3.5 Technique of Data Collection

Data on demography (age, gender, height) were recorded in the AAP, and a copy was kept at the clinic. Data on PEFR reading and ACT score were recorded in the asthma action plan, and a copy was kept at the clinic. The data were then analysed using the SPSS program.

4.0 RESULTS

4.1 Sociodemographic Characteristics

At the beginning of the study, 634 asthmatic patients from all the 6 participating clinics had fulfilled the criteria and intervened. All the respondents were registered and given the intervention package.

Of the total 634 respondents, 516 completed the study. 118 respondents were dropped due to default in follow up and no outcomes available. Among the reasons was inability to make contact and possible change place of treatment.

Details of socio-demographic characteristic are shown in Table 1. There is no significant difference between gender, ethnicity and age group between these two groups.

4.2 Key Outcomes

The results (Table 2) show that compared to the baseline, there is a significant decrease in percent of those with a PEFR of < 60%, those with ACT score of < 15 and poor asthma control clinically. There is also a significant improvement in proportion of those with an ACT score of 20-25, those clinically classified as controlled as well as higher use of preventer medication.

4.3 Comparison on Change in Asthma Control Based on ACT in the Post Intervention Cohort

The percentage of controlled asthma changed from 39.7%to 52.9% (refer Table 3). There is also a reduction in the proportion of those uncontrolled asthma from 25.6% to 13.8%. There is significant relationship in asthma control with gender and Indian ethnicity. There is no relationship between asthma control and age category.


Table 1. Baseline versus post intervention sociodemographic characteristic

CharacteristicBaseline

(Pre-intervention)Post Intervention

(includes phone follow up) Dropouts

Count % Count % p-value* Count % p-value+

Total 634 100 516 77.1 – 118 22.9 –

Age (yrs)

≤20y 39 6.2 29 5.6 0.8 10 8.5 0.34

21-30y 53 8.4 40 7.8 0.79 13 11.0 0.33

31-40y 91 14.4 72 14.0 0.91 19 16.1 0.65

41-50y 161 25.4 134 26.0 0.88 27 22.9 0.56

51-60y 150 23.7 123 23.8 0.1 27 22.9 0.92

>60y 140 22.1 118 22.9 0.81 22 18.6 0.38

Total 634 100 516 100 – 118 100.0 –

Ethnicity

Malay 329 51.9 274 53.1 0.73 55 46.6 0.24

Chinese 75 11.8 63 12.2 0.92 12 10.2 0.64

Indian 218 34.4 170 32.9 0.65 48 40.7 0.14

Others 12 1.9 9 1.7 0.97 3 2.5 0.84

Total 634 100 516 100.0 – 118 100.0 –

Gender

Male 237 37.4 192 37.2 0.1 45 38.1 0.93

Female 397 62.6 324 62.8 0.1 73 61.9 0.93

Total 634 100 516 100 – 118 100.0 –

* p-value comparing baseline and post intervention using Z test for paired proportions+ p-value comparing post intervention and dropouts using Z test for paired proportions


Table 2. Key Outcome of Intervention

OutcomeBaseline

(Pre-intervention)Post Intervention

(includes phone follow up) p-value*Count % Count %

PEFR

> 80 % 161 25.4 126 30.1 0.10

60-80 % 242 38.2 179 42.8 0.15

<60 % 226 35.6 112 26.8 0.003

Missing 5 0.8 1 0.2 0.46

Total 634 100 418 100.0 –

ACT Score

20-25 227 35.8 273 52.9 < 0.001

15-19 223 35.2 172 33.3 0.55

< 15 181 28.5 71 13.8 < 0.001

Missing 3 0.5 0 0.0 0.33

Total 634 100 516 100.0 –

Clinical Assessment of Asthma

Controlled 227 35.8 273 52.9 < 0.001

Partially controlled

223 35.2 172 33.3 0.55

Uncontrolled 181 28.5 71 13.8 < 0.001

Missing 3 0.5 0 0.0 0.33

Total 634 100 516 100.0 –

Usage of Preventer

Yes 428 67.5 474 85.9 < 0.001

No 200 31.5 73 13.2 < 0.001

Missing 6 0.9 5 0.9 0.82

Total 634 100 552 100.0 –

* p-value comparing baseline and post intervention using Z test for paired proportions


Tabl

e 3.

Com

paris

on o

f AC

T ou

tcom

e fo

r pat

ient

coh

ort p

re a

nd p

ost i

nter

vent

ion

Base

line

Cont

rolle

dPa

rtia

lly c

ontr

olle

dU

ncon

trol

led

Tota

l

n%

95%

CI

n%

95%

CI

n%

95%

CI

n%

95%

CI

LLU

LLL

UL

LLU

LLL

UL

Post intervention

Cont

rolle

d16

681

7686

7944

.137

5128

21.2

1428

273

52.9

4957

Part

ially

co

ntro

lled

3215

.611

2189

49.7

4257

5138

.630

4717

233

.329

37

Unc

ontr

olle

d7

3.4

16

116.

13

1053

40.2

3249

7113

.811

17

Tota

l20

539

.735

44

17

934

.731

39

13

225

.6 2

229

51

6 –

– –

*

LL =

Low

er L

imits

, UL=

uppe

r lim

its


Baseline asthmatic status controlled

Post interventionasthmatic status controlled

Male

Sex of patient

95%

C I

Female

0.6

0.5

0.4

0.3

Figure 2. Error bar according to gender for ACT score 20-25

Baseline asthmatic status uncontrolled

Post interventionasthmatic status uncontrolled

Male

Sex of patient

95%

C I

Female

0.4

0.3

0.2

0.1

Figure 3. Error bar according to gender for ACT score <15




Malay Chinese

Race of patient

95%

C I

Indian Other

1.00

0.75

0.50

0.25

0.00

-0.25

-0.50

Figure 4. Error bar according to ethnicity for ACT score 20-25



Malay Chinese

Race of patient

95%

C I

Indian Other

0.8

0.6

0.4

0.2

0.0

-0.2

Figure 5. Error bar according to ethnicity for ACT <15




1 2 3

Age according to category

95%

C I

4 5 6

0.8

0.6

0.4

0.2

Figure 6. Error bar according to age category for ACT 20-25



1 2 3

Age according to category

95%

C I

4 5 6

0.5

0.4

0.3

0.2

0.1

0.0

Figure 7. Error bar according to age category for ACT <15


5.0 DISCUSSION

5.1 Statement of Principle Findings

Asthma control is recognized as a critical aspect of the evaluation and management of the disease. In this study from the 6 participating clinics, a total of 634 respondents were intervened at baseline. Majority of them were Malays, female and aged between 40 to 50 years old.

At baseline 35.8% of asthmatics were controlled, 35.6% had a PEFR less than 60% (of best predicted value) and 67.5% were on preventer medication. 77.1% of all respondents completed the study. There is no significant sociodemographic difference in term of age, ethnic and gender distribution between the baseline and the post intervention group and also no difference between those who completed the study and those without any outcome.

After undergoing the interventional package, the proportion of those with asthma controlled increased to 52.9%, those with a PEFR less than 60% (of best predicted value) decreased to 26.8% and those on preventer medication increased to 85.9%). Furthermore proportion of patients with uncontrolled asthma reduced from 25.6% (95%CI 22-29) to 13.8% (95%CI 11-17). After the intervention, the asthmatic control among those of Indian ethnicity significantly improved from 25% (95%CI 18-31) to 42% (95%CI 35-50) and those aged 41-50 years showed a significant degree of improvement as well from 41% (95%CI 33-49) to 59% (95%CI 51-67). One possible reason is that these groups may have work related exposure to allergen or social allergen and thus may be improved by better treatment strategies such as in the interventional package. Most epidemiological studies show a significant association between air pollutants and exacerbations of asthma.

5.2 Strengths and Weaknesses of the Study

The monitoring of peak flow measurement which was done at every clinical visit helps in assessing the lung function in a simple way besides the use of the ACT score which was a key tool as it allowed an objective way of assessing asthma control. Peak expiratory flow has been recommended and used for self-management of asthma. However poor adherence to daily PEF monitoring suggests that this may not be a practical approach for most patients. Buist et at 2006 has found that peak flow monitoring has no advantage over symptom monitoring as an asthma management. Despite these, it is shown that only a small proportion of patients with asthma use a peak flow meter regularly. Another study (Turner et al. 1998) has shown that education, regular follow up and an action plan are effective in improving asthma control and quality of life but the routine use of PFM to guide intervention is not the only way to accomplish these objectives. The ACT is reliable, valid, and responsive to


changes in asthma control over time in patients new to the care of asthma specialists. A cutoff score of 19 or less identifies patients with poorly controlled asthma. In a clinical setting the ACT should be a useful tool to help physicians identify patients with uncontrolled asthma and facilitate their ability to follow patients’ progress with treatment. (Wechsler ME.)

The introduction of handy asthma control handbook in this study to provide information and knowledge to the patient besides asthma record treatment book served as tools for self empowerment for both the patient and health care provider. Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. It is found that the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self monitoring) and treatment (Matthew et al. 2008). Although several versions of the WAAP exist, all share certain features. In this study by introducing the asthma handbook patients and the health care provider needed to know that they have to monitor their symptoms or peak expiratory flow (PEF) to detect deviations from the usual state of controlled asthma. Reminders of warning signs and symptoms as well as potential precipitating factors or personal triggers were included. By incorporating the ACT score as a guide for patient-initiated treatment, options to restore control were explicitly provided in writing. In addition danger signs and contact information were included. This information was documented in the handbook for the patient reference at all time.

This study obtained data on asthma control as opposed to previous studies that mainly focused on asthma severity.

The lack of a control group hampered comparison and historical (internal) controls were used. It was felt that it is not acceptable to use a control group as patient identified with uncontrolled asthma could not be left without intervention in the exiting health care provision environment.

The sampling was convenient quota sampling but every patient identified in all 6 clinics were included and offered intervention.

There was a large dropout of patients (22.9%) despite attempts to trace them by phone. However analysis showed that those who dropped out were similar in socio-demographic characteristic.

The diagnosis of asthma in this study was based on healthcare provider clinic judgment and not on any objective criteria.


5.3 Strengths and Weaknesses in Relation to Other Studies

Epidemiologic evidence related to asthma control in patients from the general population is scant (Cazzoletti et al. 2007). Many earlier studies look into symptom or severity of asthma, but not much data is available on asthma control. Furthermore, there is a wide variation in the definition of asthma which may explain the differences with other studies.

Sociodemographic profile of this study was comparable to a national survey (NHMS III 2006, Malaysian National Health & Morbidity Survey) which showed a higher prevalence among Malays, females and also those aged between 45-49 years old. A local study of 93 asthmatics from two government health clinics and a state hospital in Negeri Sembilan (Malaysian Asthma CPG 2002) shows that fewer than 50% achieved minimum day or night symptoms and no restriction in daily activities. However, among the severe asthmatics, only 19.4% were on inhaled corticosteroids, and only 36.1% of adult asthmatics ever had their peak flow measured. NHMS III shows that 74.23% of asthmatics had intermittent asthma and 25.77% had persistent asthma. Due to difference in definition, it is not possible to compare the number of asthmatics controlled.

An Asia-Pacific study (AIRIAP 2) involving China, Hong Kong, Korea, Malaysia, Philippines, Singapore, Taiwan, and Vietnam looks into severity of asthma. It is shown that among respondents, 51.4% had daytime asthma symptoms, 44.3% reported sleep disturbance caused by asthma in the preceding 4 weeks and 13.6% were currently using an inhaled corticosteroid.

Western studies (Cazzoletti et al. 2007) has found that among Inhaled corticosteroid users, the prevalence of uncontrolled asthma shows great variability across Europe, ranging from 20% in Iceland (range 7% to 41%) to 67% in Italy (35% to 90%). In US, prevalence data from the state and the local health department asthma programs through the Behavioral Risk Factor Surveillance System (BRFSS) has found among respondents with current asthma, 54.4% reported routine check-ups for asthma during the preceding 12 months, an estimated 71.6% of respondents with current asthma reported no days of activity limitation, 60.9% reported no days of disturbed sleep, and 21.8% reported having no symptoms during the preceding 30 days. An estimated 47.2% of respondents with current asthma reported no asthma attack or episode during the preceding 12 months. Two Canadian studies (Fitzgerald JM et al. 2006) show that 55% of patients with asthma had daily symptoms (in 1996) and that 57% of patients suffered from poorly controlled asthma (in 1999). Finding from the Real-world Evaluation of Asthma Control and Treatment (REACT) study (Peters et al. 2007) has shown that uncontrolled asthma is highly prevalent (55%) in patients using standard asthma medications.


A population-based study on treatment adequacy and the control of asthma (de Marco R et al. 2005) has noted that despite the increase in the use of inhaled corticosteroids, half of the persistent asthmatics from the general population are using a medication regimen below their severity level with 48% of persistent asthmatics receiving inadequate treatment and 66% did not use their medication daily.

In the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007 confirms the importance of teaching patients skills to self-monitor and manage asthma and to use a written asthma action plan, which should include instructions for daily treatment and ways to recognise and handle worsening asthma. The intervention package used in this study accommodates these concepts. In REACT study it is reported that large proportion of patients with controlled asthma (74%) and patients with uncontrolled asthma (65%) reported never receiving an asthma action plan. Written asthma action plans are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. The key elements of an effective written asthma action plans include concise, detailed recommendations regarding asthma exacerbation recognition, patient self monitoring and treatment.( Matthew AR et al. 2008).

In this study asthma control status post intervention were also gathered through telephone interviewed. Kosinski et al. (2009) has found that ACT scores from a telephone interview are reliable and comparable to ACT scores from a self-administered paper-and-pencil format.

5.4 Meaning of the Study (Possible Mechanisms and Implication for Policy Makers/ Clinicians)

This study has shown that only one third of the asthmatics on follow up at government primary care clinic have their asthma controlled. There is an urgent need to improve this status. Use of the intervention package from this study may be useful to increase the level of asthma control to at least half. Patient empowerment must be included in any initiative to improve asthma control.

Although 67.5% of patients were on preventer medication at baseline this did not translate to control in all of them possibly because they were used incorrectly, inadequate dose or were inappropriate (required more effective preventer medication).



This study has shown that only one third of the asthmatics were controlled at baseline.

The overall rate of asthmatic control for those patients who complete the intervention improved from 39.7% (95% CI 35 – 44) to 52.9% (95% CI 49-57). Furthermore proportion of patients with uncontrolled asthma reduced from 25.6% (95% CI 22-29) to 13.8% (95% CI 11-17). Use of preventer medication increased from 67.5 to 85.9%. After the intervention, the asthmatic control among those of Indian ethnicity and those aged 41-50 years has shown a significant degree of improvement. The intervention package used in this study is effective in improving asthma control.

Recommendations:

1. Asthma control is poor with only one third of the asthmatics controlled in primary care clinics. There is need to improve the level of control in patients.

2. The intervention package used in this study is effective in improving asthmatic controlled. It was based on the CPG with modification with ACT & patient handbook included to provide self empowerment. It is recommended that this intervention package be used to improve asthma control in primary care clinics in Perak and wider.

REFERENCES

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2. Bateman ED et al.2007. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 2008; 31:143-178

3. Buist AS, William MV., Sandra RW, E. Ann Frazier, Arthur D.H. 2006. A Randomized Clinical Trial of Peak Flow versus Symptom Monitoring in Older Adults with Asthma. Am Journal of Resp and crit care med, Vol 174. pp. 1077-1087.

4. CaressA.L,,Luker,K.,Baver,K.,Woodcock,A.2002. Adherence to peak flow monitoring. Information provided by meters should be part of self management plan.BMJ. ; 324(7346):1157.

5. Cazzoletti L, Marcon A, Janson C, Corsico A, et.al.2007. Asthma Control in Europe: A real-world evaluation based on an international population-based study.J of Allergy & Clin. Immuno 120(6):1360-1367.

6. Clinical practice guidelines for management of adult asthma. Ministry of Health Malaysia 2002

7. de Marco R, Cazzoletti L, Cerveri I, Corsico A et al. 2005.Are the Asthma Guideline Goals Achieved in Daily Practice? A Population-Based Study on Treatment Adequacy and the Control of Asthma. Int Arch Allergy Immunol;138:225-234.


8. Education for a partnership in asthma care: Expert panel report 3: guidelines for diagnosis and management of asthma, National guideline clearinghouse. Available from: http://www.guideline.gov/summary/summary.aspx.

9. FitzGerald JM,et al.2006. Asthma control in Canada remains suboptimal: the Reality of Asthma Control TRAC ; study. Can Respir J; 13(5): 253-259.

10. Gibson PG et al. 2003. Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews. CD001117. DOI: 10.1002/14651858. CD001117.

11. Gibson PG, Coughlan J, Wilson AJ, et al.; 2000. Monitoring the patient with asthma: an evidence-based approach. J Allergy Clin Immunol :106:17.-26.

12. Guidelines for the diagnosis and management of asthma- part 2-managing asthma long term. Available from: http://www.Medscape.com/viewarticle/564654

13. H Ross Anderson prevalence of asthma BMJ 2005:330:1037-1038.14. ISAAC committee 1998, ‘Worldwide variation in prevalence of systems of asthma’,

Lancet, Vol.351, pp.1225-1232.15. Jones et al. and the British Thoracic Society research Committee 1995. Peak flow

based asthma self management: a RCT in general practice. Thorax 50:851-85716. Kosinski et al. March 2009,Comparability of the Asthma Control Test telephone

interview administration format with self-administered mail-out mail-back format : Current Medical Research and Opinion, Volume 25, Number 3, pp. 717-727(11)

17. Matthew AR, Gerald WV.,James TC et al.2008; Formulating an Effective and Efficient Written Asthma Action Plan. Mayo Clin Proc;83(11):1263-1270

18. National Asthma Education and prevention Program (NAEPP) expert panel report 2003, guidelines for diagnosis and management of asthma- selected topics 2002, National Institutes of Health Publications, no.02-5074.

19. National Heart, lung and blood institute. Guidelines for the diagnosis and management of asthma. Bethesda Dept of Health and Human services: 1997. NIH pub 97-405.

20. National Institutes of health; National Heart, Lung and Blood Institute, 1997; Practical Guide for the Diagnosis and Management of Asthma. NIH pub no 97-4053

21. Primary care based clinics for asthma: http://www.medscape.com/viewarticle/486668.

22. Peters SP, Jones CA, Haselkorn T, Mink DR, Valacer DJ, Weiss ST, 2007.Real-world Evaluation of Asthma Control and Treatment (REACT): Findings from a national Web-based survey Volume 119, Issue 6, Pages 1454-1461.

23. QAP Primary Health Care. Appropriate management of asthma . Ministry of Health Malaysia 2001

24. The 3rd National Health and Morbidity survey 2006. Institute for Public Health National Institute of Health, Malaysia Ministry of Health 2008.


25. Thoonen BPA, Schermer TRJ, Boom GV et al, 2003. Self management of asthma in general practice, asthma control and quality of life: a Randomized Controlled Trial: Thorax : 58:30-36 ).

26. Tjard R.S et al. 2002.Randomized Controlled Economic Evaluation of Asthma Self-Management in Primary Health Care. American J of Resp & CCM Vol 166. pp 1062-1072.

27. Turner MO, Taylor D, Bennett R, FitzGerald JM. 1998. A randomized trial comparing peak expiratory flow and symptom self management plans for patients with asthma attending primary care clinic.AM J respire Crit Care Med ;157:540-546.

28. Van der P.J et al. 1997. Compliance with inhaled medication and self treatment guidelines following a self management program in adult asthmatics. Eur respir j ;10 ;652-657

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30. Wechsler ME. Managing asthma in primary care: putting new guideline recommendations into context. Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA. [email protected]

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ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper. Our sincere gratitude and appreciation to Perak Health State Department, Clinical Research Center, Hospital Raja Permaisuri Bainun Ipoh, Institute Health Research Centre and all the facilitators for their guidance and support throughout the preparation and implementation of this survey. We also like to thanks the Quality Metric Incorporated Lincoln, GSK to allow us to use the Asthma Control test.

Last but not least thanks to all the clinical staff who were directly or indirectly involved in this research project.


APPENDICES

Appendix A

Appendices Appendix A

Flow Chart of Management of Chronic Asthma (Health Care Provider)

Partially controlled if any of the following: - any nocturnal symptom - one or more exacerbation / year - any limitation in activities - use of reliever more than 2x / week. - < 80% predicted PEF

Control if - no nocturnal symptoms - no exacerbation - no limitation in activities Within the last four weeks -use of reliever 2x or less / week - > 80% predicted PEF

Educating patient, check appropriateness of medication and compliance, inhaler technique, identifying and avoidance of triggering factors

Assess asthma status Review history and asthma symptoms, respond to treatment, physical examination and review of ACT. Monitor PEFR trend.

Reinforce on compliance, asthma action plan, PEFR monitoring and Asthma Control Handbook

Poor

Reinforce compliance, inhaler technique, avoidance of triggering factor, PEFR monitoring, asthma action plan and Asthma Control Handbook

TCA 1/12 – 2/12 to review symptoms

Good

Step up medications, asthma action plan, PEFR monitoring and Asthma Control Handbook

TCA 3-6/12 to review symptom

ACT is a self assessment test for asthmatic control and use as guidance for health provider and empowerment of patient

Uncontrolled if 3 or more features of partially controlled asthma present


Appendix B

Appendix B

Modified Management Approach Based on Asthma Control (healthcare provider)

Level of Control Treatment Action

Controlled Maintain and find lowest controlling step

Partially Controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbation Treat as exacerbation

Reduce Treatment Steps Increase

Step 1 Step 2 Step 3 Step 4 Step 5Asthma Education

Short-acting beta2-agonist as

needed Short-acting beta2-agonist (salbutamol / terbutalline) as needed

Salbutamol / Terbutalline (prn basis)

Low-dose ICS (Beclomethasone

/ Budesonide) 200 mcg bd

+/- oral prednisolone

(1mg/kg/day – 30-60mg daily

for 1 week)

(Select one) (Add one or more)

Physician referral for long-

acting beta2-agonist

Medium dose ICS (Beclomethasone




for 1 week)

High dose ICS (Beclomethasone




for 1 week)

Low dose ICS (Beclomethasone

/ Budesonide) 200 mcg bd + sustained

release theophylline (Neulin SR)



for 1 week)

Medium dose ICS (Beclomethasone

/ Budesonide) 400 mcg bd +

sustained release theophylline (Neulin SR)



for 1 week)


Appendix C

Appendix C Peak Flow Chart for female and male to predict level of asthma control

Average predicted PEF for male

0

100

200

300

400

500

600

700

140 150 160 170 180 190 200

height

PEFR

PEFRPEFR 80%PEFR 60%

Average predicted PEFR for female

0

100

200

300

400

500

600

140 150 160 170 180 190 200

height

PEFR PEFR

PEFR 80%PEFR 60%

Source: Modified from PEF predicted table produced by Respiratory Department, HKL 1997 using Malaysian sample (average predicted PEFR was taken in referral to age 40 for both male and female).

Good

Fair

Best

Poor

Best

Good

Fair

Poor


Appendix D

Appendix D

Asthma Action Plan Age: Gender: Height:

Current Medication: ( Please tick if you are using these medicines)

Reliever: MDI Salbutamol MDI Terbutaline Preventer: MDI ICS (Steroid Inhaler) 0ral medication (Theophylline)Oral prednisolone Others (Symbicort, Seretide, Singulair,etc)

Best current lung function (PEFR)

Predicted PEFR: Poor (<60%) Fair (60-80%) Good (>80%) This means your Asthma is: Uncontrolled Partially

controlled Well controlled

Questions on Asthma Control 1 2 3 4 5

Write Your Score Here

a) In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

b) During the past 4 weeks, how often have you had shortness of breath?

More than once a day

Once a day

3 to 6 times a week

Once or twice a week

Not at all

c) During the past 4 weeks, how often did your asthma symptoms (wheezing, shortness of breath, chest tightness or pain) wake you at night or earlier than usual in the morning?

4 or more nights a week

2 or 3 nights a week

Once a week

Once or twice a week

Not at all

d) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication?

3 or more times per day

1 or 2 times per day

2 or 3 times per week

Once a week or less

Not at all

e) How would you rate your asthma control during the past 4 weeks?

Not controlled at all

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

Actions Required Base on Score If your score is: 5-14 15-19 20-25 This means your Asthma is: Uncontrolled Partially controlled Well controlled

You should be on the following medication:

Start steroid Inhaler (MDI ICS), or Increase dose of steroid Inhaler (MDI ICS), or Add oral medicine (Theophylline)


Continue your current medicines


d) During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication?

3 or more times per day

1 or 2 times per day

2 or 3 times per week

Once a week or less

Not at all

e) How would you rate your asthma control during the past 4 weeks?

Not controlled at all

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

Actions Required Base on Score

If your score is: 5-14 15-19 20-25 This means your Asthma is: Uncontrolled Partially controlled Well controlled

You should be on the following medication:



Continue your current medicines


Appendix E

Appendix E

Patient Flow Chart in Health Clinics

Registration of asthmatic patient

Screening room: Asthma control handbook give to patient. And stamp together with patient’s asthmatic cord. Patient will be given ACT questionnaires to assess

his/her asthma latest control. PEFR will be done by healthcare provider

Patient will be informed regarding their asthma control level base on ACT score

and PEFR reading.

Consultation with medical officer or assistant medical

officer

Step up, continue or step down medications and education based on Asthma Control Handbook


Appendix F

Appendix F

Training Module for Healthcare Provider • Introduction on purpose and methodology of asthma study • Assessment of asthma control – ACT and peak flow meter • Management of asthma, and usage of asthma action plan • Inhaler technique • Asthma control handbook • Asthma treatment record • Data collection

123

The Involvement of Lay Educators In Diabetic Control Of Type 2 Diabetic Patients Health Systems Research 2006/2007

Authors

Sebrina Su HCInstitute for Health Systems Research

Nurhayati IsaPadang Rengas Health Clinic

Zawiyah Yusof Lintang Health Clinic

Parasuraman ParamaisvaryHospital Sungai Siput

Amar-Singh HSS Clinical Research Centre Perak, Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak


Ranjit Kaur Praim SinghKuala Kangsar District Health Office

Narwani HussinPerak State Health Department

Asmah Zainal AbidinKuala Kangsar District Health Office

Mazilah JamalludinPadang Rengas Health Clinic

Khairul Amir Abdul RashidPadang Rengas Health Clinic

Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Sebrina Su HC, Nurhayati Isa, Zawiyah Yusof, Parasuraman Paramaisvary, Amar-Singh HSS, Sondi Sararaks, Ranjit Kaur Praim Singh, Narwani Hussin, Asmah Zainal Abidin, Mazilah Jamalludin, Khairul Amir Abdul Rashid. ”The Involvement of Lay Educators In Diabetic Control Of Type 2 Diabetic Patients” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 123. (ISBN: 9789671063484)

ISBN

9789671063484

124 The Involvement of Lay Educators In Diabetic Control Of Type 2 Diabetic Patients


Abstract 125

1.0 Introduction 127

1.1 Background



2.0 Objectives 129

2.1 General Objectives


3.0 Methodology 129

3.1 Study Design

3.2 Sample size and Sampling method

3.3 Variables

3.4 Data Collection Techniques

3.5 Data Analysis


4.0 Results 135

5.0 Discussion 147


References 151

Acknowledgement 152

Appendices 153

125The Involvement of Lay Educators In Diabetic Control Of Type 2 Diabetic Patients

ABSTRACT

The Involvement of Lay Educators in the Diabetic Control of Type 2 Diabetic Patients

Sebrina Su HC1, Nurhayati Isa2, Zawiyah Yusof3, Parasuraman Paramaisvary4, Amar-Singh HSS5,6, Sondi Sararaks1, Ranjit Kaur Praim Singh7, Narwani Hussin8, Asmah Zainal Abidin7, Mazilah Jamalludin2, Khairul Amir Abdul Rashid2

1 Institute for Health Systems research2 Padang Rengas Health Clinic3 Lintang Health Clinic4 Hospital Sungai Siput5 Clinical Research Centre Perak6 Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak7 Kuala Kangsar District Health Office8 Perak State Health Department

Introduction

Type 2 diabetes is one of the most commonly found illnesses worldwide and is associated with high mortality and morbidity rates. The introduction of health promotion programs involving community health workers are known to help diabetic patients bring about positive lifestyle modifications which in effect reduces many adverse risk factors associated with the disease.

Objectives

This study aimed to improve the diabetic control in type 2 diabetic patients by using lay educators to educated diabetic patients in the areas of knowledge of diabetic control, dietary changes, weight reduction, physical activity levels, HbA1c levels and BMI reduction. The study also aimed to review the effectiveness of using lay educators in the health setting to educate patients to improve health outcomes.

Methodology

This interventional study was carried out from October 2006 to November 2007 which involved Sungai Siput Hospital as the control centre and Padang Rengas Health Clinic as the intervention centre. 50 diabetic patients were involved in each group. 16 trained lay educators were selected to educate the diabetic patients in the intervention centre. Variables measured were knowledge of diabetic control, dietary changes, physical activity levels, weight reduction, HbA1c levels and body mass index. Data was collected from interview-based questionnaires and by extracting information from patient’s treatment cards. Preliminary data was collected and compared to data collected 3 months following the intervention and analysed.


Results

There were significant differences in the socio-demography between the populations of the intervention and control groups. Data collection at 3 months post intervention showed a significant improvement in the knowledge, physical activity, daily calories intake and weight reduction in the intervention group compared to the control group. Socio-demographic factors of the intervention group were compared to the above mentioned variables. The results showed that knowledge score was significantly improved in the intervention group regardless of socio-demography. Physical activity was significantly improved amongst female patients and patients with duration of diabetes of less than 5 years. Daily calorie intake was also significantly improved in patients who have had diabetes for less than 5 years. Weight reduction was recorded for all patients regardless of socio-demographic factors. A survey was also carried to review the opinions of lay educators and patients in the intervention group regarding the program. Positive feedbacks were received indicating that patients and lay educators alike felt that the program was useful.

Conclusion

The program was well received by both lay educators and patients in the intervention group. Significant improvements were also noted in several areas namely knowledge, physical activity, weight reduction and daily calories intake. However variables such as HbA1c and BMI did not show any changes because these variables require a longer time for significant changes to occur. Therefore it is recommended that the program be continued further to review the effectiveness of the program.

Keywords

lay educator, patient self-management programme, diabetic control, HbA1c, physical activity


1.0 INTRODUCTION

1.1 Background

Type 2 diabetes is one of the most common chronic illnesses worldwide. Current figures showed that up to 194 million people worldwide suffer from diabetes and this figure is estimated to increase to 333 million in the year 20251. The National Health Morbidity Survey has shown that in 1996, 608,000 of the Malaysian population suffer from diabetes and this accounts for 8.3% of the general population. This number is estimated to rise to 1 558 600 in the year 2020 and this will account for 13.1% of the general population.2

Poor blood glucose control in type 2 diabetes leads to high mortality and morbidity rates. UKPDS data confirmed that improvement of glycaemic control by lowering of the HbA1c lowers the risk of developing both macro-vascular and micro-vascular complications. Each 1% reduction in updated mean HbA1c was associated with a reduction in risk of 21% for any end point related to diabetes, 21% for deaths related to diabetes, and 37% for micro-vascular complications.3

Besides that, studies have shown that lifestyle modifications are effective in reducing many adverse risk factors associated with diabetes. A meta-analysis of the effects of exercise on diabetic control in type 2 diabetic patients reported a HbA1c reduction of 0.66%, independent of changes in body weight.4 Studies have also shown that strict diet control improves glycemic outcomes (HbA1c decreases of 1.0-2.0%, depending on the duration of diabetes).5


The Malaysian government has implemented a set of guidelines for healthcare professionals in an effort to treat patients suffering from type 2 diabetes. However during the years (2002-2004), the Malaysian health ministry reported that 68% of patients still have a HbA1c > 7.0% despite the nation-wide implementation of clinical practice guidelines for diabetes.2 One possible reason for this is that there are limitations in the current methods of delivering education and teaching of self-management skills by healthcare staff.

In the western world, many health promotion programs involving community health workers are organized to strengthen the links between health care providers and the community.These workers work almost exclusively in community settings and serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate health care. The concept of involving community health workers in public health is practiced in Malaysia and an example of such a group is Rakan Kesihatan. However these workers are not given adequate training to educate on specific diseases. In several


developed countries such as the United Kingdom, community health workers are given professional training regarding common chronic illnesses such as diabetes. These workers are recognized as lay diabetic educators. Our study essentially aims to assess the improvement that may arise in diabetic control following the involvement of lay educators in providing relevant education to patients.


Involvement of lay educators to improve diabetic control in type 2 diabetic patients are influenced by several factors. Among those factors are:

1. Lay educator factors, such as accessibility, their acceptability of being a lay diabetic educator, role, sustainability, identification, incentives provided and training.

2. Patient factors, such as accessibility and acceptability of the lay diabetic educator.

3. Staff factors such as method of training, number of staff involved, when and who to train the lay educators.

4. Method of implementations, such as size of the group, location and duration.

The Involvement of Lay Educators in Diabetic Control of Type 2 Diabetic Patients 5

1.3 Problem Analysis Involvement of lay educators to improve diabetic control in Type 2 diabetic patients are influenced by several factors. Among those factors are: 1. Lay educator factors, such as accessibility, their acceptability of being a lay diabetic

educator, role, sustainability, identification, incentives provided and training. 2. Patient factors, such as accessibility and acceptability of the lay diabetic educator. 3. Staff factors such as method of training, number of staff involved, when and who to train

the lay educators. 4. Method of implementations, such as size of the group, location and duration.

Figure 1: Problem analysis chart to analyze the use of lay educators to improve diabetic control in type 2 diabetic patients.

Will the use of lay diabetic educators Improve diabetic

control in type 2 DMPatient factor

Accessibility

Sustainalibility

When to train

Number of staff involved

Staff factor

RoleSocio

Demographic

Identification

Acceptibility of lay diabetic educator

Lay educatorfactor

Method of training

Qualification

Who trains the staff

Incentive

Method of implementation

1 : 1/small group Location

Duration

Record

Type of training

Figure 1. Problem analysis chart to analyze the use of lay educators to improve diabetic control in type 2 diabetic patients.


2.0 OBJECTIVES


To improve the diabetic control in type 2 diabetic patients by using lay educators.


1. To compare diabetic control in patients involved with lay diabetic educators and those without in the following areas:

a. Knowledge of diabetic control in patientsb. Daily calorie intakec. Activity levelsd. HbA1c levelse. BMI reductionf. Weight differences

2. To identify the problems arising and the acceptability of both providers as well as patients in the implementation of diabetic lay educators in the management of diabetes.

3. To make recommendations on the use of lay diabetic educators.

3.0 METHODOLOGY

3.1 Study Design

This is an interventional study, involving the outpatient department of Sungai Siput Hospital and Padang Rengas Health Clinic. This study was carried out from October 2006 to November 2007. Type 2 diabetic patients receiving treatment at the outpatient department of Hospital Sungai Siput were taken as the control group while those receiving treatment at the outpatient department of Padang Rengas Health Clinic were taken as the intervention group.

Phase 1

Lay diabetic educators were chosen based on the following selection criteria:

1. Non-medical staff*2. Volunteers3. Ability to communicate effectively in Bahasa Melayu, English, Chinese or Tamil.4. Ability to attend meetings with diabetic patients during office hours.5. Has own means of transportation.6. Ability to work effectively with diverse groups.* Retired medical staff can be considered to participate


The lay diabetic educators were then trained based on a designated educational module (Refer to Appendix A) over two 2 hours sessions. Relevant reference materials were also provided as guidance (Refer to Appendix B). The lay educators were then given an assessment to assess their diabetic knowledge (Refer to Appendix C). Another post-assessment session was conducted for the lay educators to review the questions in the assessment and to answer any queries. Due to unavoidable limitations, only 16 lay educators were selected for the study. Each lay educator was placed in charge of a minimum of 2 patients or a maximum of 4 patients. These lay educators met their assigned patients on an individual or group basis. The following incentives were offered to the lay educators:

1. Meals during each session.2. Certificate of gratitude.3. Lay educator name tag.

Phase 2

Preliminary data collection on the socio-demographic distribution and the studied variables were carried out in both study groups to get a baseline result. The studied variables were knowledge score, daily calorie intake, physical activity, HbA1c, Body Mass Index (BMI), weight difference. Patient’s diabetic knowledge was assessed from an interviewer-guided questionnaire that was based on a similar questionnaire published by the Ministry of Health in May 20058 (Refer to Appendix D). From the questionnaire, a knowledge score was calculated as a percentage of questions answered correctly against the total number of questions. Sample answers of the questions are also shown in Appendix D. The questionnaire was also sorted into the following categories to assess patient’s understanding of the disease. A patient was considered to have correctly answered a particular question only if the following criteria were met:

1. General diabetic knowledge · Question 1 answered correctly2. Symptoms of diabetes · At least 2 out of Questions 2b, c, d or e answered correctly3. Complications of diabetes · At least 2 out of Questions 3a, b, d or e answered correctly4. Knowledge on causes of hypoglycaemia · At least 2 of Questions 4a, b, c or d answered correctly5. Symptoms of hypoglycaemia · At least 2 of Questions 5b, e, f or g answered correctly6. Causes of hyperglycaemia · At least 2 of Questions 6a, b or d answered correctly


7. Symptoms of hyperglycaemia· At least 2 of Questions 7b, c or e answered correctly8. Knowledge on a diabetic diet · At least 2 of Questions 8b, c, d or e answered correctly9. Knowledge of oral hypoglycaemic agents · At least 2 of Questions 10b, c or d answered correctly

Data on patient’s daily calorie intake was obtained from a 24 hour diet recall questionnaire (Refer to Appendix E). The calories content in each food item were obtained from the Nutrient Composition of Malaysian Foods (Energy and Fat)9 guide, and a total calculated in kcal was obtained. Patients total daily calorie intake was then categorized into three groups according to their gender and age based on a recommended set of guidelines published by the Ministry of Health10. The categories were: below; within; and above recommended daily calorie intake.

Data on HbA1c, weight and height were obtained from the patient’s treatment card. All these were carried out by trained paramedics at both Sungai Siput Hospital and Padang Rengas Health Clinic. The patient’s body mass index was then calculated based on the following formula:

Body Mass Index (BMI) = weight (kg) / height2 (m2)

Patient’s frequency and intensity of physical activity was obtained from a physical activity checklist (Refer to Appendix F) which categorized a collection of common physical activities based on their intensity as listed in The Compendium of Physical Activities Tracking Guide11. Physical activity was interpreted using the unit of metabolic equivalent (MET) as a continuous indicator. This unit, measured as MET-minutes per week, is the ratio of a person’s working metabolic rate relative to the resting rate and is used to characterize physical activities at different levels of effort12. One MET is defined as the energy cost of sitting quietly and is equivalent to a caloric consumption of 1 kcal/kg/hour. Based on the Global Physical Activity Questionnaire Analysis Guide published by the World Health Organization12 it has been estimated that, compared to sitting quietly, a moderately active person’s caloric consumption is 4 times as high while a vigorously active person’s caloric consumption is 8 times as high. Thus, to calculate a person’s total physical activity, 4 METs get assigned to the time spent in moderate activities and 8 METs to the time spent in vigorous activities12. This can be summarized in the following formula:

MET = [Time spent on vigorous-intensity activity per week (mins) x 8] + [Time spent on moderate-intensity activity per week (mins) x 4]

Table 1 shows the categories of physical activities based on MET-minutes per week values whereby a high MET level indicates a higher extent of physical activity.


Following baseline data collection, patients in the intervention group met with their assigned lay diabetic educators for at least one 2 hour session over a period of 3 months. During each session the lay diabetic educator provided information and conducted open discussions with the patients based on lecture notes and relevant pamphlets provided to them by the research organizers.

Patients in the control group received treatment as usual.

Phase 3

Post intervention data was collected 3 months following the initiation of the intervention regardless of the number of lay educator to patient meetings. The same variables as studied in the preliminary data collection were measured. Furthermore, a questionnaire was given to both lay diabetic educators and patients in the intervention group to review their opinions and acceptance of the program. (Refer to Appendix G)

Questionnaire was given to both lay diabetic educators and patients in the intervention group to review their opinions and acceptance of the program. (Refer to Appendix F)

3.2 Sample Size and Sampling Method

Sampling

Systematic sampling of patients with type 2 diabetes who sought treatment at the outpatient department of Sungai Siput Hospital and Padang Rengas Health Clinic was carried out. Patients who fulfilled the inclusion and exclusion criteria were selected as samples in each centre.

Inclusion Criteria

The following are the inclusion criteria for patients selected for the study:1. Type 2 diabetes mellitus diagnosed 10 years or less.2. Treated for type 2 diabetes with oral hypoglycaemic agents only.

Exclusion Criteria

The following are the exclusion criteria for patients selected for the study:1. Patients who are pregnant.2. Patients who suffer from psychiatric disorders.3. Patients who are unable to attend the program due to physical limitations.4. Patients with type 2 diabetes on insulin treatment.5. Patients with type 2 diabetes on diet control only.6. Patients who suffer from end stage renal failure.

133The Involvement of Lay Educators In Diabetic Control Of Type 2 Diabetic Patients The Involvement of Lay Educators in Diabetic Control of Type 2 Diabetic Patients 10

Phase 1 Phase 2 Phase 3 Figure 2: Flow chart of study design

Design of educational module for lay diabetic

educators

Training and assessment given to 16 lay diabetic

educators.

Baseline Data Collection (Knowledge score, daily calorie intake, physical activity, weight,

HbA1c, body mass index)

Control Group (Hospital Sungai Siput)

n=50

Intervention Group (Padang Rengas Health Clinic)

n=50

Usual Care

Implementation of intervention:

Patients meet lay educators for at least

one 2 hour session for a period of 3 months

Post Intervention Data Collection after 3 months Comparison of the effectiveness of the intervention

(Knowledge score, daily calorie intake, weight, physical activity, HbA1c, body mass index)

Post-intervention survey Review the opinions of both lay educators and patients in the intervention group, regarding the

program.



Table 2. Definitions and scale of measurement of studied variables.

Conceptual definition of variables Operational definition of variables Scale of

Measurement

HbA1cMeasurement of glycosylated haemoglobin levels in the blood.

%

WeightWeight was taken using a calibrated Seca balance scale.

Kg

HeightHeight was measured using a calibrated Seca balance scale.

m

BMIBody Mass Index was calculated based on he following formula:BMI = Wt (kg)/ Ht2 (m2)

Kg/m2

Physical Activity

Physical activity was calculated based on the amount of time spent on each activity on an average week as well as the intensity of each activity (sedentary, moderate and vigorous).

METS-min/week

Daily Calorie IntakeDaily calorie intake was measured according to the total calorie intake based on a 24 hour diet recall.

kcal

Knowledge Score

The patient’s knowledge was assessed based on a questionnaire which covered the following aspects: diabetic general knowledge, diabetic complications and medication.

%

Table 1. Criteria to determine levels of physical activity.

Level Criteria

High7 or more days of any combination of walking, moderate, or vigorous intensity activities achieving a minimum of at least 3,000 MET-minutes per week

Moderate5 or more days of any combination of walking, moderate or vigorous intensity activities achieving a minimum of at least 600 MET-minutes per week

LowPhysical activities that amounts to less than 600 MET-minutes per week


Sample Size

The sample size was calculated using the Epicalc 2000. An assumption was made that 20% of the patient population has good diabetic knowledge and we aimed to increase this figure to 45%. The sample size was also selected based on an 80% power at a significance level of 0.05%. Based on these factors, the calculated sample size was 53 patients in each group. After considering an estimated 10% drop out, the total sample size was set as 60 patients in each group. However, due to the time constraints of the study and unavoidable patient factors, the sample size was reduced to 50 patients per centre.

3.3 Variables

Variables that were used in this study are shown in Table 1.


Pre- and post-data collection were carried out by a group of trained paramedics using a set of questionnaires and checklists, over a period of 2 months each. (Refer to Appendix C, D, E and F)

3.5 Data Analysis

SPSS version 11.0 and Epicalc 2000 were used to analyze the results of the study.

3.6 Ethical Considerations

All data were kept confidential. However, the results of the study were relayed to the respective hospital or health clinic and will be published if relevant.

4.0 RESULTS

The results of the assessment given to the lay educators before and after training are shown in Table 3. The results showed improvements in the assessment scores before and after training were given.

Table 3. Results of assessment for lay educators before and after training.

Assessment Score (%) Pre-Training Post-Training p-value

Mean 77.88 84.75

0.41

Median 77.00 87.00

Std. Dev. 10.89 6.19

Minimum 54 72

Maximum 94 94


Table 4. Comparison of socio-demographic data between intervention and control group

VariablesBaseline

Intervention Group

Control Group

p-value*

Age (years)

Mean 60.76 53.52

0.002

Median 62.00 54.50

Std Dev. 10.87 11.44

Minimum 34 33

Maximun 79 76

SexMale 18 (36%) 19 (38%) 1.000

Female 32 (64%) 31 (62%) 1.000

EthnicityMalay 42 (84%) 18 (36%) < 0.001

Non Malay 8 (16%) 32 (64%) < 0.001

OccupationUnemployed 40 (80%) 28 (56%) 0.018

Employed 10 (20%) 22 (44%) 0.018

Educational Level

Primary Education 32 (64%) 37 (74%) 0.387

Secondary Education and above

18 (33%) 13 (26%) 0.583

Duration of diabetes(months)

Mean 37.40 34.84

0.678

Median 28.50 27.00

Std Dev. 34.11 26.91

Minimum 1 1

Maximum 204 120

* p-values were calculated using a chi-square test.


Tabl

e 5.

Com

paris

on o

f mea

sure

d va

riabl

es in

the

inte

rven

tion

and

cont

rol g

roup

at b

asel

ine

and

post

inte

rven

tion

at 3

mon

ths

Vari

able

s

Inte

rven

tion

Gro

upCo

ntro

l Gro

up

Base

line

Post

In

terv

enti

on

at 3

Mon

ths

p-v

alue

*Ba

selin

ePo

st

Inte

rven

tion

at

3 M

onth

sp

-val

ue*

Know

ledg

e Sc

ore

(%)

Mea

n68

.96

77.7

0

0.00

6

73.0

470

.52

0.11

2M

edia

n74

.00

80.0

075

.00

73.0

0St

d D

ev18

.45

9.24

13.4

612

.09

Min

18.0

058

.00

42.0

042

.00

Max

94.0

092

.00

98.0

094

.00

No

of p

atie

nts

pass

(%)*

41 (8

2)49

(98)

0.02

448

(96)

47 (9

4)1.

00

Phys

ical

A

ctiv

ity

(hou

rs/

wee

k)

Mea

n31

.1239

.69

0.02

6

30.9

126

.30

0.04

0M

edia

n25

.62

36.9

028

.25

25.5

0St

d D

ev20

.26

19.6

720

.85

17.3

9M

in2.

604.

001.

502.

00M

ax85

.00

91.2

078

.40

84.5

0

Phys

ical

A

ctiv

ity

(MET

S-m

inut

es p

er

wee

k)

Mea

n27

98.6

648

79.0

5

<0.0

01

3824

.30

3120

.57

0.04

5M

edia

n20

40.0

044

90.0

033

60.0

025

20.0

0St

d D

ev25

00.2

426

50.8

435

76.8

831

59.8

5M

in24

0.00

1320

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0.00

96.0

0M

ax10

080.

0011

520.

0015

564.

0014

580.

00M

ETs

high

, fre

quen

cy (%

)11

(22)

33 (6

6)<0

.001

26 (5

2)16

(32)

0.06

8M

ETs

mod

erat

e, fr

eque

ncy

(%)

35 (7

0)14

(28)

<0.0

0116

(32)

16 (3

2)N

AM

ETs

low

, fre

quen

cy (%

)4

(8)

1 (2

)0.

378

8 (1

6)8

(16)

0.79


Vari

able

s

Inte

rven

tion

Gro

upCo

ntro

l Gro

up

Base

line

Post

In

terv

enti

on

at 3

Mon

ths

p-v

alue

*Ba

selin

ePo

st

Inte

rven

tion

at

3 M

onth

sp

-val

ue*

Dai

ly

Calo

rie

Inta

ke (k

cal)

Mea

n12

28.6

511

06.14

0.01

3

1198

.65

1128

.14

0.30

8M

edia

n11

40.0

010

29.0

011

92.0

010

48.7

5St

d D

ev37

2.25

299.

9744

7.73

348.

07

Min

Max

569.

0068

4.00

541.

0060

1.50

2320

.00

2119

.00

2426

.50

2354

.00

No

or p

atie

nts

tota

l cal

orie

s =

reco

mm

ende

d da

ily re

quire

men

t (%

)46

(92)

49 (9

8)0.

378

46 (9

2)48

(96)

0.67

4

No

of p

atie

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tota

l cal

orie

s <

reco

mm

ende

d da

ily re

quire

men

t (%

)4

(8)

1 (2

)0.

378

2 (4

)1

(2)

1.00

No

of p

atie

nts

tota

l cal

orie

s >

reco

mm

ende

d da

ily re

quire

men

t (%

)0

0N

A2

(4)

1 (2

)1.

00

HbA

1c (%

)

Mea

n8.

108.

11

0.95

5

7.41

7.46

0.71

9M

edia

n7.

707.

507.

207.

20St

d D

ev1.

902.

101.

681.

59M

in4.

905.

604.

704.

60M

ax14

.014

.012

.90

14.6

0N

o of

pat

ient

s ac

hiev

ing

targ

et

HbA

1c (%

)9

(18)

15 (3

0)0.

251

14 (2

8)14

(28)

0.82

4

Tabl

e 5

(con

tinu

ed)


Vari

able

s

Inte

rven

tion

Gro

upCo

ntro

l Gro

up

Base

line

Post

In

terv

enti

on

at 3

Mon

ths

p-v

alue

*Ba

selin

ePo

st

Inte

rven

tion

at

3 M

onth

sp

-val

ue*

BMI (

kg/m

2 )

Mea

n26

.52

26.2

0

0.06

9

27.11

27.0

9

0.86

1M

edia

n26

.05

25.6

527

.36

27.4

3St

d D

ev4.

654.

304.

564.

53M

in18

.00

18.0

016

.01

16.0

1M

ax41

.20

40.8

039

.76

41.7

3N

o of

pat

ient

s un

derw

eigh

t (%

)1

(2)

2 (4

)0.

985

2 (4

)2

(4)

0.60

9N

o of

pat

ient

s w

ith id

eal B

MI (

%)

9 (1

8)11

(22)

0.81

16

(12)

6 (1

2)0.

758

No

of p

atie

nts

obes

e (%

)40

(80)

37 (7

4)

0.64

5

42 (8

4)42

(84)

0.78

5W

eigh

t ch

ange

s (k

g)

No

of p

atie

nts

with

redu

ced

wei

ght

(%)

NA

31 (6

2)N

A22

(44)

No

of p

atie

nts

with

no

wei

ght

chan

ges

(%)

NA

4 (8

)N

A15

(30)

No

of p

atie

nts

with

incr

ease

d w

eigh

t (%

)N

A14

(30)

NA

13 (2

6)

Tabl

e 5

(con

tinu

ed)

*

p-v

alue

s w

ere

obta

ined

from

pai

red

sam

ple

t-te

sts.

** P

assi

ng m

arks

wer

e ≥

50

mar

ks


Socio-demographic analysis of the baseline data collected from both the intervention and control groups are shown in Table 4. The results showed that there is a significant difference in the ages of patients in the intervention and control group with patients in the intervention group being older. Furthermore there were statistically significant differences in ethnic populations in both groups with Malays being more dominant in the intervention group and non-Malays being more dominant in the control group. Significant differences in employment were also seen between both the intervention and control groups. Other variables such as sex, education level and duration of diabetes were not significantly different in both arms of the study.

Table 5 showed the comparison of measured variables in the intervention and control groups at baseline and post intervention at 3 months. The variables measured are knowledge score (%), physical activity (hours/week), physical activity (METS-minutes per week), daily calorie intake (kcal), HbA1c (%), BMI (kg/m2) and weight (kg).

There were significant improvements in terms of knowledge score in the intervention group while there were no significant differences in the control group. The number of patients who passed was significantly higher in the intervention group after the intervention while there were no differences in the control group. However, at baseline, it was shown that the number of patients who passed the questionnaire in the intervention group was only 82% compared to 96% in the control group.

Analysis of physical activity measured in hours of activity per week showed a significant increase in the intervention group while there was a significant decrease in the control group. Physical activity was also measured in terms of METS-minutes per week whereby there was a very significant increase in the number of patients who fell within the high physical activity category in the intervention group. There was a significant decrease in number of patients in the high physical activity category in the control group. Comparison of number of patients in the moderate physical activity category in the intervention group showed a very significant decrease in number of patients.

The study also showed a significant decrease in the mean daily calorie intake in the intervention group while there were no significant differences in the mean daily calorie intake in the control group. The data also showed no significant differences between the total numbers of patients whose daily calorie intake fell below, within or above their respective recommended daily requirements in both the intervention and control group.

Baseline HbA1c values were found to be higher in the intervention group (8.10%) compared to the control group (7.41%). However, there were no significant differences in the number of patients achieving the target HbA1c of ≤ 6.5% after data collection was carried out 3 months post-intervention.

No significant changes in BMI were noted in both arms of the study at 3 months post intervention. The number of patients who fell below the ideal BMI range in both arms


of the study was similar. However, there were slightly more patients in the ideal BMI range in the intervention group compared to the control group. In both the control and intervention group, the majority of patients fell into the obese category. There were no significant differences in the number of patients in the aforementioned categories.

Weight changes before and 3 months after the intervention were calculated for both the intervention and control groups. It was shown that 62% of patients in the intervention group lost weight while only 44% of patients in the control group lost weight within this period. Analysis of the significance of these changes was carried out by using the 2-by-2 unstratified test in Epicalc version 2000 and yielded a p-value of 0.055.

Table 6 and 7 demonstrate the effect of socio-demographic factors on the measured variables in the intervention group. The socio-demographic variables measured were age, sex, ethnicity, occupation, education level, duration of diabetes and number of patient-educator meetings. These were compared against the following variables: number of patients who pass the knowledge questionnaire (≥50%); number of patients with high or moderate physical activity (categorized according to patients METs values); number of patients achieving recommended daily calorie intake; the number of patients achieving the recommended HbA1c level (≤ 6.5%), number of patients achieving target BMI and number of patients who recorded weight reduction after 3 months.

The study showed that the number of patients who passed the knowledge questionnaire at baseline compared to at 3 months after intervention were significantly different amongst all socio-demographic variables measured. The number of patients who fall within the high or moderate physical activity groups were not significantly different in any of the socio-demographic variables measured. There was a significant decrease in number of patients who achieved the recommended daily calorie intake range for patients with duration of diabetes of less than 5 years. There were also no significant changes in terms of number of patients who achieve ideal HbA1c and BMI amongst all socio-demographic variables. Weight reduction was observed in more than 50% of patients when patients were categorized into socio-demographic groups with the exception of patients with duration of diabetes of less than 5 years.

The knowledge questionnaire was classified into several aspects as shown in Table 8 to assess intervention group patient’s knowledge on diabetes and its treatment. There were significant improvements in the general knowledge, complication of diabetes, symptoms of hypoglycemia and knowledge on diabetic diet. However there were significant decreases on knowledge of oral hypoglycaemic drugs.

HbA1c levels were measured at baseline (n = 50), at 3 months (n = 7) and at 6 months (n = 33) for patients in the intervention group. The results of number of patients who achieve target HbA1c are sown in Table 9.


Tabl

e 6.

Soc

io-d

emog

raph

ic d

iffer

ence

s am

ongs

t pat

ient

s of

the

inte

rven

tion

grou

p w

ho d

o w

ell i

n kn

owle

dge

scor

e, p

hysi

cal

activ

ity a

nd d

aily

cal

orie

inta

ke.

Vari

able

Kno

wle

dge

No

of p

atie

nts

who

pas

s (%

)

Phys

ical

Act

ivit

yN

o of

pat

ient

s w

ith

high

or

mod

erat

e ph

ysic

al a

ctiv

ity

(%)

Dai

ly C

alor

ie In

take

No

of p

atie

nts

achi

evin

g re

com

men

ded

daily

cal

orie

in

take

(%)

Base

line

n =

50

Post

3 m

thn

= 47

p-v

alue

*Ba

selin

en

= 50

Post

3 m

thn

= 47

p-v

alue

*Ba

selin

en

= 50

Post

3 m

thn

= 47

p-v

alue

*

Age

(yea

rs)

< 6

020

(8

3.3)

24 (1

00)

0.01

024

(100

)24

(100

)N

A1

(4.2

)0

0.47

0

> 6

021

(8

0.8)

25 (1

00)

0.00

522

(8

4.6)

23

(95.

8)0.

133

3 (1

1.5)

1 (3

.8)

0.30

0

Sex

Mal

e16

(8

8.9)

18 (1

00)

0.05

517

(9

4.4)

17

(94.

4)N

A2

(11.

1)1

(5.6

)0.

543

Fem

ale

25

(78.

1)31

(100

)0.

002

29

(90.

6)30

(100

)0.

093

2 (6

.3)

00.

239

Ethn

icity

Mal

ay35

(8

3.3)

41 (1

00)

0.01

040

(9

5.2)

40 (1

00)

0.38

63

(7.1)

1 (2

.4)

0.54

5

Non

-M

alay

6 (7

5.0)

8 (1

00)

<0.0

016

(75.

0)7

(87.

5)0.

190

1 (1

2.5)

0N

A

Occ

upat

ion

Une

mpl

oyed

31

(77.

5)39

(100

)0.

002

36

(90.

0)37

(97.

4)0.

284

3 (7

.5)

1 (2

.5)

0.51

0

Empl

oyed

10 (1

00)

10 (1

00)

NA

10 (1

00)

10 (1

00)

NA

1 (1

0.0)

0N

A


Vari

able

Kno

wle

dge

No

of p

atie

nts

who

pas

s (%

)

Phys

ical

Act

ivit

yN

o of

pat

ient

s w

ith

high

or

mod

erat

e ph

ysic

al a

ctiv

ity

(%)

Dai

ly C

alor

ie In

take

No

of p

atie

nts

achi

evin

g re

com

men

ded

daily

cal

orie

in

take

(%)

Base

line

n =

50

Post

3 m

thn

= 47

p-v

alue

*Ba

selin

en

= 50

Post

3 m

thn

= 47

p-v

alue

*Ba

selin

en

= 50

Post

3 m

thn

= 47

p-v

alue

*

Educ

atio

n Le

vel

Prim

ary

scho

ol

and

no s

choo

ling

25

(78.

1)31

(100

)0.

002

28

(87.

5)29

(9

6.7)

0.19

62

(6.3

)0

0.23

9

Seco

ndar

y sc

hool

and

ab

ove

16

(88.

9)18

(100

)0.

055

18 (1

00)

18 (1

00)

NA

2 (1

1.1)

1 (5

.6)

0.54

3

Dur

atio

n of

Dia

bete

s (y

ears

)

< 5

7

(87.

5)8

(100

)0.

036

7 (8

7.5)

7 (1

00)

NA

11 (1

2.5)

00.

036

> 5

34

(8

1.0)

41 (1

00)

0.00

539

(9

2.9)

40

(97.

6)0.

545

3 (7

.1)1

(2.4

)0.

545

No.

of

patie

nt-

educ

ator

m

eetin

gs

< 3

mee

tings

22

(84.

6)25

(100

)0.

015

24

(92.

3)24

(96)

0.73

31

(3.8

)1

(3.8

)0.

595

≥ 3

mee

tings

19

(79.

2)24

(100

)0.

003

22

(91.

7)23

(100

)0.

129

3 (1

2.5)

00.

036

* p

-val

ues

wer

e ca

lcul

ated

usi

ng tw

o pr

opor

tions

test

s

Tabl

e 6

(con

tinu

ed)


Tabl

e 7.

Soc

io-d

emog

raph

ic d

iffer

ence

s am

ongs

t pat

ient

s of

the

inte

rven

tion

grou

p w

ho d

o w

ell i

n H

bA1c

, wei

ght r

educ

tion

and

BMI.

Vari

able

HbA

1cN

o. o

f pat

ient

s w

ho a

chie

ve

reco

mm

ende

d le

vel (

%)

Wei

ght

No.

of p

atie

nts

who

redu

ced

wei

ght (

%)

BMI

No.

of p

atie

nts

wit

h id

eal w

eigh

t (%

)

Base

line

n =

50

Post

3 m

thn

= 47

p-v

alue

*Ba

selin

en

= 50

Post

3 m

thn

= 47

p-v

alue

*Ba

selin

en

= 50

Post

3 m

thn

= 47

p-v

alue

*

Age

(yea

rs)

< 6

03

(12.

5)5

(20.

8)0.

409

–15

(62.

5)–

8 (3

3.3)

7 (2

9.2)

0.82

9>

60

6 (2

3.1)

10 (3

8.5)

0.15

4–

16 (6

1.5)

–13

(50.

0)12

(46.

2)0.

864

Sex

Mal

e2

(11.

1)5

(27.

8)0.

067

–12

(66.

7)–

7 (3

8.9)

7 (3

8.9)

0.83

5Fe

mal

e7

(21.

9)10

(31.

3)0.

413

–19

(59.

4)–

14 (4

3.8)

12 (3

7.5)

0.67

1

Ethn

icity

Mal

ay6

(14.

3)12

(2.6

)0.

091

–25

(59.

5)–

18 (4

2.9)

17 (4

0.5)

0.97

3N

on-M

alay

3 (3

7.5)

3 (3

7.5)

0.83

4–

6 (7

5.0)

–3

(37.

5)2

(35.

0)0.

964

Occ

upat

ion

Une

mpl

oyed

8 (2

0)13

(32.

5)0.

242

–26

(65.

0)–

17 (4

2.5)

16 (4

0.0)

0.96

5Em

ploy

ed1

(10)

2 (2

0)0.

272

–5

(50.

0)–

4 (4

0.0)

3 (3

0.0)

0.41

3

Educ

atio

n Le

vel

Prim

ary

scho

ol a

nd n

o sc

hool

ing

7 (2

1.9)

12 (3

7.5)

0.14

4–

20 (6

2.5)

–16

(50.

0)14

(43.

8)0.

683

Seco

ndar

y sc

hool

and

ab

ove

2 (1

1.1)

3 (1

6.7)

0.61

4–

11 (6

1.1)

–5

(37.

8)5

(37.

8)0.

834

Dur

atio

n of

Dia

bete

s (y

ears

)

< 5

1

(12.

5)2

(25)

0.18

6–

3 (3

7.5)

–4

(50.

0)3

(37.

5)0.

301

> 5

8

(19)

13 (3

1)0.

257

–28

(66.

7)–

17 (4

0.5)

16 (3

8.1)

0.97

3

No.

of

patie

nt-

educ

ator

m

eetin

gs

< 3

mee

tings

2 (7

.7)

6 (2

3.1)

0.06

7–

16 (6

1.5)

–9

(34.

6)8

(30.

8)0.

856

≥ 3

mee

tings

7 (2

9.2)

9 (3

7.5)

0.51

5–

15 (6

2.5)

–12

(50.

0)11

(45.

8)0.

833

* p

-val

ues

wer

e ca

lcul

ated

usi

ng tw

o pr

opor

tions

test

s


Table 8. Comparison of intervention group patient’s knowledge on different categories

Knowledge Categories BaselinePost-Intervention

(3 months)p-value*

General knowledge 37 (74%) 44 (88%) 0.019

Symptoms of diabetes 46 (92%) 45 (90%) 0.731

Complications of diabetes 44 (88%) 47 (94%) 0.042

Causes of hypoglycaemia 42 (84%) 44 (88%) 0.241

Symptoms of hypoglycaemia

42 (84%) 46 (92%) 0.045

Causes of hyperglycaemia 41 (82%) 44 (88%) 0.153

Symptoms of hyperglycaemia

40 (80%) 42 (84%) 0.320

Knowledge of diabetic diet 40 (80%) 46 (92%) 0.014

Knowledge of diabetic oral hypoglycaemic agents

46 (92%) 34 (68%) 0.022

* p-value based on z test

Table 9. Number of patients who reach target HbA1c level at baseline, 3 months post intervention and 6 months post intervention.

HbA1c (%)Number of patients who reach target HbA1c (%)

Baselinen = 50

Post intervention 3 months, n = 47

Post intervention 6 months, n = 33

≤ 6.5 9 (18) 15(30) 15 (45.5%)


Table 10. Patient and lay educator opinions of the ‘Lay Educator Program’

QuestionNo. of Patients (%)

n = 46No. of Lay Educators

(%), n = 151) No. of patients who think the

program is beneficial to them personally

45 (97.8) 15 (100)

2) No. of patients who think the program would be beneficial in their residential area

42 (91.3) 15 (100)

3) No. of patients who think the program should be continued in the future

40 (86.96) 15 (100)

4) No. of patients who think that the program should be continued because:*

i) It provides relevant information about diabetes

34 (73.9) 15 (100)

ii) It provides an opportunity for discussion regarding diabetes

24 (82.17) 14 (93.33)

iii) Other reasons 5 (10.87) 05) No. of

patients who think that the program should not be continued because:*

i) It is a waste of time

0 0

ii) It is not beneficial

0 0

iii) It is burdensome 0 0

iv) Other reasons 0 0

6) No. of patients who encountered problems during the program due to:*

i) Language barrier

7 (15.22) 1 (6.67)

ii Reference materials were insufficient

19 (41.30) 10 (66.67)

iii) Time constraints 15 (32.61) 6 (40)iv) There were too

many patients in each group

4 (8.70) 2 (13.33)

* Patients/ lay educators were allowed to choose more than one answer for questions 4, 5 and 6.


A post-intervention survey was conducted amongst 46 patients in the intervention group and the 15 lay educators involved in the study to obtain their opinion regarding the ‘Lay Educator Program’. The results of the assessment are shown in Table 10. The results concluded that the majority of patients and all lay educators feel that the program is beneficial to them personally and would also be benefit occupants in their residential area. Furthermore, most patients and lay educators feel that the program should be continued in the future with the commonest reason being that it provides an opportunity for discussion regarding diabetes followed by the reason that it provides relevant information about diabetes. None of the patients felt that the program should not be continued. When patients were asked about problems encountered during the program, the most popular problem chosen was insufficient reference materials followed by time constraints, language barrier and having too many patients in each group. However amongst the lay educators, the majority felt that insufficient reference materials were a problem followed by time constraints, having too many patients in a group and language barriers.

5.0 DISCUSSION

Diabetes mellitus is one of the most common chronic medical illnesses encountered in health clinics and hospitals nationwide. The number of patients diagnosed in the health setting is on the rise every year. Diabetic control is important to prevent acute and late complications associated with the disease. The cost of treating complications associated with the disease poses a very large financial burden to the government and to individuals likewise thus there is an immediate need to prevent the occurrence of diabetic complications.

One important factor in the management of diabetes and its complications is education. Health education is usually carried out by medical staff such as doctors and paramedics, as the role of lay educators is yet to be recognized in the country. However, lay educator health programs are commonly implemented in the health setting in westernized countries and our group aimed to study and review its appropriateness in the Malaysian heath setting. The study was carried out over a period of 1 year in Padang Rengas Health Clinic with Sungai Siput Hospital as the control centre.

Prior to the implementation of the program, lay educators were given lectures and training to prepare them for the program. They were then assessed based on a written questionnaire before and after training was given. There were no significant differences in the results of the assessment before and after training however there was an increase in the minimum score achieved from 54% before training was given, to 72% after training was given indicating that the teaching module was effective in improving the lay educators’ diabetic knowledge.


Comparisons of measured variables in the intervention and control group at baseline and post intervention at 3 months were carried out. The results showed significant improvements in knowledge score, physical activity and daily calorie intake in the intervention group but no changes were noted in the control group. There were no changes in HbA1c and BMI for both groups 3 months post intervention probably because 3 months was too short to allow for any major changes. Weight reduction in both intervention group and control groups were significant indicating that health education was effective in lifestyle modifications in patients.

Analysis of the socio-demographic differences between patients in the intervention and control centre showed a significant difference between age, ethnicity and occupation between both populations. Patients in the intervention group were older than patients in the control group. Furthermore there were more patients in the intervention group who were unemployed compared to patients in the control group. These findings were probably caused by the intervention group population being largely comprised of pensioners. Furthermore, the populations in the control centre, Hospital Sungai Siput were largely involved in FELDA plantation programs. The control centre also mainly comprised of Indians whereas the intervention centre comprised mainly of Malays. Due to these significant differences between both the intervention and control groups, direct comparison of socio-demographic differences to the measured variables between both groups could not be carried out.

A socio-demographic comparison of patients in the intervention group was done against the measured variables of the study. The results showed that in terms of physical activity, patients who had diabetes for less than 5 years had a significant increase in physical activity following the intervention. This was probably due to this group of patients being younger and more susceptible to change whereas patients who have had diabetes for more than 5 years were probably older and suffered from other comorbidity or complications that limited their amount of physical activity. These patients also probably had weekly routines which they found difficult to alter. Besides that, patients who had diabetes for less than 5 years failed to maintain their daily calorie intake within the recommended range and many were found to have daily calorie intakes below the recommended range. A possible explanation for this is that these patients are falsely reporting their 24 hour diet recall as the results do not coincide with their weight.

In terms of knowledge score improvement, there were significant improvements in knowledge score for all populations regardless of their socio-demographic differences. This indicates that the education program was effective and patients understood what was conveyed to them by the educators. The improvement in knowledge in female patients were more obvious than those in male patients possibly because the female patients paid more attention during the meetings with educators and were more willing and interested to learn new information compared to their male counterparts. There were no


improvements in the knowledge score of employed patients in the intervention group because at baseline 100% of these patients passed the questionnaire.

There were no significant changes in HbA1c and BMI in all socio-demographic factors analysed in the study because the post intervention data was only collected at 3 months and the duration was too short to allow for any major changes in these variables to occur. However, weight reductions were measured and the results showed significant improvements in all populations based on socio-demographic data.

Knowledge regarding diabetes and other related areas of concern were analysed from the knowledge questionnaire. The results showed that the intervention was effective in improving patient’s knowledge in diabetes but was inadequate in terms of educating patients regarding oral hypoglycaemic agents.

The diabetic lay educator program was implemented at Padang Rengas Health Clinic with the support from the local community. This program was a new concept to the local residents especially for the diabetic patients. The program received very positive feedback from the patients and lay educators involved with lay educators showing interest in continuing the program as shown in results of the post-intervention survey.

Staff, patients and lay educators involved in the program contributed useful suggestions for improvement as several limitations were encountered during the course of the study:

a) Staff. There is a need for dedicated medical staff to be officially allocated to the program, as their role is important in ensuring that the program runs smoothly during each session. They are required to handle the logistics of the program and also to address issues brought up by both the lay educators and patients. The lack of such dedicated staff led to several complications during the course of our study such as miscommunications and delays in contacting either lay educators or patients for the monthly sessions.

b) Lay Educators. We initially encountered problems sourcing for volunteers to become lay educators due to factors such as disinterest, low education level and lack of commitment. At the start of the program we had 35 lay educators but towards the end of the program there were only 16 left. The lack of interest and dedication of these educators were de-motivating to the patients and lay educator patient groups had to constantly be changed due to lay educators dropping out of the program. Committed and interested volunteers who are willing to become permanent lay educators are required to avoid such complications from occurring. Furthermore, there is a need for lay educators of different races to address language barriers. In our study, all the lay educators were Malays and they had problems communicating with patients of other ethnicity. As the numbers of dedicated lay educators were very limited, we were unable to choose lay educators depending on their assessment score, as this will further reduce the number of lay educators involved in the study.


Ideally, lay educators should be chosen based on their assessment results to ensure that the educators are competent enough to educate patients.

c) Patients. The initial plan for the study was for patients in the intervention group to meet the lay educators assigned to them at least 3 times throughout the course of the study. Meetings were scheduled to be carried out in Padang Rengas Health Clinic at least once a month but time constraints and transportation problems caused many patients to be unable to attend each meeting as planned. At the end of the intervention, only 48% of patients were able to attend 3 sessions and the remaining 52% did not receive the full intervention. The number of patients allocated to each lay educator should be limited to 3 and ideally patients should meet their assigned lay educators on a 1:1 basis to ensure effective learning.

d) Learning Materials. Lay educators were given lectures on diabetes mellitus and training prior to the implementation of the intervention. They were then supplied with lecture notes and relevant reference materials however patients were not supplied with these. There were also insufficient pamphlets and posters for teaching purposes. Standard teaching and reference materials should be provided to both lay educators and patients to aid their continuous learning process. Reference materials should be in lay terms rather than complicated medical terms so as not to confuse patients. The materials should also be available in different languages to cater for patients and lay educators of other ethnicity. A standard guideline on topics for discussions between the lay educator and patient is needed to ensure a more focused discussion.

Other suggestions for improvement include the need to increase the frequency of the program to two times per month for better monitoring of patients.

6. 0 CONCLUSION & RECOMMENDATION

The diabetic lay educator program was implemented at KK Padang Rengas. It was done with the cooperation from the community. It was a useful program for diabetic patient at health clinics.

The diabetic lay educator program is a new program implemented at Padang Rengans Health Clinic. It was handled by members of the local community and aimed to help diabetic patients improve their knowledge about diabetes in the following areas: symptoms of hypo- and hyperglycaemia, causes of hypo- and hyperglycaemia, diabetic complications, diabetic diet, physical activity and diet control. HbA1c and BMI results did not show any improvement after 3 months of the implementation of the intervention but improvements are expected 6 months after the intervention.


In view of the positive findings of this study, we recommend that this program to be continued in clinics and health centres in other parts of the country. We should also utilize this program to improve diabetic control in their patients. This program is especially useful in dealing with the education of diabetic patients where the lack of medical staff in hospitals and clinics limits the effectiveness of this.

REFERENCES

1. Sicree R, Shaw J, Zimmet P. The Global Burden of Diabetes. In: DeliceGan editor(s). Diabetes Atlas. Second Edition. Brussels: International Diabetes Federation, 2003:17-71.

2. Diabetes Malaysia [monograph on the internet]. Malaysia: Diabetes Malaysia. Available from: http://www.dph.gov.my/ncd/diabetes/informasi/statistik.htm

3. Stratton IM, Adler AI, Neil HAW, Matthews DR, Manley SE, Cull CA. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321:405-412

4. Boule NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus. A meta-analysis of controlled clinical trials. Jama 2001; 286: 1218-27.)

5. Goldhaber-Fiebert JD, Goldhaber-Fiebert SN, Tristan ML, Nathan DM. Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type diabetic patients in rural Costa Rica. Diabetes Care 2003; 26: 24-29.

6. Beam N, Tessaro I. The Lay Health Advisor Model in theory and practice: an example of an agency-based program. Farm Community Health. 1994; 17:70-79.

7. American Association of Diabetes Educators. Diabetes Community Health Workers. The Diabetes Educator. 2003; 29(5): 818-824.

8. Hospital Putrajaya, Bahagian Pendidikan Kesihatan Bahagian Perkhidmatan Perubatan, Kementerian Kesihatan Malaysia. Diabetes Protokol Pendidikan Pesakit Diabetes Bagi Warga Kesihatan.

9. Nutrient Composition of Malaysian Foods (Energy and Fat). Nutrient Composition of Malaysian Foods 4th Edition. 1997.

10. Recommended Nutrient Intakes for Malaysia. A Report of the Technical Working Group on Nutritional Guidelines. National Coordinating Committee on Food and Nutrition. Ministry of Health Malaysia. Putrajaya. 2005.

11. Norman J. Arnold. The Compendium of Physical Activities Tracking Guide. Prevention Research Centre. School of Public Health, University of South Carolina. 2002. http://prevention.sph.sc.edu/tools/doc/documents_compendium.pdf


12. Global Physical Activity Questionnaire Analysis Guide. Surveillance and Population-Based Prevention Department of Chronic Diseases and Health Promotion. World Health Organization. http://www.who.int/chp/steps/resources/GPAQ_Analysis_Guide.pdf

ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper. Our sincere gratitude goes to the Perak State Health Department for organizing this valuable health research program. Our appreciation also goes to Dr Hajjah Sabaridah Haji Ismail, Medical Officer of Kuala Kangsar District Health Office and Dr Kamalakshi A/P Saminathan, Director of Hospital Sungai Siput for allowing our group to conduct our study in both Padang Rengas Health Clinic and Sungai Siput Hospital respectively. We would also like to thank Dr Thong Kah Mean, Mr Faisal bin Mohamed, Mr Habibullah bin Mohd Khatib, Ms Noor Hasmiza bt Azmi, Ms Khairina Khalil and the 16 lay educators involved in our study for their invaluable input and continuous cooperation throughout the study. Last but not least we are hugely indebted to our facilitators Dr Ranjit Kaur, Dr Amar-Singh HSS, Dr Sondi Sararaks and Dr Narwani Hussin for their tireless patience and guidance in helping us make this study possible.


APPENDICES

Appendix A: Educational module for lay diabetic educators

Module 1 (2 hours): Introduction

1. Definition of diabetes.2. Risk factors - Genetics - Obesity - Age 35 years or older - History of Gestational Diabetes Mellitus - Hypertension - Hyperlipidaemia 3. Signs and symptoms of hyperglycaemia - Polyuria - Polydypsia - Weight loss4. Signs and symptoms of hypoglycaemia - Dizziness - Palpitations - Sweating5. Target of sugar level - HbA1c < 6.5 %6. Medications - Method of administration - Side effects7. Complications - Macrovascular and microvascular

Module 2 (2 hours): Life- style modification and medication counseling

1. Diet - recommended servings - 24 hours diet recall2. Physical Activity - recommended duration of physical exercise


Appendix B: Assessment questionnaire for lay educators

Nama:______________________________________ Tarikh:____________

Penilaian Tahap Pengetahuan Mengenai Penyakit Kencing Manis

I. PENGETAHUAN MENGENAI PENYAKIT DIABETES

Ya Tidak1) Diabetes adalah sejenis penyakit yang dihidapi seumur hidup.

2) Apakah tanda-tanda yang akan dialami bila menghidapi penyakit kencing manis? (jawapan boleh lebih daripada satu)a) Kehausan

b) Kehilangan berat badan

c) Kerap buang air kecil

d) Jangkitan yang lambat sembuh

e) Penglihatan yang semakin kabur

f) Terasa pening kepala

g) Tangan dan kaki terasa kebas

3) Apakah komplikasi-komplikasi yang akan dialami oleh anda jika tidak mengawal kencing manis? (jawapan boleh lebih daripada satu)a) Kegagalan buah pinggang

b) Serangan sakit jantung

c) Mati pucuk

d) Kerosakan pada mata

e) Gangrene

f) Angin ahmar / strok

g) Hujung kaki/tangan menjadi kebas/hilang deria sentuh

h) Gangguan saraf

4) Apakah yang menyebabkan kejadian paras gula di dalam darah menjadi terlalu rendah? (jawapan boleh lebih daripada satu)

a) Pengambilan makanan secara tidak teratur

b) Pengambilan makanan yang sedikit

c) Tidak mengambil makanan selepas mengambil ubat

d) Meninggalkan pengambilan makanan utama (skipped meal)

e) Dos ubat yang berlebihan

f) Mengambil bahagian dalam aktiviti yang lasak serta pengambilan makanan yang mencukupi


5) Apakah tanda-tanda sekiranya paras gula di dalam darah menjadi terlalu rendah? (jawapan boleh melebihi satu)

a) berpeluh terlalu banyak

b) rasa lapar

c) terasa panas

d) terasa segar e) denyutan jantung menjadi pantas

f) penglihatan kabur

g) koma

6) Apakah yang menyebabkan paras gula di dalam darah menjadi tinggi? (jawapan boleh melebihi satu)

a) Pengambilan makanan yang bergula dan kandungan karbohidrat secara berlebihan

b) Mengambil terlalu banyak makanan pada satu masa

c) Tekanan perasaan

d) Berat badan berlebihan

e) Jangkitan dan demam

7) Apakah tanda-tanda sekiranya paras gula di dalam darah menjadi terlalu tinggi?

a) hilang selera makan

b) kerap membuang air kecil

c) muntah-muntah

d) letih lesu

e) dahaga

f) kesukaran bernafas

II. PENGETAHUAN TENTANG PEMAKANAN

8) Apakah jenis makanan yang perlu dihadkan oleh pesakit kecing manis? (sila jawab semua soalan) a) sayur-sayuran hijau

b) nasi, roti, bijiran

c) mee, mihun, kuey tiow

d) lobak, labu, kentang, ubi kayu, keledek

e) buah-buahan

f) teh/kopi


9) Jika terlepas makan waktu malam, pesakit kencing manis boleh menggantikannya dengan mengambil makanan yang lebih pada waktu makan seterusnya.

III. PENGETAHUAN TENTANG UBAT-UBATAN

10 a) Apabila terlupa dos, dos tersebut boleh diambil bersama dengan dos yang seterusnya

b) Boleh diambil bersama dengan alkohol

c) Harus diambil berdasarkan pada jadual yang ditetapkan


Appendix C: Questionnaire for Knowledge Score

Borang Soal Selidik Pengetahuan Mengenai Kawalan Kencing Manis Di kalangan Pesakit Kencing Manis (Jenis 2)

Bahagian A: Biodata

1) RN:

2) No Kad Pengenalan:

3) Umur: tahun

4) Jantina: LelakiPerempuan

5) Bangsa: MelayuCinaIndiaSikhLain-lain Nyatakan : _______________________

6) Pendidikan: Tidak bersekolahSekolah rendahSekolah menengahSijil/Diploma/Ijazah

7) Pekerjaan: Tidak bekerjaBuruhSemi-profesionalProfesional

8) Berat Badan: kg

9) Tinggi: cm

10) BMI: kg/m2

11) HbA1C: %

12) Tempoh mengidap kencing manis: tahun bulan


Bahagian B : Pengetahuan Ya TidakI. Pengetahuan mengenai penyakit diabetes1) Diabetes adalah sejenis penyakit yang dihidapi seumur hidup.

2) Apakah tanda-tanda yang akan dialami bila menghidapi penyakit kencing manis? (jawapan boleh lebih daripada satu)

a) Kehausan

b) Kehilangan berat badan

c) Kerap buang air kecil

d) Jangkitan yang lambat sembuh

e) Penglihatan yang semakin kabur

f) Terasa pening kepala

g) Tangan dan kaki terasa kebas

3) Apakah komplikasi-komplikasi yang akan dialami oleh anda jika tidak mengawal kencing manis? (jawapan boleh lebih daripada satu)

a) Kegagalan buah pinggang

b) Serangan sakit jantung

c) Mati pucuk

d) Kerosakan pada mata

e) Gangrene

f) Angin ahmar / strok

g) Hujung kaki/tangan menjadi kebas/hilang deria sentuh

h) Gangguan saraf

4) Apakah yang menyebabkan kejadian paras gula di dalam darah menjadi terlalu rendah ? (jawapan boleh lebih daripada satu)

a) Pengambilan makanan secara tidak teratur

b) Pengambilan makanan yang sedikit

c) Tidak mengambil makanan selepas mengambil ubat

d) Meninggalkan pengambilan makanan utama (skipped meal)

e) Dos ubat yang berlebihan

g) Mengambil bahagian dalam aktiviti yang lasak serta pengambilan makanan yang mencukupi

5) Apakah tanda-tanda sekiranya paras gula di dalam darah menjadi terlalu rendah? ( jawapan boleh melebihi satu)

a) berpeluh terlalu banyak

b) rasa lapar

c) terasa panas

d) terasa segar

e) denyutan jantung menjadi pantas

f) penglihatan kabur

g) koma


6) Apakah yang menyebabkan paras gula di dalam darah menjadi tinggi? ( jawapan boleh melebihi satu)

a) Pengambilan makanan yang bergula dan kandungan karbohidrat secara berlebihan

b) Mengambil terlalu banyak makanan pada satu masa

c) Tekanan perasaan

d) Berat badan berlebihan

e) Jangkitan dan demam

7) Apakah tanda-tanda sekiranya paras gula di dalam darah menjadi terlalu tinggi?

a) hilang selera makan

b) kerap membuang air kecil

c) muntah-muntah

d) letih lesu

e) dahaga

f) kesukaran bernafas

II. Pengetahuan tentang pemakanan8) Apakah jenis makanan yang perlu dihadkan oleh pesakit kecing manis?

(sila jawab semua soalan) a) sayur-sayuran hijau

b) nasi, roti, bijiran

c) mee, mihun, kuey tiow

d) lobak, labu, kentang, ubi kayu, keledek

e) buah-buahan

f) teh/kopi

9) Jika terlepas makan waktu malam, pesakit kencing manis boleh menggantikannya dengan mengambil makanan yang lebih pada waktu makan seterusnya.

III. Pengetahuan tentang ubat-ubatan 10 a) Apabila terlupa dos, dos tersebut boleh diambil bersama

dengan dos yang seterusnya

b) Boleh diambil bersama dengan alkohol

c) Harus diambil berdasarkan pada jadual yang ditetapkan


Appendix D: 24 Hour Diet Recall

TarikhWaktu

Pengambilan Makanan

Jenis Makanan Saiz/Hidangan Cara Masakan Nilai Kalori

Sarapan Pagi

Minum Pagi

Makan T/Hari

Minum Petang

Makan Malam

‘Supper’


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Appendix F: Post-intervention Survey

Soalan Kajiselidik “Lay Educator” dan Pesakit Diabetis

1) Adakah anda dapati program ini berfaedah kepada anda ? Ya Tidak Tidak pasti2) Adakah anda dapati program ini berfaedah untuk program diabetis di tempat anda? Ya Tidak Tidak pasti3) Adakah anda merasakan program ini patut diteruskan pada masa depan? Ya (jika ya, sila rujuk soalan 4) Tidak (jika tidak, sila rujuk soalan 5) Tidak pasti4) Program ini patut diteruskan pada masa depan kerana: (boleh pilih lebih daripada satu jawapan) Menambahkan pengetahuan tentang penyakit kencing manis Mewujudkan peluang untuk perbincangan Lain- lain (sila nyatakan): ______________________________________5) Program ini TIDAK patut diteruskan pada masa depan kerana: (boleh pilih lebih daripada satu jawapan) Membuang masa Tidak berfaedah Membebankan Lain-lain (sila nyatakan) : _______________________________________6) Apakah masalah yang anda hadapi semasa menyertai program ini? (boleh pilih lebih daripada satu jawapan) Komunikasi bahasa Bahan pengajaran/rujukan tidak mencukupi Masa Terlalu ramai pesakit dalam satu kumpulan7) Apakah cadangan anda untuk memperbaiki modul pengajaran ini ?

a) Masa: ____________________________________________________

b) Bilangan peserta dalam satu kumpulan: __________________________

c) Bilangan bahan rujukan sebagai pengajaran: _______________________ d) Cadangan untuk menambah bilangan “Lay Educators” (untuk dijawab oleh

“lay educators” sahaja) ________________________________________

163

Improving Knowledge Of Type 2 Diabetes Mellitus Patients On Oral Hypoglycaemic AgentsHealth Systems Research November 2007

Authors

Mohd Rohaizad ZamriHospital Teluk Intan

Umi Hani Mohd AsmawiHospital Teluk Intan

Mohd Fadhil SamsuriHilir Perak Health Office

Liliwati IsmailHilir Perak Health Office





Ruzzita MustaffaHilir Perak Health Office

Sabab HashimHospital Raja Permaisuri Bainun Ipoh

Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Mohd Rohaizad Zamri, Umi Hani Mohd Asmawi, Mohd Fadhil Samsuri, Liliwati Ismail, Amar-Singh HSS, Sondi Sararaks, Ranjit Kaur Praim Singh, Asmah Zainal Abidin, Ruzzita Mustaffa, Sabab Hashim. ”Improving Knowledge Of Type 2 Diabetes Mellitus Patients On Oral Hypoglycaemic Agents” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 163. (ISBN: 9789671063491)

ISBN

9789671063491

164 Improving Knowledge Of Type 2 Diabetes Mellitus Patients On Oral Hypoglycaemic Agents


Abstract 163


1.1 Background and problem analysis


2.0 Objectives 170



3.0 Methodology 170

3.1 Study type and Design

4.0 Sampling 174

4.1 Inclusion criteria

4.2 Exclusion criteria


4.4 Variables

4.5 Data collection techniques

4.6 Ethical Issues

5.0 Results 179

5.1 Overview of the study

5.2 Patient’s knowledge

6.0 Discussion 187

6.1 Problems and limitations

6.2 Discussion of results


7.1 Conclusion

7.2 Recommendations

References 191

Acknowledgement 193

Appendices 194

165Improving Knowledge Of Type 2 Diabetes Mellitus Patients On Oral Hypoglycaemic Agents

ABSTRACT

Improving Knowledge Of Type 2 Diabetes Mellitus Patients On Oral Hypoglycaemic Agents

Mohd Rohaizad Zamri1, Umi Hani Mohd Asmawi1, Mohd Fadhil Samsuri2, Liliwati Ismail2, Amar-Singh HSS3,6, Sondi Sararaks4, Ranjit Kaur Praim Singh5, Asmah Zainal Abidin5, Ruzzita Mustaffa2, Sabab Hashim6

1 Hospital Teluk Intan2 Hilir Perak Health Office3 Clinical Research Centre Perak4 Institute for Health Systems Research5 Perak State Health Department6 Hospital Raja Permaisuri Bainun Ipoh

Introduction

Healthcare providers nowadays are encountering a vast number of diabetic patients in Malaysia and the prevalence is increasing every year and so does the use and number of oral hypoglycaemic agents. The National Health and Morbidity Survey had shown an increase in the number of type 2 diabetic patients from 6.3% in 1986 to 8.3% in 1996 (Malaysian Consensus Clinical Practice Guidelines 2004). The situation is similar in District of Hilir Perak, where in 2004 the number of diabetic patients was 4952 and has increased to 5063 in February 2005. In outpatient department of Hospital Teluk Intan itself, there is a total of 2967 diabetic patients registered up to June 2006 (Daftar Diabetes 2005 & 2006. PKD Hilir Perak). Compliance towards medication is regarded as a major problem in healthcare. Better understanding of the problem is needed in order to improve the medication compliancy of patients (Norehan Abdullah 2002). A study in Hospital Taiping revealed 25% of patients are non-compliant towards their medication due to poor knowledge (Ng C.B., 2002) and another 46% in a similar study in Kedah.

To improve knowledge among diabetic patients on oral hypoglycemic agent (OHA) in outpatient departments in Hilir Perak District by implementing intervention program.

Methodology

An interventional experimental study on type 2 diabetic patients on OHA treatment was conducted from November 2006 to August 2007 in outpatient department in District of Hilir Perak (Hospital Teluk Intan and 3 health clinics). This study consists of three phases. Phase 1 was baseline data collection using a standard structured questionnaire, Phase 2 was development of an intervention package to educate patient. The package consists of standardized structured guidelines (Buku Panduan OHA Untuk Pesakit Diabetes Mellitus Jenis 2) (Appendix 1), OHA Chart (Appendix 2), medication explanation checklist (Appendix 3), reminder stickers for OHA envelopes (Appendix 4) and pamphlets (Appendix 5). Phase


3 was implementation of the package done continuously everyday and followed by post-intervention study using the same questionnaire. Two post-intervention studies were done in May and August to evaluate effectiveness of the program.

Results

There was a significant difference between two different settings (hospital and health clinics) in baseline socio-demographic characteristics and clinical profile (age and number of co-morbidities p-value = 0.003, ethnicity and duration of illness p value <0.001). The intervention produced significant improvement across all socio-demographic factors (p-value <0.001), in both settings, more prominently in health clinics. In hospital setting, patients with socio-demographic factor of lower educational level showed significant improvement of knowledge after intervention, but in health clinics, solely diabetics showed improvement in knowledge after intervened.

Conclusion

Patients’ baseline knowledge regarding OHA is poor. The intervention module is effective showed by significant improvement in overall knowledge for both hospital and health clinics. However, improvement in health clinic is more than in hospital.

Recommendations

Continuation of this intervention package is highly recommended to a more extended scope regardless of socio-demographic background. The application of reminder sticker shall be continued and extended to all health centers because it provides complete and specific information on OHA. Intervention shall stress more in elderly (age >60 years old) in general and in specific, OHA names are stressed for those who cannot read with perhaps a different approach.

1.0 INTRODUCTION

1.1 Background and problem analysis

Diabetes Mellitus (DM) has been defined by World Health Organization (WHO) as a state of chronic hyperglycemia. The prevalence in the United States (USA) and European countries is approximately 6% (www.diabetes.niddk.nih.gov/dm/pubs/statistics). The clinical classification of DM syndromes follows the WHO recommendation; type 1, type 2, DM secondary to other diseases, gestational DM and impaired glucose tolerance. More than 95% of diabetics in Europe and USA fall into type 2 category. The disease affects people older than 40 years, especially the elderly. Diabetes is widely recognized as one of the leading causes of death and disability worldwide. It is associated with long term complications that affect almost


every part of the body. Total annual diabetes cost in the USA approximately USD135 billion.

The goal of diabetes care is to manage the disease so that the patient can lead as near to normal life as possible. Healthcare providers nowadays are encountering a vast number of diabetic patients in Malaysia and the prevalence is increasing every year and so does the use and number of oral hypoglycaemic agents.

The National Health and Morbidity Survey had shown an increase in the number of type 2 diabetic patients from 6.3% in 1986 to 8.3% in 1996 (Malaysian Consensus Clinical Practice Guidelines 2004). The situation was similar in District of Hilir Perak, where in 2004 the number of diabetic patient was 4952 and has increased to 5063 in February 2005. In outpatient department Hospital Teluk Intan itself, there are a total of 2967 diabetic patients registered up to June 2006 (Daftar Diabetes 2005 & 2006. PKD Hilir Perak).

Compliance towards medication is regarded as a major problem in healthcare. Better understanding of the problem is needed in order to improve the medication compliancy of patients (Norehan Abdullah 2002). It has been generally accepted that educational programs can be beneficial in the treatment of a number of chronic disease such as diabetes. The findings of one study has shown a positive short and long term impact of a structured educational intervention on the patient’s knowledge of issues related to hypertension (Cuspidi C et al., 2000). One outcome study in Pakistan emphasizes the need for diabetes education at all levels, both for the patients as well as the health care providers to counter the pandemic of diabetes-related complication globally (Jabbar A et al., 2001). Many studies have shown that diabetic patient education activities should be directed primarily at stimulating adherence to the drug dosage and awareness of side effect (Timmer JW et al. 1999; Donnan et al. 2002) A study in Hospital Taiping revealed 25% of patients are non-compliant towards their medication due to poor knowledge (Ng C. B., 2002) and another 46% in a similar study in Kedah. In additional, it was showed that among all medication used in Malaysia, sulphonylureas were the most widely used (21.157 DDD/1000 population per day) (Malaysian Statistic of Medicine 2004).


Patient’s knowledge regarding their medication is one of the crucial elements in ensuring compliance as part of knowledge on the disease itself. Most of the medical personnel are facing difficulties to implement effective measures to improve patient’s understanding towards their medication as it involves multiple limitations and obstacles with absence of a systematic and unified module for patient education.

Apart from this reason, together with certain limitations, it would be appropriate for this study to further focus in educating patients on their medication in order


to improve compliance and subsequently help in controlling the morbidity and mortality from diabetes mellitus.

It is well known that medications are not taken correctly as directed. Some patient may not obtain maximal therapeutic benefit because of poor adherence to their treatment plans (Vivian EM, 2007). Compliance towards medication is regarded as a major problem in healthcare, and a better understanding of the problem is needed in order to improve the medication taking behavior of patients (Norehan Abdullah 2002). A study in Hospital Taiping revealed 25% of patients are non-compliant towards their medication due to poor knowledge (Ng C. B., 2002). Another similar study done in Kedah revealed 46% of patients with non-compliance due to the very same reason.

Another study was done to assess knowledge about oral hypoglycemic agents among patients with diabetes and non-specialist healthcare professionals. This study found that patients’ and professionals’ knowledge of oral hypoglycemic agents is poor. More appropriate advice and information to patients from prescribers may improve patient understanding and hence compliance (Browne D. L. et al. 2000).

In order to achieve recommended glycaemic control, The Global Partnership for Effective Diabetes Management proposed 10 key practical recommendations. The 10th step was implementing a multi- and interdisciplinary team approach to diabetes management to encourage patient education and self-care and share responsibility for patients achieving glucose goals (Prato S. D. et al. 2005). This recommendation proves the importance of patients’ education program that we did now.

A study was done by Timmer JW et al. 1999 indicates patient education activities directed at users of OHA are desirable in the community. According to the result, patient education activities should be directed primarily at stimulating adherence to the dosage regimen and increasing awareness of side effects. Preconditions that should be considered when implementing these activities were structural cooperation with medical officer and diabetic nurses and pharmacist.

From analysis, there are many contributing factors that affect patient’s knowledge on Oral Hypoglycemic Agent (OHA) today. Both patient and healthcare provider are two major groups contributing to this problem.

One tablet per day administration was associated with greater adherence than multiple tablets. Poor adherence is a major obstacle in the treatment of type 2 diabetes (Donnan P. T. 2002).

Common patient factors contributing to this problem are educational level, socioeconomic status, lack of awareness or motivation, physical or cognitive impairment and age. Common healthcare provider factors are inadequate


IMPROVING KNOWLEDGE OF TYPE 2 DIABETES MELLITUS PATIENTS ON ORAL HYPOGLYCEMIC AGENTS

9

Figure 2: Bubble chart of problem statement of the study

Assessing knowledge of

diabetic patient on OHA

Patient’s factor

Service delivery problem

Educational

level

Lack of awareness

age

Multiple Medical problem

confusion

Misunderstanding

Disability

Deaf, dumb,

blind

Poor health

seeking attitude

Exposure

Socio economic

status Encourage- ment

Staff factor

Inadequate Man power

Expanded

scope

Lack of

time

Poor explanation

Assume Patient know

language

Wrong

information

Figure 1. Bubble chart of problem statement of the study

human resource, wrong or uncoordinated information, time constraint and poor communication skills (refer to Figure 1).

Therefore, the scenario stated has necessitate this study to be done in order to assess diabetic patient knowledge on the OHA that they are consuming every day, hence recommend areas needed to be improved in our population.

This study aims to evaluate on patient basic knowledge towards OHA. The study also aims to assess contributing factors to patient knowledge on OHA. At the end of this study we hope that the data and results can be used to improve patient knowledge on OHA. From problem analysis bubble chart, there are many contributing factors that affect patient’s knowledge on Oral Hypoglycemic Agent (OHA) today. Both patient and healthcare provider are two major groups contributing to this problem.


2.0 OBJECTIVES


To improve knowledge among diabetic patient on oral hypoglycemic agent (OHA) in all outpatient department in District of Hilir Perak.


i. To assess the current limitations in patient’s knowledge regarding OHA treatment.

ii. To develop an interventional package for OHA medication usage by:a. Providing specific educational tools to healthcare providers for use on

patients.b. Providing focused educational material to patients.c. Improving dispensing practice.

iii. To assess effectiveness of the module by a pre and post test assessment of knowledge.

iv. To make recommendations on the value of the interventional package.

3.0 METHODOLOGY

3.1 Study Type and Design

This is an interventional experimental study design that was conducted for 11 months from November 2006 until August 2007. This study took place in outpatient departments in District of Hilir Perak, focused on type 2 diabetic patients on oral hypoglycemic agents (OHA) treatment in outpatient department Hospital Teluk Intan (hospital) and another three health clinics in Hilir Perak District (health). Patients who fulfilled the inclusion criteria from these centers were included in this study.

This study was divided into three phases. Figure 2 shows an overview of the research design.

Phase I: Baseline Data Collection

In this phase, a cross-sectional study was done upon 302 patients in both hospital and health clinics using a structured questionnaire to obtain the baseline data of our study population. No reminder or information was given prior to this study to make sure that there is no bias. A number of 150 patients were involved from hospital and another 152 from health clinic. This study was done within one month period. Face-to-face interviews were done by trained staff, namely pharmacists, pharmacy assistants and dedicated staff nurses. The main purpose of this study was to obtain baseline information data among our study population regarding their


socio-demographic status, limitations in knowledge regarding their own OHA and possible factors associated with their performance in our test.

Phase II: Development of Intervention Package and Planning for Intervention Program

Interventional package were developed to be used during the intervention program. The package consisted of focused educational materials to be used by healthcare provider and for patients. For healthcare providers, they were given three items, namely a standardized structured guidelines (Buku Panduan OHA Untuk Pesakit Diabetes Mellitus Jenis 2 (appendix 1), OHA Chart / education aid (appendix 2) and medication explanation checklist (appendix 3). Two materials focusing on patients were reminder stickers for OHA envelopes (appendix 4) and pamphlets (appendix 5). The descriptions for each material were as followed below.

1. Standardized Structured Guidelines Booklet for Instructors

This is a small six pages booklet (including cover), sized of half an A4 page, with a title “BUKU PANDUAN PENDIDIKAN OHA UNTUK PESAKIT DIABETES MELLITUS JENIS 2” as the cover page. The first and second pages consist of a list of 12 instructions for healthcare providers with a subtitle “MANUAL UNTUK PETUGAS DI KLINIK DAN FARMASI PESAKIT LUAR HOSPITAL”. The same instructions were printed again on the third and fourth page but in English Language. Page five until eight show the same information as in the OHA charts mentioned earlier regarding OHA, one OHA per page. Page nine and ten are copies of the checklist and reminder stickers respectively. On the last page (back of booklet) there are printed names, work addresses and telephone numbers of each researcher for instructors to contact should inquiries arise later. These booklets are given away to instructors during training sessions and to be used during intervention.

2. Medication Explanation Checklist

This checklist is a small piece of white (A4 quality) paper, sized 8cmx15cm, consists of a title “Senarai Semak Pendidikan Ubat-ubatan OHA”, and a simple sentence instructing educators to tick (√) in the columns accordingly. The rest of the space is occupied with a simple table with eight rows and three columns (8x3 table). Leftmost column is for 7 aspects on OHA that need to be explained to patients, namely number of OHA taken, their names, single tablet dosage, side effects, actions if missed a dose, brief physical descriptions of OHA and patients own specific dosage of OHA (time and how many tablets). The other two columns are left blank for instructors in two different locations (consultation room and dispensary) to put a tick (√) sign if they have explained each aspect mentioned.


Legible patients were given this checklist upon registration at the counter, presented this checklist in the consultation room (doctors or medical assistants) and dispensary (pharmacists and pharmacy assistants). This checklist was stapled together with patients’ prescription slips to ensure that the checklist would not be lost along the way. This checklist would be recollected at the dispensary counters for audit purposes.

3. OHA charts

OHA charts were used as an education aid by healthcare provider. This is a white A4 sized piece of paper, consists of a title “Ubat Kencing Manis Yang Saya Ambil Ketika Ini” with a two-by-two table (four square boxes), each box sized 11.5cm x 6.5cm, containing information of each OHA. It mentions generic name, trade names, strength per tablet, main side effects and consumption instructions (before or after meals). A special feature of this chart is that it has a colored picture of the mentioned OHA in each box. These charts would be given away to patients. Another set of charts have the actual OHA tablets in small plastic containers, pasted in the respective boxes. However, these are only to be used during consultation only and not for patients to take home.

4. Pamphlets

Our pamphlet is a yellow colored A4 sized piece of paper, both sides divided into three columns to optimize information. It consists of overview of diabetes mellitus and symptoms, complications, aims and goals of treatment and another three columns of specific OHA’s. This was given away to patients for them to take home.

5. Reminder Stickers for OHA Envelopes

These stickers are green in color, sized 2.5 cm x 9 cm, and of four types, namely Metformin, Glibenclamide, Gliclazide and Acarbose. Each sticker consists of name of the medication, strength per tablet, main side effects and consumption instructions (regarding to meals). These stickers will be pasted behind patients’ medication envelopes.

Before starting the intervention program, healthcare providers who involve directly in this program should be taught and trained. This is important for them to get familiarized with the program and the materials, as well to ensure quality of the program. Training sessions for educators was done upon doctors, medical assistants, staff nurses, pharmacist and pharmacy assistant through a power point presentation. It was done initially in December 2006, and repeated twice in March and June 2007 to ensure continuity of intervention. The presentation contained overview of the study, objective of the study, limitations in patients knowledge (result of baseline data)


and last but not least about the intervention program and intervention package. Three sessions were done in December 2006, March 2007 and Jun 2007 in hospital and health clinic separately.

Intervention program started before patient sees a doctor or a medical assistant in the consultation room (Figure 3). At the clinic registration counter, legible patients are identified and an OHA Explanation Checklist was given to patients. Patients were instructed to ask doctors during consultation to explain to them according to checklist. Once patients see a doctor or medical assistant, points in checklist being explained to patients and checklist filled in accordingly with a tick (√) sign. Checklist then stapled together with patients’ prescription slip and patient adjourned to pharmacy to collect medications.

The next stage of process continued at the dispensary as patient claims the medications. The pharmacist or assistant pharmacist would repeat to counsel patients based on the same OHA Explanation Checklist and again, points in checklist being explained to patients and checklist filled in accordingly with a tick (√) sign. Then, Reminder Stickers were pasted behind patient’s medication envelope respectively and checklist is completed. Completed checklists are then separated from prescription slip and collected back for auditing purpose later.

Phase III: Implementation and improving dispensing practice

The last phase of this study witnessed the implementation of the intervention package for the next eight months. In May, a cross-sectional study was done in both centers aiming to see the progress of this study and effects of intervention with the same manner of face-to-face interview and used the same questionnaires. The final step was a post-intervention survey conducted in August in both centers which another sample was evaluated and subsequently the value of the interventional package was analysed, discussed, considered and concluded.

Evaluation of Patients’ Knowledge

From the questionnaire (appendix 6), there were seven aspects of knowledge that we evaluate. Patients will be given a score of 1 for each question that they answer right. This is quite straightforward for questions number 6 and 7.

However, for question number 1 until 5, since each of them inquire each OHA separately, therefore each patients would have to answer correctly for each OHA in order to score 1 for one question. For example, if a patient is on two OHA, for question regarding names of OHA, he or she would have to name both her OHA correctly in order to score 1. The same principle applied for patients with three OHA. Seeing that this might cause complicated mathematics, we had come to an


agreement of how should these patients marks calculation would be. The summary of scoring system is shown in Table 1.

Table 1. Scoring system for questions number 1, 2, 3, 4 and 5

Number of OHAsCombination of answers for

OHA1/OHA2/OHA3Considered Score

1 OHACorrectwrong

10

2 OHAsCorrect/ CorrectCorrect/wrongWrong/ wrong

100

3 OHAs

Correct/ Correct/CorrectCorrect/ Correct/wrongCorrect/wrong/wrongWrong/wrong/wrong

1100

Eventually, total score for those who answer all questions right was 7 and any patient who scored 4 and above question correctly would be considered as having good knowledge on their OHA.

4.0 SAMPLING

4.1 Inclusion Criteria

i. All type 2 diabetic patients with at least on one type of OHA (including BIDS regime).

ii. Patients who are under follow-up in outpatient department, Hospital Teluk Intan and 3 selected health clinics (KK Hutan Melintang, KK Sungai Sumun and KK Langkap).

iii. All patients on OHA (biguanides, sulphonylurea and α-glucosidase inhibitors) are legible for this study.

4.2 Exclusion Criteria

i. Patients with physical illness/abnormality that disabled them to be involved in this study such as blindness, mental retardation, dementia etc.

ii. Patients who are dependent to care-givers in order to consume medications.iii. Patients on insulin therapy (except Bedtime Insulin regime).iv. Patients who are not well conversed in neither Bahasa Malaysia nor English.

175Improving Knowledge Of Type 2 Diabetes Mellitus Patients On Oral Hypoglycaemic AgentsIMPROVING KNOWLEDGE OF TYPE 2 DIABETES MELLITUS PATIENTS ON ORAL HYPOGLYCEMIC AGENTS

16

Figure 4.1: Flow chart of study design

Cross sectional study for baseline data n = 300

Duration: 1 month (November 2006) Venue: Hospital and health clinics

While patients waiting for their turn at dispensary

Development of intervention package comprising of: 1. guideline for health-care provider 2. medication explanation checklist 3. pamphlets 4. OHA charts 5. reminder stickers for the particular medicine envelope

Duration: 2 weeks

Training of healthcare providers to get familiarized with intervention package Duration: 2 weeks

Cross sectional study (Post-intervention 1)

n = 150 Duration: 1 month (May 2007)

Data analysis (hospital) n = 150

Implementation of intervention packages (hospital) Duration: 8 months

(January – August 2007)

Implementation of intervention packages (health clinics) Duration: 8 months

(January – August 2007)

Data analysis (health clinics) n = 150


n = 150 Duration: 1 month (May 2007)


n = 150 Duration: 1 month (August 2007)


n = 150 Duration: 1 month (August 2007)

Phase 1

Phase 2

Phase 3



Figure 3. Flow of patient movement from registration until dispensary during intervention programme


17

Patient came to clinic

Registration counter: All type 2 diabetic patients on OHA were identified, checklist were given, and patients were instructed to ask doctors during

consultation to explain to them according to checklist

Dispensary: Pharmacists or pharmacy assistants explained to patients and checklist were filled in accordingly, respective stickers were pasted on

respective medication envelopes accordingly, and the completed checklists were collected back from prescription slip for auditing purposes

Consultation room: Points in checklist were explained to patients using pamphlets and OHA chart and checklist were filled in accordingly, checklist then

stapled together

Patients went home

4.3 Sample Size and sampling method

The calculated sample size was 300 after taking into account 20% drop out. Sample size was calculated using Epicalc 2000 using two proportions based on 90% power at a significance level of 0.05, with expected increment in knowledge of 15% (50% to 65%). The calculated sample size was for both before and after the intervention. Sampling method was convenient sampling.

4.4 Variables

Variables used in this study are listed in Table 2.


Data were collected through a set of standardized structured questionnaire. This questionnaire was designed to gain demographic data and to assess patients’ knowledge on OHA for baseline data and post intervention. This questionnaire comprised of two sections. The first section inquired about patients’ socio-demographic background such as sex, age, and ethnicity and so on. The second section of the questionnaire comprised of seven questions pertaining patients’


Table 2. Variables used in this study

Variables Description Measuring Scale

Age of patient Number of completed years of study Years

SexBiological status of reproductive role as stated in identification card

MaleFemale

RaceEthnicity status based on paternal side

MalayChineseIndian

Educational level

The highest level of education achieved by respondents

No formal educationPrimary educationLower secondary educationHigher secondary educationTertiary education or higher

Co-morbidities

Other physiological or functional illness such as hypertension, asthma, etc

How many type

Duration of OHA usage

Duration from the year OHA was started until year of study done

Years

Knowledge

Respondents’ knowledge regarding their medications : i. knowledge regarding name of

OHA usedii. knowledge regarding physical

characteristic of OHA usediii. knowledge regarding dosage of

OHA usediv. knowledge regarding how many

tablets and frequency of the tablet to be taken daily

v. knowledge regarding time of OHA to be taken

vi. knowledge regarding steps to be taken if miss medication

vii. knowledge regarding side effect of medications

Answer correct = 1 scoreAnswer wrong = 0 score



21

5. RESULTS


This study took place in outpatient department of Hospital Teluk Intan (Hospital) and three

health clinics (Health). Figure 5.1 shows flow of the study.

Figure 5.1: Overall result of study

Intervention package developed 1-15 December 2006

Training of healthcare providers to get familiarized with intervention package

16-31 December 2006

Post-intervention 1 (P1) Cross sectional study

n = 106 (May 2007)

Baseline Data: Hospital (Cross sectional Study)

n = 150

Hospital Implementation of intervention

Duration: 8 months (January – August 2007)


n = 151 (August 2007)

Phase 1

Phase 2

Phase 3

Baseline Data: Health Clinics (Cross sectional Study)

n = 152

Health Clinics Implementation of intervention

Duration: 8 months (January – August 2007)


n = 70 (May 2007)


n = 93 (August 2007)

Figure 3. Overall result of study


OHA(s). Pilot studies of 10 questionnaires were used for pre-testing. Face-to-face interview technique was conducted by trained interviewers (mainly pharmacists and staff nurses) to gain information needed. This is the best method so far internationally since apart from collecting data, it also intervenes. It is well accepted like what was done in 2004, a meta-regression to analyze which variable within an education intervention that best explained variance in glycaemic control revealed interventions which included a face-to-face delivery cognitive reframing teaching method were more likely have greater effect (Ellis SE et al 2004).

4.6 Ethical issues

There is no ethical concern in this study. Before starting the program, we get a written approval from Director of Hospital and Medical Officer of Health clinic in District of Hilir Perak. Before starting the interview, verbal consent were taken from patients. Respondents’ information will be kept confidential together with his/her current medical records in the clinics, accessible to only medical personnel involved and researchers only.

5.0 RESULTS


This study took place in outpatient department of Hospital Teluk Intan (Hospital) and three health clinics (Health). Figure 3 shows flow of the study.

5.1.1 Comparison between hospital and health clinics (baseline data)

Before analysis of socio-demographic factors, in general, our baseline population showed major lacking in knowledge area of dosage, name, and side effects. However, at the end of this study, it was found that these three areas improved drastically in knowledge on side effects of OHA. However, because of the demographic differences in hospital and health which will be further explained below, the figures were statistically not valid since it did not reflect the true distribution of sample.

Table 3 showed distribution of data for socio-demographic characteristic. A number of 302 patients involved in baseline data collection which was held on November 2006, where 150 patients were from hospital and 152 from health clinic. This table showed that there were significant difference between hospital and health clinics in term of age, ethnicity and clinical profile (duration of illness and number of co-morbidity).

Distribution of age was larger in hospital compare to health clinic, probably due to larger population come to hospital to get treatment, rather than


health clinic. In health clinic, patients were limited to those who live nearby the clinic and those who on regular follow up.

Malay and Chinese showed significant difference in choosing between hospital and health clinic. More Malay came to health clinic rather than hospital, whereas more Chinese came to hospital rather than health clinic.

Clinical profile of patients also showed significant difference between hospital and health clinic. Duration of the illness was categorized into 3 group; less than 5 years, 6-10 years and more than 11 years. For less than 5 years group and more than 11 years group, there was significant difference in choosing between hospital and health clinic. More patients came to health clinic in the less than 5 years group whereas in the more than 11 years group more patients came to hospital. Patients who came to hospital have more morbidity rather than who came to health clinic, only have diabetes mellitus.

Therefore, these two centers will be further commented separately.

5.1.2 Socio-demographic data and clinical profile of patients in hospital population

A total 150 patients involved in baseline data collection, 106 in post-intervention 1(P1) and 151 in post-intervention 2 (P2). Statistically there were no significant different between baseline and both two post-intervention in term of gender, education level and number of co-morbidities. There was a significant difference in mean age in P2 compared to baseline patients. In term of ethnicity, Indian patients made a significant increase in P2. Patients who suffered from diabetes mellitus for less than 5 years made a significant increase in both P1 and P2. Patients on single OHA were found statistically significant drop during P2 sampling. As a summary we can see gender, educational level and number of co-morbidities have not affected the knowledge of the patients in Hospital Teluk Intan.

5.1.3 Socio-demographic data and clinical profile of patients in health clinics population

A total 152 patients involved in baseline data collection, 70 in post-intervention 1(P1) and 93 in post-intervention 2 (P2). Statistically there were no significant difference between baseline and both two post-intervention in term of mean age, gender, education level and number of OHA consumed. In term of ethnicity, similarly with hospital, Indians patients showed significant drop in P2 samples. However, there was significant


Tabl

e 3.

Soc

io-d

emog

raph

ic C

hara

cter

istic

s of

All

Sam

ples

of S

tudi

ed P

opul

atio

n in

Hili

r Per

ak

Cent

reH

ospi

tal

Hea

lth

clin

ics

p-v

alue

(B

asel

ine

hosp

ital

vs

hea

lth)

Mon

th

Bas

elin

e (N

ovem

ber

2006

)

Post

-int

erve

ntio

n 1

(May

200

7)Po

st-i

nter

vent

ion

2 (A

ugus

t 200

7)B

asel

ine

(Nov

embe

r 20

06)

Post

-int

erve

ntio

n 1

(May

200

7)Po

st-i

nter

vent

ion

2 (A

ugus

t 200

7)

n=15

0n=

106

p-v

alue

n=15

1p

-val

uen=

152

n=70

p-v

alue

n=93

p-v

alue

Mea

n ag

e in

ye

ars

(SD

)59

.63(

9.68

)57

.82(

11.5

2)0.

174

56.4

2(9.

97)

0.00

557

.23(

10.3

7)57

.63(

10.0

1)0.

787

57.1

2(10

.51)

0.93

60.

030

Gen

der,

n (%

)•

Mal

e63

(42.

0)50

(47.

2)0.

488

63(4

1.7)

0.94

560

(39.

5)23

(32.

9)0.

425

26(2

8.0)

0.09

00.

741

•Fe

mal

e87

(58.

0)56

(52.

8)88

(58.

3)92

(60.

5)47

(67.1

)67

(72.

0)Et

hnic

, n (%

)•

Mal

ay70

(46.

7)51

(48.

1)0.

919

62(4

1.1)

0.38

710

9(71

.7)

48(6

8.6)

0.75

072

(77.

4)0.

402

<0.0

01•

Chi

nese

45(3

0.0)

23(2

1.7)

0.18

131

(20.

5)0.

079

9(5.

9)7(

10.0

)0.

416

15(1

6.1)

0.01

7<0

.001

•In

dian

35(2

3.3)

32(3

0.2)

0.27

858

(38.

4)0.

007

34(2

2.4)

15(2

1.4)

0.98

66(

6.5)

0.00

20.

950

Educ

atio

nal l

evel

, n (%

)•

Prim

ary

and

none

95(6

3.3)

56(5

2.8)

0.12

010

0(66

.2)

0.68

610

8(71

.1)

47(6

7.1)

0.66

571

(76.

3)0.

449

0.19

1•

Seco

ndar

y an

d hi

gher

55(3

6.7)

50(4

7.2)

51(3

3.8)

44(2

8.9)

23(3

2.9)

22(2

3.7)

Dur

atio

n of

illn

ess,

n (%

)•

≤5 y

ears

64(4

2.7)

67(6

3.2)

0.00

283

(55.

0)0.

043

100(

65.8

)47

(67.1

)0.

964

53(5

7.0)

0.21

3<0

.001

• 6-

10 y

ears

50(3

3.3)

24(2

2.6)

0.08

637

(24.

5)0.

118

35(2

3.0)

16(2

2.9)

0.88

626

(28.

0)0.

475

0.06

2•

≥11

year

s36

(24.

0)15

(14.

2)0.

074

31(2

0.5)

0.55

817

(11.

2)7(

10.0

)0.

975

14(1

5.0)

0.49

30.

005

No.

of c

omor

bidi

ties,

n (%

)•

No

com

orbi

d27

(18.

0)21

(19.

8)0.

839

15(9

.9)

0.06

451

(33.

6)42

(60.

0)<0

.001

36(3

8.7)

0.49

60.

003

• H

as

com

orbi

d(s)

123(

82.0

)80

(80.

2)13

6(90

.1)

101(

66.4

)28

(40.

0)57

(61.

3)

No.

of O

HA

, n (%

)•

1 O

HA

51(3

4.0)

27(2

5.5)

0.18

630

(19.

9)0.

008

68(4

4.7)

32(4

5.7)

0.99

340

(43.

0)0.

895

0.07

3•

>1 O

HA

99(6

6.0)

79(7

4.5)

121(

80.1

)84

(55.

3)38

(54.

3)53

(57.

0)

(All

calc

ulat

ions

of P

val

ues

wer

e us

ing

Z te

st E

pica

lc 2

000

com

parin

g tw

o pr

opor

tions

)


increase in Chinese patients sampled in P2. There was also a reduction in sampling of solely diabetics and it was statistically significant in P2.

As a summary, gender wise, educational level and number of OHA consumed does not affect the knowledge of the patient in Health Clinics.

From the formulated questionnaire used in this study, for questions pertaining knowledge on OHA, each question carries one mark should the patient managed to answer at least more than 50% correctly. There were a total of seven major questions pertaining knowledge on OHA. Hence, total full marks of seven. From the formulated questionnaire used in this study, patients were labeled as having good knowledge only if they scored more than 3 out of 7 marks.

5.2 Patients Knowledge

Table 4 showed distribution of patients with good knowledge on OHA. From the beginning, it could be seen that patients in hospital and health clinics had a significant difference in baseline knowledge. Therefore, it was wise to compare these two centers separately.

Generally, both hospital and health clinics showed statistical improvement of knowledge throughout the study. In hospital, there was significant improvement of knowledge after four months of intervention, and further improved after seven months of continuous intervention. However, the increase from May to August was found to be not statistically significant.

In health clinics, the improvement had always been better sustained statistically significant throughout the study. As a conclusion, this intervention benefited patients in both centers in general.

Table 5 showed individual areas of knowledge on OHA among patients in outpatient department, Hospital Teluk Intan. There were seven aspects of knowledge that were evaluated. namely the name, physical properties, dosage, method of consumption, frequency, action if missed a dose and correct side effects of OHA.

Among these seven areas, only questions pertaining to action if missed a dose and side effects of OHA showed statistical improvement after intervention for both samplings. Statistical significant improvement were noted for question which looking into correct action if missed a dose for patients who consume more than one OHA. However, the improvement between first and second post intervention sampling was not significant statistically.


Tabl

e 4.

Dis

trib

utio

n of

Pat

ient

s w

ith G

ood

know

ledg

e on

OH

A (S

core

>3

Out

of 7

Que

stio

ns)

Cent

erB

asel

ine

Post

in

terv

enti

on

May

200

7 (P

1)

p-v

alue

* (C

ompa

riso

n be

twee

n ba

selin

e an

d P1

)

Post

in

terv

enti

on

Aug

ust 2

007

(P2)

p-v

alue

*(C

ompa

riso

n be

twee

n ba

selin

e an

d P2

)

p-v

alue

(B

asel

ine

Hos

pita

l vs

Hea

lth)

p- v

alue

*(C

ompa

riso

n be

twee

n P1

an

d P2

)

Hos

pita

ln

150

106

0.01

315

1<0

.001

0.00

40.

140

No.

of p

atie

nts

(%)

39(2

6.0)

44(4

1.5)

78(5

1.7)

Hea

lthn

152

70<0

.001

93<0

.001

<0.0

01N

o. o

f pat

ient

s (%

)19

(12.

5)37

(52.

9)48

(51.

6)

* Ca

lcul

ated

usi

ng E

pica

lc 2

000

com

parin

g of

two

prop

ortio

ns

Tabl

e 5.

Ind

ivid

ual a

reas

of k

now

ledg

e on

OH

A a

mon

g Pa

tient

s in

Out

Pat

ient

Dep

artm

ent,

Hos

pita

l Tel

uk In

tan

Pati

ent K

now

ledg

eN

o. o

f O

HA

Bas

elin

ePo

st in

terv

enti

on M

ay (P

1)Po

st in

terv

enti

on A

ugus

t (P2

)p

-val

ue**

* (C

omp

aris

on

bet

wee

n P1

and

P2)

n%

n%

p-v

alue

*n

%p

-val

ue**

Corr

ect n

ame

of O

HA

1 O

HA

508.

027

14.8

0.58

030

100.

919

0.33

1>1

OH

A10

09.

079

10.1

0.99

012

18.

30.

963

0.78

4Co

rrec

t phy

sica

l pr

oper

ties

of O

HA

1 O

HA

5092

.027

92.6

0.72

030

96.7

0.72

10.

232

>1 O

HA

100

88.0

7986

.10.

875

121

90.9

0.62

90.

315

Corr

ect d

osag

e of

O

HA

1 O

HA

504.

027

7.4

0.91

630

6.7

1.00

00.

974

>1 O

HA

100

4.0

795.

10.

982

121

6.6

0.54

60.

817

Corr

ect f

requ

ency

of

OH

A1

OH

A50

64.0

2777

.80.

323

3083

.30.

621

0.34

4>1

OH

A10

071

.079

65.8

0.56

212

158

.70.

078

0.23

8Co

rrec

t met

hod

of

cons

umpt

ion

of O

HA

1 O

HA

5070

.027

77.8

0.64

330

73.3

0.94

90.

500

>1 O

HA

100

52.0

7955

.70.

732

121

57.0

0.54

10.

937

Corr

ect a

ctio

n if

mis

sed

a do

se1

OH

A50

40.0

2763

.00.

091

3060

.00.

133

0.72

2>1

OH

A10

041

.079

64.6

0.00

312

164

.50.

001

0.90

8Co

rrec

t sid

e ef

fect

s

of O

HA

1 O

HA

502.

027

14.8

0.09

030

43.3

<0.0

01<0

.001

>1 O

HA

100

9.0

7925

.30.

006

121

48.8

<0.0

01<0

.001

*

Com

paris

on b

etw

een

base

line

and

P1 u

sing

Z te

st E

pica

lc c

ompa

ring

two

prop

ortio

ns**

Com

paris

on b

etw

een

base

line

and

P2 u

sing

Z te

st E

pica

lc c

ompa

ring

two

prop

ortio

ns**

* Com

paris

on b

etw

een

P1 a

nd P

2 us

ing

Z te

st E

pica

lc c

ompa

ring

two

perc

enta

ges


For question asking for correct side effect(s) of OHA, it showed significant improvement after for both samplings compared to baseline data in all diabetic patients sampled.

Patients have always been good in describing the physical properties of tablets. This can be seen in areas of physical properties of OHA. Regardless of how many tablets of OHA are they on, the knowledge has been good from the start. Although the percentage rise was statistically not significant, it is sustained.

On the other hand, greater improvement was seen in health clinics setting as seen in Table 6. After four months of intervention, patients showed statistical improvement in almost all areas regardless the number of OHA consumed, except for questions regarding physical properties of OHA and actions if missed OHA dose. Whereas, in the second post intervention sampling, improvement were seen in similar areas as in the first sampling except question for dosage of OHA showed a significant decline.

Comparison between first and second post intervention sampling showed significant improvement in questions regarding physical properties of OHA (for patients on single OHA), frequency of OHA taken (for patients on single OHA), and correct actions if missed a dose (for all diabetics).

Table 7 showed socio-demographic factors affecting patients’ knowledge on OHA. Samples were divided into hospitals and health clinics since the demographic profile was found to be different earlier, therefore not likely to be comparable. For samples from outpatient department, Hospital Teluk Intan, there were no significant demographic factors associated with patients’ knowledge on OHA except for educational level. After four months of intervention, it showed that there is a statistically significant improvement in patients’ knowledge on OHA among those whose highest education level was primary school or even less.

After seven months of intervention, this same group showed further improvement which is statistically significant. However, for those who had secondary education as their minimal education, there was also a significant deterioration of knowledge seen but statistically improved after seven months of intervention. This showed that this intervention benefited all regardless of educational level in the long run.

For the health clinics, there were no significant demographic factors associated with patients’ knowledge on OHA except for number of co-morbid(s). Statistically significant improvement of knowledge could only be witnessed among those who had diabetes mellitus as their sole morbidity after four months of intervention, and had a non-significant drop of knowledge after seven months. This again showed that this intervention benefited all regardless of educational level in the long run.


Tabl

e 6.

Ind

ivid

ual A

reas

of K

now

ledg

e on

OH

A a

mon

g Pa

tient

s in

Hea

lth C

linic

s, H

ilir P

erak

Pati

ent K

now

ledg

eN

o. o

f O

HA

Bas

elin

ePo

st in

terv

enti

on M

ay (P

1)Po

st in

terv

enti

on A

ugus

t (P2

)p

-val

ue**

* (C

omp

aris

on

bet

wee

n P1

and

P2)

n%

n%

p-v

alue

*n

%p

-val

ue**

Corr

ect n

ame

of

OH

A

1 O

HA

684.

432

31.3

0.00

140

17.5

0.05

50.

061

>1 O

HA

841.

230

18.4

0.00

253

11.3

0.02

60.

292

Corr

ect p

hysi

cal

prop

ertie

s of

OH

A

1 O

HA

6891

.532

90.6

0.77

640

100.

00.

134

0.00

9

>1 O

HA

8488

.138

84.2

0.76

553

90.6

0.86

40.

319

Corr

ect d

osag

e of

O

HA

1 O

HA

684.

432

18.8

0.05

040

17.5

0.05

50.

994

>1 O

HA

841.

238

13.2

0.01

753

9.4

0.08

20.

607

Corr

ect f

requ

ency

of

OH

A

1 O

HA

6861

.832

84.4

0.04

040

95.0

<0.0

010.

044

>1 O

HA

8441

.738

50.0

0.50

853

58.5

0.08

10.

357

Corr

ect m

etho

d of

co

nsum

ptio

n of

OH

A

1 O

HA

6852

.932

78.1

0.02

940

80.0

0.00

90.

920

>1 O

HA

8416

.738

55.3

<0.0

0153

64.2

<0.0

010.

323

Corr

ect a

ctio

n if

mis

sed

a do

se

1 O

HA

6851

.532

40.6

0.42

540

60.0

0.50

90.

022

>1 O

HA

8452

.438

47.4

0.75

153

64.2

0.23

90.

047

Corr

ect s

ide

effe

cts

of

OH

A

1 O

HA

684.

432

28.1

0.00

240

30.0

0.00

10.

928

>1 O

HA

844.

838

55.3

<0.0

0153

41.5

<0.0

010.

112

*

Com

paris

on b

etw

een

base

line

and

P1 u

sing

Z te

st E

pica

lc c

ompa

ring

two

prop

ortio

ns**

Com

paris

on b

etw

een

base

line

and

P2 u

sing

Z te

st E

pica

lc c

ompa

ring

two

prop

ortio

ns**

* Com

paris

on b

etw

een

P1 a

nd P

2 us

ing

Z te

st E

pica

lc c

ompa

ring

two

perc

enta

ges


Tabl

e 7.

Per

cent

age

of P

atie

nts

Who

Hav

e G

ood

Know

ledg

e (S

core

d At

Lea

st 4

out

of

7 Q

uest

ions

) acr

oss

Diff

eren

t So

cio-

dem

ogra

phic

Fac

tors

Cent

reH

ospi

tal

Hea

lth

clin

ics

Mon

thB

asel

ine

(Nov

embe

r 20

06)

n=15

0

Post

-int

erve

ntio

n 1

(May

200

7)n=

106

Post

-int

erve

ntio

n 2

(Aug

ust 2

007)

n=15

1

Bas

elin

e (N

ovem

ber

2006

) n=

152

Post

-int

erve

ntio

n 1

(May

200

7)n=

70

Post

-int

erve

ntio

n 2

(Aug

ust 2

007)

n=93

Pass

(%)

Pass

(%)

P va

lue*

Pass

(%)

P va

lue*

*Pa

ss (%

)Pa

ss (%

)P

valu

e*Pa

ss (%

)P

valu

e**

Age

• Le

ss th

an 6

0 ye

ars

old

20(2

7.4)

30(4

7.6)

0.02

348

(53.

3)0.

001

15(1

6.1)

24(5

8.5)

<0.0

0128

(51.

9)<0

.001

• 60

yea

rs o

ld a

nd a

bove

19(2

4.7)

14(3

2.6)

0.47

530

(49.

2)0.

005

4(6.

8)13

(44.

8)<0

.001

20(5

1.3)

<0.0

01G

ende

r•

Mal

e17

(27.

0)19

(38.

0)0.

383

35(5

5.6)

0.00

45(

8.3)

15(6

5.2)

<0.0

0113

(50.

0)<0

.001

• Fe

mal

e22

(25.

3)25

(44.

6)0.

026

43(4

8.9)

0.00

214

(15.

2)22

(46.

8)<0

.001

35(5

2.2)

<0.0

01Et

hnic

• M

alay

23(3

2.9)

26(5

1.0)

0.06

937

(55.

7)0.

004

13(1

1.9)

25(5

2.1)

<0.0

0138

(52.

8)<0

.001

• N

on-M

alay

16(2

0.0)

18(3

2.7)

0.14

041

(46.

1)<0

.001

6(14

.0)

12(5

4.1)

0.00

110

(47.

6)0.

009

Educ

atio

nal l

evel

• Pr

imar

y an

d no

ne18

(19.

1)14

(27.

5)0.

346

41(4

1.4)

0.00

113

(12.

0)22

(46.

8)<0

.001

38(5

3.5)

<0.0

01•

S eco

ndar

y an

d hi

gher

20(3

6.4)

29(5

9.2)

0.30

337

(71.

2)<0

.001

6(13

.6)

15(6

5.2)

<0.0

0110

(45.

5)0.

011

Dur

atio

n of

illn

ess

• ≤5

yea

rs18

(28.

1)28

(41.

8)0.

145

38(4

5.8)

0.04

314

(14.

0)26

(55.

3)<0

.001

28(5

2.8)

<0.0

01•

6 ye

ars

and

mor

e21

(24.

4)16

(41.

0)0.

094

40(5

8.8)

<0.0

015(

9.6)

11(4

7.8)

0.00

120

(50.

0)<0

.001

No.

of c

omor

bid(

s)•

No

com

orbi

d8(

29.6

)11

(52.

4)0.

193

5(33

.3)

0.92

010

(19.

6)27

(64.

3)<0

.001

19(5

2.8)

0.00

2•

Has

com

orbi

d(s)

31(2

5.2)

33(3

8.8)

0.05

273

(53.

7)<0

.001

9(8.

9)10

(35.

7)0.

001

29(5

0.9)

<0.0

01N

o. o

f OH

A•

1 O

HA

13(2

5.5)

15(5

5.6)

0.01

720

(66.

7)0.

001

12(1

7.6)

17(5

3.1)

0.00

122

(55.

0)<0

.001

• >1

OH

A26

(26.

3)29

(36.

7)0.

181

58(4

7.9)

0.00

27(

8.3)

20(5

2.6)

<0.0

0126

(49.

1)<0

.001

* p

valu

e co

mpa

ring

base

line

and

P1 c

alcu

late

d us

ing

Epic

alc

2000

com

parin

g tw

o pr

opor

tions

** p

-val

ue c

ompa

ring

base

line

and

P2 c

alcu

late

d us

ing

Epic

alc

2000

com

parin

g tw

o pr

opor

tions


6.0 DISCUSSIONS

6.1 Problems and Limitations

In this study, problem and limitations had been identified and described below.

Problems

From the study, it was found that some patients have significant poor education level, thus difficult to be held responsible for information regarding their own medication. At this point, all the staffs who involved in this study were verbally instructed during the training session to involve the family members and caregivers who are held responsible in managing patients, although they are not the focus of this study (diabetic patients). At the same time, supplied medications were revised and checked again during every follow-up.

Some of the patients were not interested to participate in this study for various reasons. In view to overcome this problem, in terms of sampling, convenient sampling method was chosen. Efforts were also made in order to improve earlier pamphlets which were produced in black and white form, later upgraded to colored papers with more attractive graphics, in hope that it would attract patients to read them. Similar efforts were done on OHA charts. What was initially having only colored pictures of OHA tablets later diversified by having actual OHA tablets on each chart itself so that the patients would understand and remember more, hoping that patients would have a clearer picture of their own OHA tablets. Continuous patients’ encouragement by the staffs also promoted awareness to the patient regarding benefit of this study.

Frequent exchange, relocation and restructuring of staffs in hospitals and health clinics also led to dropouts of manpower, indirectly led to transient discontinuation or dyssynchronisation in the intervention program. As a result, it reduced the chances of effective intervention for this study. That was why multiple repeated training sessions were done involving as many health staffs as possible at different points of time throughout the study period. Eventually, some permanent staffs were appointed, dedicated to monitor the progression of intervention for the eight months of intervention period. However, this was not possible for every outpatient department due to lack of manpower.

Technical delay was another problem that contributed to a slow progression of the study initially. There was a delay in production of reminder stickers, an important item of this intervention package, at the early phase of the study in view of minimal funding. However, once the financial allocation was sorted out in May 2007, the problem ended. Management of financial distribution was centralized to ensure


transparency and easy access of funds, in order to settle purchases and expenditures effectively with time.

Limitations

Initial analysis of the baseline data between hospital and health clinics had shown a significant difference rendering these two samples not comparable for further analysis. This indirectly split our initial sample size into two, making the sample size smaller. This had also opened the possibilities of difference in effectiveness of this intervention between these two centers.

The convenient sampling method and time chosen opened the possibility of sampling patients who had never been intervened before.

This study took into account illiterate patients and the intervention package materials for patients are mainly reading materials. A substantial portion of the samples were illiterate in this study, therefore, they might not benefit from this study and this might also affect the outcome.

Pamphlets and reading materials (charts, stickers) were produced in one language only, therefore limited the use for those who can only read in Bahasa Malaysia only. While in our samples, the non Malays are a substantial bulk of patients.

6.2 Discussions of Results

As discussed earlier in the problem statement under the introduction chapter, patients’ knowledge on OHA are affected by several factors. Socio-demographic difference in diabetic patients would yield different levels of knowledge on their own OHA.

As described in the analysis, the intervention yield statistically significant improvement in patients’ knowledge on OHA in both hospital and health clinics. Health clinics showed significant improvement but not hospital. This was mainly due to dedicated staffs appointed in health clinic to maintain and supervise this intervention which was not available in hospital due to problem in manpower.

Analysis on seven specific questions regarding OHA revealed initial good knowledge of patients for both hospital and health clinics (≥90%). Subsequent analysis of p value showed p>0.05. This is not worrying since substantial change in this area is not expected. If critically considered, hospital showed increase from 92.0% to 92.6% in P1 and 96.7% in P2, while in health clinic 91.5% to 90.6% in P1 and eventually 100% in P2.

From this study, even with drastic change (p value <0.001), patients knowledge about OHA side effect in both centers remained low. It was similar to a study done


by Thomson FJ et al 1991 – 88% patients taking OHA denied any knowledge of hypoglycemia. 54% of the OHA groups have been associated with severe and prolonged hypoglycemia.

In outpatient department in hospital, patients with lower education level, namely those who had primary school as their maximum education (patients with no formal education were included), was found to have significant improvement of knowledge after continuous intervention done. This is quite odd as patients with higher education level, namely those who had secondary education as their minimum education, was expected to yield better result than the former group.

However, in this study, it was the other way around. This was most probably due to premature judgment by healthcare providers that patients with higher education level did not need intensive counseling and attention in terms of explanation compared to those with lower educational level.

This stereotype misconception among healthcare providers led to different approaches to patients. Those with higher education level would be explained in a faster way and less time spent with them educating about OHA, healthcare providers were prone to use complicated terminologies rather than simple ones, and less repetition of information was done.

However, in health clinics, the intervention gave out better effects on patients who were having diabetes mellitus as their sole morbidity. However, this improvement was not statistically sustained with significance until P2. It could be seen that this group of patients would benefit from the intervention as we hoped.

Out of seven areas of question regarding knowledge of OHA, health clinics improved significantly in question on physical OHA properties, frequency and correct action if missed medication. However, most of the improvement only can be seen in those who on single OHA. Obviously, patient with less medication are able to concentrate more on their medication and subsequently will be less confused.

In the other hand, Hospital OPD patients only showed significant improvement in knowledge regarding correct side effect of the OHA. This improvement was significant in the entire patient regardless of their number of OHA. This was because this specific area was very poorly understood prior to intervention, thus intervened, this area improved so much. Other areas was not so bad in the beginning, therefore a little rise was not significant but still good.

However, question pertaining to the name of the consumed OHA did not show improvement. This was because this study had a significant amount of patients who were poorly educated (primary schooled and no formal education). Therefore, they had a problem in memorizing name since they could not even read the material


given to them, namely OHA charts, reminder stickers and let alone the six pages pamphlets.

A study was done in Taiwan entitled Community Education Program on Medication Use with similar methodology (single group pre and post comparison study). This study showed that medication knowledge at baseline was positively correlated with education level and negatively correlated with age. This was also seen in our study for baseline knowledge, those who were more than 60 years old performed less (39.7% scored 4 and above) as compared to those who were less than 60 years old (60.3% scored 4 and above).

The same study in Taiwan (Huang Y. M. et al. 2006) revealed that female were more aware drug-related information than were males. This was also seen in our study, in which female with good knowledge on their own OHA with percentage of 62.1% during baseline study, 58.0% during P1 and 61.9% during P2. On the other hand, male scored only 37.9% during baseline, 42.0% in P1 and 38.1% in P2.

A drastic and promising result was seen in the percentage of patients who had good knowledge (scored 4 and above) across all socio-demographic factors in both hospital and health clinics in general. Almost all comparisons showed average p value of <0.001. This result was very similar to the study in Taiwan, in which at the end of the program, the participant showed a significant improvement in medication knowledge (p value <0.001) (Huang Y. M. et al. 2006).

A decline in knowledge was seen (p value 0.193 in P1 and 0.920 in P2) in hospital patients specifically those who were sole diabetics. However, statistical validity of this specific group was questionable since the total number of sample for each was too small (<30), which is 27 during baseline, 21 in P1 and 15 in P2.


7.1 Conclusion

Patients’ baseline knowledge regarding OHA was poor. The most lacking area was dosage of OHA, followed by side effect, name of OHA, action if miss dose and time of taking OHA with regards to meal.

Interventional package that we developed for this study consisted of:1. guideline for health-care provider2. medication explanation checklist3. OHA chart4. pamphlets5. reminder sticker for the particular medicine envelope


7.2 Recommendations

1. The intervention module designed was effective, with better improvement in the health clinic setting than in hospital. It should be implemented in all health and hospital outpatient clinics with some modifications (see below).

2. Any repeated studies of this nature should have a longer time frame for intervention to improve the outcome as suggested by international studies.

Revised Intervention Package

1. Feedback from health providers who involved directly with this study suggested several recommendations. The application of reminder sticker on the medication envelope should be continued and extended to all health centers because it provides complete information on the particular OHA.

2. However, there is more room for improvement in other areas of the questionnaire especially question pertaining the name of the consumed OHA, which is more important. The intervention package should stress more in educating patients to know their own OHA names.

3. This study should be applied to all patients regardless of literacy level. Currently the educational material developed for this study are more useful for those who able to read such as the pamphlet and OHA reminder sticker. Different approach of OHA education should be formulated for illiterates for example involving families, caregivers or even forming a group of lay educators.

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14. National Diabetes Audit. Key Findings about the Quality of Care for People with Diabetes in England. Report for the Audit Period 2003/2004. Health and Social Care Information. Centre.

15. Ng C.B, Kajian Terhadap Komplian Pesakit di Farmasi Pesakit Luar Hospital Taiping: Persidangan Penyelidikan dan Pembangunan Farmasi 2002

16. Norrehan A., Assessing compliance in patient on anti-hypertensive and anti-diabetic medications. In: Pharmaceutical Research and Development Conference 2002; 2202 August 5-7; Kota Bharu, Kelantan. Kuala Lumpur, 2002 p. 30

17. Pharmaceutical Services Division and the Clinical Research Center Ministry of Health Malaysia. Malaysian Statistics on Medicine, 2004. Kuala Lumpur, Malaysia. The National Medicine Use Survey; 2006.

18. Prato SD et al., On behalf of The Global Partnership for Effective Diabetes Management; Improving Glucose management: Ten Steps To Get More Patients With Type 2 Diabetes to Glycemic Goal, Recommendation from the Global Partnership for Effective Diabetes Management. International Journal of Clinical Practice, November 2005, 59, 11, 1345-1355

19. Raynor DK et al., Effect of computer generated reminder charts on patient’s compliance with drug regimens: BMJ 1993 May 1, 306 1158-61

20. Saripah S., Peratusan Pesakit Komplian Terhadap Pengambilan Ubat-ubatan Diabetik: Persidangan Penyelidikan dan Pembangunan Farmasi 2002

21. Steven B. Leichter, Making outpatient care of Diabetes More Efficient: Analyzing Noncompliance: Clinical Diabetes 23:187-190, 2005, American Diabetes Association Inc 2005

22. Thomson FJ et al. Lack of knowledge of symptoms of hypoglycemia by elderly diabetic patients. Age ageing 1991 Nov, 20(6): 404-6

23. Thomson FJ, Masson EA, Leeming JT, Boulton AJ. Lack of knowledge of symptoms of hypoglycaemia by elderly diabetic patients. Age Ageing. 1991 Nov; 20(6): 404-6


24. Timmer JW et al. patient education to users of oral hypoglycemic agents: the perspective of Dutch community pharmacist. Pharm world Sci 1999 Oct; 21(5): 200-4

25. Timmer JW, de Smet PA, Schuling J, Tromp TF, de Jong-van den Berg LT. Patient education to users of oral hypoglycaemic agents: the perspective of Dutch community pharmacist. Pharm World Sci .1999 Oct;21(5): 200-4

26. Vivian EM. The pharmacist’s role in maintaining adherence to insulin therapy in type 2 diabetes mellitus. Consult Pharm. 2007 Apr;22(4): 320-32

27. diabetes.niddk.nih.gov [homepage on the internet]. United States: The National Diabetes Information Clearinghouse (NDIC);2007 [updated July 2007; cited Nov 2007]. Available from: http://www.diabetes.niddk.nih.gov/dm/pubs/statistics/

28. Zawawi U. (Health System Research Institue, MOH, Kuala Lumpur). Kajian Ketidakpatuhan Pengambilan Ubat Oral Hipoglisemia di Kalangan Pesakit Diabetes di Unit Pesakit Luar Poliklinik Durian Tunggal dan Poliklinik Masjid Tanah, Daerah Alor Gajah 2004. (unpublished)

ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper and the Health Department of Perak, for conducting this useful health research program. Our sincere thanks to all our facilitators, Dr. Liliwati Ismail, who had contributed a lot in this study, and whose time and effort would be remembered by each and every member of the research team. Also, we would definitely thank the great Dr. Amar-Singh HSS, Dr. Sondi Sararaks and Datin Dr. Ranjit Kaur Pram Singh for their precious and timeless guidance and support.

Our appreciation to Dr. Krishna Kumar, Director of Hospital Teluk Intan, and Dr. Ruzita Mustaffa, Medical Officer of Health Clinic, District of Hilir Perak for their full support in conducting this study, in terms of administrative, financial, technical and moral advise and consultation aiding us to make this study a success.

Bravo and kudos for fellow team members for their endless and amazing co-operation, namely Umi Hani Binti Mohd Asmawi, Mohd Rohaizad Bin Zamri, Mohd Fadhli Bin Samsuri, Sabab Bin Hashim and Maimunah Binti Ahmad. Although there are many obstacles faced and many conflicts arises, but managed to get through with strong friendship and love.

Last but not least, we would like to thank the staff of Hospital Teluk Intan, Health Office of Hilir Perak District and three health clinics involved, namely Klinik Kesihatan Hutan Melintang, Klinik Kesihatan Sungai Sumun and Klinik Kesihatan Langkap, with special thanks to Klinik Kesihatan Chenderong Balai, for their help and efforts in order to make this project an amazing journey.


APPENDICES

APPENDIX 1

RESEARCH TO IMPROVE KNOWLEDGE OF TYPE 2 DIABETIC PATIENTS TOWARDS THEIR ORAL HYPOGLYCAEMIC MEDICATIONS

IN OUTPATIENT DEPARTMENT HILIR PERAK

Guidelines For Health Provider In Outpatient Department And Pharmacy Hospital Teluk Intan

1. The intervention program includes: a. Medical officersb. Medical assistantsc. Staff nurses / Community nursesd. Pharmacist / Pharmacy assistant

2. This programme will involve all type 2 diabetic patients who is on oral hypoglycemic agent’ (OHA); Glibenclamide, Gliclazide, Metformin dan Acarbose.

3. Each MO and MA room and pharmacy counter will be provided with GUIDELINES OF OHA FOR DIABETIC PATIENT which consist of: a. Type & name of the OHAb. Dosagec. Physical characteristic of the OHAd. Time to take the OHAe. OHA side effectf. What to be done if patient missed a dose

4. Legible patient who come to registration counter will be given a MEDICATION EXPLANATION CHECKLIST and instructed to ask doctor during consultation to explain to them according to the checklist.

5. Every diabetic patient on OHA will be explained briefly about their OHA using GUIDELINES OF OHA FOR DIABETIC PATIENT based on the checklist.

6. The responsible staff who had given the explanation will be going to tick ‘√’ on the MEDICATION EXPLANATION CHECKLIST

7. Patient who has been seen by MO / MA will claim their medication at the pharmacy counter by handing over the prescription slip and the medication explanation checklist.

8. At dispensing counter, pharmacist / pharmacy assistant in-charge will recheck the checklist. If the checklist is not completed, they will explained which part that not been told yet.


9. A reminder sticker was already stick at back of the medication envelop. The sticker consist of:a. Name of OHAb. Time / how to be takenc. Common Side effects

10. Patient will be given a pamphlet contain general information of Diabetes Mellitus and OHA medications.

11. Pharmacist will collect the checklist for auditing.

Reminder• Patients are encouraged to claim their medication by themselves at the dispensary. Care-giver

assistance maybe needed for those who are unable


APPENDIX 2

OHA CHART: APAKAH YANG PESAKIT PERLU TAHU?

NAMA: METFORMIN 500MG

• NAMA LAIN: GLUCOPHAGE®

• UBAT UNTUK KENCING MANIS

• DOS SEBIJI = 500 MILIGRAM

• PERLU DIAMBIL SELEPAS MAKAN

• KESAN SAMPING UTAMA: KETIDAKSELESAAN PERUT

NAMA: GLIBENCLAMIDE 5MG

• NAMA LAIN: DAONIL®• UBAT UNTUK KENCING MANIS


• PERLU DIAMBIL 15 MINIT SEBELUM MAKAN

• KESAN SAMPING UTAMA: HIPOGLISEMIA (KURANG GULA DALAM DARAH)

NAMA: GLICLAZIDE 80MG

• NAMA LAIN: DIAMICRON®• UBAT UNTUK KENCING MANIS


• PERLU DIAMBIL 15 MINIT SEBELUM MAKAN

• KESAN SAMPING UTAMA: HIPOGLISEMIA (KURANG GULA DALAM DARAH)

NAMA: ACARBOSE 50MG

• NAMA LAIN: GLUCOBAY®• UBAT UNTUK KENCING MANIS


• PERLU DIAMBIL BERSAMA SUAPAN PERTAMA MAKANAN

• KESAN SAMPING UTAMA: KEMBUNG PERUT


APPENDIX 2

OHA Chart (to be given to the patient)


APPENDIX 3

OHA Medication Checklist for Use of Healthcare Providers to Facilitate Patient Education

No siri : ____________

SENARAI SEMAK PENDIDIKAN UBAT-UBATAN OHASila tanda ‘√’ pada ruang yang ditentukan.Sila kepilkan borang ini bersama slip ubat pesakit.

Tarikh: ________________ Tandatangan dan cop doktor ______________________

Senarai Semak Doktor / MA Farmasi

Berapa jenis ubat OHA yang diambil?

Nama ubat OHA pesakit (generic atau nama pasaran) (termasuk dos sebiji tablet)

Kesan samping utama ubat

Apa yang perlu anda buat jika terlupa makan ubat pada waktu yang sepatutnya

Rupa bentuk dan warna ubat OHA pesakit

Berapa biji dan kekerapan mengambil ubat dalam sehari

Aturan makan ubat (sebelum / selepas)


APPENDIX 4

Actual Form Of The OHA Reminder Sticker Sticked\On The Medication Envelope


APPENDIX 5

OHA Pamphlet Side A (To Be Given To Patient)


OHA Pamphlet Side B (To Be Given To Patient)


APPENDIX 6

KAJIAN UNTUK MENINGKATKAN PENGETAHUAN PESAKIT DIABETES MELLITUS JENIS 2 TERHADAP UBAT ‘ORAL HYPOGLYCAEMIA’

YANG DIAMBIL DI JABATAN PESAKIT LUAR HILIR PERAK

Borang Soal Selidik

Borang ini akan diisi oleh kakitangan di Jabatan Farmasi secara temu bual

1.3 Umur: ..............

1.4 Jantina:

1 (L)

2 (P)

1.5 Bangsa :

1 (M)

2 (C)

3 (I)

4 (L)

1.6 Pendidikan :

1

2

3

4

5

1.7 Tempoh alami kencing manis: ..........................

1.8 Bilangan co-morbiditi ...........................

Bahagian 1: Latar Belakang Pesakit

1. Nama: ........................................................................................................................

2. No. Kad Pengenalan (baru sahaja):

- -

3. Umur: ........................................................................................................................

4. Jantina: Lelaki / Perempuan

5. Bangsa: Melayu / Cina / India / Lain-lain: .....................................................

6. Tahap Pendidikan Tertinggi:

1 Universiti / Kolej

2 Sekolah Menengah Atas

3 Sekolah Menengah Rendah

4 Sekolah Rendah

5 Tidak Pernah Bersekolah

7. Tahun / tempoh mendapat penyakit kencing manis: ...................................

8. Sejarah Perubatan (dari buku / kad rekod pesakit):

senaraikan ...............................................................................................................

......................................................................................................................................

9. Maklumat tentang OHA semasa yang diambil (dari buku / kad rekod pesakit)

Ubat Dos terkini

Glibenclamide

Gliclazide

Metformin

Acarbose


Bahagian 2: Pengetahuan Pesakit Tentang Ubat Oral Hypoglycaemia yang Diambil

1. Berapakah jenis ubat diabetes mellitus anda (ubat makan)? ......................................................... jenis

2. Pengetahuan tentang ubat :

Nama ubatWarna dan

bentukDos

(gram)Bil tablet dan

kekerapan / hariAturan makan ubat

(sebelum/selepas makan)

3. Jika terlupa mengambil ubat pada masa yang sepatutnya, apa yang perlu dilakukan:i. Ambil bila teringatii. Ambil dos bergandaiii. Tidak ambil langsung

4. Adakah anda tahu kesan samping utama ubat yang diambil :Ya / tidakJika ya, nyatakan: ………………………………………………

Penilaian pengetahuan pesakit tentang ubat OHA yang diambil Tandakan () jika jawapan pesakit sama dengan rekod pesakit Tandakan ( jika jawapan pesakit berbeza / tidak sama dengan rekod pesakit

Rekod pesakit (sebagai rujukan)

Ubat OHA yang diambil Dos terkini

1

2

3

Bil Pengetahuan pesakitUbat OHA yang diambil

1 2 3

1 nama OHA yang diambil

2 ciri fizikal OHA

3 dos OHA yang diambil

4 bilangan tablet / kekerapan yang diambil sehari

5 aturan makan ubat

6 lakukan perkara yang sepatutnya jika terlupa makan ubat?

7 tahu kesan samping ubat

205

Health Seeking Behaviour towards Communicable Diseases among Foreign Workers in Industrial & Agriculture Sectors of Selected Districts in Perak, Malaysia Health Systems Research 2008/2009

Authors

Kean-Yau KohSungai Siput Hospital

Kuo-Ghee OngDepartment of Medicine, Taiping Hospital

Noor Asmah Ahmad Shah AziziGrik District Health Department

Wan Asmuni Wan Mohd SamanUniversiti Teknologi MARA


Marina KamaruddinPerak State Health Department

Amar-Singh HSSClinical Research Centre Perak Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak



Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Kean-Yau Koh, Kuo-Ghee Ong, Noor Asmah Ahmad Shah Azizi, Wan Asmuni Wan Mohd Saman, Asmah Zainal Abidin, Marina Kamaruddin, Amar-Singh HSS, Sondi Sararaks, Ranjit Kaur Praim Singh. ”Health Seeking Behaviour towards Communicable Diseases among Foreign Workers in Industrial & Agriculture Sectors of Selected Districts in Perak, Malaysia” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 205. (ISBN: 9789671063439)

ISBN

9789671063439

206 Health Seeking Behaviour towards Communicable Diseases among Foreign Workers in Industrial & Agriculture Sectors of Selected Districts in Perak, Malaysia


Abstract 207


2.0 Objectives 212



3.0 Methodology 212


3.2 Study type


3.4 Variables




4.0 Results 221

4.1 Socio-demographic characteristics of respondents

4.2 Health seeking behaviour for reported illness

4.3 Geographical, social, and cultural accessibility to health care facilities on possible communicable illness

4.4 Availability and accessibility of health care services

5.0 Discussion 239

5.1 Statement of principle findings

5.2 Strengths & weakness of the study


5.4 Meaning of study (implication for policy makers)

5.5 Unanswered questions & future research


References 241

Acknowledgement 242

Appendices 243

207Health Seeking Behaviour towards Communicable Diseases among Foreign Workers in Industrial & Agriculture Sectors of Selected Districts in Perak, Malaysia

ABSTRACT

Health Seeking Behaviour towards Communicable Diseases among Foreign Workers in Industrial & Agriculture Sectorsin Selected Districts in Perak, Malaysia

Kean-Yau Koh1, Kuo-Ghee Ong2, Noor Asmah Ahmad Shah Azizi3, Wan Asmuni Wan Mohd. Saman4, Asmah Zainal Abidin5, Marina Kamaruddin5, Amar-Singh HSS6,7, Sondi Sararaks8, Ranjit Kaur Praim Singh5

1 Sungai Siput Hospital, Perak2 Department of Medicine, Taiping Hospital, Perak3 Grik District Health Department, Perak4 Universiti Teknologi MARA, Selangor5 Perak State Health Department6 Clinical Research Centre Perak7 Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak8 Institute of Health Systems Research


Information regarding the pattern of behaviour of foreign workers in seeking health and utilisation of health facilities is limited. This may hinder formulation and implementation of strategic policies in the health system. This study was to determine the health seeking behaviour towards communicable diseases among foreign workers in the industrial and agriculture sectors of an administrative district.

Methodology

A cross-sectional community survey was done to look at health seeking behaviour towards communicable diseases among foreign workers in the agriculture sector from Hulu Perak & Kuala Kangsar districts and industrial sectors from Kinta district in Perak. Purposeful sampling was conducted to ensure all relevant sectors and ethnic groups were included. Information was gathered through interviews or self-administrated using a standardised, pre-tested questionnaire. Health seeking behaviour for reported illness of foreign workers and possible communicable illnesses (4 clinical scenarios) were evaluated. Availability, accessibility, and choice of health care services as well as perceived obstacles were assessed.

Results

710 foreign workers were interviewed. The majority of respondents were Bangladeshis (30.4%), followed by Indonesians (27.7%), Thais (16.9%), Nepalese (14.1%), and Vietnamese (10.8%). 338 (47.9%) workers were from the agricultural sector and 372 (52.4%) were from the industrial sector. 328 (46.2%) were from Hulu Perak, 331 (46.6%) from Kinta, and 51 (7.2%) from Kuala Kangsar districts. Most respondents were legal workers (90.3%), and only 9.7% were illegals. Out of the total 710 respondents, 70 (9.9%) experienced serious illness,


and 209 (29.4%) experienced mild illness. 68 out of 70 respondents (97.14%) with serious illness sought medical treatment as compared to only 172 (82.3%) out of 209 respondents with mild illness. Of the 172 respondents who sought treatment for mild illness, equal percentage (48.8%) of them sought treatment at government and private clinics and hospitals. 19.8% of respondents were admitted to hospitals, and 85.5% of them considered the fees affordable. In response to 4 clinical scenarios (pulmonary tuberculosis, malaria, cholera, and typhoid symptoms), they would seek appropriate healthcare. Majority from the agriculture sector (82.5%) needed to travel more than 20 km whereas 93.7% from the industrial sector only needed to travel less than 5 km to seek treatment.

Conclusion

This study shows that foreign workers do not seem to have problems in seeking health care. Access to care is a problem in the agriculture sector in terms of geographical location. Both legal and illegal workers seek health care for serious and mild illnesses. Legal and illegal foreign workers appear to understand serious illness and take appropriate action. There is a need to improve access to health care for agriculture workers.

Keywords

health seeking behaviour, foreign workers, industrial and agriculture sectors, communicable diseases


1.0 INTRODUCTION

1.1 Background

In 2006, the Ministry of Home Affairs Malaysia reported that the number of legal foreign workers in Malaysia is 1.8 million, comprising about 16% of the total employed work force. Of these, 1,215,036 were Indonesians, 200,200 Nepalese, 139,716 Indian nationals, 92,020 Burmese, 85,835 Vietnamese, 58,878 Bangladeshis, 22,080 Filipinos, 15,071 Pakistanis, 7,282 Thais, 6,637 Cambodians, 5,076 Sri Lankans, and 2,262 from other countries.1 These numbers represent only the legal workers; previous data in 2001 reported that there were approximately 450,000 illegal immigrants in the country.

In Malaysia, all legal foreign workers are regular screened for infectious disease within 1 month of entry and annually for 3 years.2,3 The mechanism in place is able to detect and refuse entry of foreign workers having communicable diseases into Malaysia. It was reported in 2007 that maids had tuberculosis (16,697), hepatitis B (10,953), and syphilis (2,824). Those who had HIV/AIDS numbered 683 while 147 were found to be suffering from psychiatric problems. Nevertheless, this screening system is fraud with loopholes and deficiencies, whereby certain diseases like syphilis, Hepatitis A & C are not screened, and some panel doctors did not follow proper stringent screening protocols.2-4 In addition, illegal foreign workers virtually entered the country without any health checks.

These foreign workers usually originated from less developed countries, which have higher incidence of infectious diseases such as malaria, cholera, and tuberculosis as compared to Malaysia. Hence, these immigrants posed an infection risk to our overall health situation and additional burden towards health care services for both communicable and non-communicable diseases.5


The health seeking pattern and health facilities utilisation behaviour of foreign workers within the context of their diverse physical, socio-economic, cultural, and political aspects are unknown; these factors have hindered proper strategic policy formation in the health system.6 In this study, we seek to find the pattern of health seeking behaviour on recent illness, perceived barriers to accessibility to health facilities, pattern of health care utilisation by foreign workers, and their perceived actions towards communicable diseases. These results will be useful to formulate preventive measures to protect the local community from communicable diseases, creation of rapid response in case of an outbreak, and for health authorities to plan and deliver better health care services to foreign workers in the future.


Figure 1. Problem analysis chart



Health seeking behaviours among foreign workers are determined by a wide variety of factors (Figure 1), which can be grouped into 3 broad categories:7-9

a) Characteristics of health services and enabling factors Examples: government policies, availability of health care facilities, accessibility

issues in terms of transportation and distance, affordability and costs, acceptability from personal perspective and employer’s policy & support.

b) Predisposing factors Examples: demographic & communication barriers.

c) Characteristics and illness perception Examples: personal attitudes & knowledge in terms of belief, severity of illness,

social stigma, and cultural practices.

Previous research showed that the factors discussed above did not favour foreign workers in seeking proper health care. Concerted effort is thus required for designing behavioural health promotion campaigns through inter-sectorial collaboration, focusing on disadvantaged segments of the population. The potential outcomes of research on the determinants of health seeking behaviour of foreign workers are summarised in Figure 2.

Figure 2. Potential outcomes of research on social determinants of health seeking behaviour


2.0 OBJECTIVES


To determine the health seeking behaviour towards communicable diseases among foreign workers in the industrial and agriculture sectors of an administrative district.


1. To determine the health seeking behaviour of foreign workers by socio-demographic data and legal status with respect to:

a. illness in relation to perceived severity, treatment seeking, and self-care

b. geographical, economical, and cultural accessibility

c. pattern of utilisation of health care for private, government, traditional health services and self-care factors in preventing foreign workers from assessing private or government health care services.

2. To make recommendations to improve the health care services for foreign workers.

3.0 METHODOLOGY


A cross-sectional community survey was conducted to determine the health seeking behaviour towards communicable diseases among two major groups of foreign workers in the agriculture and industrial sectors of three districts in Perak. Agricultural and industrial sectors were selected in this survey as both sectors made up 73% of the total number of foreign workers in Perak (Table 1). Foreign workers in the agriculture sector of Hulu Perak and Kuala Kangsar districts and the industrial sector of Kinta district were involved in the study. Purposeful sampling was done to ensure that all relevant sectors and ethnic groups were included. The samples were collected as such for logistic purpose, as the main economic activity in Hulu Perak and Kuala Kangsar districts were agricultural; whereas Kinta district was the major industrial area in Perak.

Study information was gathered through interviews with respondents or via self-administration using a standardised, pre-tested questionnaire (Appendix A). Response to the questions was mainly based on recall of illness experience as well as opinions on scenarios of communicable diseases. The survey questionnaire also included sections on socio-demographic information, health seeking behaviour, utilisation of health services, and perceived barriers from health services. The work


Table 1. Statistics of foreign workers in the state of Perak from January to December 2007

CountryIndustrial Agriculture Others Total

n % n % n % n %

Indonesia 6,424 22.74 17,641 63.36 16,004 89.02 40,169 54.16

Nepal 10,827 38.33 2,697 9.69 182 1.01 13,706 18.48

India 1,127 3.99 4,653 16.71 1,150 6.40 6,931 9.35

Vietnam 4,888 17.30 181 0.65 156 0.87 5,225 7.04

Bangladesh 1,971 6.98 1,885 6.77 119 0.66 3,975 5.36

Myanmar 2,469 8.74 647 2.32 157 0.87 3,273 4.41

Cambodia 369 1.31 51 0.18 78 0.43 499 0.67

Philippines 20 0.07 16 0.06 90 0.50 126 0.17

Sri Lanka 79 0.28 7 0.02 12 0.07 98 0.13

Pakistan 45 0.16 24 0.09 13 0.07 82 0.11

Thailand 29 0.10 25 0.09 16 0.09 70 0.09

China 1 0 17 0.06 0 0 18 0.02

Total 28,249 100 27,841 100 17,977 100 74,172 100

(Source: Perak Immigration Department, 2008)

flow of the interview or self-administered questionnaire is shown in Figures 3 and 4.

3.2 Study type

This was a cross-sectional survey conducted among two major groups of foreign workers in the industrial and agriculture sectors of three districts in Perak. Foreign workers from the agriculture sector in Hulu Perak and Kuala Kangsar districts and the industrial sector of Kinta district were involved in the study.


The Medical Research and Ethics Committee (MREC) of the Ministry of Health Malaysia had approved the study. Verbal consent was taken from the respondents and those who refused were excluded from the study. All respondents who agreed to participate in the study were assured of the confidentiality of their identities and responses, and were free from any legal complications.


Figure 3. Work process of the interview or self-administered questionnaire


3.4 Variables


DistrictThe district of the respondent’s work place

Hulu Perak / Kuala Kangsar / Kinta

Sector

Job nature of the respondent at the time of interview. Agriculture: plantation area / estates / other agricultural activities. Industrial: factory or construction sites. Others: other than these 2 sectors

Agricultural / Industrial / Others

Distance to nearest health service

Distance from respondent’s residence to the nearest health service as assessed by the interviewer

Kilometres

NationalityCountry of origin of respondent as obtained from respondent to a direct question

Thai / Indonesian / Bangladeshi/ Nepali Myanmar / Vietnamese / Others

AgeAge in completed years as obtained from respondent to a direct question

Years

Gender Gender of respondent Male / Female

Figure 4. Health behaviour assessment questions



Legal statusAbility of respondent to produce a legal working permit

Yes / No

Education levelHighest level of education as obtained from respondent to a direct question

Tertiary / Secondary / Primary / No formal education

Fluency in Malay or English

Ability of respondents to communicate verbally in Malay or English

Yes / No

Length of stay in Malaysia

The length of time the respondent has been staying in Malaysia

Years and months

Experience of serious illness

Experiencing serious illness in the past 1 year as defined as any hospitalisation or inability to work for 3 or more days (excluding injuries)

Yes / No

Experience of illness

Experiencing any illness in the past 2 weeks while staying in Malaysia (excluding injuries)

Yes / No

Seeking treatment for mild and serious illness

Respondent’s utilisation of health service for illness

Yes / No

Health facilities sought for mild and serious illness

Health facilities sought by the respondent for illness

Government clinic/hospital / Private or panel clinic/hospital / Traditional/complementary medicine centre

Hospital admission

Admission to hospital for mild and serious illness

Yes / No

Importance of health care provider

The importance of the health care provider to the respondent

Government clinic/hospital / Private or panel clinic/hospital / Traditional/complementary medicine centre



Reasons for the choice of health care provider

Respondent’s reason for choosing the particular health care provider to seek treatment for illness

Nearby to resident or workplace / Easily reached from resident or workplace / Encouraged by family/ friends / Confident with healthcare treatment or medication given / Satisfied with attitude and behaviour of healthcare staff / Others

Payment mode of treatment fees

Respondent’s mode of payment of treatment fees for illness

Employer paying out of pocket / Own money / Panel clinic/doctor / Health insurance / Others

AffordableRespondents opinion on the affordability of treatment fees

Yes / No

Mode of transport to health care facilities

Methods of transportation used by the respondent

Own transport / Public transport / Company/employer transport / Walking / Others

Expectation towards healthcare services

Respondent’s expectation on healthcare services currently available in Malaysia

Good / Average / Poor / Not sure

Action taken if did not seek treatment

Action taken by the respondent if they did not seek treatment for illness

Self care / do nothing

Reason for not seeking treatment

Respondent’s reason for not choosing to seek treatment for illness at any health care provider

Too far / Too expensive / Poor employer support / Mild illness / Prefer self care / Not confident with treatment or medicine given / Not satisfied attitude and behaviour of health care staff / Afraid of painful treatment or side effect / Others



Availability

Respondent’s opinion on the availability of health care service at working/residential area

Yes / No

Connecting road

The type of road that connects the respondent’s resident to the nearest health service

Tar road / Non-tar road / Others

AccessibilityRespondent’s opinion on the accessibility of health services

Yes / No

Travelling permit

The type of travelling permit of the respondent

Working Permit / Tourist Visa / Student Visa / Nothing

Personal monthly income

Based on respondent’s monthly salary as per reported verbally

Ringgit Malaysia


The sample size was calculated using the EpiCalc 2000 software by setting the proportion at 7% and precision level at 3%. This was based on the National Health and Morbidity Survey of 1996, which stated that 7% of the population admitted in the period of 1 year had serious illness. The minimum sample size in each study population of both the agriculture and industrial sectors is 277 respectively. The total sample size was targeted at 300 workers from the agricultural and 300 workers from the industrial sector.

The sampling frame in this study consisted of foreign workers working in the agriculture sector of Hulu Perak and Kuala Kangsar districts and the industrial sector of Kinta district. An estimated number of foreign workers in each study district are obtained from the vector control unit from the respective district health offices. The vector unit statistics was chosen because they included both the legal and illegal foreign workers working in the areas.

From this sampling frame, respondents were then enrolled for study using a 2-staged random stratified sampling method for the villages, plantation sites or factory and convenient quota sampling within the random sampling frame according to the worker’s nationality. In the first stage, the villages, plantation sites and manufacturing plants were selected using simple random sampling method according to the list from the statistics obtained from the vector units of the district health offices. In the


second stage, adequate representative numbers of foreign workers from different nationalities in each sector were enrolled via convenient sampling method.

The 3 highest proportions of foreign workers in terms of their nationality were enrolled from the agriculture sector, i.e. 100 Indonesian, 100 Thai, and 100 Bangladeshi agriculture workers from the Hulu Perak and Kuala Kangsar districts. The 4 highest proportions of foreign workers in terms of their nationality were enrolled from the industrial sector; i.e. 75 Indonesians, 75 Bangladeshis, 75 Nepalese, and 75 Vietnamese from the Kinta district. This sampling method was designed in such a way to ensure that the health seeking behaviour of each nationality was included in the study, and allowed subsequent comparisons in terms of nationalities, legal status, and other socio-demographics.

3.5.1 Inclusion criteria

All foreign workers working in the agriculture sector of Hulu Perak and Kuala Kangsar districts and the industrial sector of Kinta district who agree to participate in the study.

3.5.2 Exclusion criteria

1. Foreign workers from developed countries with high socioeconomic status.

2. Foreign workers with permanent resident status.3. Foreign workers who are illiterate and with inadequate language

ability for interview purpose.4. Foreign workers working in other sectors (maids, constructions,

service).


One health inspector, one assistant health inspector, and 5 community nurses from Grik Health District Office were trained for 2 sessions in administering the questionnaire and were subsequently directly involved in data collection process. Literate foreign workers were encouraged to self-administer the questionnaire on the spot with assistance from the interviewer. The questionnaires were prepared in 5 languages, i.e. English, Malay, Bangladesh, Nepali, and Vietnam languages. Interviewers directed themselves to the pre-defined areas where the foreign workers stay or work in casual attire to prevent anxiety to the person being interviewed. Eligible subjects were approached in the streets or at the door of their homes or at the entrance of their common meeting places. The respondents were approached for interviews irrespective of their nationality or gender. Interviews were conducted from early morning until late at night from July to October 2008. An average of 3-4 visits was needed to accumulate the required sample size for the study.


Table 2. Socio-demographic characteristics of foreign workers

Characteristic Frequency (n) Percentage (%)SectorAgriculture 338 47.6Industrial 327 52.4NationalityThai 120 16.9Indonesian 197 27.7Bangladeshi 216 30.4Nepali 100 14.1Vietnamese 77 10.8Gender Male 527 74.2Age group< 30 years 495 72.331 – 40 years 148 20.8> 40 years 49 6.9Education levelNo formal education 66 9.3Primary 275 38.7Secondary 345 48.6Tertiary 24 3.4Able to communicate in Malay or EnglishYes 552 77.9No 158 22.3Monthly income (mean = RM 729.44; median = RM 650.00)<RM 500 264 38RM 500 - RM 1,000 374 53.8> RM 1,000 57 8.2Length of stay in Malaysia (mean = 30 months; median = 20 months)< 12 months 184 25.913 - 24 months 249 35.125 - 60 months 208 29.3> 60 months 69 9.7Distance to nearest health service (mean = 15 km; median = 10 km)< 2 km 104 14.62 - 5 km 165 23.26 - 10 km 139 19.611 - 20 km 103 14.5> 20 km 199 28.5Legal statusLegal 641 90.3Illegal 69 9.7


At the end of interview process, the researches took the opportunity to distribute information pamphlets to the respondents on symptoms suggestive of tuberculosis, malaria, typhoid, and cholera (Appendix B). The respondents were also informed on how treatment can be accessed from the nearest biomedical health services.


Data collected was summarised and analysed in SPSS using univariate analysis.

4.0 RESULTS

4.1 Socio-demographic characteristics of respondents

A total of 710 foreign workers participated in this study. The socio-demographic characteristics of these workers are shown in Table 2. There were 338 (47.6%) agriculture and 372 (52.4%) industrial workers. Most were Bangladeshis (30.4%) and Indonesians (27.7%). Majority were below 30 years of age (72.3%). Most had secondary (48.6%) and primary (38.7%) education. Majority were able to communicate verbally in Malay or English (77.9%). Their mean and median monthly income was RM729.44 and RM 650.00 respectively. A small percentage entered the country illegally (9.7%). Those who had valid working permits were considered legal, and those without working permits (i.e. tourist visa, student visa, no traveling document) were considered illegal. The workers reported a mean and median length of stay in Malaysia of 30 and 20 months respectively. The mean and median distance to the nearest health service was 15 km and 10 km respectively.

4.2 Health seeking behaviour for reported illness

Of the total 710 respondents, 70 (9.85%) experienced serious illness and 209 (29.4%) experienced mild illness during their stay in Malaysia (Table 3). The remaining 431 (60.7%) did not have any illness during their stay in Malaysia. Therefore, health seeking behaviour for reported illness was assessed in a total of 279 respondents.

Table 3. Health seeking behaviour of foreign workers who reported illness by illness severity

Serious illness Mild illness No illness Total

Seek treatment 68 (9.6) 172 (24.2) 0 (0.0) 240 (33.8)

Did not seek treatment

2 (0.3) 37 (5.2) 431 (60.7) 470 (66.2)

Total 70 (9.9) 209 (29.4) 431 (60.7) 710 (100)

* Data are presented as number (percentage).


Table 4. Health seeking behaviour for reported mild illness by socio-demographics

Characteristics Sought Treatment for Mild Illnessn % Lower limit of 95% CI Upper limit of 95% CI

SectorAgricultural 103 74 65 82Industrial 106 91 85 96NationalityThai 30 67 49 85Indonesian 58 72 61 84Bangladeshi 56 88 79 96Nepali 40 93 84 100Vietnamese 25 96 88 100Gender Male 162 81 75 87Female 47 87 77 97Age group< 30 years 129 81 74 8831 – 40 years 67 84 74 93> 40 years 13 92 76 100Education levelNo education 20 80 61 99Primary 76 82 73 90Secondary 105 82 74 89Able to communicate in Malay or English Yes 179 80 74 86No 30 97 90 100Monthly income <RM 500 44 98 93 100RM 500 - RM 1,000 145 79 73 86> RM 1,000 18 67 43 91Length of stay in Malaysia< 1 year 21 76 56 961 - 2 years 88 77 68 862 - 5 years 74 91 84 97> 5 years 26 81 65 97Legal statusLegal 189 84 78 99Illegal 20 70 48 92


68 out of 70 respondents (97.14%) who experienced serious illness sought medical treatment, as compared to only 172 (82.3%) out of 209 respondents with mild illness.

Table 4 compares the probability of respondents who seek care for mild illness with their socio-demographic characteristics. Work sector and nationality significantly affected the decision to seek treatment for mild illness. However, no significant association was noted in relation to the respondent’s gender, age groups, education levels, language ability, income levels, duration of stay in the country, and their legal status.

The relationship of work sector and nationality with the decision to seek treatment for mild illness is depicted in the error charts below. In terms of working sector, significantly more industrial workers would seek treatment as compared to agriculture sector workers (Figure 5). In terms of nationality, the percentage of respondents who sought treatment ranged from 67% to 96%. Vietnamese were found to be significantly more likely to seek treatment for mild illness compared to Indonesians and Thais (Figure 6).

When the legal status of respondents was taken into consideration when comparing their health seeking behaviour, it was observed that a significantly higher percentage of legal workers in the industrial sector would seek treatment for their mild illness than legal agriculture/plantation workers (Figure 7). However, when health seeking behaviour for treatment of mild illness was compared in terms of nationality and legal status, no significant difference was observed (Figure 8). Overall, 87% of legal and 72% of illegal workers would seek treatment for mild illness.

The health seeking behaviour for reported mild illness was compared between the two work sectors, taking into account the nationality of the respondents (Figure 9). There was a significant difference in the behaviour of seeking treatment for mild illness among Thai and Indonesian agriculture/plantation workers as compared to Nepal workers in the industrial sector.

4.2.1 Health seeking practice: choice of health care provider

Among the 172 respondents who sought treatment for mild illness, equal percentage (48.8%) of them sought treatment at government and private hospitals & clinics. The choice of seeking treatment at government and private hospitals & clinics did not differ significantly by nationality of the respondents when their work sector was taken into consideration (Figures 10 and 11). Overall, there was no significant difference in terms of the choice of health care provider among sectors and nationality. 19.8% of these respondents who sought treatment for mild illness were subsequently admitted to hospitals for medical observation or treatment. 85.5% of them considered the treatment fees affordable.


Figure 5. Comparison of health seeking behaviour for reported mild illness by sector

Figure 6. Comparison of health seeking behaviour for reported mild illness by nationality

Thailand Indonesia Bangladesh Nepal Vietnam

Nationality

Plantation Industry

Sector

95%

CI E

ver S

eek

Trea

tmen

t95

% C

I E

ver

See

k Tr

eatm

ent

1.2

1.0

0.8

0.6

0.4

1.0

0.9

0.8

0.7


Figure 7. Comparison of health seeking behaviour for reported mild illness by legal status and sector

Figure 8. Comparison of health seeking behaviour for reported mild illness by legal status and nationality

Plantation Industry

Sector

95%

CI

Eve

r S

eek

Trea

tmen

t


Figure 9. Comparison of health seeking behaviour for reported mild illness by nationality and sector

Figure 10. Choice of government health care provider by nationality and sector


Figure 11. Choice of private health care provider by nationality and sector

Figure 12. Perception of good health care service by nationality and sector


Figure 13. Source of payment for treatment fees

Figure 14. Reasons for not seeking treatment


4.2.2 Health seeking practice: rating of health care provider

The 172 respondents were asked to rate the provision of health care service in Malaysia. Majority (70.3%) considered the health care service good. There was a significant difference in the perception of good health care among nationality and sector (Figure 12). Indonesian and Bangladeshi workers gave higher ratings than Nepalese and Vietnamese workers.

4.2.3 Health seeking practice: mode of transportation

Among the 172 foreign workers, 55.2% used employers’ transport, 22.6% used their own transport, and the remaining used either public transport or walked to the health care provider to seek treatment for mild illness. There was no significant difference in the mode of transportation among sector and nationality.

4.2.4 Payment of treatment fees

Of the respondents who reported seeking treatment for mild illness, they were interviewed on the payment source of their treatment fees. Majority of the respondents who sought treatment for their illness had their treatment fees paid by their employers (Figure 13). These comprised 75 and 72 workers in the agricultural and industrial sectors respectively. A large number of respondents (45 agriculture and 29 industrial workers) had to fork out their own money to pay their treatment fees. The treatment fees of some respondents were covered by their panel clinic/doctor and health insurance. Similarly, a larger number of workers in the industrial sector had this privilege.

4.2.5 Reasons for not seeking treatment

We interviewed the 39 respondents who experienced mild or severe illness to determine their reasons for not seeking treatment for their illness (Figure 14). The main reason given by these respondents was mild illness not requiring treatment (30, 76.9%). This next reason given was the distance of the health care provider from their residence (9, 23.1%). Other reasons reported were preference of self-care (5, 12.8%), fear of treatment and poor employer support (3, 7.7%), and not confident with treatment (2, 5.1%). Only 1 respondent reported the treatment being too expensive as the reason of not seeking treatment. Non-satisfaction with the health care service was not one of the reasons for not seeking treatment for illness.


Figure 15. Health seeking behaviour for pulmonary tuberculosis by nationality and sector

Figure 16. Health seeking behaviour for pulmonary tuberculosis by legality and sector


Figure 17. Health seeking behaviour for malaria by nationality and sector

Figure 18. Health seeking behaviour for malaria by legality and sector


Figure 19. Health seeking behaviour for cholera by nationality and sector

Figure 20. Health seeking behaviour for cholera by legality and sector


4.3 Geographical, social, and cultural accessibility to health care facilities on possible communicable illness

4.3.1 Health seeking behaviour for pulmonary tuberculosis

Respondents were given a few clinical scenarios and were asked to answer questions accordingly. Of the total 710 respondents, 671 (94.5%) reported that they had cough for more than 2 weeks. 65.8% of them who had cough would seek treatment at government hospitals or clinics as compared to only 28.2% who chose to go to private facilities. In terms of nationality and work sector, there was no significant difference in the willingness to seek treatment for their illness (Figure 15). Similarly, no significant difference was observed when the willingness to seek treatment was compared by the legal status of the respondents, taking into consideration their work sector (Figure 16).

4.3.2 Health seeking behaviour for malaria

Question C7 of the questionnaire interviewed respondents on their health seeking behaviour for malaria. Of the total 710 respondents, 674 (94.9%) admitted to having fever, shivers, and sweats. Majority (64.2%) would seek treatment from government hospitals or clinics while only 30% would prefer private facilities. There was a significant difference in the health seeking behaviour of respondents for malaria symptoms in terms of nationality and sector. Bangladeshi and Nepalese workers in the industrial sector are more likely to seek treatment compared to Thai and Indonesian workers in the agriculture sector (Figure 17). However, there was no difference in the willingness to seek treatment for malaria symptoms between legal and illegal workers, taking into account their work sector (Figure 18).

4.3.3 Health seeking behaviour for cholera

We interviewed the respondents on their health seeking behaviour for the symptoms of cholera. 617 (86.9%) reported to have severe diarrhoea. Most preferred to seek treatment at government hospitals and clinics (63.9%) while 30.7% sought health from private facilities. In terms of nationality and sector, there was a significant difference in the health seeking behaviour for severe diarrhoea; Bangladeshi and Nepalese industrial workers were more likely to seek treatment as compared to Thai and Indonesian agriculture workers (Figure 19). However, the health seeking behaviour for severe diarrhoea did not differ significantly between legal and illegal workers of both sectors (Figure 20).


Figure 21. Health seeking behaviour for cholera by nationality and sector

Figure 22. Health seeking behaviour for typhoid by legality and sector


4.3.4 Health seeking behaviour for typhoid

Respondents were also interviewed on their health seeking behaviour for symptoms of typhoid. 684 (96.3%) reported feeling very unwell with high fever more than 1 week. More respondents preferred seeking treatment at government hospitals and clinics (65.6%) as compared to only 30.0% from private facilities. In terms of nationality and sector, there was a significant difference in seeking treatment for high fever; Bangladesh and Nepal industrial workers were more likely to seek treatment for symptoms of typhoid as compared to Indonesian workers (Figure 21).

4.4 Availability and accessibility of health care services

4.4.1 Availability of health care services

Among the 710 respondents, 82.3% reported that health care services were available to them. These respondents reported a higher availability of government facilities (57.2%) than private facilities (42.5%). In general, majority (98.7%) of the industrial workers sought treatment as compared to 64.2% in the agricultural sector. Nepal and Vietnam industrial workers considered health care services more available to them than Thai, Indonesian, and Bangladesh agriculture workers (Figure 23).

4.4.2 Accessibility to health care services

Of the total 710 respondents, majority (90.0%) considered health care services easily accessible to them. 94.6% industrial workers and 84.9% agricultural workers accessed health care services in the country. There was a significant difference in the accessibility to health care services among respondents of different nationality and work sector (Figure 24).

4.4.3 Distance to health service

Among the 506 respondents, 53.2% had to travel within 5 km and 46.8% had to travel more than 20 km to the nearest health care facility. Foreign workers from the agriculture sector (82.5%) needed to travel more than 20 km whereas 93.7% from the industrial sector only needed to travel within 5 km to seek treatment. The percentage of respondents who travelled less than 5 km and more than 20 km to the nearest health service differed significantly by nationality and sector (Figures 25 and 26).

4.4.4 Mode of transport to health service

Respondents were interviewed on their mode of transport to health service. Of the total 710 respondents, most (65.9%) used company/employer’s


Figure 23. Availability of health care services by nationality and sector

Figure 24. Accessibility to health care services by nationality and sector


Figure 25. Distance to health service less than 5 km by nationality and sector

Figure 26. Distance to health service more than 20 km by nationality and sector


Figure 27. Usage of own transport by nationality and sector

Figure 28. Usage of public transport by nationality and sector


transport to access to health service, followed by 21.7% who used their own transportation, and 6.6% who took public transport. Interestingly, majority of Thai workers (67.5%) used their own transport to access to health service, as compared to other nationalities used company/employer’s transport (Figure 27, 28 and 29).

5.0 DISCUSSION

5.1 Statement of principle findings

In this study, we observed that majority of the foreign workers seek treatment when they experienced serious illness (97.1%) and mild illness (82.3%). There was a significant difference in health seeking behaviour by employment sector. Foreign workers in the industrial sector (91%) were more likely to seek treatment for mild illness than those in the agriculture sector (74%).

In terms of nationality, Vietnamese, Nepalese, and Bangladeshi were more likely to seek care than Indonesian and Thai workers. This is possibly due to the fact that Vietnamese and Nepalese worked solely in the industrial sector. For the Bangladeshi workers in both sectors, their health seeking behaviour was better when compared to workers of other nationalities.

Figure 29. Usage of company/employer’s transport by nationality and sector


Foreign workers in the industrial sector were able to access health care facilities within 5 km (93.7%) of their residence as they are served by panel doctors provided by their employers. On the other hand, majority of the workers in the agriculture sector need to travel for more than 20 km (82.5%) to the nearest health care facility and were more likely to use government facilities. In general, foreign workers in the industrial sector preferred private health care facilities while those in the agriculture sector preferred government health care facilities. There was no significant difference in the health seeking behaviour between legal (84%) and illegal (70%) foreign workers for mild or serious illness.

5.2 Strengths & weaknesses of the study

There were several limitations in this study. Our study focused on the industrial and agriculture sectors for convenience in getting access to the foreign workers. Hence, results obtained from this study cannot be generalised to other work sectors. In addition, no data was collected on foreign workers who declined to participate in the study. They comprised mainly those in the industrial sector in Kinta district. Important information and implications could have been neglected due to this factor. Another limitation was the small number of reported illegal foreign workers in this study. The legal status of foreign workers who participated in this study could not be independently ascertained because to ensure compliance, immigration documents were not inspected.

Despite the above limitations, this is this first study that assessed the health seeking behaviour of a large number of foreign workers. Findings from this study can be used to develop strategies for health systems in order to respond to the perspectives and needs of foreign workers in the country.


Currently, there are very limited studies regarding the health seeking behaviour among foreign workers in Asia. To date, no such studies have been done in Malaysia. Assessment of health seeking behaviour in this study was mainly based on the Health Care Utilization Model, Kroeger’s Model, and “four As” model.

5.4 Meaning of study (implication for policy makers)

Although findings of this study show that foreign workers do not seem to have problems in seeking health care, access to care is a problem in the agriculture sector which needs to be addressed. The private health sector can play an important role in supporting the health care needs of foreign workers.


5.5 Unanswered questions & future research

The health seeking behaviour of foreign workers in other employment sectors needs to be studied. There is a need to obtain a larger sample for illegal foreign workers to understand their health seeking behaviour and a mechanism for funding.


6.1 Conclusion

This study shows that foreign workers do not seem to have problems in seeking health care. Access to care is a problem in the agriculture sector in terms of geographical location. Both legal and illegal workers seek health care for serious and mild illness. Legal and illegal foreign workers appear to understand serious illness and take appropriate action accordingly.

6.2 Recommendations

Based on the study findings, we wish to make the following recommendations:1. There is a need to improve access to health care for workers in the agriculture

sector. 2. Employers of the agriculture industries must be responsible to provide onsite

health care facilities, panel doctors or transport to the nearest government or private hospital or clinic.

3. Relevant government authorities must be responsible to make sure employers are providing healthcare to their foreign workers, especially those in the agriculture sector.

4. Initiation of a multi-agency meeting with the involvement of the Perak government to improve health care service delivery to foreign workers especially those in the agricultural sector.

REFERENCES

1. Labour Force Statistics, Malaysia, 2006.2. World Malaria Report 2005, WHO.3. World Tuberculosis Report 2008, WHO.4. Selvarani P, Audrey V. Maid for trouble. The New Straight Tines. 2008 May 25.5. WHO Weekly Epidemiological record4 AUGUST 2006, 81st YEAR / 4 AOÛT 2006,

81e ANNÉE No. 31, 2006, 81, 297-308. Available from: http://www.who.int/wer6. Maimunah AH, Sondi S, Sing LM, Safurah J, Haniza MA, John A, et al. National Health

and Morbidity Survey 1996. Public Health Institute, 1999.


7. Babar T. Shaikh. Understanding social determinants of health seeking behaviours, providing a rational framework for health policy and systems development. J Pak Med Assoc 2008;58(1):33-6.

8. Babar TS, Juanita H. Health seeking behavior and health service utilization in Pakistan: challenging the policy makers. J Public Health 2004;27(1):49-54.

9. Torres AM. Health care provision for illegal immigrants: should public health be concerned? J Epidemiol Commun Health 2000;54:478-9.

ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper. We would like to extend our highest gratitude to the Perak State Health Department for their endorsement of this health systems research programme.

Our sincere thanks are also extended to all facilitators of this research project for their invaluable guidance and support.

Lastly, we also appreciate the assistance from all staff of Clinical Research Centre Perak, Grik Health District, health inspectors, assistant health inspectors, and community nurses who worked endlessly during the fieldwork and for their cooperation in conducting this research till its fruition.


APPENDICES

Appendix A: Questionnaire

Health Seeking Behaviour towards Communicable Diseases among Foreign Workers in Industrial & Agriculture Sectors of Selected Districts in Perak, Malaysia

Unique IDDistrict Sector Locality

Distance to nearest health service

km

We are conducting a study on how foreign workers seek health care in Malaysia. Your response will benefit foreign workers in getting health care in Malaysia and in improving health service in this country. All information obtained will be kept strictly confidential and will not be disclosed to the authorities.

Would you like to participate in this study? Yes No

Questionnaire Interview Self-administered

Interviewer’s name ______________________________ Date: _______________

Section A: Respondent’s socio-demographics

Nationality Thai Indonesian Bangladeshi Nepalese

Myanmar Vietnamese Others ______________________

Age

______ years

Gender Male Female

Education level Tertiary Secondary Primary No formal education

Are you able to communicate in Malay or English comfortably? Yes No

How long have you been staying in Malaysia? _____ Years _____Months


Section B: Respondent’s health seeking practices

1. Have you ever experienced any serious illnesses while staying in Malaysia? For example: hospital admission, unable to go to work for 3 days or more (excluding

injuries)Yes (If Yes, please proceed to Question 3)No (If No, please proceed to Question 2)

2. Have you ever experienced any illnesses while staying in Malaysia? (excluding injuries)Yes (If Yes, please proceed to Question 3)No (If No, please proceed to Section C)

3 Did you seek treatment for your illness?Yes (If Yes, please proceed to Question 4)No (If No, please proceed to Question 5)

4. If you sought treatment for your illness,4.1 Where did you seek treatment for your illness? (you may choose more than 1

answer)\Government clinic / hospitalPrivate or panel clinic / hospitalTraditional / complementary medicine centre

4.2 Were you admitted to hospital for that illness?YesNo

4.3 If you visited more than one health care provider, which health care provider was the most important for you? (please choose 1 answer)Government clinic / hospitalPrivate or panel clinic / hospitalTraditional / complementary medicine centre

4.4 Why did you choose to go to that health care provider? (you may choose more than 1 answer)Nearby to residence or workplaceEasily reached from residence or workplaceEncouraged by family/friendsConfident with healthcare treatment or medication givenSatisfied with attitude and behaviour of health care staffOthers, please specify _______________________________________


4.5 How did you pay your treatment fees for that illness? (you may choose more than 1 answer)Employer paying out of pocketOwn moneyPanel clinic/doctorHealth insuranceOthers, please specify _________________________________________

4.6 Do you think the treatment fees were affordable?YesNo

4.7 How did you go to the health service for that illness?Own transportPublic transportCompany’s/employer’s transportWalkOthers, please specify ________________________________________

4.8 Overall, how would you rate the health care services available in Malaysia?GoodAveragePoorNot sure

5. If you did not seek treatment for your illness, 5.1 If you did not seek treatment, what did you do?

Self care (i.e. home remedies, herbal preparation, buy medicine from pharmacy etc.)

Do nothing

5.2 Why did you choose not to go to any health care provider for your illness? (you may choose more than 1 answer)Too farToo expensivePoor employer supportMild illnessPrefer self-careNot confident with treatment or medicine givenNot satisfied with attitude and behaviour of health care staffAfraid of painful treatment or side effectsOthers, please specify ________________________________________


Section C: Possible communicable illnessThese scenarios meant to help us plan for health care service, please answer them according to what you are most likely to do.

6. If you have cough for more than 2 weeks or cough out blood, would you seek treatment?Yes If ‘Yes’, where would you go for treatment? (please choose 1 answer) Government hospital / clinic

Private hospital/ clinic

Traditional / Complementary Medicine Centre

No If ‘No’, what would you do? Self-care

Do nothing

7. If you have fever, shivering followed by sweating for few days, would you seek treatment?Yes If ‘Yes’, where would you go for treatment? (please choose 1 answer) Government hospital / clinic




Do nothing

8. If you have severe diarrhoea for more than 10 times a day, would you seek treatment?Yes If ‘Yes’, where would you go for treatment? (please choose 1 answer) Government hospital / clinic




Do nothing

9. If you have high fever for more than 1 week and feel very unwell, would you seek treatment?Yes If ‘Yes’, where would you go for treatment? (please choose 1 answer) Government hospital / clinic




Do nothing


Section D: Availability and accessibility of health care services

10. Is there any health care service available at your working/residential area?Yes If yes, what is the health care service available? Government hospital / clinic



No

11. What type of road connects you from your residence to the nearest health service?Tar roadNon-tar roadOthers, please specify ____________________________________________

12. How would you go to the health service if you are ill?Own transportPublic transportCompany’s/employer’s transportWalkOthers, please specify ____________________________________________

13. Do you think health services are easily accessible?YesNo

14. How do you think your utilisation of health services can be improved?

_____________________________________________________________

_____________________________________________________________

15. What type of travelling permit do you have?Working PermitTourist VisaStudent VisaNothing

16. What is your average monthly income? RM ___________________

Thank you for your kind cooperation.


Appendix B: Educational pamphlet

Health Seeking Behaviour towards Communicable Diseases among Foreign Workers Page 6

Appendix B: Educational pamphlet

If you have these symptoms:• Bad cough for more than 2 weeks or coughing up blood.• Fever with shivering, lots of sweating for a few days• Severe diarrhoea more than 10 times in a day• High fever more than 1 week, very unwell with difficulty getting to work

You may have get an infectious disease.

Please come and get help from the nearest government clinic. These diseases are curable with modern medicine. According to Malaysia CDC Law, if suspected or confirmed patients with certain infected disease, you will be treated for free.Your action may benefit you and others.

Please contact nearest gov. clinicfor more information…

249

Improving Blood Pressure Controls in Primary Care SettingsHealth Systems Research 2006/2007

Authors

Zarina BaharinPerak Tengah Health District Office

Fauziah AhmadKerian Health District Office

Syah Izaini KhalibManjung Health District Office

Morni Fauziah AhmadPerak Tengah Health District Office





Marina KamaruddinGerik Hospital

Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Zarina Baharin, Fauziah Ahmad, Syah Izaini Khalib, Morni Fauziah Ahmad, Sondi Sararaks, Amar-Singh HSS, Ranjit Kaur Praim Singh, Asmah Zainal Abidin, Marina Kamaruddin. ”Improving Blood Pressure Controls in Primary Care Settings” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 249. (ISBN: 9789671063415)

ISBN

9789671063415

250 Improving Blood Pressure Controls in Primary Care Settings


Abstract 251


1.1 Background



2.0 Objectives 255



3.0 Methodology 255

3.1 Study Design



3.4 Sample Size

3.5 Variables

3.6 Data Collection Technique


3.8 Data Analysis

4.0 Results 260

4.1 Phase I

4.2 Phase II

4.3 Phase III

5.0 Discussion 270

References 273

Acknowledgement 273

Appendices 274

251Improving Blood Pressure Controls in Primary Care Settings

ABSTRACT

Improving Blood Pressure Controls in Primary Care Settings

Zarina Baharin1, Fauziah Ahmad2, Syah Izaini Khalib3, Marina Kamaruddin4, Amar-Singh HSS5,8, Sondi Sararaks6, Ranjit Kaur Praim Singh7, Morni Fauziah Ahmad1, Asmah Zainal Abidin7

1 Perak Tengah Health District Office2 Kerian Health District Office3 Manjung Health District Office4 Gerik Hospital5 Clinical Research Centre Perak6 Institute for Health Systems Research7 Perak State Health Department8 Hospital Raja Permaisuri Bainun Ipoh

Introduction

Hypertension is a major public health problem with a high prevalence. There are many barriers to the effective management of patients with hypertension including specific physician and patient factors. In this study we reported a provider and community intervention to improve blood pressure control among essential hypertension patients in the primary care setting.

Methodology

This was a controlled community trial to assess the effectiveness of an intervention targeted at health care providers and patients. Health clinics that participated were from three semi-urban locations in Malaysia. In each district, 2 clinics were chosen for intervention and 2 clinics for control. 339 patients were interviewed and a focus group discussion held with paramedics and medical officers to identify basic knowledge of hypertension and problems in managing patients with hypertension. From this data an interventional package was developed. Multiple cross-sectional surveys on blood pressure control were done at baseline and monthly for 4 consecutive months post intervention.

Results

A total of 3,000 patients were sampled at baseline and 1 to 4 post intervention assessments. There was a significant improvement in the proportion of patients whose blood pressure was treated to target at 1 month post intervention as compared to baseline. This improvement was sustained over four consecutive months in the clinics with intervention. Blood pressure treated improved from 44% at baseline to 66% at 4 months post intervention. The percentage of blood pressure treated to target was significantly improved among females and those aged less than 60 years.


Conclusion

The interventional package in this study has significantly improved the blood pressure controlled in patients with essential hypertension in a busy primary care setting.

Keywords

blood pressure to target, primary care, hypertension, community trial, health care provider


1.0 INTRODUCTION

1.1 Background

Hypertension is a major public health problem due to its high prevalence with the lack of awareness amongst the general population and its poor control impacting on cardiovascular morbidity and mortality. Hypertension is common and is one of the causes that contribute to strokes, heart attacks and premature death. The rule of halves states that only half of the patient diagnosed with hypertension receives treatment, of which only half have well controlled blood pressure. There is also considerable evidence of deficiency in patient management.

The National Health and morbidity Survey 1996 showed that 30% of Malaysians above 30 years of age have hypertension. The prevalence seen was similar to those in developed country, for example in US the prevalence of hypertension among non-institutionalized adults aged 20 and over was 30 %. Among the people who are diagnosed with hypertension, only 18% of them with well-controlled blood pressure. Those detected to have hypertension, their blood pressure often remained uncontrolled because they failed to comply with or dropped out from treatment (Lim TO 1991; Lim TO 1992).

The primary goal in treating hypertension is to achieve optimal blood pressure levels, thereby reducing the risks of cardiovascular morbidity and mortality (Hassan et al 2005). It is known that lowering blood pressure reduced stroke by 40%; myocardial infarction by 25% and heart failure by 50%.

Compliance describes the extent to which a person’s behaviors coincided with medical advice. Compliance had been evaluated from a wide range of scientific and clinical perspectives since 1950s. Compliant patients are defined as those who accept their physician’s advice to start drug therapy and take their medication at least 80% of the time.


From the results of the National Health and Morbidity Survey 1996, among the hypertensive, 33% were aware of their hypertension, 23% were currently on treatment, however only 6% had controlled blood pressure. The distribution of blood pressure based on JNC V classification showed that 17% had high normal, 20% had Stage 1, 8% had Stage 2 and 4% had Stage 3-4 hypertension.

As we know that hypertension is a major risk factor for cardiovascular disease (Kannel WB, 1996), it is greatly important to have adequate blood pressure control so as to prevent these complications.


To achieve this, concerted public health effort is required to detect, treat and control hypertension in the community, as shown by the experiences of many countries (Henauw et al., 1998; Kastarinen et al., 1998; Burt et al., 1995).


Inadequate blood pressure control among essential hypertension patients is contributed by many factors (Figure 1). The factors include:

1. Health care provider factors, such as lack of knowledge, attitude problem, time constraint and lack of staff.

2. Patient factors, such as age, lack of awareness, ignorance, financial, family support and compliance.

3. Lack of specific hypertension programmed, such as specific health education, hypertension resource centre, hypertension registry and screening for target organ damage.

4. Provision factors, such as lack of availability of certain drugs in health centers, lack of equipment and financial constraint.

Figure 1. Problem Analysis Chart showing factors that affecting the blood pressure control in essential hypertension patients in primary care setting.

Poor Understandingof illness

Side effects of drugs

IgnorancePolypharmacy

Illiterate

Logistics

Family support

Health education

Age

Lack of awareness

Poor complianceFinancial factor

Patient factor

Lack of equipment

Financial constraint Wrong choice of drugs

Health provider

Time constrain

Complicated CPG

Personal factor

Attitude problem

New staff

Lack of staff

Availability of drugs in health centre

Lack of knowledge

Provision factor

Lack of hypertension specific programme

Screening for TOD / TOC

Hypertension resource centre

Hypertension registry Lack of

commitment

Why BP control is inadequate in primary care setting?


2.0 OBJECTIVES


To improve the control of blood pressure in patients with essential hypertension in the primary care setting.


1. To study the factors that affecting the control of blood pressure among essential hypertension patients including:a. Health care provider factorsb. Patient factorsc. Provision factors

2. To devise an intervention package to improve blood pressure control.3. To measure the effectiveness of the intervention package.4. To make recommendations for improving blood pressure control in the primary

care.

3.0 METHODOLOGY

3.1 Study Design

This study was conducted in selected health clinics in 3 districts in Perak. They are Perak Tengah, Manjung and Kerian. In this particular study we selected 6 clinics for the intervention group and 6 clinics for the non intervention group. In each district, 2 clinics were chosen for intervention and 2 clinics for control. The selection of the clinics was based on the geographical locations so that the intermingling of subjects between control and intervention is minimized.

Table 1. The Clinics selected for the study

DistrictsIntervention Control

Clinics Clinics

Perak Tengah

Klinik Kesihatan Bota KiriKlinik Kesihatan Kg. Gajah

Klinik Kesihatan Ulu DedapKlinik Kesihatan Parit

ManjungKlinik Kesihatan Pulau PangkorKlinik Kesihatan Pantai Remis

Klinik Kesihatan BeruasKlinik Kesihatan Lekir

KerianKlinik Kesihatan Bagan SeraiKlinik Kesihatan Tanjung Piandang

Klinik Kesihatan Gunung Semanggol

Klinik Kesihatan Kuala Kurau

This study is comprised of three phases.


Phase I

In this phase, a cross sectional study was carried out. Random 10% of essential hypertensive patients from each intervention and control clinics were selected using validated self devised questionnaires (Appendix A) to study their socio-demography, knowledge about hypertensive disease and compliance. This is carried out by trained medical officers and paramedics. In this phase, Focus Group Discussions( FGD) were carried out among health care personals involved in the clinical aspects of hypertensive managements in all clinics studied, both intervention and control. This FGD was mainly focused on the problems that might affect the effective management of hypertensive patients with respect to health care provider factors, patient factors and provision factors as well as participant opinions regarding ways to improve blood pressure. This phase had been carried out from October to December, 2006.

Phase II

Following the data obtained from the phase I’s cross sectional study and FGD, an interventional package had been devised in January specifically for health care providers and patients in order improve the blood pressure control. Before the implementation of the interventional package, pre-intervention blood pressure had been taken in end of December, 2006 in both intervention and control.

The health care provider interventional package is as follows;

1. Distribution of simplified protocol or user friendly protocol based on Malaysia Clinical Practice Guideline on Hypertension which is displayed in the room.

2. Training of all medical officers and the medical assistants about the simplified protocol.

3. Reminder for the health care staff the steps that need to be taken if patients have uncontrolled blood pressure by following the flow chart of management of hypertension. (Appendix D).

4. Handling regular Continuous Medical Education as part of Continuous Professional Development for all paramedics and medical officers on effective management of hypertension as proposed by CPG.

The patient interventional package is as follows;

1. Giving health education and counseling to the patients on regular basis regarding the hypertension and its pharmacological and non pharmacological management.

2. Giving out advice slips to the patients with uncontrolled blood pressure to remind them that their blood pressure is under controlled and advice on steps to be taken.(Appendix B)


3. To stamp in the patient’s book and outpatient card regarding the current status of their blood pressure, using specialized design stamp. (Appendix C)

The interventional package has been implemented in January and in the end of May, the first post intervention blood pressure readings were measured in both intervention and control clinics.

Phase III

In phase III, post intervention data was collected monthly for four consecutive months beginning from end of May till end of August, designated as Post intervention 1, 2, 3, and 4. Data on blood pressure, age, and sex of 300 samples from each intervention and control clinics were collected. The intervention group continued with the implementation of specific intervention programmes whereas the control group continued with their current management during this phase periods.


Patients with essential hypertension.


1. Patients with Type 1 and Type 2 Diabetes2. Patients with secondary hypertension3. Patients with other concomitant medical illnesses4. Patients with psychiatric disorders

3.4 Sample size

Sample size was calculated using Epicalc 2000, using two proportions with the power of 80% at a significant level of 0.05. The calculated sample size is 292 in each intervention and control group. For this study, 300 samples were randomly selected from each intervention and control clinics during pre-intervention and post-intervention data collection. Since three districts are involved, the samples are evenly divided among these three districts so that each district will have 100 samples each. In the district itself, the sample is further evenly divided so that each clinic will have 50 samples. The same goes for control clinics. Total samples collected including intervention and control for this study are 3000 in which 600 for pre intervention in phase 2, and 2400 in phase 3 for post-intervention over period of four consecutive months.


Table 1. The sample size for each clinic selected for the study

DistrictsIntervention n=300 Control n=300

Clinics n Clinics n

Perak Tengah

Bota KiriKg. Gajah

5050

Ulu DedapParit

5050

ManjungPulau PangkorPantai Remis

5050

BeruasLekir

5050

KerianBagan SeraiTanjung Piandang

5050

Gunung SemanggolKuala Kurau

5050

3.5 Variables

Variables that had been used in this study are shown below.

Definition of controlled hypertension

A controlled blood pressure is defined as blood pressure reading of 140/85 mmHg or less, 2 out of 3 readings during the last 3 consecutive clinic visits at least one month apart.

Conceptual definition of variable

Operational definition of variableScale of

measurement

Pre test blood pressure

Blood pressure reading of randomly selected patient ( n=300) from each control and intervention group before intervention in December

mmHg

Post test blood pressure 1

First blood pressure at the end of May for both control and intervention group which are randomly selected

mmHg


Second blood pressure at the end of June for both control and intervention group which are randomly selected

mmHg


Third blood pressure at the end of July for both control and intervention group which are randomly selected

mmHg


Fourth blood pressure at the end of August for both control and intervention group which are randomly selected

mmHg


Figure 2. Flow chart of study design 12

Phase I

Phase II

Phase III

Figure 2: Flow chart of study design

Usual care Implementation of an interventional

package to the intervention group started in January

300 random samples from 6 intervention clinics (n=50 per clinic) from 3 districts (2 clinics per district)

300 random samples from 6 control clinics (n=50 per clinic) from 3 districts( 2 clinics per district)

Development of an interventional package in January

Cross sectional using questionnaires study among hypertensive patients to

study the socio-demography and knowledge about the disease and

compliance. (October to December) (n=339)

Focused Group Discussion with

paramedics and medical officers. (October to December)

Post –intervention blood pressure measurement, taken monthly for four consecutive months (May to August,),

300 from each groups each month and total of 600 each month

Pre intervention data collection on blood pressure, age and sex in the end of December (n=600)

300 random samples from 6

intervention clinics (n=50 per clinic) from 3 districts( 2 clinics per district)

300 random samples from 6 control

clinics (n=50 per clinic) from 3 districts( 2 clinics per district)



Data had been collected using a standard format by the same trained medical officers and paramedics.


All data had been kept confidential. However the result of the study will be relayed to the respective district for improvement.

3.8 Data analysis

Data had been entered and analysed using SPSS version 11.5. Descriptive analysis of the factors that contribute to the blood pressure control of essential hypertension patients are used. Simple logistic regression is used for categorical data. A p-value < 0.05 is taken as significant with a confidence interval of 95%.

4.0 RESULTS

This study is divided into 3 phases.

1. Phase I a. Cross sectional study using interview style questionnaires on 10

% patients from each clinic totaling 339 subjects to study on socio-demography and their knowledge on hypertensive disease in October.

b. Focus group Discussion among health care providers to explore and study the problems that affecting the management of hypertensive patients in December.

2. Phase IIa. Pre-intervention blood pressure measurement both 300 control subjects

and 300 intervention subjects throughout December 2006,b. Implementation of intervention packages in intervention clinics from

January till April before the first post intervention data collection.

3. Phase IIIa. Post intervention data collection on 300 subjects from each intervention

and control groups totaling 600 samples monthly over period of four consecutive months from end of May till end of August totaling to 2400 sample from both intervention and control clinics.


Table 2. Results from Phase 1 Cross sectional socio-demography study on 339 samples from district of Manjung, Perak Tengah and Kerian

Variables Number (n=339) Percentage (%)

Age< 2020-4041-60>60

050

168121

0

14.749.635.7

SexMaleFemale

132207

38.961.1

Marital statusSingleMarriedWidow

1628835

4.785.010.3

RaceMalayChineseIndianOther

244612915

72.018.08.61.5

OccupationStudentEmployedUnemployedPensioner

512015163

1.535.444.518.6

Education levelNot schoolingPrimarySecondaryTertiaryOthers

621757123 8

18.351.620.96.82.4


4.1 Phase I

4.1.1 The interview style questionnaires cross sectional study results

A total of 339 hypertensive patients (10% from all hypertensive patients of all clinics) had successfully completed the interview style questionnaires to study their socio-demographic status, knowledge about the disease and compliance before intervention. Majority of the respondents were from district of Manjung 132(38.9%) and Perak Tengah 122(36.0%), only 85(25.1%) from Kerian. Most of them were female with 61.1%. As far ethnicity is concerned, 72.0% (244) were Malays. Most of the respondents (85.0%) were married. The majority of (168) 49.6% were from age group of 41-60 year old. About 51.6% (175) had primary education level and the majorities (44.5%) were unemployed. Table 2 shows the results of cross sectional study on socio-demographic data for patients before intervention.

4.1.2 Results of knowledge about hypertensive disease and compliance in Phase 1 cross sectional study

Majority of the respondents 90% understood the reason for the treatment of their hypertension. Majority of the respondents 74.3% understood the long term treatment of hypertension. Most of the respondents 81.4% knew about at least one complication of hypertension. The knowledge about normal range of blood

Table 3. Results of Knowledge on hypertension and compliance from 339 samples of district of Manjung,Perak Tengah and Kerian

VariablesNumber (%)

YES NO

Knows reason for taking medication 305 (90%) 34 (10%)

Knows the need for lifelong treatment 252 (74.3%) 57 (16.8%)

Knows the hypertension complication 276 (81.4%) 63 (18.6%)

Knows the normal blood pressure 170 (50.1%) 169 (49.9%)

Knows their recent blood pressure level 189 (55.8%) 150 (44.2%)

Compliance 263 (77.6%) 76 (22.4%)


pressure is 50.1% was almost the same with those who had no knowledge of normal blood pressure range. Majority of the respondents 55.8% were aware of their own latest blood pressure. Majority of the respondents 77.6% claimed that they had good compliance to antihypertensive drugs.

4.1.3 Focus group discussion

Participants are medical officers, medical assistants and nurses in charge of outpatients’ clinic in all intervention clinics in all three districts. The sessions were held separately conducted by researchers of respective districts.

Aims of the sessions are to explore the problems that might affect the management of patients thus their outcome and finally to get the opinions regarding ways to improve blood pressure control. The FGD mainly focused on the knowledge of the health care provider regarding the standard and latest management of hypertension according to the Clinical Practice Guidelines (CPG).

FGD were carried out in all intervention and control clinics among the staff that involved in clinical the management of hypertensive patients who are medical officers, medical assistants, staff nurses and community nurses. The sessions took place in the clinic meeting room during the non busy afternoon for duration of at least 1 hour.

From that discussion we found several major problems, 1. Almost all paramedics and nurses admitted that they never

used the CPG in management of hypertensive patients as opposed to medical officers.

2. Majority of paramedics and nurses have limited knowledge about hypertensive disease.

3. Majority of paramedics have limited knowledge regarding the range of hypertensive drugs and dosage

4. Almost all staff said they were overloaded with work because lack of staff and as a result they could not give their best in the management of patients.

5. Many medical officers said that their treatment is limited by the availability of latest drugs.

6. Most staff said there lack of structured programmes on management of hypertension in their clinics such as CME.


7. Some medical officers raised the need for resources centre so that they can update their knowledge.

8. Most staff said there is lack of promotional programmes on hypertension such as seminar for patients as opposed to normal one to one counseling.

9. Some medical officers also raised the need for structured hypertensive medical notes.

4.2 Phase II

4.2.1 Pre intervention data collection

A total of 300 patients comprised of 117 males (39%) and 183 females (61%) with their baseline blood pressure taken. They have the mean SBP of 139.87 and DBP of 84.56. Only 132 (44%) out of the 300 patients have controlled blood pressure.

4.2.2 Implementation of Intervention packages

From January the intervention packages are implemented in intervention clinics as follows:1. The flow chart on the management of hypertension were

developed and distributed to the 6 interventions clinics to be displayed in the rooms.

2. First training to the medical officers, paramedics and nurses in each district of intervention clinics involved in clinical management of hypertensive management conducted on 26th January 2007. (Table 4)

Table 4. The distribution of healthcare professionals trained in management of hypertension in selected primary health clinics

DistrictsIntervention Clinics

Clinics MO MA Nurses

Perak TengahBota KiriKg. Gajah

11

22

51

ManjungPulau PangkorPantai Remis

21

32

23

KerianBagan SeraiTanjung Piandang

11

22

42

Total 7 13 17


3. Intervention during consultationa. Reminder note to the health care professional (Appendix

D).b. Advice slip to patients were also distributed.c. Stamp on blood pressure reading

· Uncontrolled: blood pressure reading highlighted and they were given an advice slip (Appendix B).

· Appointment date given according to the protocol. 4. Continuous promotional activities which includes seminar

for patients and video show during clinic.5. Second training had been conducted a month later, which

was on 23rd February 2007 to the same medical officers and paramedics to refresh them on management of hypertension patient.

6. In the control clinic, the patient had received the usual care from their health care providers. There were no interventions done in the control clinic.

4.3 Phase III

4.1.1 Post Intervention data

In the end of May which is five months after intervention was implemented, the first post intervention blood pressure measurement was collected and this continue monthly for next three consecutive months (June to August 2007). Also collected are age and sex. Each month 300 samples were taken for each group. In total, there are four sets of post intervention data comprising blood pressure, age and sex in both intervention and control groups which designated as Post 1 (May), Post 2 (June), Post 3 (July) and Post 4 (August).

The Table 5 showed the results of blood pressure outcomes, age and sex within intervention group from May till August before and after.

From the Table 5, we could see that the improvement in number of patients whom their blood pressure treated to target in post intervention 1 intervention group was very significant when compared with pre intervention. In the control group difference between pre intervention and post intervention 1 was not significant. In the following month, the improvement was not significant but just sustaining. However in post intervention 3, there was a drop in the percentage of patients in intervention group


Tabl

e 5.

Res

ults

of b

lood

pre

ssur

e, s

ex a

nd a

ge in

the

inte

rven

tion

grou

p du

ring

pre

and

post

inte

rven

tion

perio

ds

IN

TERV

ENTI

ON

n=1

500

Base

line

(Dec

200

6)

n=30

0

Post

In

terv

entio

n 1

(May

200

7)

n=30

0

p-v

alue

p1*

Post

In

terv

entio

n 2

(Jun

e 20

07)

n=30

0

p-v

alue

p1*(

p2)*

Post

In

terv

entio

n 3

(Jul

y 20

07)

n=30

0

P va

lue

p1*(

p3)*

Post

Inte

rven

tion

4 (A

ug 2

007)

n=

300

p-v

alue

p1*

(p4)

*

Gen

der

• M

ale

117

(39%

)88

(2

9.3%

)0.

0111

2 (3

7.3%

)0.

7397

(3

2.3%

)0.

1099

(3

3%)

0.15

• Fe

mal

e18

3 (6

1%)

212

(70.

7%)

0.01

188

(62.

7%)

0.73

203

(67.

7%)

0.23

201

(67%

)0.

15

Mea

n in

age

in y

ears

57.9

5(S

D 1

1.7)

60.6

1(S

D 1

1.6)

0.98

57.8

7(S

D 1

2.2)

1.0

56.5

3(S

D 1

1.8)

0.91

62.7

2(S

D 1

1.7)

0.76

Mea

n SB

P13

9.87

(SD

17.

3)13

5.61

(SD

15.

7)–

133.

45(S

D 1

6.2)

–13

1.03

(SD

15.

2)–

134.

34(S

D 1

7.5)

–

Mea

n D

BP84

.56

(SD

8.8

)82

.21

(SD

8.1

)–

81.9

0(S

D 7

.5)

–82

.09

(SD

7.8

)–

81.1

9(S

D 8

.1)

–

Perc

enta

ge o

f co

ntro

lled

SBP

199

(66.

3%)

229

(76.

3%)

0.00

924

2(8

0.7%

)0.

0001

253

(84.

3%)

<0.0

001

236

(78.

7%)

0.00

1

Perc

enta

ge o

f co

ntro

lled

DBP

148

(49.

3%)

199

(66.

3%)

<0.0

001

208

(69.

3%)

<0.0

001

200

(66.

7%)

<0.0

001

224

(74.

7%)

<0.0

001

Perc

enta

ge o

f co

ntro

lled

BP13

2(4

4.0%

)17

9(5

9.7%

)0.

0002

186

(62.

0%)

<0.0

001

(0.6

)18

2(6

0.7%

)<0

.000

1(0

.8)

198

(66.

0%)

<0.0

001

(0.2

7)

* (p

1) =

p v

alue

bas

elin

e ve

rsus

pos

t int

erve

ntio

n of

the

mon

th

(p2)

= p

val

ue P

ost 1

ver

sus

Post

2

(p3)

= p

val

ue P

ost 2

ver

sus

Post

3

(p4)

= p

val

ue P

ost 3

ver

sus

Post

4


Tabl

e 6.

Res

ults

of b

lood

pre

ssur

e, s

ex a

nd a

ge in

the

cont

rol g

roup

dur

ing

pre

and

post

inte

rven

tion

perio

ds

CON

TRO

L n=

1500

Base

line

(Dec

200

6)n=

300

Post

Inte

rven

tion

1

(May

200

7)n=

300

p-v

alue

p1*

Post

Inte

rven

tion

2(J

une

2007

)n=

300

p-v

alue

p1*(

p2)*

Post

Inte

rven

tion

3

(Jul

y 20

07)

n=30

0

p-v

alue

p1*(

p3)*

Post

Inte

rven

tion

4

(Aug

200

7)n=

300

p-v

alue

p1*(

p4)*

GEN

DER

• M

ale

111

(37%

)10

8 (3

6%)

0.86

97

(32.

3%)

0.26

118

(39.

3%)

0.61

112

(37.

3%)

1.0

• Fe

mal

e18

9 (

63%

)19

2 (6

4%)

0.86

203

(67.

4%)

0.23

182

(60.

7%)

0.61

188

(62.

7%)

1.0

Mea

n in

age

in y

ears

59.1

(SD

12.

0)58

.5(S

D 1

2.7)

1.0

57.9

(SD

11.

5)1.

057

.5(S

D 1

2.1)

0.91

59.2

(S

D 1

1.3)

1.0

Mea

n SB

P13

6.6

(SD

16.

4)13

3.8

(SD

18.

0)–

133.

60(S

D 1

7.5)

–13

7.01

(SD

20.

5)–

138.

8 (S

D 1

7.8)

–

Mea

n D

BP82

.4(S

D 7

.6)

81.1

9(S

D 8

.6)

–81

.42

(SD

9.7

)–

82.4

1(S

D 9

.6)

–82

.38

(SD

8.9

)–

Perc

enta

ge o

f co

ntro

lled

SBP

224

(74.

7%)

230

(76.

7%)

0.63

240

(80.

0%)

0.14

218

(72.

7%)

0.64

203

(67.

7%)

0.07

Perc

enta

ge o

f co

ntro

lled

DBP

203

(67.

7%)

207

(69.

0%)

0.79

216

(72.

0%)

0.29

190

(63.

3%)

0.30

199

(66.

3%)

0.79

Perc

enta

ge o

f co

ntro

lled

BP18

2(6

0.7%

)18

5(6

1.7%

)0.

919

4(6

4.7%

)0.

35(0

.5)

160

(53.

3%)

0.08

(0.0

06)

153

(51.

0%)

0.02

(0.3

2)

* p1

= p

val

ue b

asel

ine

vers

us p

ost i

nter

vent

ion

of th

e m

onth

(p

2)=

p v

alue

Pos

t 1 v

ersu

s Po

st 2

(p

3)=

p v

alue

Pos

t 2 v

ersu

s Po

st 3

(p

4)=

p v

alue

Pos

t 3 v

ersu

s Po

st 4


who had their blood pressure treated to target but the drop was not significant which again showed that the improvement made in the first intervention was sustained. In the post intervention 4, there was increased percentage of patients treated to target compare with the following month but it was not significant. Again it clearly showed that the improvement was sustained over four consecutive months after the Post intervention 1 in the clinics where interventional package has been implemented.

As far as the age and sex are concerned in the intervention group, the samples between pre and post intervention were comparable as the different is not statistically significant.

Looking at Table 6, it can be seen that the improvement of percentage of patient treated to target in post intervention 1 and pre intervention in control group was not significant. This trend continues till post intervention 3 when there was significant drop in percentage of patients in control group treated to target. This continues to drop in post intervention 4 but it was not significant.

Figure 3. Percentage of patients whom blood pressure treated to target between male and female in both intervention and control groups


As far as the age and sex are concerned in the control group, the samples between pre and post intervention are comparable as the different was not statistically significant.

Looking at Figure 3, we can see that percentage of blood pressure treated to target significantly improved among female in intervention group as opposed to male.

In control group, the changes in percentage of patients treated to target between female and male are not significant.

In this Figure 4, we can see that the age group less than 40 in intervention group made a significant improvement in percentage of blood pressure treated to target. Other age groups however do not show any significant changes.

In control group , there is no significant changes among age groups with respect to blood pressure treated to target over four months periods.

Figure 4. Percentage of patients treated to target according to age group between intervention and control groups


In this Figure 5, we can see that all districts in intervention group make steady improvement in the percentage of patients treated to target with time after intervention except for Manjung and Kerian. In Manjung, there was a drop in post 2 and post 3 then remain the same in post 4. In Kerian the drop is noticed in post 3 and remains the same in post 4. However, there was significant improvement in Perak Tengah intervention group from post 3 to Post 4.

In control group, the changes in percentage of patients treated to target across district are significant.

5.0 DISCUSSION

There were several limitations in the study.

1. Our interventions and control were in the same districts. The doctors and medical assistants are at times needed to cover other clinics. Even though the intervention only being done in the intervention clinic the doctors and medical assistant from the other clinic also get to know about it.

2. Duration of the illness were not taken into consideration in this study that may also affect the controlled of blood pressure.

Figure 5. Percentage of patients whom blood pressure treated to target according to district both intervention and control groups


3. There was also movement of staff during the study period, this also affect our study. One of the doctors had move from intervention clinic to control clinic, the other doctor transferred to the hospital and one resign from governments. One of the medical assistant from the intervention clinic were promoted and transferred.

4. The trained staffed in the intervention are not always available during clinic days. These maybe due to their taking leave or going for courses and being relieved by untrained staff.

5. We are not doing card auditing so we cannot assess weather staffs involved actually practiced all the interventions. Same also to the patients.

As far as we know, this is the first study that attempt to look into the effectiveness of intervention in the management of patients with essential hypertension involving three districts in Perak, namely Perak Tengah, Manjung and Kerian. Knowledge of patients regarding hypertension was good. Majority of them knew why they should take medication, the need for lifelong treatment and their complication. Only 50% of the patients know what are normal blood pressure and their current status. So, at majority of our patients knows about hypertension but did not aware of their target blood pressure.

From focus group discussion we found that Clinical Practice Guidelines and protocols are available but their usages are limited hence the knowledge. Paramedic had limited knowledge regarding the range of anti hypertensive that is available whereas the medical officers having problem with List A drugs. Majority of the staff also said that they are over worked.

In phase 3, there were significant differences between the percentages of pre interventions blood pressure control as compare to post interventions in the intervention group. When compared between the post interventions the percentage of controlled blood pressure, it did not show significant difference. There were improvements initially but not sustained over the time. These might be due to relocation of staff causing loss of trained staff. By minimized the movements of staff and reinforced on the used of interventional package.

In the control group, we found that there were significant improvement in controlled blood pressure in May and Jun but there were dropped in July and dropped further in August.

Perak Tengah had shown a continuous good improvement in controlled blood pressure in the intervention clinic. In districts of Manjung, the percentage of controlled blood pressure had increased for the first month but deteriorate after that. The change of doctors and medical assistant in Klinik Kesihatan Pulau Pangkor might had contributed to this deterioration. In Klinik Kesihatan Pantai Remis, the medical officer went for maternity leave for two month. Relocation of staff had a great impact on the management of patient as the officer that replaces might not familiar with the intervention that had been implemented and there were also no proper handlings over of task before leaving the


clinic. For Kerian, the percentage of controlled blood pressure were increased for May and Jun but dropped later, however the dropped were not significant. It dropped a bit in July as one medical officer from the intervention clinic from Tanjung Piandang had left the government service leaving the clinic without resident medical officers.

In controlled group the percentage of controlled blood pressure shown an improvement in districts of Perak Tengah for the first two month and dropped after that.

In the intervention group, most of the increment in blood pressure control between pre- intervention and post-intervention were due to increments in the controlled of blood pressure among female patients. So the intervention has more impact on female patients (refer to Figure 6). From previous study, we noted that women are more concern about health and willing to change their behaviors as needed. Further analysis had shown that the intervention that had been implemented had shown marked improvements in the percentage of control blood pressure in woman in the districts of Perak Tengah. Women in all the districts had shown significant improvement after the intervention, but women in the district of Perak Tengah shown significant improvement from June onwards.

Figure 6. Percentage of controlled blood pressure in three districts in between gender



The study had shown that the interventional package that had been implemented had significantly improved the blood pressure controlled in patients with essential hypertension. The intervention package had a better impact on female patients and in the District of Perak Tengah.

It is recommended that:

1. The intervention programme that had been devised and implemented in this study is useful and should be implemented in all health clinics in Perak.

2. Initiatives to improve blood pressure controlled in the male population requires more study.

REFERENCES

1. Ministry of Health: Cinical Practise Guideline The Management of Hypertension. 2002, Malaysia

2. Roslan I et al, Kajian Pengetahuan, Sikap dan Amalan di Kalangan Pesakit Hipertensi Di Poliklinik Masyarakat Damak Jerantut Pahang, October 2004, Malaysia.

3. Ong CL, Evaluation of Educational and managerial strategies to improve the management of hypertensive patient in Hospital Bukit Mertajam October 1988, Malaysia.

4. D’Cruz A and Kumar S, Trend Rawatan kes kes darah tinggi di Jabatan Pesakit Luar Hospital raub dalam jangkamasa lima tahun dari 1989 hingga 1993

5. Public Health Institute: A Study on the high defaulter Rate at the hypertension clinic in the outpatient department, hospital Sultanah Aminah, Johor Bharu. April 1992, Malaysia

6. A study on the Adequacy of Outpatient Management of essential hypertension in MOH Hospitals and health Centre, 2006, Malaysia.

ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper and the State Health Department of Perak for conducting this useful program. Our sincere thanks also, to all our facilitators for their invaluable guidance and support. Last but not least the most important thank goes to all the staff involved in this study for their endless cooperation.


APPENDICES

Appendix A

Borang Soal Selidik (pesakit):

Tajuk: A Study Of Adequacy Of Outpatient Management Of Essential Hypertension In Selected Health Clinic In Perak.

1. Umur: ________________ tahun

2. Jantina: lelaki perempuan

3. Status kahwin: bujang kahwin

bercerai/ janda/duda

4. Bangsa: Melayu Cina

India Lain-lain

5. Pekerjaan: _______________________

6. Tahap pendidikan: tidak bersekolah sekolah rendah

sekolah menengah diploma/ ijazah

lain-lain

7. Masa dari rumah ke klinik: _______________________

8. Untuk apakah ubat yang anda makan ini? _______________________

9. Berapa lamakah anda telah dirawat untuk penyakit ini ( untuk penyakit darah tinggi)?

_________________________

10. Adakah darah tinggi memerlukan rawatan berpanjangan?

Ya Tidak

11. Apakah komplikasi darah tinggi? ( boleh tanda lebih dari 1)

a. penyakit jantung

b. strok/ angin ahmar

c. kerosakan buah pinggang

d. kerosakan mata


12. Apakah had normal tekanan darah atas dan bawah?

13. Adakah anda tahu tekanan darah anda terkini?

Ya Tidak

14. Apakah ubat yang anda ambil? _________________________

Berapa biji untuk setiap jenis ubat setiap kali makan? ______________

Berapa kali sehari? _________________________

15. Adakah anda rasa ubat yang anda makan sesuai untuk anda?

Ya Tidak

16. Pada pendapat anda, bagaimanakah cara untuk meningkatkan mutu rawatan dan pengawalan tekanan darah? Bincangkan.

a. Telefon klinik tentang pendapat untuk rawatan

b. Ceramah atau pendidikan tentang penyakit darah tinggi

c. Penglibatan badan sukarela dalam pengurusan

d. Lain-lain


Appendix B

Advice slip

1. Your blood pressure is _________________

2. Your blood pressure is not controlled. It should be 140/85 or less.

3. Please make sure that:

a. You take your medication as ordered by your doctor

b. Be careful with your diet

i. take low salt diet. only 6gm of sodium chloride per day or less than 1 ¼ teaspoonful of salt.

ii. avoid food with high salt content, for example dried salted fish, soy souce, budu and processed food

iii. take less oily food

c. Exercise regularly for example brisk walking for 30 to 60 minutes at least 3 times a week or for most days of the week.

4. If possible check your blood pressure regularly

Please bring all of medications to the clinic on follow up.


Appendix C

Tarikh: Tekanan darah anda:

Kategori Tekanan darah

Terkawal ≤ 140/85

Tidak terkawal > 140/85; ≤ 180/110

Tindakan segera > 180/110

Tarikh: Tekanan darah anda:

Kategori Tekanan darah

Terkawal ≤ 140/85

Tidak terkawal > 140/85; ≤ 180/110

Tindakan segera > 180/110

Appendix D

REMINDER FOR THE HEALTH CARE STAFF

1. Controlled Blood Pressure is 2 out 3 BP readings during the last 3 consecutive clinic visits in at least one month apart.

2. The BP taking method must be correct.

3. If target BP is still uncontrolled, the following steps must be taken:

a. MO/MA who treats the patient should either increase the antihypertensive or add another group of anti hypertensive drugs.

b. Ask about patient’s compliance to medications.c. Advice slips should be given to the patients and must be recorded in the card.d. Highlighting the BP on patient’s card with fluorescent pen.e. Patients should be seen in the clinic in one month’s period or more frequently

if indicated.f. For those with controlled BP, need to be taken the BP reading monthly at the

nearest health centers or Community Clinic.g. Refer to Clinical Practice Guidelines (CPG)-The Management of Hypertension

(2002) if needed.


Appendix E

Flow Chart of Hypertension Clinic

Registration

Blood pressure check by staff nurse or medical assistant

(Status of BP control indicated and highlighted in the patient record book and medical card with stamp provided)

Patient told regarding BP reading and status

Patient given advice slip

Consultation with medical officer or medical assistant


Appendix F

Clinic :

Bil Age Sex SBP DBP

281

An Intervention Programme Among Overweight Primary School Children Health Systems Research 2006/2007

Authors

Shir-Ley GuiKinta District Health Department

Saerah ShaharuddinKinta District Health Department

Sheleaswani Inche Zainal AbidinKinta District Health Department

Ainul Salhani Abdul RahmanKinta District Health Department

Kulandaimmal LourdusamyKinta District Health Department

Amar-Singh HSSClnical Research Centre Perak Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak


Marina KamaruddinPerak State Health Department


Normah Mohd ZainPerak State Health Department

Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Shir-Ley Gui, Saerah Shaharuddin, Sheleaswani Inche Zainal Abidin, Ainul Salhani Abdul Rahman, Kulandaimmal Lourdusamy, Amar-Singh HSS, Sondi Sararaks, Marina Kamaruddin, Asmah Zainal Abidin, Normah Mohd Zain. ”An Intervention Programme Among Overweight Primary School Children” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 281. (ISBN: 9789671063446)

ISBN

9789671063446

282 An Intervention Programme Among Overweight Primary School Children


Abstract 283


1.1 The onset of obesity

1.2 Obesity and health problems

1.3 Prevalence of obesity in Perak, Malaysia

2.0 Objective 288



3.0 Methodology 288

3.1 Study design

3.2 Sampling & data collection

3.3 Anthropometric measurements

3.4 Questionnaires

3.5 Physical activities

3.6 Interventional package

3.7 Variables

3.8 Statistical analysis

3.9 Benefit of the study

3.10 Potential utilisation of research

4.0 Results 294


4.2 Key outcomes

5.0 Discussion 302


References 304

Acknowledgement 305

Appendices 306

283An Intervention Programme Among Overweight Primary School Children

ABSTRACT

An Intervention Programme among Overweight Primary School Children

Shir-Ley Gui1, Saerah Shaharuddin1, Sheleaswani Inche Zainal Abidin1, Ainul Salhani Abdul Rahman1, Kulandaimmal Lourdusamy1, Amar-Singh HSS2,5, Sondi Sararaks3, Marina Kamaruddin4, Asmah Zainal Abidin4, Normah Mohd Zain4

1 Kinta District Health Department2 Clinical Research Centre Perak 3 Institute of Health Systems Research4 Perak State Health Department5 Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak


Obesity is defined as an excessive accumulation of body fat. The onset of obesity may occur at any age. Five years’ data (2002-2006) obtained from the School Health Services, in district of Kinta, Perak shows that the prevalence of obesity (defined as weight-for-height in excess of 120 percent of the ideal), ranges from 6.30% to 8.90% among Year 1 students; 12.80% to 17.00% among Year 6 students and 8.50% to 13.30% among Form 3 students, respectively. The objective of this study is to evaluate an intervention programme among overweight primary school children.

Methodology

SK Haji Mahmood was selected as the intervention school and SK Perpaduan was selected as the control school. Body mass indexes (BMI) for year 4 and 5 students were calculated and those with BMI > 19.84 were included in the study. A total of 70 and 83 students from intervention and control schools respectively were given consent by their parents to be involved in this study. Subjects in both schools were given a self-administered questionnaire (to assess dietary knowledge and habit, and physical activity) and had their BMI calculated, at baseline (bl), pi-1 (pi-1, after 3 months) and post intervention 2 (pi-2, after 6 months). Intervention group was seen monthly as part of the programme. Subjects were given knowledge on dietary and physical aspects in seminars, small group discussion, quizzes and games. Control group was seen only during data collections.

Results

There was no significant difference in BMI between intervention and control group. There was an increment in percentage of intervention group having good nutrition knowledge but it was not significant (bl, p=0.357; pi-1, p=0.061; pi-2, p=0.152). There was also no significant difference in meal practice in both groups. As for food frequency habit, there were significant difference at bl (p=0.048) and pi-2 (p=0.027). Intake of leafy vegetables, other vegetables, fruit, fish, chicken and pulses also showed no significant differences. There were no significant differences in perception on family, except at pi-2 (p=0.043)


and psychological factor in both schools. As for physical activities that were tabulated in METs, significant differences were seen at pi-1 and pi-2. Both groups reported television viewing as the most frequent activity. However in intervention group, the minutes spent on television viewing reduced from 137 minutes (at bl) to 101 minutes (at pi-1) and 76 minutes (pi-2) respectively. In other non-physical activities, significant differences were also found in playing computer games, and writing & drawing at pi-2. In more vigorous activities, it was found that the control group was having higher frequency in cycling, playing football and hockey.

Conclusion

In conclusion, the intervention programme was successfully carried out. A longitudinal study is needed for determination of success rate for the subjects that participated in this programme. Parents should be encouraged to join and be involved actively in this programme to provide more supportive environment and effective behavioural changes. Teachers and canteen operators should be empowered to run this programme for a better commitment and monitoring of subjects. The success of this intervention programme will depend on all sectors: schools, canteen operators, parents and health staffs.

Keywords

Intervention programme, overweight, obese, primary school children, students


1.0 INTRODUCTION

Obesity is defined as an excessive accumulation of body fat. Obesity is present when total body weight is more than 25 percent fat in boys and more than 32 percent fat in girls (Lohman 1987). According to Dietz, 1983; Lohman, 1987 although childhood obesity is often defined as a weight for height in excess of 120 percent of the ideal, skin fold measures are more accurate determinants of fatness. The onset of obesity may occur at any age, and is triggered by factors such as early weaning, eating disorders and problems related to relationship, especially during growth spurts. Whitaker et al and Price showed that it is necessary to identify overweight children as soon as possible in order to prevent them from becoming obese adult. Cutting et al. concluded that sedentary lifestyle and an inadequate family meal pattern may contribute towards early onset of obesity.

1.1 The Onset of Obesity

In Malaysia, rapid and marked socio-economic advancement over the past two decades has brought about significant changes in the lifestyles of communities. These include significant changes in dietary patterns e.g. an increase in consumption of fats, oils, and refined carbohydrates and a decrease intake of complex carbohydrates. As a result there was a decline in the proportion of energy from carbohydrates, while an increase in the percentage contribution of fat has been observed (Tee, 1999).

The National Health and Morbidity Study of 1996 showed that in Malaysia, the prevalence of obesity in adults by body mass index was 4.4%, overweight 16.6% and underweight 25.2%. A study done by Prof Mohd Ismail Noor (Head of Nutrition and Dietetic) on 1,026 schoolchildren aged 7 to 10 years revealed that childhood obesity was a result of uncontrolled diet, lifestyle changes and other factors. The same study revealed that 12.5% of male children were obese compared to 5% of female children; and Malay male children had the highest obesity rate (16.8%) whilst Chinese females had the lowest at 4.1%. JP Judson and P Kavitha did a survey in 2004 on 309 students, aged 7 to 11 years old and found out that the prevalence for overweight and obese were 11.7% and 10.7% respectively.

1.2 Obesity and Health Problems

Obesity is the most common nutritional problem among children in developed countries (Sorof & Daniels, 2002). It is a complex, multifactorial and chronic condition resulting from interplay between environment and genetics (Segal & Sanchez, 2001). The prevalence of obesity has been growing at alarming rate for decades in both children and adults (Giammattei et al., 2003).

Overweight and obesity are currently regarded as public health problem that affects both young people and adult. They have become a global epidemic (WHO consultation on obesity, 3rd -5th June 1997) and are increasing rapidly in


both childhood and adolescence (Will, Beata; Zeeb, Hajo; Baune, Bernhard 2005). Obesity presents numerous problems for the children. It is associated with significant morbidity and mortality. In addition to increasing the risk of obesity in adulthood, childhood obesity is the leading cause of pediatric hypertension, is associated with type 2 diabetes mellitus, increases the risk of coronary heart disease, increases stress on the weight – bearing joints, lower self esteem, and affects relationship with peers. Some authorities feel that social psychological problems are the most significant consequences of obesity in children.

Being an overweight child under 3 years of age, does not predict future obesity unless at least one parent is also obese. After the age of 3 years, the likelihood that obesity will persist into adulthood increases with advancing age of the child and is higher in children with severe obesity in all age groups. After an obese child reaches 6 years of age, the probability that obesity will persist into adulthood exceeds 50 %, and 70%-80% of obese adolescents will remain so as adults (Segal & Sanchez, 2001).

1.3 Prevalence of Obesity in Perak, Malaysia

There is no single data on the prevalence of obesity among schoolchildren in the state of Perak. However, individual data gathered from the various districts school health teams showed that apart from Kerian district, the rest of the districts had low prevalence of obesity. Review of five years data from Kerian district showed prevalence of obesity ranging from 4.45% to 6.30% among Year 1 students; 7.60% to 16.80% among Year 6 students and 5.0% to 13.90% among Form 3 students respectively. A study done in Hilir Perak district by Pon Lai Wan et al (2004) revealed that 8.5 % from 558 students were found to be overweight and obese. Five years’ data obtained from the School Health Services showed that the prevalence of obesity (defined as weight-for-height in excess of 120 percent of the ideal) in the district of Kinta, ranges from 6.30% to 8.90% among Year 1 students; 12.80% to 17.00% among Year 6 students and 8.50% to 13.30% among Form 3 students respectively.

It is thus felt that there is a need for an intervention programme for young schoolchildren so as to reduce future morbidity and mortality, and further help to decrease the economic burden on the health system.


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2.0 OBJECTIVES


To evaluate an interventional programme for overweight primary school children in a selected school in the Kinta district.


1. To identify factors contributing to overweight among primary school children in Kinta district with respect to:

a. dietary intake.b. activity level (including exercise).c. family factors (obesity in family, lifestyle).d. psychological factors (self image etc).

2. To design and introduce an interventional package focusing on motivational aspects and incentives to reduce weight.

3. To make recommendations to reduce weight amongst primary school children.

3.0 METHODOLOGY

3.1 Study Design

This is an interventional (quasi experimental) study. It was conducted in a selected school in the Kinta district. The study was done in three phases (Figure 2).

Phase One

Phase one consisted of identifying children who were overweight in a selected school. All children in year 4 and 5 in the school had their weight and height measured and their body mass index (BMI) calculated according to Cole et al 2000. Those with a BMI of 19.84 or higher were included in the study.

Phase Two

Phase two was conducted simultaneously. It consisted of a cross sectional study that identified the factors affecting overweight in the children. A guided, classroom style, self administered questionnaire was used to identify factors affecting overweight in these children (see Appendix A). The questionnaires included the pre-intervention data including current weight, height and BMI, knowledge on nutrition and current food pattern, current physical activity level, psychosocial factors regarding present weight and current family factors.


Overweight report, Kinta 9

3.0 Methodology

3.1: Study Design

This is an interventional (quasi experimental) study. It was conducted in a selected school in the Kinta district. The study was done in three phases (Figure 2). Phase 1 Phase 2 Phase 3 Figure 2: Methodology flow chart

Phase One

Phase one consisted of identifying children who were overweight in a selected school. All

children in year 4 and 5 in the school had their weight and height measured and their body

Cross sectional study All overweight and obese children were identified Factors affecting overweight in the children were identified

Patient Selection Questionnaires to children with the consent form to parents and guardians were distributed School children were invited to participate in the intervention programme Data were collected on weight, height and BMI, knowledge on nutrition and current food pattern, current physical activity level, psychosocial factors regarding present weight and current family factors

Intervention Group Control group (No intervention)

Intervention package was implemented (Appendix D)

Intervention Group (Outcome)

Control Group (Outcome)

At 3 months and 6 months post-intervention, data were collected on weight, height and BMI, knowledge on nutrition and current food pattern, current physical activity level, psychosocial factors regarding present weight and current family factors.

Figure 2. Methodology flow chart


Phase Three

Phase three was the implementation of the intervention package to reduce the prevalence of overweight among primary school children. The intervention group was seen monthly as part of the intervention package. At 3 months and 6 months post-intervention data were collected on these parameters namely current weight, height and BMI, knowledge on nutrition and current food pattern, current physical activity level, psychosocial factors regarding present weight and current family factors for the children participating in the study using the same questionnaires.

3.2 Sampling & Data Collection

All students in year 4 and 5 from two primary schools in the Kinta district namely Sek Keb Haji Mahmud Chemor, and Sek Keb Perpaduan, that fulfilled the inclusion criteria from the study population were included in the study. Selections of the subjects were based on the following criteria.

Inclusion Criteria

1. Overweight students in year 4 and 5 from a selected primary school in Kinta district.

2. Given consent by their parents / guardian to participate in this study.

Exclusion Criteria

1. Students who were denied permission by their parents / guardian to participate in this study.

2. Overweight students with medical problems (eg: asthma, diabetes).

3.3 Anthropometric Measurements

The parameters measured were height and weight. The weight of the subjects was taken using a Dial type bathroom weighing scale (model 762). Measurement of height was taken using Mobile height (model 214). Body Mass Index (BMI) was computed using the following formula:

weight (kg)BMI = Height (m) X Height (m)

3.4 Questionnaires

Subjects were given questionnaires adapted from Fatimah A et al 2001 with modifications. The questionnaires consisted of 5 key areas besides the socio-demographic data. Subjects were required to answer the questionnaire at onset of


the study, after 3 and 6 months post intervention. Prior to that, the questionnaires were pre-tested in a school in PKD Kinta.

3.5 Physical Activity

The metabolic equivalent (MET) value was used to measure the level of physical activity. According to ‘The Compendium of Physical Activities Tracking Guide’, MET is defined as ‘the ratio of the work metabolic rate to the resting metabolic rate’ (Ainsworth). MET is computed using the following formula:

calorie (kcal)MET = Body weight (kg) / Time (hr)

MET values were also defined as “multiples of resting metabolic rate”. ‘The Compendium of Physical Activities Tracking Guide’ stated that the MET value for vigorous activity is more than 7 whilst for moderate activity it is in the range of 3 to 6. Thus, the MET value of physical activities can be calculated using the formula as stated below:

MET (min/week) = [Moderate exercise time (mins/week) x 4] + [Vigorous exercise time (mins/week) x 8]

MET can be categorized into 3 levels namely:

High – exercise seven (7) days a week of walking, moderate or vigorous intensity exercise, MET value >6000 MET min/week

Moderate – exercise five (5) days a week of walking, moderate or vigorous intensity exercise, MET value is within the range of 3000 – 6000 MET min/week

Low – any value that does not fulfil the above criteria

3.6 Interventional Package

3.6.1 Seminar Programme

Subjects in the intervention school were exposed to several seminars conducted over a period of time. The seminar covered areas on the introduction to obesity and intervention of obesity.

3.6.2 Diet Intervention

Subjects and teachers in the intervention school were introduced to the ‘Diet Epstein’s food traffic light system’. It is based on the colours on the traffic light where each colour meant:


Red: Types of food that should be avoided High in calorie (>381 kcal)Yellow: Types of food that should be taken moderately The calorie value ranging from 83-381 kcalGreen: Types of food that should be consumed more Low in calorie (<83 kcal)

This system was also introduced to the school canteen operators. They were advised to label the food categories according to the system. Subjects were also given a log book to record their dietary intake for the past 24 hours (24 hour diet recall) and physical activities for the past two weeks.

3.6.3 Physical Activities

Subjects and teachers in the intervention school were introduced to regular aerobic exercise and physical activities. The regular aerobic exercise was held on almost every co-curriculum day which was on the second and fourth Saturday of every month. The aerobic session was conducted by trained healthcare personnel. The subjects were also asked to exercise at home and to record every activity that they have done, into their log book.

Regular programmes were done at interval of three months each, which comprised of breathing exercises, aerobic exercises and treasure hunts. At the end of the study period, a telematch was done between the intervention and the control schools.

3.6.4 Incentives/Reward Systems

The incentive or reward system was produced to ensure the subjects were kept motivated all the time.

3.7 Variables

Table 1. Variables

Variable Operational DefinitionScale of

measurement

At risk of overweight and obese

85th to less than the 95th percentile according to NCHS chart

Weight – kg Height – cm

Overweight and obese

Body weight measurement exceeding 95th percentile according to NCHS chart

Weight – kg Height – cm

Physical Activity/ Activity level

Vigorous activity > 15 minutesModerate activity > 30 minutesMild activity > 60 minutes

Minutes


Variable Operational DefinitionScale of

measurement

Dietary Intake Frequency of eating fast food, eating out Frequency

Family factorsFamily history of obesityEating habitPhysical activity habit

No. of family members, height and weight, frequency and duration

Psychological factors

Self image and social stigmaEmotional feeling

Questionnaires

Motivational aspects and incentives

Feeling good about selfReward

Questionnaires Stepper to school and T shirts

3.8 Statistical Analysis

Statistical analysis was performed using the SPSS social statistics package (Version 11.5).

3.9 Benefit of the Study

1. Improve the quality of life and boost the child’s self esteem.2. Reduce complications due to the problems associated with overweight.3. Implement the programme to other school.

3.10 Potential Utilisation of Research

This study hopes to identify the factors leading to the development of overweight and obesity among the school children and develop a suitable interventional programme which hopefully can be applied to other overweight and obese schoolchildren in Malaysia.

Recommendations

1. It is recommended that the state education department should organise this interventional programme in school in the near future.

2. It is recommended that more health topics could be included into the school syllabus.

3. It is recommended that good collaborations could be established between the Ministry of Health and the Ministry of Education.


4.0 RESULTS

4.1 Socio-demographic Data

In the first part of the study, 924 students were assessed, with 510 students coming from intervention school and 414 students coming from control school. Among these students, 193 (20.9%) students were overweight and obese (Table 2). However, only 79.3% of these overweight and obese groups were given consent by their parents to join the programme.

Table 2. Cross sectional summary

SchoolNumber of

studentsOverweight or

obese

Number of students given

consent

Intervention 510 101 (19.8%) 70 (69.0%)

Control 414 92 (22.2%) 83 (90.0%)

Total 924 193 (20.9%) 153 (79.3%)

Table 3 below shows the numbers of subject from baseline (bl), pi-1(pi-1), and post intervention 2 (pi-2). There was a decrease in total subjects in pi-1, and 2, both in intervention and control school. A decrease of 0.4% and 3.1% in intervention school and 8% and 2.9% in control school during pi-1 and 2 were observed.

Table 3. Number of subjects at bl (bl), pi-1 (pi-1) and pi-2 (pi-2)

School bl pi-1 pi-2

Intervention school 70 (13.7%) 68 (13.3%) 54 (10.6%)

Control school 83 (20.0%) 50 (12.0%) 71 (17.1%)

The socio-demographic characteristics of the study subjects are described in Table 4. Total subjects were 70 students from intervention school and 83 students from control school. Most of the study samples were 11 years old, 40 students from intervention school, and 60 students from control school. Both schools were predominantly Malay. Based on the BMI calculated, both schools have similar percentage of overweight students, intervention group (60%) and control group (57.8%).


Table 4. Socio-demographic characteristics of subjects in intervention school and control school at bl

Intervention n=70 Control n=83p-value*

Number % Number %

Age10 30 42.9 23 27.7

0.0511 40 57.1 60 72.3

Gendermale 36 51.4 52 62.7

0.17female 34 48.6 31 37.3

EthnicMalay 65 92.9 82 98.8

naIndian 5 7.1 1 1.2

BMIoverweight 42 60 48 57.8

0.79obese 28 40 35 42.2

* chi-square test

4.2 Key Outcomes

Table 4 shows nutrition knowledge, activity level, perception on family, psychological factor and BMI. Students were assessed on these during bl and post intervention, which were at the 3rd month and the 6th month after intervention.

At bl, the intervention school had poorer knowledge on nutrition compared to the control school. There was an increase in the percentage of students from the intervention school having good nutrition knowledge; from 7.1% at bl to 22.9% at pi-2. However, the students in the control school did not show any increment in nutrition knowledge (14.5% at both bl and pi-2). There were high percentages of poor nutrition knowledge in both control and intervention schools throughout the study period.

There was no significant difference between the two schools during bl in terms of physical activity, which was tabulated in METs. However, there was significant difference after pi-1 and pi-2. In this study, the subjects were also asked about their perception on own family member. There was no significant difference in both schools during bl and pi-1. Only after pi-2, we found a significant difference in perception between 2 schools. In another aspect, it was found, there were no significant changes in psychological factor and BMI. However, for BMI, there was a reduction in percentage in overweight students in intervention school (bl: 60%, pi-1: 45.6%, pi -2: 38.9%).


Tabl

e 5.

Nut

ritio

n kn

owle

dge,

food

pra

ctic

e, a

ctiv

ity le

vel,

perc

eptio

n on

fam

ily, p

sych

olog

ical

fact

or a

nd B

MI

Char

acte

ristic

sBl

pi-1

(3/1

2)pi

-2 (6

/12)

Inte

rven

tion

Cont

rol

p-

valu

e*In

terv

enti

onCo

ntro

lp

-va

lue*

Inte

rven

tion

Cont

rol

p-

valu

e*n

%n

%n

%n

%n

%n

%N

utri

tion

kno

wle

dge

good

57.1

1214

.5

0.35

7

1521

.49

10.8

0.06

1

1622

.912

14.5

0.15

2m

oder

ate

3144

.334

4125

35.7

2934

.925

35.7

3339

.8po

or34

48.6

3744

.628

4012

14.5

1318

.626

31.3

mis

sing

0–

0–

2–

33–

16–

12–

Phys

ical

Act

ivit

y (M

ETs,

min

/wee

k)H

igh

1018

.216

23.5

0.71

0

811

.822

44.0

< 0

.001

611

.130

42.3

< 0

.001

Mod

erat

e13

23.6

1725

.017

25.0

1530

.09

16.7

1622

.5Lo

w32

58.2

3551

.543

63.2

1326

.039

72.2

2535

.2

Mis

sing

15–

15–

2–

33–

16–

12–

Perc

epti

on o

n fa

mily

:O

bese

811

.411

13.3

0.73

3

1014

.74

8.0

0.26

6

47.

43

4.2

0.04

3N

ot o

bese

6288

.672

86.7

5885

.346

92.0

5092

.668

95.8

Mis

sing

0–

0–

2–

33–

16–

12–

Psyc

holo

gica

l fac

tor

Posi

tive

1318

.619

22.9

0.51

3

1116

.213

26.0

0.19

0

1120

.418

25.4

0.51

3N

egat

ive

5781

.464

77.1

5783

.837

74.0

4379

.653

74.6

Mis

sing

0–

0–

2–

33–

16–

12–

Body

mas

s in

dex

(BM

I)no

rmal

00

00

0.45

8

22.

92

2.4

0.90

5

23.

70

0

0.25

7ov

erw

eigh

t42

6048

57.8

3145

.624

28.9

2138

.930

42.3

obes

e28

4035

42.2

3551

.524

28.9

3157

.441

57.7

mis

sing

0–

0–

2–

33–

16–

12–

* ch

i-squ

are

test


Tabl

e 6.

Mid

-ter

m re

sult

of 3

mai

n su

bjec

ts

Scho

olBa

hasa

Mal

aysi

ap

valu

e*M

athe

mat

icp

valu

e*Sc

ienc

ep

valu

e*>4

0 m

arks

<40

mar

ks>4

0 m

arks

<40

mar

ks>4

0 m

arks

<40

mar

ks

Inte

rven

tion

5713

0.04

821

49<0

.001

2842

<0.0

01Co

ntro

l77

652

3165

18

Tabl

e 7.

M

eal p

ract

ice

Mea

lPr

acti

ce

BlPi

-1Pi

-2

Inte

rven

tion

cont

rol

Pva

lue*

Inte

rven

tion

cont

rol

pva

lue*

Inte

rven

tion

cont

rol

pva

lue*

no%

no%

no%

no%

no%

no%

Brea

kfas

t

yes

2840

.040

48.2

0.54

2535

.724

28.9

0.52

2028

.625

30.1

0.98

no13

18.6

56.

015

21.4

33.

68

11.4

1113

.3

occ

2921

.438

35.8

2840

.023

27.7

2637

.135

42.2

Lunc

h

yes

5984

.361

73.5

0.12

9

4868

.840

48.1

0.29

4057

.154

65.1

0.71

no0

0.0

33.

35

7.11

1.2

22.

91

1.2

occ

1115

.719

22.9

1521

.48

9.6

1217

.116

19.3

Din

ner

yes

3854

.347

56.6

0.10

6

2637

.126

31.3

0.28

2028

.631

37.3

0.76

no2

2.9

910

.84

5.7

22.

45

7.16

7.2

occ

3042

.927

32.5

3854

.321

25.3

2941

.434

41

* ch

i-squ

are

test

Tabl

e 5.

Nut

ritio

n kn

owle

dge,

food

pra

ctic

e, a

ctiv

ity le

vel,

perc

eptio

n on

fam

ily, p

sych

olog

ical

fact

or a

nd B

MI

Char

acte

ristic

sBl

pi-1

(3/1

2)pi

-2 (6

/12)

Inte

rven

tion

Cont

rol

p-

valu

e*In

terv

enti

onCo

ntro

lp

-va

lue*

Inte

rven

tion

Cont

rol

p-

valu

e*n

%n

%n

%n

%n

%n

%N

utri

tion

kno

wle

dge

good

57.1

1214

.5

0.35

7

1521

.49

10.8

0.06

1

1622

.912

14.5

0.15

2m

oder

ate

3144

.334

4125

35.7

2934

.925

35.7

3339

.8po

or34

48.6

3744

.628

4012

14.5

1318

.626

31.3

mis

sing

0–

0–

2–

33–

16–

12–

Phys

ical

Act

ivit

y (M

ETs,

min

/wee

k)H

igh

1018

.216

23.5

0.71

0

811

.822

44.0

< 0

.001

611

.130

42.3

< 0

.001

Mod

erat

e13

23.6

1725

.017

25.0

1530

.09

16.7

1622

.5Lo

w32

58.2

3551

.543

63.2

1326

.039

72.2

2535

.2

Mis

sing

15–

15–

2–

33–

16–

12–

Perc

epti

on o

n fa

mily

:O

bese

811

.411

13.3

0.73

3

1014

.74

8.0

0.26

6

47.

43

4.2

0.04

3N

ot o

bese

6288

.672

86.7

5885

.346

92.0

5092

.668

95.8

Mis

sing

0–

0–

2–

33–

16–

12–

Psyc

holo

gica

l fac

tor

Posi

tive

1318

.619

22.9

0.51

3

1116

.213

26.0

0.19

0

1120

.418

25.4

0.51

3N

egat

ive

5781

.464

77.1

5783

.837

74.0

4379

.653

74.6

Mis

sing

0–

0–

2–

33–

16–

12–

Body

mas

s in

dex

(BM

I)no

rmal

00

00

0.45

8

22.

92

2.4

0.90

5

23.

70

0

0.25

7ov

erw

eigh

t42

6048

57.8

3145

.624

28.9

2138

.930

42.3

obes

e28

4035

42.2

3551

.524

28.9

3157

.441

57.7

mis

sing

0–

0–

2–

33–

16–

12–

* ch

i-squ

are

test


Tabl

e 8.

Cha

ract

eris

tic o

f die

tary

ass

essm

ent

Type

&

Freq

uenc

y

BlPi

-1Pi

-2

Inte

rven

tion

cont

rol

pIn

terv

enti

onco

ntro

lp

Inte

rven

tion

cont

rol

p

no%

no%

valu

e*no

%no

%va

lue*

no%

no%

valu

e*

Food

freq

uenc

y ha

bit

Goo

d23

33.3

1619

.3

0.04

8

2131

.314

28.0

0.69

6

2748

.221

29.2

0.02

7Po

or46

66.7

6780

.746

68.7

3672

.029

51.8

5170

.8

mis

sing

10

333

1411

Leaf

yve

g

neve

r7

106

7.2

0.28

45.

96

12.0

0.12

611

.08

11.3

0.89

daily

2738

.637

44.6

2232

.419

38.0

1629

.620

28.2

2-3

x w

k21

3035

42.2

3348

.524

48.0

2240

.733

46.5

once

1521

.45

69

13.2

12.

010

18.5

1014

.1

Oth

erve

g

neve

r9

12.9

67.

2

0.47

7

811

.86

12.0

0.09

8

1018

.57

9.9

0.17

7da

ily23

32.9

3643

.412

17.6

918

.013

24.1

2231

.0

2-3

x w

k25

35.7

2732

.524

35.3

2754

.018

33.3

3245

.1

once

1318

.614

16.9

2435

.38

16.0

1324

.110

14.1

Frui

ts

neve

r3

4.3

33.

6

0.37

57.

40

0.0

0.15

9

47.

43

4.2

0.71

daily

2028

.639

4713

19.1

1428

.013

24.1

1318

.3

2-3

x w

k26

37.1

3036

.132

47.1

2550

.025

46.3

3752

.1

once

2130

1113

.318

26.5

1022

.012

22.2

1825

.4


Type

&

Freq

uenc

y

BlPi

-1Pi

-2

Inte

rven

tion

cont

rol

pIn

terv

enti

onco

ntro

lp

Inte

rven

tion

cont

rol

p

no%

no%

valu

e*no

%no

%va

lue*

no%

no%

valu

e*

Fish

neve

r2

2.9

22.

4

0.66

22.

92

4.0

0.67

11.

92

2.8

0.86

8 da

ily30

42.9

3238

.620

29.4

2346

.016

29.6

2535

.2

2-3

x w

k22

31.4

3441

3145

.622

44.0

2444

.427

38.0

once

1622

.915

18.1

1522

.13

6.0

1324

.117

23.9

Chic

ken

neve

r1

1.4

44.

8

0

34.

43

6.0

0.33

47.

42

2.8

0.60

3da

ily4

5.7

2226

.52

2.9

510

.07

137

9.9

2-3

x w

k28

4036

43.4

3247

.118

36.0

2546

.335

49.3

once

3752

.921

25.3

3145

.624

48.0

1833

.327

38.0

Puls

es

neve

r16

22.9

2024

.1

0.81

6

2638

.218

36.0

0.97

1935

.226

36.6

0.63

1da

ily7

1011

13.3

45.

98

16.0

35.

61

1.4

2-3

x w

k24

34.3

2428

.923

33.8

918

.014

25.9

2028

.2

Onc

e23

32.9

2833

.715

22.1

1530

.018

33.3

2433

.8

*

chi-s

quar

e te

st


Tabl

e 9.

Sum

mar

y of

phy

sica

l act

iviti

es

Type

&

freq

uenc

y of

ph

ysic

al

acti

vity

Uni

t

BlPi

-1Pi

-2In

terv

enti

onco

ntro

lp

valu

e

Inte

rven

tion

cont

rol

pva

lue

Inte

rven

tion

cont

rol

p-

valu

eN

o (m

ean)

No

(mea

n)N

o (m

ean)

No

(mea

n)N

o (m

ean)

No

(mea

n)

PJpe

r wee

k1.

331.

730.

208

1.44

9.42

0.11

21.

111.

520.

289

min

/ se

ssio

n64

.71

69.7

10.

558

.08

64.9

20.

106

56.3

874

.36

0.06

9

Cycl

ing

per w

eek

2.31

30.

269

2.37

11.3

0.03

11.

933.

730.

016

min

/ses

sion

54.0

953

.47

0.03

245

.51

68.12

0.05

844

.72

67.0

40.

062

Jogg

ing

per w

eek

1.18

1.4

0.46

21.

419.

360.

061

1.13

3.49

0.49

6m

in /

sess

ion

39.4

240

.29

0.71

239

.85

53.9

20.

159

31.7

566

.54

0.08

Foot

ball

per w

eek

1.18

1.24

0.03

20.

569.

30.

001

0.5

1.8

0.03

1m

in /

sess

ion

33.3

30.8

80.

298

22.8

662

.84

0.00

320

.55

46.0

50.

049

Hoc

key

per w

eek

0.13

0.37

0.66

0.04

8.32

0.01

40.

130.

340.

748

min

/ se

ssio

n6.

3712

.79

0.51

22.

224

.72

0.04

5.7

12.2

50.

706

Swim

min

gpe

r wee

k0.

230.

190.

223

0.1

8.16

0.05

80.

190.

460.

435

min

/ se

ssio

n18

.1211

.47

0.53

55.

2925

.32

0.05

912

.79

22.8

10.

193

Oth

ers

per w

eek

2.23

0.35

0.42

10.

388.

280.

141

2.22

0.25

0.05

1m

in /

sess

ion

16.13

13.2

30.

251

8.52

16.3

20.

216

.29.

50.

041

Tele

visi

onpe

r wee

k5.

465.

450.

053

5.93

14.4

60.

034

2.63

4.97

0.00

1m

in /

sess

ion

137.

4513

2.83

0.49

310

1.02

95.9

0.19

976

.1110

4.78

0.02

8

Com

pute

rpe

r wee

k2.

951.

120.

721.

5911

.24

0.00

90.

961.

480.

035

min

/ se

ssio

n30

.48

37.1

60.

729

.85

56.5

0.11

934

.46

61.0

20.

136

Writ

ing

/ D

raw

ing

per w

eek

32.

520.

019

3.47

13.5

0.22

23.

223.

340.

011

min

/ se

ssio

n78

.73

87.0

10.

527

57.8

987

.96

0.04

646

.83

78.3

80.

252

Indo

orpe

r wee

k4.

061.

120.

374

0.79

13.1

0.16

70.

530.

890.

582

min

/ se

ssio

n37

.83

35.14

0.34

332

.735

.10.

137

21.3

824

.94

0.37

5

* ch

i-squ

are

test


Table 6 compares the results of three main subjects for both schools; mainly Bahasa Malaysia, Mathematic and Science. There were significant differences for all three subjects.

Table 7 shows the pattern of meal intake at bl, pi-1 and pi-2. The percentage of subjects taking lunch and dinner were higher at bl (84.3% taking lunch, 54.3% taking dinner) compared to pi-1 (68.8% taking lunch, 37.1% taking dinner) and pi-2 (57.1% taking lunch, 28.6% taking dinner). However, there was no significant difference in meal practice in both schools.

Table 8 shows the characteristic of dietary assessment at bl, pi-1 and pi-2 of children in intervention and control school.

There were an increase in percentage of students from the intervention school having good food frequency habit; from 33.3% at bl to 48.2% at pi-2; even though there was a slight decrease at pi-1 (31.3%). The students in the control school showed an increase in good food frequency habit as well; from 19.3% at bl to 28.0% and 29.2% at pi-1 and pi-2, respectively.

Percentage of subjects taking at least once a week of leafy vegetable increased from bl (90%) to 92.8 % in pi-1. However this percentage was reduced to 88.8 % in pi-2. The same result was also seen in the practice of taking other vegetables at least once a week from bl (87.2%) to 92.8 % in pi-1. However this percentage was reduced to 81.5 % in pi-2.

The practise of take fruits at least once a week did not increase in percentage over the 6 months period of intervention, however there was an increase in control school from 96.4 % to 100 %.

The intake of fish at least once a week had increased from 97.2 % to 98.1 % after 6 month intervention. The intake of chicken at least once a week was recorded at 98.6 % at bl, 95.6 % in pi-1 and 92.6 % in pi-2. The intake of pulses was 77.2 % at bl, 61.8 % at pi-1 and 64.8 % at pi-2.

Table 9 shows that television viewing at bl in the intervention group was the most frequent activity undertaken with an average of 5.46 times per week, followed by indoor games and writing & drawing (both 4.06 times / week) and playing computer games (2.95 times/week).

In control group, television viewing was also the most frequent activity (5.00 times/week) followed by cycling (3.00 times/week), writing & drawing (2.52 times / week) and physical education (1.37 times/week).

In pi-1, the most frequent activity in intervention group was television viewing (5.39 times/week) followed by writing & drawing (3.47 times/week), cycling (2.37 times/


week) and playing computer games (1.59 times/week). In the control group, the most frequent activity was television viewing (14.46 times/week) followed by writing & drawing (13.5 times/week), indoor games (13.1 times/week) and lastly, cycling (11.3 times/week).

As for pi-2, the intervention group most frequent activity was writing & drawing (3.22 times/week), television viewing (2.63 times/week), others (2.22 times/week) and cycling (1.93 times/week). In the control group, most frequent activity was television viewing (4.97 times/week) followed by cycling (3.73 times/week), jogging (3.49 times/week) and writing & drawing (3.43 times/week).

5.0 DISCUSSION

One of the limitations in this study was the lack of co-operation from the school and no collaboration at all from the canteen operators. In a Medscape Medical News by Claire Kittredge (2006), it was reported that a community-based programme was done to reduce BMI in children. The programme involved 100 community events, 4 parent forums, newsletters, before-and-after school programme and teachers using a special curriculum. The traffic light system was hence only theoretically introduced to the students and was not practiced by the canteen operators. Parents were not involved actively and therefore, changes in dietary pattern were limited.

The duration of study was also not adequate to see any significant changes or sustainability in any dietary or physical activities changes. In a study by Warren J.M. et al (2003), that was carried out for 14 months, also reported duration of study as one of their limitations. The small number of subjects, constant drop out and new recruitment at every post intervention of data collection were also one of the limitations of this study.

In this study, we had compared socio-demographic factors, nutrition knowledge, food practice, activity level, body mass index, perception on family image and psychological factor between intervention and control school. The two schools were chosen based on the data of overweight school children obtained from the school health teams.

The intervention package was successfully implemented. However it was disappointing that, there were minimal changes in the parameters that were captured.

There was no significant difference in nutrition knowledge among intervention school and control school during bl, pi-1 and pi-2. This might be due to the understanding of the questionnaire given. Both school mid term results (Bahasa Melayu, Science and Mathematics) were compared and there was a significant difference in all 3 subjects (BM: p=0.048, Mathematics & Science = p<0.001). The control school scored better marks in all three subjects.


Scoring of food frequency habit was significantly different among both schools at bl, p= 0.048 and pi-2, p= 0.027. Intervention school had better food frequency practice compared to control school at bl and pi-2. This might be due to the education given to the children along the whole intervention programme.

After six months’ intervention, the subjects did not show an improvement or increase in percentage of meal practice i.e. breakfast, lunch and dinner. These could be due to the intervention package which did not focused on the importance of taking the three main meals daily. The intervention package introduced to the subjects focused on changing to healthier lifestyle which included eating according to the traffic light system and getting involved in more physical activities.

The intake of leafy green and other vegetables at least once a week was higher after pi-1. However the percentage dropped in both practice after pi-2. This maybe caused by lack of parents’ support in this study. In a study by Epstein et al (2001), a parent focused, targeted behavioural intervention demonstrated the desired behaviour change in dietary intake; increase consumption of vegetables and fruits.

It was found out that television viewing was the most frequent activity throughout the study period. The time spent on each television session was reduced significantly after intervention package was introduced. These also applied to the control school whereby minutes spent on television viewing were reduced in pi-1, but increased in pi-2. These might be the reason for BMI reduction in the intervention school as reported by Anderson R.E. et al (1998). Children who watched television for longer hours are less likely to participate in vigorous activity and have the tendency to have higher BMIs. Unfortunately, in this study, this reduction was not significant.

In non-physical activities such as playing computer, writing & drawing, and having indoor games, the time spent in these activities had reduced. However it was found that, only in pi-2, the time spent in writing & drawing and playing computer games were significantly reduced in both schools. All these reduction in time spent on non-physical activities might be due to the intervention package which was conducted during weekends and thus, these subjects have lesser time to spend at home.

Such trends were not seen in vigorous activities. The only significant difference was seen in the frequency of cycling, playing football and playing hockey. In these activities, the control school was more actively involved. This may explain the reduction in BMI in control school in pi-1.

All the physical and non-physical activities were also tabulated in METs. At baseline, there was no significant difference between both schools. However, at pi-1 and pi-2, there was significant difference. Control school had more subjects and an increasing trend in ‘high METs’ category.



Prevention of childhood obesity should be done in collaboration with the health sectors and the schools in addition to the input and cooperation from parents. The intervention programme should be carried out by the school teachers and the health sector to supervise and evaluate monthly. Parents should be involved to provide more comprehensive information on family hereditary characteristics, dietary intake, physical activities and the family social economic background. More precise methods and objective measurement using activity monitors or logs are needed to get more accurate data. Therefore the success of the intervention package will depend on all sectors: schools, canteen operators, community and parents.

REFERENCES

1. Trim And Fit (TAF) Programme 2. Factor associated with obesity in school children. (ped.com.br Jornal de Pediatria),

http://Preventing Childhood Obesity, AFIC 3. Preventing Obesity among Children, National Center for Obesity4. Sherina Mohd Sidek & Rozali Ahmad (2004) Childhood obesity: Contributing factors,

consequences and Intervention5. Pon Lai Wan, Mirnalini Kandiah & Mohd Nasir Mohd Taib (2004 ) Body image

perception, dietary practices and physical activity of overweight and normal weight Malaysian female adolescents.

6. Fatimah Arshad, Wan Asma WI, Md Idris MN, Ruzita AT, Roslee R, Nik Mazlan M & Nor Afizah I (2001) The effectiveness of childhood obesity intervention program and the psychosocial factors involved in maintaining in weight changes in urban areas.


ACKNOWLEDGEMENT

First, we would like to thank God for blessing us into making it this far, through all the hard works and pains, but not forgetting all the sweet memories.

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper. We would like to take this opportunity to express our sincere gratitude to our much-respected facilitators, Dr Amar-Singh HSS, Dr Sondi Sararaks, Dr Marina Kamaruddin and Dr Asmah Zainal Abidin for their patience, guidance, supports, encouragements and constructive comments throughout the course of this research work.

Our appreciation also goes to school health teams of Kinta district, the headmasters, teachers and students of SK Haji Mahmud, Chemor and SK Perpaduan for their valuable assistances and co operations in managing the health programmes throughout the course works.

We are also indebted to our colleagues of the HSR 2006-2007 team for their collaborations and helps.

Last but not least, we would like to thank the Ministry of Health for funding our research work.


APPENDIX A

Overweight report, Kinta

Appendix A

Borang Soalselidik Kajian Keberkesanan Program Intervensi Berat Badan Berlebihan Di Kalangan Murid Murid Sekolah Di Daerah Kinta. Questionaires on study of an effectiveness of an intervention program among overweight primary school children in the District of Kinta.

A. DATA DEMOGRAFI / SOCIODEMOGRAPHY DATA:

Sekolah /school: Tahun / year : Nama /Name : Jantina /sex : Bangsa / race : Melayu Cina India Lain-lain Malay Chinese Indian Others Alamat / address : No Tel / tel no : Pemeriksaan Fizikal / physical examination : Tinggi Berat : BMI : -------------% percentile Height : --------------cm Weight :---------------kg Tandakan (� ) bagi kenyataan yang benar untuk soalan-soalan berikut :- Tick the right statement which is agreeable to you

B. FAKTOR PEMAKANAN / FOOD FACTORS

I. Pengetahuan ( knowledge ) 1. Apakah amalan makan yang baik ?

A. Makan dengan banyak B. Makan banyak ayam goreng C. Makan pelbagai jenis makanan D. Makan makanan mahal E. Tidak tahu

2. Apakah piramid makanan ?

A. Piramid di Mesir B. Permainan piramid yang mengandungi makanan C. Panduan untuk memilih makanan yang sihat D. Tempat meletak makanan berbentuk piramid E. Tidak tahu

3. Mengikut piramid makanan, kumpulan makanan paling banyak yang perlu

dimakan ialah : A. Sayur-sayuran dan buah-buahan B. Daging, ikan, ayam dan kekacang C. Nasi, bijirin dan ubi D. Lemak, minyak, garam dan gula E. Susu dan hasil tenusu F. Tidak tahu



4. Mengikut piramid makanan, kumpulan makanan yang perlu dimakan sedikit ialah: A. Sayur-sayuran dan buah-buahan B. Daging, ikan, ayam dan kekacang C. Nasi, bijirin dan ubi D. Lemak, minyak, garam dan gula E. Susu dan hasil tenusu

5. Apakah zat (nutrien) yang membina badan?:

A. Protein B. Vitamin dan mineral C. Lemak D. Karbohidrat E. Tidak tahu

6. Apakah jenis zat ( nutrien ) yang memberi tenaga ? A. Protein D. Karbohidrat B. Vitamin dan mineral E. Tidak tahu C. Lemak 7. Diantara makanan berikut yang mana mempunyai paling banyak karbohidrat? A. Daging D. Sayur-sayuran B. Susu E. Tidak tahu C. Roti 8. Diantara makanan berikut yang mana mempunyai paling banyak protin? A. Ikan D. Sayur-sayuran B. Nasi E. Tidak tahu C. Roti 9. Diantara makanan berikut yang mana mempunyai paling banyak serat ( fiber )? A. Ikan D. Kuih-muih B. Roti dan biskut E. Tidak tahu C. Sayur-sayuran dan buah-buahan 10. Adik boleh mendapat semua zat ( nutrien ) dengan : A. Makan banyak makanan D. Makan makanan yang mahal

B. Makan banyak ayam E. Tidak tahu C. Makan pelbagai jenis makanan 11. Daging dan ikan kaya dengan zat :

A. Vitamin D. Karbohidrat B. Lemak E. Tidak tahu C. Protein 12. Buah oren dan jambu batu kaya dengan vitamin : A. Vitamin A D. Vitamin D B. Vitamin B E. Tidak tahu C. Vitamin C



13. Cara memasak yang manakah akan meningkatkan kandungan lemak? A. Stim D. Rebus B. Goreng E. Tidak tahu C. Panggang 14. Makanan yang mengandungi paling banyak garam ialah : A. Kicap D. Minuman dalam tin B. Daging E. Tidak tahu C. Tomato 15. Pengambilan garam yang berlebihan boleh menyebabkan : A. Penyakit kulit D. Sakit gigi B. Kencing manis E. Tidak tahu C. Tekanan darah tinggi 16. Makanan yang mengandungi paling banyak gula : A. Lobak merah D. Minuman dalam tin B. Air mineral E. Tidak tahu C. Roti sandwich 17. Pengambilan gula yang berlebihan boleh menyebabkan : A. Sakit jantung D. Pening kepala B. Kencing manis E. Tidak tahu C. Penyakit kulit 18. Makanan yang manakah mengandungi kolesterol paling tinggi? A. Daging lembu D. Santan kelapa B. Kuning telur E. Tidak tahu C. Susu 19. Adakah adik pernah mendengar tentang program pemilihan makanan melalui sistem lampu isyarat? A. Ya B. Tidak 20. Adakah adik tahu bagaimana untuk memilih makanan dan minuman yang sihat mengikut sistem lampu isyarat? A. Ya B. Tidak 21. Makanan dari kumpulan hijau adalah : A. Makanan yang tinggi kalori dan lemak B. Makanan yang perlu dimakan sedikit sahaja C. Makanan yang rendah kalori dan lemak D. Makanan dari kumpulan sayur-sayuran E. Tidak tahu

309An Intervention Programme Among Overweight Primary School Children Overweight report, Kinta

22. Makanan dari kumpulan merah adalah: A. Makanan berwarna merah dan banyak darah B. Makanan yang perlu dimakan dengan banyak C. Makanan yang rendah kalori dan lemak D. Makanan yang perlu dielakkan dan dihadkan E. Tidak tahu

II. Amalan (Practice)

23. Tandakan (� ) kenyataan berikut /tick the appropriate statement:

Kenyataan Ya /yes

Tidak / no

Kadang-kadang /

sometimes

Apa yang anda selalu makan utk sarapan / what do you

usually have for breakfast? Saya bersarapan setiap pagi / I take breakfast every morning

Saya makan tengahari setiaphari / I take lunch everyday

Saya makan malam setiap hari / I take dinner everyday

24. Berapa kerap anda makan makanan berikut / how often do you take the following foods:

Jenis makanan / Type of food

Setiap hari/ daily

2-3 kali seminggu/

week

Seminggu sekali / 1 X

per week

Tidak pernah /

never

Kegemaran anda / your

favorites Sayur-sayuran hijau / leafy vegetables

Sayur-sayuran lain / other vegetables eg cabbage, carrot

Buah-buahan /fruits

Ikan / fish

Ayam /chicken

Kekacang (Kacang hijau, dal)/ pulses



25. Berapa kerap anda makan dan minum, makanan berikut / how often do you take the following :

Jenis makanan / Type of food

Setiap hari/ daily

2-3 kali seminggu

/week

Seminggu sekali

/weekly

2-3 kali sebulan /month

Tidak pernah /never

Pizza / Burger Ayam goreng /fried chicken Kentang goreng /french fries Keropok lekor Nasi lemak Roti canai Sosej /sausage Minuman tin/ bergas /carbonated drinks Air sirap /cordial drinks Air kotak Air kosong /plain water Coklat /gula-gula /sweet Makanan ringan /snacks Mi segera /instant noodles

26. Apakah makanan kegemaran anda, dan berapa kerap anda memakannya dalam

seminggu / what are your favourite foods and how often do you take them weekly.

Makanan kegemaran anda / your favorite foods Kekerapan / frequency a. b. c. d. e.

27. Apakah minuman kegemaran anda dan berapa kerap anda meminumnya dalam

seminggu / what are your favourite drinks and how often do you take them weekly.

Minuman kegemaran anda / your favorite drinks Kekerapan / frequency a. b. c. d. e.



28. Berapa banyak duit poket anda setiap hari dan apa yang anda selalu beli / how much pocket money do you get daily and what do you usually buy? RM .........................

Makanan minuman yang selalu dibeli /

food & drinks that your usually buy Kekerapan / frequency a. b.

C. FAKTOR AKTIVITI FIZIKAL/ PHYSICAL ACTIVITES FACTOR

29. Bagaimana anda ke sekolah /how do you commute to school ? Tandakan /please tick ( � )

Naik bas/ kereta/motorsikal By bus/car/motorcycle

Berbasikal Bicycle

Jalan kaki walking

30. Berapa lama anda melakukan senaman dalam seminggu, tandakan dalam kotak dibawah / how long do you exercise weekly, fill in the following box:

Jenis aktiviti /activities Ya/yes Tidak/

no

Kekerapan/ frequency Berapa kali

Dlm seminggu/ times per

week

Berapa Jam setiap kali/

hours each time 1 Pendidikan jasmani (PJ ) 2 Berbasikal /cycling 3 Berjogging/jogging, walking 4 Bersukan /sports :

i. Bolasepak /football ii. Hoki/ hockey iii Berenang /swimming iv Lain-lain,nyatakan/others, please specify



31. Berapa lama anda melakukan aktiviti sedentari ( tidak aktif ) seperti berikut dalam seminggu / how long do you spend for the following sedentary activities:

Jenis aktiviti /activities

Ya/yes

Tidak/

no

Kekerapan /frequency Berapa kali

Dlm seminggu/ times per

week

Berapa Jam setiap kali/

hours each time 1. Menonton TV/ tv viewing 2. Bermain komputer/ permainan

video/ computer & video games

3. Membaca,melukis,menulis /reading, writing ,drawing.

4. Chess,dam, carom,congkak /indoor games

5. Lain-lain nyatakan /others, please specify : i. ii. iii.

D. FAKTOR PSIKOSOSIAL / PSYCHOSOCIAL FACTORS

32. Saya rasa berat badan saya sekarang / I feel that I am ? :

Kurus/ thin Biasa /normal Gemuk /fat

33. Pada pendapat anda adakah seseorang yang lebih berat badan perlu mengurangkan berat badan mereka/ do you think those who are overweight should reduce their weight

Ya /yes Tidak/no

34. Adakah anda merasa berat badan berlebihan atau kegemukan sebagai suatu penyakit/ do you think that being overweight will causes disease

Ya /yes Tidak/no

313An Intervention Programme Among Overweight Primary School Children Overweight report, Kinta

35. Tandakan ( � ) pada ruangan yang bersesuai mengenai keluarga anda. Bulatkan kedudukan anda dalam keluarga: Tick the correct box which describes your family

Ahli Keluarga / family Kurus/thin Biasa/normal Gemuk/fat Ayah/father Ibu/mother Anak 1 Anak 2 Anak 3 Anak 4 Anak 5

36. Tandakan ( � ) pada kenyataan yang mengambarkan diri anda / tick the

statement which applies to you :

Bil Kenyataan Ya/yes Tidak/no a Saya selesa dengan keadaan berat badan saya sekarang

/ I am comfortable with my current weight

b Saya merasa disisih oleh kawan-kawan di sekolah /I feel my friends discriminate me

c Sindiran / ejekan oleh kawan-kawan membuat saya rasa sedih/ I feel sad when my friend tease me

37. Tandakan ( X ) pada skala berikut bagi mengambarkan perasaan anda disebabkan berat badan semasa/ please tick the scale below which best describe your feeling because of your weight problem .

0 1 2 3 4 5 6 7 8 9 10 Sangat Biasa Sangat Sedih Gembira


APPENDIX B


Appendix B Kebenaran bertulis dari ibubapa Sukacita dimaklumkan pihak kami akan menjalankan satu kajian intervensi terhadap berat badan yang berlebihan di kalangan murid –murid darjah 3, 4 dan di Sek keb Haji Mahmud, Chemor. Kajian intervensi yang akan dijalankan memerlukan ibubapa dan pelajar menjawab soalan-soalan yang merangkumi aspek –aspek berkaitan :

1. Jenis dan tabiat pemakanan seharian di kalangan pelajar 2. Aktiviti –aktiviti seharian di sekolah dan di rumah . 3. Persepsi ibubapa terhadap pemakanan anak-anak. 4. Pengetahuan pelajar serta ibubapa terhadap penyakit yang disebabkan oleh

kegemukan yang berlebihan. Sebarang maklumat adalah rahsia , maklumat yang diterima adalah untuk tujuan kajian intervensi semata-mata. Kepada para ibubapa dan pelajar yang bersetuju untuk bekerjasama dalam program ini, sila tandatangan di bawah ruangan yang telah di sediakan. Saya .......................................................................................Ibubapa / penjaga kepada pelajar yang bernama ...........................................................................dengan ini bersetuju /tidak bersetuju membenarkan anak saya untuk menyertai program kajian intervensi untuk menurunkan berat badan. Jika anda tidak bersetuju sila nyatakan sebab-sebabnya. .................................................................................. Tandatangan ibubapa : Saya bernama .....................................................................bersetuju /tidak bersetuju untuk menyertai program kajian intervensi untuk menurunkan berat badan. Jika anda tidak bersetuju sila nyatakan sebab-sebabnya. ........................................................................................................................................... Tandatangan pelajar :


APPENDIX C


Appendix C Pengetua, Sek Keb Haji Mahmud, Chemor Melalui Pejabat Pendidikan Daerah Kinta Tuan / puan , MEMOHON KEBENARAN UNTUK MENJALANKAN PROGRAM KAJIAN INTERVENSI PENURUNAN BERAT BADAN Merujuk kepada perkara di atas, pihak kami ingin memohon kebenaran dari pihak sekolah untuk menjalankan program kajian intervensi penurunan berat badan dikalangan pelajar darjah 3,4 dan 5 . Kajian ini merangkumi tiga fasa di mana fasa pertama akan mengenal pasti pelajar yang mempunyai berat badan yang berlebihan dengan mengambil ukuran berat badan dan ketinggian pelajar. Pelajar yang menepati kriteria tertentu dan bersetuju untuk menyertai program ini akan di kenalpasti. Dalam fasa kedua, faktor-faktor yang menyebabkan berat badan yang berlebihan akan dikenalpasti , di mana pelajar dan ibubapa yang telah bersetuju untuk menyertai program tersebut perlu menjawab soalan -soalan yang berkaitan berat badan yang berlebihan yang merangkumi aspek –aspek :

1. Tabiat dan cara pemakanan di kalangan pelajar . 2. Aktiviti seharian pelajar di sekolah dan di rumah . 3. Persepsi ibubapa terhadap cara pemakanan di kalangan relajar . 4. Pengetahuan pelajar dan ibubapa terhadap masalah yang berkaitan dengan masalah

kegemukan yang berlebihan. Dalam fasa ketiga , program intervensi akan dijalankan untuk menurunkan berat badan di mana pelajar akan di awasi oleh para peserta kajian secara berperingkat iaitu selepas sebulan , 3 bulan dan 6 bulan. Diharap mendapat kerjasama dari pihak sekolah untuk melicinkan lagi program yang akan dijalankan. Sekian Terima kasih.


APPENDIX D


Appendix D Focus What Who When / How Food / Diet • Types of food

• Quantity / Portion • Preparation • Meal regularity • Balanced diet

• Nutritionists • Dietitians • Nurses

• Lectures • Demonstrations on

balanced food, portions, cooking techniques

• Food pyramid • Group counseling

Physical Activity (Exercise)

• Importance / Advantages • Types • Practice • Period of activities /

Time • Frequency and Intensity

• Instructors • School

teacher • Peer

• Walking • Gardening • Sports • Stairs

Health hazard of obesity

• Related diseases • Complications • Case presentation

• Doctors • Nurses

• Lectures • Group counseling • Patients

Family factors

• Lifestyles

• Respected person

• Physical activities • Food

Psychological factors

• Lifestyle • Stress • Image

• Parents • Peers • Teachers • Health staff

• Home • Counseling

Motivational aspects

• Support group • Praise

• Parents • Peers • Teachers • Health staff


Incentives • Rewards (eg: games, stepper for school and T-shirts

• Parents • Teachers • Health staff



APPENDIX E


Appendix E

Reference: WHO (1995), BMI-for-age Adapted from: Assoc Prof Dr Poh Bee Koon,Latihan Asas Pengurusan Diet Terapi Remaja 12-16Sept 2005

0

2

4

6

8

10

12

14

16

Poh et al (1991) Tio et al (2000) Tee et al (2002) Pann et al (2002)

%

Reference: WHO (1995), BMI-for-age Adapted from: Assoc Prof Dr Poh Bee Koon,Latihan Asas Pengurusan Diet Terapi Remaja 12-16 Sept 2005

0

5

10

15

20

25

30

Poh et al (1991) Tio et al (2000) Tee et al (2002) Pann et al (2002)

%

Prevalence of overweight among young adolescents in Klang Valley

Prevalence of underweight among young adolescents in Klang Valley


APPENDIX F


Appendix F Comparison of overweight and obesity among adolescent in Malaysia

18.5

943 18.4 1046 MALAYSIA

6.7 897 4.5 847 Netherlands

14.4 1113 9.5 1222 UK

13.9 122 10.5 114 Germany (Jena)

17.6 369 15.4 415 Germany

10.1 623 20.3 661 Hong Kong

13.9 115 20.5 117 Hungary

25.9 309 22.9 314 Germany

17.6 1584 25.5 1660 Singapore

18.5 384 27.8 392 Japan

31.4 344 29.6 334 Italy

%

Samp

%

Samp

Girls Boys Country


APPENDIX GAppendix G Year 1 District 2001 2002 2003 2004 2005 Kinta 1009 (6.5%) 1227 (8.1%) 1170 (7.5%) 592 (4.0%) * 1278(8.9%) LMS NA NA NA 129(1.9%) 253(4.1%) K.Kangsar 16(0.5%) 27(0.9%) 0 1(0.02%) 5(0.15%) Kerian 159(4.45%) 174(4.9%) 230(6.3%) 208 (5.5%) 214(6.3%) B.Padang 0 17(7.7%) 15(2.5%) 12(2.2%) 17(2.6%) Perak Tengah 61(3.05%) 107(5.3%) 66(3.5%) 6(0.32%) 12(0.62%) Hulu Perak 51 (2.4%) 71(3.6 %) 80 (3.6%) 63 (3%) 81 (4.1%) Hilir Perak 109 (8.6%) 102 (7.85%) 120 (8.8%) 102 (8.2%) 98 (7.7%) Manjung 194 (3.8%) 51 (1%) 39 (0.76%) 20 (0.39%) 56 (1.2%) Year 6 District 2001 2002 2003 2004 2005 Kinta 1851(14%) 2383(17%) 2020(14.7%) 1028(7.3%)* 2053(13.6%) LMS NA NA NA 176(2.7%) 485(7.3%) K.Kangsar 114(3.6%) 86(2.9%) 3(0.8%) 54(1.7%) 24(0.73%) Kerian 260(7.6%) 449(12.8%) 513(14.3%) 491(14.5%) 615(16.8%) B.Padang 0 27(8.2%) 22(3.6%) 34(5.7%) 37(6.04%) Perak Tengah 111(5.7%) 218(11%) 92(4.6%) 90(4.4%) 16(0.8%) Hulu Perak 97 (4.5%) 146 (6.6%) 239 (11.4%) 279 (12.2%) 281 (13.6%) Hilir Perak 105 (8.9%) 103 (7.5%) 107 (9.7%) 107 (7.8%) 104 (8.9%) Manjung 282 (6.6%) 80 (1.7%) 177 (3.8%) 30 (0.6%) 132 (2.8%) Form 3 District 2001 2002 2003 2004 2005 Kinta 1611(11.4%) 1736(13.3%) 1586(11.7%) 956(7.6%)* 1244(9.5%) LMS NA NA NA 235(3.6%) 252(4.0%) K.Kangsar 105(2.8%) 116(3.5%) 9(0.25%) 76(2.4%) 7(0.21%) Kerian 213(5.6%) 178(5.1%) 497(13.7%) 468(13.7%) 461(13.9%) B.Padang 0 1(0.3%) 51(10.3%) 19(3.5%) 12(1.9%) Perak Tengah 24(1.2%) 21(1.0%) 38(2.0%) 18(0.9%) 10(0.4%) Hulu Perak 116 (5.8%0 262 (12.5%) 296 (13.2%) 337 (13.7%) 273 (13.4%) Hilir Perak 101 (6.1%) 95 (5.3%) 81 (4.2%) 67 (5.6%) 64 (6.4%) Manjung 230 (5.4%) 46 (1.1%) 2 (0.05%) 21 (0.52%) 39 (0.94%)

321ISBN

9789671063460

Effectiveness of the Diabetic Foot Care Programme in a Primary Care SettingHealth Systems Research 2006/2007

Authors

Awisul Islah GhazaliTaiping Hospital

Mohd Ikhwan Mohd RusliLarut Matang & Selama District Health Office

Geok-Ping ChiewLarut Matang & Selama District Health Office

Shafina Mohd YunusLarut Matang & Selama District Health Office

Abdul Karim MohamadLarut Matang & Selama District Health Office

Syed Mud Puad Syed AmranLarut Matang & Selama District Health Office




Clinical Research Centre (CRC) Perak recommends using the following statement to cite this report in our publication entitled “Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference”: Shir-Ley Gui, Saerah Shaharuddin, Sheleaswani Inche Zainal Abidin, Ainul Salhani Abdul Rahman, Kulandaimmal Lourdusamy, Amar-Singh HSS, Sondi Sararaks, Marina Kamaruddin, Asmah Zainal Abidin, Normah Mohd Zain. ”Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting” in Health System Research (HSR) in Perak 2006-2009: Using Research to Make a Difference. Clinical Research Centre (CRC) Perak, 2013, pp 321. (ISBN: 9789671063460)

322 Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting


Abstract 323




2.0 Objective 129



3.0 Methodology 328


3.2 Intervention package

3.3 Study type


3.5 Variables

3.6 Sampling

3.7 Techniques for data collection & pre-testing


4.0 Results 333



4.3 Comparison of change in asthma control based on ACT in the post intervention cohort

References 339

Appendices 340

Editor’s statement

The final report of the HSR study entitled “Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting” is incomplete with the discussion and the conclusion sections inadequately written. Hence, the study is presented up to the result section for the purpose of this compilation.

323Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting

ABSTRACT

Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting

Awisul Islah Ghazali1, Mohd Ikhwan Mohd Rusli2, Geok-Ping Chiew2, Shafina MohdYunus2, Abdul Karim Mohamad2, Syed Mud Puad Syed Amran2, Amar-Singh HSS3,6, Sondi Sararaks4, Ranjit Kaur Praim Singh5

1 Taiping Hospital2 Larut Matang & Selama District Health Office3 Clinical Research Centre Perak4 Institute for Health Systems Research5 Perak State Health Department6 Department of Paediatrics, Hospital Raja Permaisuri Bainun Ipoh, Perak


Diabetes is a major and growing health problem in most countries causing considerable amount of disability, premature mortality, and loss of productivity as well as imposing increased demands on healthcare facilities. In Malaysia, the prevalence of diabetes mellitus has steadily increased over the years with an estimate of 0.65% in 1960, to 2.00% in 1982. Foot problems are a leading cause of hospitalisation and it was estimated that 15% of the people in the United States with diabetes will develop a serious foot condition some time in their lives. Currently, the diabetic foot care programme in Malaysia is based on the Clinical Practice Guideline (CPG) on the Management of Diabetic Foot that was issued in 2003 by the Ministry Of Health. For the district of Larut Matang & Selama (LMS), 6000 diabetic patient have been officially recorded into the diabetes registry and this number is increasing every year. A number of activities have been put in place to reduce the complication rate, and the nationwide diabetic foot care programme is one of them. This study aimed to evaluate the effectiveness of the implementation of the foot care programme in the District of LMS. The assessment covered the extent of the implementation, knowledge of the patient and the delivery of the programme by the healthcare personnel.

Methodology

This study is a cross-sectional study on the implementation of a newly designed diabetic foot care programme in the District of LMS in Malaysia. This study was conducted over a period of eleven months (from January 2007 to November 2007). All health clinics in the district were involved. The study was carried out during the diabetic clinic days in each of the clinics involved. The study was divided into two phases. An evaluation on the quality and problems arising from the foot care programme was done in the first phase, followed by an intervention phase and a re-evaluation of the patients who had received the new training.


Results

210 out of the 7017 registered patients were surveyed in phase 1 of this study. Only 42.3% of them had been exposed to diabetic foot care education and their average knowledge score was 7.5 (SD 2.8). It is shown that there is statistical significance in terms of average knowledge score between those who were exposed and those who were not exposed (p value = 0.04). When evaluation on health workers was done on diabetic foot care demonstration, a mean of 14.1 (SD 2.9) out of the maximum possible score of 23 was obtained.

In phase 2 of the study, 3 clinics were selected to participate in this intervention programme. 113 patients out of the 1214 registered patients from all the 3 clinics were involved in this programme. The average score of selected patients before the intervention was 6.5 (SD 2.8), which is significantly lower than the average score of 15.9 (SD 4.4) post intervention (p value < 0.001).

Conclusion

From this study, it is shown that despite the centralised effort to improve the diabetic foot care knowledge, knowledge score remained low amongst diabetic patients. The extent of the problems heightens with the discovery of less than satisfactory knowledge score even amongst healthcare workers in this study. But, with the proper and effective implementation of the diabetic foot care programme using well structured modules by trained personnel, diabetic patients’ knowledge can be improved. Thus, it is recommended that proper implementation of such programme should be considered and reinforced by all relevant stakeholders including policy makers.

Keywords

effectiveness, diabetic foot care programme, primary care setting


1.0 INTRODUCTION

Diabetes is a major and growing health problem in most countries causing considerable amount of disability, premature mortality, and loss of productivity as well as imposing increased demands on healthcare facilities. 2 The disease also contributes significantly to the growing burden of chronic diseases. Diabetes is one of the four most prominent diseases besides cardiovascular disease (CVD), cancer and chronic respiratory disease that contribute significantly to the global burden of disease, disability and death.

Two major clinical forms of diabetes was recognized by World Health Organisation (WHO), namely Type- 1 Diabetes (previously known as Insulin-Dependent Diabetes Mellitus (IDDM) and Type-2 Diabetes (previously known as Non-Insulin-Dependent Diabetes Mellitus (NIDDM)). 2

In 1995, WHO estimated 135 million people worldwide living with diabetes and the number was projected to increase to 300 million by 2025.2 Factors contributing to the increase include inappropriate diet, consumption of high energy food and lack of exercise. Up to 6% of the total healthcare expenditure in industrialised countries is spent on diabetes mellitus care. 9 In 2000, in United States, diabetes is the sixth leading cause of death and is currently the leading cause of both blindness and end-stage renal disease.

In Malaysia, the prevalence of diabetes mellitus has steadily increased over the years with an estimate of 0.65% in 1960, to 2% in 1982. Another survey was carried out by the National Health and Morbidity Survey in 1986. In this survey, the prevalence of Diabetes Mellitus was estimated to be at 6.3%. However in 1996, the Second National Health and Morbidity survey has shown that the national prevalence of diabetes and Impaired Glucose Intolerance in Malaysia were 8.3% and 4.8% respectively. A total of 700,000 to 900,000 people were estimated to have diabetes in 1999 based on the prevalence among adults aged 30 and above. This concludes that there were 8 diabetics in every 100 adults.2

Diabetes mellitus is a heterogeneous group of disorders characterized by hyperglycemia and glucose intolerance. Hyperglycemia is abnormally high blood glucose level, beyond the normal range (roughly 70-150mg/ml of plasma). Glucose intolerance is a pathological stage in which blood glucose level is less than 140mg/100ml (7.8mmol/L) of plasma upon fasting and above 200mg/100ml (11.1 mmol/L) plasma at 30, 60 or 90 minutes during a glucose tolerance test. This condition is seen frequently in diabetes mellitus but can also occur with other diseases and malnourishment. Glucose is produced by the digestion of starchy foods such as rice, potatoes, bread, and from sugars in sweet food.7

The Diabetic Care Data Collection Project (DCDCP) conducted in 1997 shows that more than half of the diabetic patients were poorly controlled. 73% of diabetics had a HbA1c of 7.5% or worse and 68% had a fasting blood glucose of 7.8mmol/L or worse.2 Diabetes-related complications can be reduced by controlling blood sugar levels. 6 Uncontrolled


diabetes mellitus patients are susceptible to complications such as heart diseases, strokes, high blood pressure, blindness, kidney diseases, nervous system diseases, amputations, dental diseases and complications during pregnancy. Biochemical imbalances that cause acute life-threatening events such as diabetic ketoacidosis (DKA) and hyperosmolar (non-ketotic) coma are often caused by uncontrolled diabetes. Diabetic patients are more susceptible to other illnesses such as pneumonia or influenza and are more likely to die of complications compared to the people who do not have diabetes. 8

When circulation or nerves are impaired, diabetic patients may develop serious foot problems more quickly and they tend to develop more complications compared to healthy people.4 Diabetic neuropathy is the most common and potentially dangerous foot problem.5 It can cause insensitivity or loss in ability to feel pain, heat or cold.4 Foot problems are a leading cause of hospitalisation and it was estimated that 15% of all people in the United States with diabetes, will develop a serious foot condition some time in their lives. In the United States, more than 50,000 people each year with diabetes have a foot or leg amputated due to diabetes complications. 10 These amputations can be prevented with early detection and prompt treatment. Diabetic patients tend to disregard lesions, burns, bunions and other foot maladies. Diabetic neuropathy can also affect the muscles of the feet causing deformity such as hammertoes. More than 60 percent of non-traumatic lower-limb amputations occur among people with diabetes and 30 percent of diabetics suffer from peripheral vascular disease. 2

Currently, the diabetic foot care programme in Malaysia is based on the Clinical Practice Guideline (CPG) on the Management of Diabetic Foot, which was issued in 2003 by the Ministry Of Health. The CPG had been compiled by a committee comprising of orthopaedic and vascular surgeons from the public and private sectors. The CPG helps identify patients at risk for foot complications and also serves as a guide for the management of foot disorders in Malaysian diabetic patients. This guideline consists of diagnostic methods and evaluation, identification of risks factors, classification of diabetic foot problems with its appropriate treatment and management. According to this guideline, 30% of the total diabetes registry should be evaluated under Quality Assurance Program to assess the effectiveness of the programme.

For the district of Larut Matang & Selama (LMS), 6000 diabetics have been officially recorded into the diabetes registry and this number is increasing every year. A number of activities have been put in place to reduce the complication rate and the foot care programme is one of them.

This study aims to evaluate the effectiveness of the implementation of the foot care programme in the District of LMS.


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2.0 OBJECTIVES


To assess the effectiveness of the current diabetic foot care programme implemented in the primary care setting at Larut Matang and Selama (LMS) district, Perak.


1. To evaluate the extent of implementation of the programme in the following areas:a. Percentage of health clinics implementing the programmeb. Percentage of diabetic patients covered

2. To evaluate the quality and problems in the implementation of the programme in the following areas:a. Knowledge of patients who have received trainingb. Availability of resources (facilities, diabetic team and material)c. Ability of staff in delivering diabetic foot care education to the patientd. Problems faced by the staff in implementing diabetic foot care

programme3. To intervene on the current foot care programme and re-evaluate the

knowledge of patients who receive the new training. 4. To make recommendations on improving the current diabetic foot care

programme.

3.0 METHODOLOGY

3.1 Overview of Research Design

This study is a cross-sectional study on the implementation of diabetic foot care programme in the District of LMS, Perak. This study was conducted within a period of eleven months (from January 2007 to November 2007). All health clinics in the district were involved. The study was carried out during the diabetic clinic days in each of the clinic involved. The study was divided into two phases. An evaluation on the quality and problems arising from the foot care programme was done in the first phase, followed by an intervention phase and a re-evaluation of the patients who had received the new training. (See Figure 2)

Phase One: Evaluation on the quality and problems of the current diabetic foot care programme

For phase one, data collection was done using 3 methods:

1. Questionnaires for trained health staff on the diabetic foot care programme implementation.


Evaluation of diabetic foot care programme

5

Figure 2: Methodology flowchart

Intervention Intervention was done to three selected clinics which include 2 clinics situated in the rural area (Redang Panjang Clinic and Kuala Sepetang Clinic) and 1 clinic situated in an urban area (Kamunting Clinic): a) Standardisation of the diabetic foot care module b) Modification of current education program (focused

and stressed on foot care in on session rather than educating patient on every aspect of diabetes)

c) Diabetic patients in these clinics were given training and education on foot care management

Phase 2

Pre Intervention Evaluation All the 10 clinics within the District of LMS were evaluated on: a) Implementation of the program in the clinics and

number of diabetic patients registered. b) Patient’s foot care knowledge c) Availability of resources which include facilities, man

power and equipment. d) Ability of the health staff to demonstrate foot

examination for diabetic patients

Phase 1

Post Intervention Evaluation The 3 selected clinics for intervention were evaluated on: a) Patient’s foot care knowledge

Figure 2. Methodology flowchart


2. Questionnaires for patients on the knowledge and practice of diabetic foot care.

3. Evaluations of the staff techniques in implementations. 4. Evaluation checklist of :

a. Extent of implementation of the programme in the health clinics (percentage of health clinics involved).

b. Availability of resources (facilities, diabetic team and material).c. Frequency of sessions d. Percentage of diabetic patients covered

Self-administered questionnaires were given based on universal sampling to all diabetic foot care trained staff at each clinic involved to identify the problems faced concerning diabetic foot care. Data obtained from the questionnaires were analysed.

All registered diabetic patients in each health clinic within the District of LMS who have received foot care training were selected (maximum of 40 patients per clinic, conveniently sampled). 400 patients, who have been trained, were questionnaires and questions were answered via a face to face interview. Their knowledge on diabetic foot care was evaluated. All data obtained was analysed.

Trained staff was required to perform a diabetic foot care demonstration and were evaluated with the help of a checklist. The evaluations were carried out by two supervisors, assessing one staff at a time on two different occasions. Mean values from both of the assessing supervisors were taken into account for each staff that had been supervised.

Extent of implementation of the programme in the health clinics (percentage of health clinics involved), availability of resources (facilities, diabetic team and material), frequency of sessions, and percentage of diabetic patients covered; were assessed by means of interview based on a checklist. Samples were taken from all health clinics in the District of LMS via the universal sampling method. All data obtained from the check-list were analysed.

Phase Two: Intervention and reevaluation of the patients who received the new training

In the intervention phase, three clinics in the LMS district (Klinik Redang Panjang, Klinik Kamunting and Klinik Kuala Sepetang) were selected which included one urban and two rural clinics. Diabetic patients in these clinics were again given training and education on foot care management. The staffs of these clinics were also given a foot care module (see Appendix E). Previously, diabetic campaigns in the District of LMS comprised of lectures, counseling and education concerning the pathophysiology, foot care, diet, medication, lifestyle and complications of a diabetic foot. In the intervention phase, which include the three chosen clinics, patients were


taught on the importance of proper foot care management and it was facilitated by organising educational talks on foot care. The diabetic team staffs in these clinics were also given a foot care module for care improvement.

Patients were then re-evaluated (using Appendix A) on their knowledge on foot care after the training. All registered diabetic patients in these three clinics who had received training on foot care were selected (maximum 40 per clinic, convenient sample). Data obtained was analysed.

A summary of the intervention Programme

1. 3 clinic were selected for this intervention programme.2. Patients from each clinic were selected using convenience sampling.3. All patients were given a talk concerning diabetic foot care by an occupational

therapist. 4. After the talk, patients were divided into 4 groups and each group was assigned

to 1 medical assistant / staff nurse (trained in diabetic foot care) to facilitate them.

5. Group work:a. All patients in a group were required to demonstrate proper diabetic

foot examination on each other under the supervision of the facilitator.b. All patients were then again exposed on diabetic foot care education

(done by facilitator).6. All teaching was done using the module laid out in Appendix E.

3.2 Sampling

For Phase 1, this study involved all registered diabetic patients and staff trained in diabetic foot care management in all the health clinics within the District of LMS.

For the Phase 2, this study included all registered diabetic patients in three selected clinics at the LMS District (Klinik Redang Panjang, Klinik Kamunting and Klinik Kuala Sepetang).

There were five different samples in the study:1. All 10 health clinics in the District of LMS were sampled. This was to address

the objectives of:a. Extent of implementation of the programme in the health clinics

(percentage of health clinics involved).b. Availability of resources (facilities, diabetic team and material).c. Frequency of sessions.d. Percentage of diabetic patients covered.

2. To evaluate quality of the implemented programme in terms of training provided by the staff to patients by observing quality of delivery. All trained


staff were required to do two demonstration (enactment) of the education provided to patients and they were evaluated using a checklist.

3. To evaluate the knowledge of all registered diabetic patients at each health clinic in the district of LMS whom have received training on foot care were selected (maximum 40 per clinic, convenient sample). It was estimated that 400 patients have so far been trained.

4. All staffs trained on diabetic foot care management were sampled to identify problems faced upon implementing diabetic foot care.

5. Three health clinics within the District of LMS were chosen for intervention and registered diabetic patients were interviewed. This is to address the objectives of evaluating patient’s knowledge after the intervention.


Ethical approval from the National Medical Research and Ethics Committee (MREC) of the Ministry of Health (MOH), Malaysia via the National Medical Research Registry (NMRR) was obtained.

In this research, all information and responses provided by the diabetic patients and relevant health workers were treated with care to maintain confidentiality. Data collected would not identify individuals and no unique identifiers were collected.

3.4 Variables

Conceptual Definition

Operational Definitions

Scale of Measurement

Method of measurement

Foot Care Programme

Presence of human resources & materials

Available or notInterview & inspection

Quality of patient’s training

Knowledge on understanding regarding patient foot care

Checklist0 : Poor1 : Average2 : Good

Questionnaire

Facilities for training

Having the organization and resources to perform foot care

ChecklistYesNo

Interview & inspection

Capability of staff

Able to perform a standard assessment and having adequate knowledge

Checklist0 : Poor1 : Fair2 : Good

OSCE examinationQuestionnaire



1. Preliminary data:a. Data on the number of healthcare workers who are part of the diabetic

team involved in the diabetic foot care programme was obtained from the clinical administration team.

b. Data on the number of diabetic patients that registered themselves with the Diabetic Registry in the LMS district were obtained from the Pejabat Kesihatan Daerah Taiping.

2. Data on patient’s knowledge regarding diabetic foot care were obtained from the questionnaire and interviews were carried out on the identified sample.

3. Data on `facilities available for diabetic foot care programme were obtained from inspection and interview with the relevant health staff.

4. Data on the problems faced by staff in implementing the diabetic foot care programme were obtained from self administered questionnaire.

5. Data on quality assessment on diabetic foot care given by the staff were obtained from a structured observational procedure using a checklist.

6. Post-intervention data on patient’s knowledge on diabetic foot care after intervention was obtained by using questionnaire in Appendix A through face to face interview.

3.6 Data analysis & interpretation

The raw data was processed on weekly basis as they were collected throughout the period of four months for the pre-intervention and 3 months for the post-intervention. Data collected were sorted out daily and processed on a weekly basis. A computer assisted analysis was used at the end of the study.

Patient’s knowledge score was then calculated from the answered questionnaires. This included only certain questions which is Question 4, 10, 11, 12, 13, and 14. The maximum possible score was 23.

4.0 RESULTS

4.1 Pre-intervention Evaluation of the Diabetic Foot Care Education Programme

All 10 clinics within the LMS District were evaluated in the study. A total of 210 patients were covered in this study (as shown in table 1). This comprised 3.0% of the total 7017 diabetic patients that attended these 10 clinics.

All the clinics had implemented the diabetic foot care programme. Out of 210 diabetic patients surveyed, a total of 42.3% were exposed to the diabetic foot care


education within the district of LMS. However the degree of implementation varied among clinics from 19% to 100%.

The average knowledge score obtained by patients who were exposed to diabetic foot care education was 7.5 (SD 2.8). The knowledge score ranged from 5 to 10. The maximum possible score is 23. This shows that the knowledge of diabetic foot care is still very poor.

For those who had not been exposed to the diabetic foot care education programme, the average knowledge score obtained was 6.8 (2.2). Comparing the mean knowledge between those who were exposed and those who were not exposed to diabetic foot care education, it is shown that it was statistically significant different (p=0.04).

Table 1. Distribution of patient exposed to diabetic foot care education programme and knowledge score by clinic

Clinic

Total diabetic patient

(A)

Patient evaluated

Total number

(B)

% of patient

(C=B/A X 100)

Total number of patients exposed

to the diabetic foot care education programme (%)

Mean knowledge score* of those who

were exposed to the diabetic foot

care education programme (SD)

Mean knowledge score* of those who

were not exposed to the diabetic foot

care education programme (SD)

KK Bandar Taiping**

3060 63 2.1 12 (19.0) 9.1 (1.7) 7.5 (2.2)

KK Kamunting**

739 19 2.6 12 (63.2) 6.4 (3.0) 4.3 (1.8)

KK Pokok Assam**

982 10 1.1 3 (30.0) 6.0 (3.5) 6.9 (2.0)

KK Changkat Jering

375 26 7.0 14 (53.9) 6.0 (3.0) 4.9 (1.6)

KK Kuala Sepetang

261 22 8.4 13 (60.0) 7.6 (3.2) 6.1 (1.5)

KK Trong 384 22 5.7 10 (45.5) 7.9 (2.9) 6.3 (1.9)

KK Sungai Kerang

180 4 2.2 2 (50.0) 6.0 (1.4) 4.0 (0)

KK Batu Kurau 662 31 4.7 12 (38.8) 8.2 (1.6) 7.7 (1.6)

KK Redang Panjang

214 9 4.2 7 (77.8) 7.0 (3.0) 2.5 (4.9)

KK Sungai Bayor

160 4 2.5 4 (100.0) 10.0 (0.8) 0 (0)

TOTAL 7017 210 3.0 89 (42.3) 7.5 (2.8) 6.8 (2.2)

* Patient’s score on knowledge of diabetic foot care (Maximum total score = 23 points)** Urban clinics


92 patients attending urban clinics had a mean knowledge score of 7.2 (SD 2.5) while 118 patients attending rural clinics had a mean score of 6.9 (2.5). There was no significant difference in the mean knowledge score between patients residing in rural areas and urban areas. (p = 0.443)

Table 2 below shows the relationship between patient’s knowledge on diabetic foot care and their demographic data, namely age group, ethnicity, education level, duration of diabetes and participation in diabetic camp. It is shown that diabetic foot care knowledge in different age group were statistically significant (p=0.002). Patients’ knowledge showed borderline statistical significance for different educational level (p=0.05). As for ethnicity, the duration suffering from diabetes and participation in diabetic camps shows no statistical significance with regards to the patient’s knowledge on diabetic foot care.

Table 2. Patient knowledge based on their age group, ethnicity, education level, duration of diabetes and participation in diabetic camp

Knowledge on diabetic foot careTotal

p-valuesVery poor*

(%)Poor**

(%)Moderate***

(%)

Age group

<50 6 (13.6) 31 (70.5) 7 (15.9) 44

0.00250-60 16 (22.9) 48 (68.6) 6 (8.6) 70

>61 41 (42.7) 50 (52.1) 5 (5.2) 96

EthnicityMalay 41 (28.3) 90 (62.1) 14 (9.7) 145

0.57Non malay 22 (33.8) 39 (60.0) 4 (6.2) 65

Education level

Not educated 49 (31.6) 97 (62.6) 9 (5.8) 1550.05

Educated 14 (25.5) 32 (58.2) 9 (16.4) 55

Duration of diabetes

0-5 48 (34.5) 79 (56.8) 12 (8.6) 139

0.09>5-10 12 (25.5) 33 (70.2) 2 (4.3) 47

>10 3 (12.5) 17 (70.8) 4 (16.7) 24

Participation in diabetic camp

Attend 23 (29.9) 46 (59.7) 8 (10.4) 77 0.77

Not attend 40 (30.1) 83 (62.4) 10 (7.5) 133

* ≤5 of knowledge score** 6-10 of knowledge score***11-15 of knowledge score


Table 3. Number and distribution of staff trained in diabetic foot care by clinic

Total number of staff in clinic

Staff trained in diabetic foot care

ClinicNumber of

MAsNumber of

Staff NursesNumber of MAs

(%)Number of Staff

Nurses (%)

KK Bandar Taiping 4 5 4 (100.0) 2 (40.0)

KK Kamunting 3 1 2 (66.7) 1 (100.0)

KK Pokok Assam 3 2 3 (100.0) 1 (50.0)

KK Changkat Jering 2 1 1 (50.0) 1 (100.0)

KK Kuala Sepetang 2 1 2 (100.0) 1 (100.0)

KK Trong 2 0 1 (50.0) 0 (0)

KK Sungai Kerang 2 0 1 (50.0) 0 (0)

KK Batu Kurau 3 0 3 (100.0) 0(0)

KK Redang Panjang 2 0 2 (100.0) 0 (0)

KK Sungai Bayor 2 0 1 (50.0) 0 (0)

Total 25 10 20 (80.0) 6 (60.0)

Table 3 shows the number of health staff involved in the diabetic foot care programme in the various clinics. Out of the 25 medical assistants, 20 of them were trained in diabetic foot care. Out of the 10 nurses, 6 of them were trained on diabetic foot care. Only 5 clinics had staff nurses involved in their diabetic foot care programme.

17 equipments were needed to implement diabetic foot care programme in each clinics. Out of the 10 clinics in the district of LMS, only 5 clinics owned all the necessary equipment to implement the diabetic foot care programme. The remainder had between 1-5 equipments missing.

The scoring of health staff on diabetic foot care demonstration shows that out of 18 staff evaluated, the mean score was 14.1 (SD 2.9). The maximum achievable score is 20, and the minimum achievable score is 10. 16 of them had proper training on diabetic foot care. Mean score for those who were trained was 14.3 (SD 2.9) and those who were not trained was 12.5 (SD 2.1). Out of 18 health workers, only 4 of them obtained a good score, 13 moderate score and 1 performed poorly (as shown in the table 4 below).

From the survey done on the 18 health staff, 94.4% and 72.2% of them complained that there wasn’t enough time to examine patient and there was no suitable place to


Table 4. Score performance of trained staff on diabetic foot care demonstration

GradeTotal

poor moderate good

Trained trained 1 11 4 16

not trained 0 2 0 2

Total 1 13 4 18

* Maximum of 21 was achievable from this demonstration

Table 5. Staff opinion on implementing the foot care programme in terms of staffing, resources, facilities, training, communication and cooperation.

Staff Opinions on Implementing the Foot Care Programme

Responses NumberPercentages

(%)

Training is beneficialYes 13 72.2No / Not sure 5 27.8

Adequate and functioning equipmentYes 13 72.2No / Not sure 5 27.8

Is equipment easy to handleYes 13 72.2No / Not sure 5 27.8

Enough time to examine patientYes 1 5.6No / Not sure 17 94.4

Suitable place for examinationYes 5 27.8No / Not sure 13 72.2

Is communication with patient a barrier to staff

Yes 6 33.3No / Not sure 12 67.7

Is patient cooperating Yes 14 77.8No / Not sure 4 22.2

Is colleague cooperating Yes 15 83.3No / Not sure 3 16.7

Staff provided during diabetic clinic adequate

Yes 4 22.2No / Not sure 14 77.8

Is supervision done employer Yes 8 44.4No / Not sure 10 56.6


examine them respectively. 77.8% of the health staff had the opinion that there was insufficient manpower during the diabetic clinic. Less than 50% of them responded that there was no adequate supervision by the family medicine specialist (FMS) or medical officer when implementing the diabetic foot care programme. All the results are shown in Table 5.

4.2 Results of Intervention Programme

Table 6 shows pre and post intervention results for 3 health clinics that had been selected to undergo the post intervention diabetic foot care programme. The average score of patient knowledge regarding diabetic foot care before intervention was 6.5 (SD 2.8). After implementing the intervention programme, the average score for the diabetic foot care knowledge increased to 15.9 (SD 4.4). The mean score after the implementation of the intervention programme was higher than that of pre-intervention. (p <0.001)

Table 6. Comparison of patient’s knowledge on diabetic foot care education programme before and after intervention

ClinicTotal

diabetic patient

(A)

Pre Intervention Post Intervention

Total number

(B)

% of patient (C=B/A X 100)

Mean knowledge

score (SD)

Total number

(B1)

% of patient (C1=B/A X 100)

Mean knowledge

score1

(SD)

KK Kamunting

739 19 2.6 5.6 (2.8) 41 5.5 15.2 (4.1)

KK Kuala Sepetang

261 22 8.4 7.0 (2.7) 37 14.2 15.1(4.1)

KK Redang Panjang

214 9 4.2 7.1 (3.1) 35 16.4 17.6 (4.7)

Total 1214 50 4.1 6.5 (2.8) 113 9.3 15.9 (4.4)

Editor’s statement

The final report of the HSR study entitled “Effectiveness of the Diabetic Foot Care Programme in a Primary Care Setting” is incomplete with the discussion and the conclusion sections inadequately written. Hence, the study is presented up to the result section for the purpose of this compilation.


REFERENCES

1. Clinical Practice Guideline, Management of Diabetic Foot, August 2003, Ministry of Health.

2. Diabetes Program in Malaysia- Current and Future, NCD Malaysia 2004, Volume 3, No. 2, Shafie Ooyub, Fatanah Ismail, Noor Azah Daud.

3. Garis Panduan Pengendalian Diabetes, 1st Edition, 2005, Cawangan Penyakit Tidak Berjangkit (NCD), Bahagian Kawalan Penyakit, Kementerian Kesihatan Malaysia

4. http://www.mmpc.com/node/add/content/diabeticfootcare5. http://www.diabeticfootproblem.com/ 6. http://www.ahrq.gov/research/oct05/1005RA07.htm7. http://www.diabetes.org.uk/Guide-to-diabetes/What_is_diabetes/What_is_

diabetes/8. http://www.diabetes.niddk.nih.gov/dm/pubs/statistic/index.htm9. http://www.ncbi.nlm.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt10. file://G:\diabetic\Diabetic Foot Problems.htm

ACKNOWLEDGEMENT

The authors wish to thank the Director-General of Health Malaysia for giving permission to publish this paper. We would like to express our gratitude and appreciation to the following parties for their contributions:1. The members of the HSR Facilitator Panel2. Ministry of Health whom have supported us financially 3. Pegawai Kesihatan Daerah who had allowed us to invest time for the purpose of

this study4. The healthcare staff within the District of LMS5. The respondents who had participated in this study6. All those who had provided valuable input and feedback


APPENDICES

Appendix A

Borang Soal Selidik Mengenai Perlaksanaan Program Penjagaan Kaki Dikalangan –Pesakit-Pesakit Diabetes.Tuan-tuan dan puan-puan yang dihormati, kami sedang menjalankan kajian mengenai perlaksanaan program penjagaan kaki dikalangan pesakit-pesakit diabetes di klinik-klinik kesihatan di Daerah Larut Matang dan Selama. Kami meminta kerjasama tuan-tuan dan puan-puan untuk menjawab soalan berikut. Segala maklumat akan dirahsiakan dan tidak akan digunakan untuk tujuan selain daripada kajian ini sahaja. Sila kembalikan semula borang ini kepada kakitangan klinik.

I/C : __________________

RBS : __________________

HbA1c : __________________

Tarikh : __________________

1. Umur : _____________tahun

2. Bangsa

Melayu ( ) Cina ( ) India ( ) Lain-lain (nyatakan): ___________

3. Tahap Pendidikan:

Tidak bersekolah ( ) Sekolah rendah ( ) Sekolah Menengah ( ) Diploma/ Ijazah ( ) Lain-Lain (nyatakan): _____________

4. Pengawalan paras gula dalam darah yang baik, boleh mengelakkan komplikasi kaki?

Ya ( ) Tidak ( )

5. Pernahkah anda diajar mengenai cara-cara penjagaan kaki?

Ya ( ) Tidak ( )

* Jika YA, sila jawab soalan 6, Jika Tidak, tidak perlu menjawab soalan 6.

6. Adakah anda faham tentang cara-cara yang diajar tersebut?

Ya ( ) Tidak ( ) nyatakan sebab:______________

7. Bilakah kali terakhir kaki anda diperiksa di klinik kesihatan? ________________

8. Bilakah kali terakhir anda menjalankan pemeriksaan kaki sendiri? ____________

9. Berapa kalikah anda membasuh kaki anda dalam seminggu? ________________


10. Senaraikan bahan-bahan yang diperlukan untuk penjagaan kaki dirumah.

Sponge Kasut yang menutup jari

Stocking yang lembut Penyepit kuku

Losyen Antiseptik (Flavine Lotion)

Kain untuk lap kaki Basin

Sabun Cermin

11. Perkara-perkara yang perlu dilakukan untuk penjagaan kaki. Tandakan ( ∕ )

Periksa kaki setiap hari

Pakai stocking / Kasut yang sesuai

Selalu mengurut kaki dengan krim yang sesuai

Berhati-hati semasa memotong kuku kuku jari kaki

Setiap hari basuh/ rendam kaki dengan air

Memakai selipar di dalam rumah

Tidak menyilang kaki semasa duduk untuk masa yang lama

Pakai kasut yang menutup jari

Selalu meletakkan kaki lebih tinggi semasa baring

12. ”Saya boleh merendam kaki saya lebih daripada 5 minit.” Adakah penyataan ini betul atau salah?

Betul ( ) Salah ( )

13. Pilih jenis kasut yang anda pakai daripada senarai berikut:

a. Selipar ( )b. Kasut yang menutupi semua jari kaki ( )c. Kasut bertumit ( )

14. Bagaimanakah anda memotong kuku anda?

............................................................................................................................................................

15. Sila senaraikan masalah-masalah lain yang dihadapi oleh pihak tuan / puan dalam penjagaan kaki anda.

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................


Appendix B

Checklist Untuk Setiap Klinik di Daerah LMS

Nama Klinik : ___________________________ Tarikh : _________________

No Program Penjagaan Kaki Pesakit Diabetes

1Bilakah kali terakhir anda menjalankan program penjagaan kaki ( secara individual atau melalui kem diabetic)?

2Bilakah kali terakhir anda dilatihkan untuk melaksanakan program penjagaan klinik?

3Dimanakah anda memeriksa dan menberikan latihan penjagaan kaki pesakit diabetes?

No Checklist untuk Peralatan Program Penjagaan Kaki Pesakit Diabetes

Ya Tidak

1 Adakah klinik ini mempunyai:

a) Cermin untuk pemeriksaan

b) Model kaki

c) Basin untuk cuci kaki

d) Monofilament

e) Tuning Fork 128

f) CNS diagnostic Set (Tendon hammer, cotton wool, pin)

g) Bangku (kerusi khas untuk pemeriksaan)

h) BP Set

i) Stethoscope

j) Weighing machine with height measurement

k) Carta Snellen dan pin hole

l) Opthalmoscope

m) Mydriacyl eye drops

n) ECG Machine

o) Buku manual Garis Panduan Pengendalian Diabetes

2Adakah sebarang pamplet diberikan kepada pesakit tentang cara-cara penjagaan kaki sebaik sahaja sesi pemeriksaan dan pengajaran dijalankan. Kalau ada, dapatkan satu pamplet.


Appendix C

Borang Soal Selidik Mengenai Perlaksanaan Program Penjagaan Kaki di kalangan pesakit-pesakit Diabetes (Soal selidik untuk staff)

Tuan-tuan dan puan-puan yang dihormati, kami sedang menjalankan kajian mengenai perlaksanaan program penjagaan kaki dikalangan pesakit-pesakit diabetes di Klinik-klinik Kesihatan di Daerah Larut Matang dan Selama. Kami meminta kerjasama tuan-tuan dan puan-puan untuk menjawab soalan-soalan berikut. Segala maklumat akan dirahsiakan dan tidak akan digunakan untuk tujuan selain daripada kajian ini sahaja. Sila kembalikan semula borang ini kepada penyelidik selepas di isi.

Nama Klinik : -----------------------------------------------------

Jawatan : -----------------------------------------------------

Setiap soalan mempunyai skala jawapan diantara 1-3 seperti di bawah.

Sila tandakan ( √ ) dalam kotak yang disediakan

1. Tidak Setuju 2. Tidak pasti 3. Setuju

A) Latihan

1. Berapa kali anda pernah menjalani latihan penjagaan kaki ?

............................................................................................................................................................

2. Adakah latihan yang anda telah jalani memberi manfaat dalam memberi latihan kepada pesakit.

1 ( ) 2 ( ) 3 ( )

B) Peralatan

1. Peralatan untuk menjalankan latihan penjagaan kaki adalah mencukupi dan masih berfungsi dengan baik dan peralatan tersebut berfungsi dengan baik.

1 ( ) 2 ( ) 3 ( )

* Jika jawapan anda TIDAK SETUJU sila senaraikan peralatan tersebut?

............................................................................................................................................................

2. Peralatan yang digunakan semasa menjalankan latihan penjagaan kaki mudah difahami dan dikendalikan?

1 ( ) 2 ( ) 3 ( )


C Masa/ Tempat

1. Anda mempunyai masa yang mencukupi untuk memberi penerangan dan latihan penjagaan kaki kepada pesakit anda ?

1 ( ) 2 ( ) 3 ( )

2. Klinik anda mempunyai ruang yang sesuai untuk menjalani latihan penjagaan kaki?

1 ( ) 2 ( ) 3 ( )

D. Komunikasi

1. Komunikasi dari aspek bahasa dengan pesakit diabetis merupakan kesukaran dalam memberi penerangan dan latihan kepada mereka.

1 ( ) 2 ( ) 3 ( )

* Jika setuju , sila nyatakan sebab

............................................................................................................................................................

E. Kerjasama

1. Anda mendapat kerjasama yang baik daripada pesakit setiap kali latihan penjagaan kaki dijalankan ?

1 ( ) 2 ( ) 3 ( )

2. Anda juga mendapat kerjasama yang baik daripada rakan sekerja semasa latihan penjagaan kaki dijalankan ?

1 ( ) 2 ( ) 3 ( )

3. Pada pandangan anda bilangan staff yang diperuntukan setiap kali sessi latihan penjagaan kaki mencukupi ?

1 ( ) 2 ( ) 3 ( )

4. Program penjagaan kaki diklinik anda mendapat pemantauaan yang secukupnya daripada pihak atasan( Pakar Perubatan Keluarga/Pegawai Perubatan dsb)

1 ( ) 2 ( ) 3 ( )

5. Sila senaraikan masalah /cadangan lain yang anda hadapi semasa mengendalikan program penjagaan kaki (Sekiranya ada).

............................................................................................................................................................

............................................................................................................................................................


Appendix D

Check-list on diabetic foot care demonstration

All staff must follow below points in sequence manner

A. Introduction

Yes No

Staff must do all the following(by demonstration or in running commentary)- ask the patient to sit, remove his/her shoes- exposed both feet under good lighting- asking foot history – numbness/pricking sensation/pain

B. General examination of both foot

Yes No

Staff must examine both feet. Check for –- skin color- corn/ulcer formation- infection- amputation(all done in running commentary)

C. Vascular system

Yes No

Checking for all pulses for both feet (staff must demonstrate)- dorsalis pedis artery- posterior tibialis artery

D. Neurological examination

Yes No

Staff must perform below test for both feet using proper tools as stated in bracket- sensation - vibration test (using 128 Hz tuning fork)- pinprick sensation test (using monofilament)- ankle reflex (using tendon hammer)


E. Patient education

Yes No

1. Daily foot care- wash your foot daily- do not soaked your foot more than 5 minute- give more attention to the web space- dry your foot with soft and dry cloth

2. Daily foot examination- usage of mirror to check for callus/corn/ulcer/crack

3. Always protect your foot- do not walk with out shoes (inside and outside house)- wearing stockings

4. Clip your nail correctly


Appendix E

MODULE FOR DIABETES FOOT CARE MANAGEMENT

INTRODUCTION

Whether you are rushing to a business meeting or standing in line at the post office,you depends on your feet to keep you moving. Diabetes increase your chances of developing foot problems,so you can’t afford to take for granted. Give them the special care they need. Foot problems won’t just go away. As diabetic, your feet have fewer defenses against everyday wear & tear. Nerves damage may mean that you can’t feel injuries. Reduced blood flow may prevent injuries from healing. Even minor injuries may quickly progress to serious infection.

MODULE 1

LIST OF EQUIPMENT & TOOLS REQUIRED (overall examination)Tools needed:· Glucometer set· Lancet pen· BP set· Stethoscope· Cholesterols meter set· Weighing macine with height measurement· Sneelen chart & pin hole· Opthalmoscope· CNS Diagnostic set (tendon hammer,cotton wool,pin)· Tuning fork (C128)· Urine albumin strips (Dip sticks)· Mydriacyl eye drops· Tool for foot examination:

- Foot model (normal, with complication & foot toe infected)- Tuning fork- Hammer toe- Monofilament ( ______.cm)- Complication foot card information- Others: ________________________________________________________

· HBA1c machine & strips (quantitative)· Microalbumin machine & strips (quantitative)· BMI chart· ECG Machine· Chemistry Analizer· Computers · Fundus Camera


MODULE 2

INSPECTING FOR YOUR FEET

Look for:

1. Colour changes a. redness with streaks means sign of infectionb. pale / blue toes means poor circulationc. darkened sign means tissue has died

2. Swelllinga. swelling with colour changes means sign of poor sirculation or infectionsb. symptoms include tenderness & an increase in the size of your foot

3. Temperature changesa. warm areas means your feet are infectedb. cold feet means feet aren’t getting enough blood

4. Sensation changesa. “ods sensations” like pin pricks,numbness,tingling,burning,or lack of feeling

means nerves are damaged5. Hot spots

a. red “hots spots” are caused by friction or pressure.b. hots spots can turn into blister,corns(thick skin or toes) or calluses(thick skin

on the bottom of the feet)6. Cracks & Ulcers

a. cracks & sores are caused by dry or irritated skinb. they are signs that skins is breaking down which could lead to ulcers

7. Ingrown Toe Nailsa. often caused by tight fitting shoes or incorrect nail trimmingb. symptoms include nails that are growing into the skin,swelling,redness or

pain.8. Drainage & Odour

a. may develop from untreated ulcersb. white or yellow moisture,bleeding & odour are often signs of infections or

dead tissue9. Call your doc immediately if you notice

a. redness or steakingb. swellingc. increased heatd. fever & chills


MODULE 3

KEEPING YOUR FEET HEALTHY

1. Check Your Shoes & Socks

- shoes & socks that fits properly can prevent foot problems- when buying a socks check that the toe box is roomy enough so u can wiggle

you toes- avoid open-toed or pen- heeled shoes- inspect your shoes & socks or for anything that could rub against your feet

2. Exercise Your Feet

- exercising regularly can help the blood flow into & out of your feet & increase your flexibility.

- suggesting exercises: walking (frequently),swimming & bicyling, doings ABCs with each foot by spelling out the alphabet in the air.(can increase blood flow & keep feet flexible)

- take immediate action if these happened: redness,burning or tenderness during & after exercise.

3. Take Special Care: ( self-care tips )

- use warm water & mild soap to wash feet. DON’T SOAK. Dry well- inspect feet daily for cracks, scratches or dry skin.- avoid heating pads & hot water bowls- don’t cross your leg (can reduce blood flow to you feet)- don’t uses razors or over-the-counter medications to treat corns & calluses

(could damage your feet)- don’t smoke. (reduce blood flow to your feet)- never walk barefoot

MODULE 4

PROVIDING ROUTINE FOOT CARE

Routine foot care helps keep thick & ingrown nails,blisters,corns,calluses & other skin irritations from developing into infections or ulcers.

Educate on:

· trim or thin your nails to keep them from becoming ingrown or thick· treat blisters so they won’t become infected · trim corns & calluses so they won’t develop into blisters or infections


MODULE 5

FOOT CARE DO’S & DON’TS

DO:

· Check your feet daily for red spots,bruises,cuts,blisters & dryness or cracks in the skin. Don’t forget under & between toes. Press gently & feel for tenderness or hot spots – this may indicate injury.

· Every day,wash your feet with mild soap & dry them thoroughly,especially between the toes.

· If the skin on your feet is dry,apply a lanolin base cream (but not between toes). If your feet perspire a lot,use talcum powder.

· Wear good-fitting,soft shoes and cleans socks. Smooth out wrinkles in socks. Choose new shoes carefully (comfort is important than style).

· Avoid foot injuries by wearing shoes or slippers around house & swim slippers at the beach or pool

· Wear insulated boots to keep feet warm on cold days.· Trim toenails to he contour of our toe. If you can’t see hem well or reach them easily,have

someone to do this for you.· Buff calluses with pumice stones

DON’T:

· Put hot water bottles or heating pads on your feet· Soak your feet (this dries out natural oils)· Cut corns or calluses or uses corn pads or corn medication· Wear shoes that are two tight or worn out,or round garters or tight socks that cut off

circulation

Sebarang pertanyaan bolehlah menghubungi:SHAFINA MOHD YUNUSJurupulih Carakerja U29,KK Kamunting(0125551582)

Published by Clinical Research Centre (CRC) Perak

July 2013

clinical research centre

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