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HIGH DEFAULTER RATE AMONG PATIENTS WITH CHRONIC DISEASES 
IN THE HEALTH CLINICS IN THE DISTRICT OF PENDANG, 2003

Dr. Hjh Hayati Mohd Radzi¹, Dr.Hjh Baizury Bashah^2,Dr.Loh Leh Teng ³,

KJK Ishah Rashid⁴, JK Julita Md Zain⁵, PP Azman Ibrahim⁶, JK Zurina Che Ani⁷, PP Hussein Abdul Rahim⁸, JK Radziah Talib⁹, PP Zainol Man¹⁰.

1. OUTLINE OF THE PROBLEM

Defaulters among patients with chronic diseases from the appointment date for follow-up  is of great concern to the service providers. This is because if the problem is not addressed effectively and efficiently, it will result in uncontrolled disease conditions and complications which may lead to high morbidity and mortality. Chronic diseases are defined as lifestyle diseases such as diabetes, hypertension and cardiovascular disease or diseases that require long term treatment such as asthma, epilepsy or psychiatric conditions.

  The district quality committee members had a meeting to identify quality problems in the district. Nominal group techinique was used to identify the problems and voting was done using the SMART criteria to prioritise the problem. The problem with the highest score was chosen as the problem which needed immediate attention. The problem chosen was the high defaulter rate among patients with chronic diseases in the health clinics in the district of Pendang.

A verification study was carried out in all the three health clinics. The card study involving all the patients with chronic diseases was reviewed for two months in 2002. It was noted that the defaulter rate averaged at 24.3% for all the three clinics. Better compliance to clinic appointment among patients with chronic disease will improve disease control, better compliance to treatment  and hence improve the quality of life. Shortage of medication given to patients may result in self-adjusting the dosage to cover for the missed appointment or by buying the medication off the counter at pharmacies. This condition may result in uncontrolled diabetes, severe hypertension, unstable angina, status asthmaticus or epileptic seizures.

The reasons for defaulting may be due to weaknesses in the patient’s management system, ineffective health education, problems to keep to the appointment given and the patients’ attitude.

Some remedial measures that hope to be implemented are to put in place such as a defaulter tracing system, reminders for the frequent defaulters, scheduled health education sessions on their disease condition and to create appointment books for doctors and medical assistants. It is hoped that with the implementation of the remedial measures the defaulter rate will reduce, thus increasing the knowledge of patients and promoting the healthy lifestyle.

  2. KEY MEASURES FOR IMPROVEMENT

The indicator chosen to indicate improvement in the defaulter rate is the percentage of patients with chronic disease complying to the appointment date given. The standard set was 15%. The standard set was due to an earlier study that showed that only 40% of the reasons for defaulting are remediable.

A model of good care was set in accordance to the management of patients with chronic diseases based on Clinical Practise Guideline issued by the Ministry of Health. The processes chosen for the model of good care were the appointment date given, reminders for patients identified as high risk of defaulting,  knowledge of patients on their diseases, scheduled health education sessions on the various topics of their disease and defaulter tracing for those who default from the appointment date. Standards and criterias were set for each process. Achievements were measured before and after the remedial measures done. The achievements were monitored monthly.

  3. PROCESS OF GATHERING INFORMATION

Data were gathered to identify the reasons for defaulting and the patients’ knowledge  on disease. A systematic random sampling was used to sampel the defaulters to ascertain the reasons for defaulting. A pretest questionnaire was designed and the patients were interviewed by trained interviewers. A total of 200 defaulters  were sampled for the month of March, 2003.  

4. ANALYSIS AND INTERPRETATIONS

The data collected were analysed using the Epi Info version 6.04. The findings for the reasons for defaulting were forgot the appointment date, was away from home/district, transportation problems, medication still available and others. 92.6% of those who defaulted will come back to the clinic in less than 2 weeks of defaulting. Only 83.8% had complete addresses on the OPD cards and only 51.3% had telephone numbers written on their treatment cards. About 75% had health education sessions about their disease but only 20.8% of patients had good knowledge (patients with score of more than 75%) on their disease. Moreover there is not much increase in their lifestyle pattern. Diet intake showed good practice of taking  balanced, nutritious and appropriate food for their disease condition.

  5. STRATEGY FOR CHANGE

Strategies carried out to improve the defaulter rate were to improve on the health education sessions, improve on the defaulter tracing system, reminder for those high risk of defaulting, complete information of patients to assist in defaulter tracing and improving the knowledge of patients on their disease conditions. Information of patients are updated which included address and telephone number (neighbours, friends etc). Defaulter tracing system was reinforced, patients who do not come after the clinic sessions will be identified and reminders will be sent via letters or they will be contacted if telephone numbers were available. Health education sessions were scheduled and health educations materials were made to assist the staffs. The health education contents stressed on facts about the chronic diseases, medication, quit smoking, eat healthy, exercise and complications of the disease etc. Those with high risk of defaulting will be identified using a checklist and will be tagged with a black thread. The will be called to remind of the appointment date or given letters of reminder.

  6. EFFECTS OF CHANGE

After 3 months of implementation of the remedial measures, the defaulter rate has improved from 24.3% to 16%. There is a reduction in ABNA from 8.3% to 1% after implementation of remedial measures. The processes and standards in the model of good care were monitored monthly. After 3 months, an evaluation study was carried out. The complete information about patient has improved at 83.8%. Patients given appointment date has improved from 98.3% to 100%. High risk patients given reminders on their appointment date has improved from 0% to 85.7%. With the implementation of scheduled health education sessions (33.3% to 100%) the knowledge of patients had improved from 20.8% to 42%. Defaulter tracing has improved from 0% to 81.5%.

  7. THE NEXT STEP

From this project, it has shown that integrated and holistic approach to implementing the remedial measures has shown tremendous improvement in the management of the patients. The involvement of nursing staff in health education has managed to scheduled the health education session and managed to improve the knowledge of patients by 20%. The defaulter tracing system was now in place and became part of the whole patient’s management system in the health clinics. The next step will be to improve in the control of the individual diseases such as control of diabetes, control of hypertension etc. because it is closely related to improving their quality of life and hence being able to reduce the complication of the disease.

1 Medical Officer of Health, 2 Family Medicine Specialist, 3 Medical and Health Officer, 4 Health Sister, 5 Staff Nurse, Pendang HC, 6 Medical Assistant Pendang HC, 7 Staff Nurse Sg. Tiang HC, 8 Medical Assistant Sg. Tiang HC, 9 Staff Nurse Kubur Panjang HC, 10 Medical Assistant Kubur Panjang HC

 ABSTRACT

HIGH DEFAULTER RATE AMONG PATIENTS WITH CHRONIC DISEASES IN THE HEALTH CLINICS IN THE DISTRICT OF PENDANG, 2003

Dr. Hjh Hayati Mohd Radzi¹, Dr.Hjh Baizury Bashah^2,Dr.Loh Leh Teng ³,

KJK Ishah Rashid⁴, JK Julita Md Zain⁵, PP Azman Ibrahim⁶, JK Zurina Che Ani⁷, PP Hussein Abdul Rahim⁸, JK Radziah Talib⁹, PP Zainol Man¹⁰

   Chronic diseases such as diabetes , hypertension and cardiovascular disease or diseases that required long term treatment such as asthma , epilepsy or psychosis conditions are  defined as lifestyle diseases.  Defaulters among these patients with chronic diseases from the appointment date for follow-up is of great concern to the service providers  If this problem is not addressed effectively and efficiently it will lead to uncontrolled disease conditions and complications  which may result to high morbidity and mortality.

A verification study was carried out in  all the three health clinics in the district of Pendang among the patients with chronic diseases.  The finding shows that  28%   among the patients with chronic diseases defaulted their apppointments and hence also defaulted their treatments .

Monitoring indicators and standards were set. The indicator is the percentage of patient with chronic disease that defaulted their apponitment date and the standard set is 15%. This standard was set following an earlier study showed that 40% of reasons of defaulting  can be   overcome by remedial actions. A  system of  defaulter tracing was introduced, all chronic cases that come for treatment are registered, registration books are kept by doctors or Medical Assistants that treat the patient so as to ensure all defaulters can trace when appointment dates are given to them.

 After 3 months of   implementing the remedial measures, the restudy showed there is an    increase in  knowledge among patients with more than 75% score knowledge on their  disease from 29.7% to 42%.  Defaulter rate decreased from 28.8% to 15.8%.

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POOR COVERAGE OF OPV/DPT BOOSTER AMONG TODDLERS 

IN DISTRICT OF PENDANG, KEDAH

Hayati Md. Radzi, Baizury Bashah, Maimunah Md. Noor, Ishah Rashid, Salihah Hashim, Azizah Ramli, Che Olah Zakaria

1. ABSTRACT

 The poor coverage of OPV/DPT booster among toddlers was identified as a quality problem following the district quality committee meeting. The project was selected thorough the nominal group technique using the SMART criteria. The booster coverage for toddler was low, achieving 60.9% in 2002. Toddler attendances was only 33.3% (2586) in 2002. Booster immunization is important to maintain optimal antibody level against immunisable diseases before another dose of DT/Polio booster is given in Std 1. Poor coverage of immunization may increase the child’s susceptibility to immunisable diseases. 

The indicator choosen was coverage of booster immunization and the standard set was at 95%. A survey on knowledge of mothers on immunization noted that only 11.1% obtained at score of > 75% and as a whole still poor in knowledge about immunization and its importance. A model of good care was designed. Among the strategies for change were filing of cards according to completion of immunization, defaulter tracing, monthly monitoring of immunization achievement, missed opportunities, health education to staffs and mothers, assessment of toddlers, supervision and activities for toddlers. 

The strategies for change were implemented for 1 year and evaluation was done. The effects of change were improvement in mother’s knowledge with score of > 75% from 11.1% to 79.6%, improvement in knowledge among health staff with > 75% score from 12.1% to 81.8%. Indicator achieved 77.1% as compared to 98% target set. 

2. OUTLINE OF PROBLEM

Childhood immunization is the most effective method of preventing infectious diseases. With the successful implementation of the national immunization programme over the 20^th century, it has seen a tremendous reduction in mortality and morbidity of immunisable diseases. 

Unfortunately the benefit of immunization may be the score of immunization side effects as seen in Australia in 1970-80. Due to overconcern of parents on the side-effects of some immunization, the immunization coverage have fallen below the level that confers herd immunity. It has caused an outbreak of pertussis. Effective immunization has resulted in eradication of some diseases in the world such as smallpox and polio.

 Immunogenicity survey with DPT booster by T.Nolan et al (1998) among 100 toddlers attending MCH clinic Melbourne noted raised Ab level to immunization after 4 – 6 weeks of DPT booster. Soong (1972) in Semenyih noted that among the reasons for poor immunization coverage among pre-schoolers were poor knowledge on importance of immunization, schedule of immunization, perception to post-immunisation side effects etc. The immunization coverage has been low among toddlers in Pendang. 

Table 1: DPT / polio booster coverage among toddler, 2000 – 2003 in Pendang District 

 Table 2: DPT and DPT Hib 3^rd dose in Health Clinics in Pendang District, 1999 – 2003 

3. PROBLEM IDENTIFICATION

The district Quality committee meeting was conducted in November 2003 to identify quality problems in the district. A brain storming session were done involving 7 members. Some of the quality problems identified were: 

-         e-sample for Food Act and regulation contravention not achieving 90% standard

-         poor coverage of premises during Aedes survey

-         inactive Dengue Free School programme

-         poor retrieving of chronic disease records

-         poor control of diabetics

-         poor control of hypertension

-         poor ABC delivery

-         poor coverage of booster immunization among toddlers 

The quality problems were prioritized by voting using the smart criteria. After voting by the 7 members, the problem of poor coverage of booster immunization among toddlers was chosen as the DSA of the district. 

4. PROBLEM ANALYSIS

Problem analysis was done and 4 factors were identified as the contributing factors namely:

1. poor toddler attendances
2. poor emphasis on toddler health services
3. inaccurate health education information
4. poor monitoring of achievement
5. missed opportunities not identified

 KEY MEASUREMENT FOR IMPROVEMENT

 Indicator chosen was booster dose immunization coverage among toddler and the standard set was 95%.

 Model of good care: 

 5. PROCESS OF GATHERING DATA 

5.1 General objective 

To increase the immunization coverage among toddler attending KK in Pendang district from 60.9% to 95% by end of 2004 

5.2 Specific objectives 

5.2.1 To ascertain reasons and factors contributing to poor boostser immunization coverage among toddler in KK 

5.2.2 To ascertain knowledge of mother and staff on the importance of toddler health care 

5.2.3 To design and implement remedial measures 

5.2.4 To reevaluate the remedial measures implemented 

5.3 Methodology 

5.3.1        Research methodology 

A cross sectional study for knowledge of mothers and staffs on booster immunization and toddler health care. 

5.3.2        Sampling method 

Systematic random sampling of 54 mothers for 3 clinics. These mothers have toddlers who have incomplete booster immunization. 66 nursing staffs were selected for the study. 

5.3.3        Sample 

The samples for mothers were those with toddler age between 18 months and 4 years and have defaulted for booster dose or defaulted clinic sessions. 

5.3.4        Data collection 

Questionnaires for mothers were prepared and pre-tested before the survey. Interviews with mothers were done by trained staff. 

5.3.5        Definition 

Toddler health care – it includes health care given to toddler between 1.5 – 4 yrs old covering development assessment, health examination, immunization booster, minor treatment, health education such as health talks, cooking demonstration and defaulter tracing. 

Toddler – children between the age of 1.5 – 4yrs old 

Defaulter to booster immunization – Immunisation given after 1 yr of DPT 3^rd dose or DPT Hib and did not attend according to appointment date given 

Defaulter tracing – Defaulter tracing within 1 week defaulting from appointment date

 Inclusion criteria:

Toddler residing in Pendang during study period

 Exclusion criteria

 Those who were not resident of Pendang and transfer in cases.

 5.3.7 Data analysis

 Data analysis is done manually and Epi Info software 

5. ANALYSIS AND INTEPRETATION

Study done in February 2004 involving 54 mothers and the findings were: 

5.1  88.8% of mothers were between the 20 – 39 yr old, 92.5% were Malays, 44.4% were housewives, 63% had secondary school qualifications and 51.9% had an income of RM501 – RM1000 / month. 11.1% of mothers obtained a score of more than 75%.

5.2  12.1% of staff had a score of more than 75% score and the majority (69.7%) had a score of 60 – 74% . 

6. STRATEGIES FOR CHANGE

6.1  Remedial measures 

1. filing of toddlers card

Toddler cards are filled according to immunization completion

Appointment dates are given to mothers during clinic sessions 

2. defaulter tracing

To keep aside toddlers cards that default clinic sessions at the end of the sessions.

Toddlers defaulting clinic sessions / immunization to be traced within 1 wk. 

3. Monitoring of booster immunization during MCH meeting

Monthly immunization monitoring during MCH meeting.

Monthly immunization target set at 7.9% / month. 

4. Missed opportunities

Given briefing for MA and MO on immunization schedule and importance of immunization 

To get immunization history for toddler attending OPD for treatment.

Referral of missed opportunities to OPD and MCH 

5. Poor knowledge on importance of toddler health done

KP study on mothers with toddlers and staffs. 

6. Improve on toddler activities at KK

Health education talks

Cooking demonstrations for toddlers

Cooking demonstrations for mothers with toddlers 

7. Growth assessment and development assessment of toddlers

Development assessment according to schedule

Milestone assessment. 

8. Health education

Toddler health care course.

KP study on health care for health staff 

9. Supervision during clinic sessions

Supervision schedule for staff. 

8. EFFECTS OF CHANGE 

 The immunization coverage for booster has improved from 60.9% to 77.7% by the end of 2005. 

7. THE NEXT STEP

The benefits obtained from this project are:

• Improvement in booster immunization coverage
• Defaulter tracing has improved
• Booster immunization achievement is monitored monthly
• Improvement in toddler health care – case filing, defaulter tracing, assessment according to schedule, activities for toddlers etc
• Improvement in knowledge of mothers and staff on toddler health care and booster immunization

As a follow-up of this project, the management of toddler with malnutrition will be looked into.

8. REFERENCES

8.1 Annual report for District of Pendang

8.2 Annual report of Ministry of Health

8.3 Nolan T, Altmann A, Hogg G, Skeljo M, Schuerman L, Antibody persistence, PRP – specific immune memory and booster responses to DTPa/Hib vaccine in children with a new combination vaccine DTPa-HBV-IPV/Hib at 2,4, and 6 months of age, University of Australia, Vaccine Research Conference, 2001

8.4 Soong,F.S, 1971/72, The immunization status of some preschool children in a new village in West Malaysia, Medical Journal of Malaysia, Vol,26, page 90-93

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To reduce the waiting time of patients with chronic diseases 
at Pendang HC and Kubur Panjang HC at Pendang District, Kedah, 2002 

1.      OUTLINE OF PROBLEM 

Client’s satisfaction is defined as feeling satisfied, safe and trusting the services given to client. Satisfaction is achieved when the product or services given achieves or satisfies the wants/specification and perception of clients. It is important as it influences the health seeking behaviour of clients, compliance to treatment and fostering good relationship with provider. This component encompasses a satisfied way of life when a person achieves better quality of life (Larsen et al, 1976). Waiting time is one of the components of patient satisfaction and this will influence the patients’ compliance to follow-up and treatment. Both components are crucial in ascertaining the quality of services, care and life of a patient with chronic illness. 

Client satisfaction survey has been conducted in all the HCs in Pendang since 1997 and it has achieved 83% clients satisfied with the services. A total of 2.7% were not satisfied with the services given. Some 82.4% of clients felt that the services given was good as compared to 8.1% clients felt it was unsatisfactory.  97.3% of respondent felt the staffs were helpful and willing to help. A total of 78% felt the counter services were good. 61.7% felt the facilities provided were satisfactory. (Zainal Che Mee et al, 1997). 

A brain mapping session was conducted with the head of units to identify the quality problems in each unit and the committee came up with 7 main quality problems. The nominal group technique was used to prioritise the quality problems identified by using the SMART criteria. Voting was done on the quality problems identified earlier namely high perinatal mortaliry rate, long waiting time at Pendang HC and Kubur Panjang HC and moderate and severe anaemia among mothers at 36 weeks of gestation. 

Long waiting time was chosen as quality problem that require urgent action and remedial measures. The other two issues are addressed in perinatal mortality audits and safemotherhood initiative project respectively. 

Clients are influenced by many factors such as individual influencers namely information processing, believe, learning behaviour, motivation and behaviour, persuasive communication and decision- making (Mowen, 1990). Clients are also influenced by environmental factors such as situation, group, family, culture, subculture, economic or policy/regulation about health services.

Parasuranam et al (1990) found that 4 main factors that influence client satisfaction such as word-of-mouth communication, personal needs, previous experience and external communication. 

A study done by A. Shukur A. Hamid (1993) in Hospital Kangar noted that the waiting time to see a Dr. is between 29.7 min – 35.5 min. The study in Kuala Krai, Kelantan noted that the waiting time to see Dr was between 3 min to 1 hr 45 min. The reasons for the long waiting time were too many patients, inadequate staffing and lost/unfound cards (Abraham, 1993). 

Waiting time has an influence on the attendance of patients as observed by Lim (1991) in his study in Hospital Mentakab, Pahang among hypertensive clinic defaulters. He noted that 72% of defaulters gave reasons for defaulting as long waiting time. A verification study was carried out at OPD Pendang HC in July 2001 and noted the waiting time for chronic patients to be:

Registration                    30 min
Waiting to see Dr            60 min

Treatment by Dr/MA        10 min

Laboratory                     12 min

Pharmacy                      20 min

Total time                     132 min

 The waiting time for cold cases: 

Registration                    30 min

Waiting to see Dr            15 min

Treatment by Dr./MA       10 min

Pharmacy                      10 min

Total                                 65 min

 Pendang Health Office has received 3 public complaints about the waiting time for the first 6 months of 2001 in Pendang HC. 

This problem if not addressed, will cause much anxiety, erode the confidence and morale of patients and affect the image of the department.   

Some of the causes identified for the long waiting time were: 

• Job description not clear and specific among the unit in OPD
• No systematic triaging and registration
• Patients do not follow the appointment date given 

Remedial measures that will be implemented and will be an indicator of improvement are:

• Waiting time as according to the client’s charter
• No public complaints from patients or relatives
• Improvement of the clients’ satisfaction 

A problem analysis was done to identify the possible contributing factors to the long waiting time. These factors were identified as: 

·        Delay in registration which may be attributed to non-compliance to appointment, cards not filed according to appointment date, inadequate staffing, losing follow-up card and patient’s attitude

·        Delay in treatment which may be attributed to no screening/triaging, inappropriate referral and too many referral by MAs to MO.

·        Delay in laboratory investigation such as inadequate staff, inappropriate lab test and attitude of staff.

·        Delay in dispensing medication may be attributed to countersigning of List A drugs, poor legibility of prescription slips and attitude of staff and patients. 

2. KEY MEASUREMENTS FOR IMPROVEMENT

The indicator selected to measure the performance of remedial measures taken is the percentage of patients with chronic diseases waiting more than 90 min from registration to obtaining medication from pharmacy. 

The standard set is not more than 50%.  

Model of good care was formulated according to the process, criteria and standard set. The processes that were identified as critical process and if control will eventually affect the overall indicator and standard set were:  

• Registration time
• Clinical examination
• Laboratory examination
• Health education
• Filing system
• Dispensing of medicine

Table 1: Model of good care

3. PROCESS OF GATHERING OF INFORMATION

A few studies have been planned to gather information about the system at HC.  

3.1             The objective of the study is to reduce the waiting time from 2 hr to 90 min for patients    with chronic disease at Pendang HC and Kubur Panjang HC

The specific objectives were to: 

3.2             To identify contributing factors to the long waiting time

3.3             To identify which section contribute to the long waiting time from     

                 bregistration to treatment

3.4             To plan the remedial and implement measures

3.5             To perform evaluation study on the remedial measures instituted 

Methodology for collection of information includes the following:

• Time motion study
• Observation at laboratory and registration
• Study of prescriptions at pharmacy
• Study on appropriate referral to MOs

The study includes all patients with chronic diseases getting treatment from Pendang HC and K,Panjang HC excluding cold cases and emergency cases seen after office hrs.

The information gathered were analysed manually and analysed by Epi Info version. 

4. ANALYSIS AND INTERPRETATIONS

4.1    Time motion study

From the time motion study done in both Pendang HC and K.Panjang HC noted that the waiting time was 174 min and 97.9 min respectively.  

Table 2: Time motion study findings at Pendang HC and K.Panjang HC 

 4.2    Observation of filing system and registration

 4.2.1       Findings of filing system 

• Card filing done according to identity card number
• Chronic pt cards not filed separately because of space constraints
• Cards were retrieved a day before clinic sessions
• Only 57.2% got their queue number by 15 minutes in Pendang HC as compared to 60% in K.Panjang HC.

4.3    Clinical examination / screening  

• 80% were examined for BP and weight in Pendang HC as compared to 100% in K.Panjang HC before seeing M&Hos or MAs

4.4    Laboratory examination 

• 78% patients got laboratory results (FBS / HbA1c) by 15 min in Pendang HC and 65% in K.Panjang HC

4.5    Pharmacy 

• Only 70% patients said that the medication given was enough for the next follow-up in Pendang HC and 90% in K.Panjang HC

           4.6    Cases seen by M&HO 

M&HOs were seeing 77.6% of uncomplicated hypertensives and 75.3% uncomplicated diabetics. This will increase the waiting time to see M&HOs because they are seeing cases that can be managed by MAs.  

4.7    Prescriptions at pharmacy 

Incomplete prescriptions were not a problem at Pendang HC (<3%) but it increased during special clinic sessions. Prescriptions that were required to be countersigned by FMS were only < 10% of the total prescriptions.  

5. STRATEGY FOR CHANGE

Several strategies for change or remedial measures were planned and implemented.  

5.1 Colour coding of chronic cases according to criteria. The cards of patients were tagged according to colours such as green, white and red. Green tag are stable cases and can be managed by MA. White tags are cases with one abnormal criteria and red tags are cases with more than one abnormal criteria. The criteria included are body weight, BP, urine sugar, FBS, HbA1c, urine albumin, frequency of asthmatic attack, peak flow chart etc. These criteria are based on the CPG produced by Ministry of Health. These cases will be reviewed by M&HO according to specified intervals.

       5.2    Filing system  

The chronic diseases card were filed separately from the usual OPD cases and the cards were retrieve one day before the clinic sessions.  

5.3    Staggering the patients by hour. 

The patients are staggered according to the hour. This will need the patients’ full cooperation. They are required to put in their appointment card according to the hour of appointment for the day.  

5.4    Promoting the new work process 

A pamphlet was designed to inform patients their responsibility and rationale of keeping to the appointment date given.  

6.0 EFFECTS OF CHANGE 

A restudy was done in June 2002 after the remedial measures were instituted for 3 months.  

6.1 Time motion study 

The waiting time has reduced from 174 min to 59.9 min in Pendang HC but increased from 97.9 min to 149.73 min in K.Panjang HC. 

In Pendang HC it was noted there was reduction in waiting time at several processes such as registration, waiting to see M&HO/MA and pharmacy. In K.Panjang HC there was increased waiting time in almost all the processes except for waiting to see M&HO / MA, laboratory and taking medication from pharmacy.  

6.2 Clinical examination 

100% of patients in both the clinics were examined before seeing M&HO or MA.

6.3 Laboratory examination

In Pendang HC, only 40% of patients obtain their laboratory results by 15 min whilst 37.9% of patients in K.Panjang receive their results by 15 min.

6.4 Health education sessions 

All patients at both clinics were provided with pamphlets concerning the new work process.  

6.5 Medications  

Only 85.9% of patients in Pendang HC had adequate supply of medications as compared to 62.1% of patients in K.Panjang HC. 

It was noted that patients waiting more than 90 min in Pendang HC were 87.1% (83) and in K.Panjang HC was 82.8% (24) waited more than 90 min.

It was noted that lack of staff affected the achievement of this indicator and standard. The situation in Pendang HC and K.Panjang HC differ in staff strength and facilities available such as HbA1c and microalbumin which is available only in Pendang HC. These two test took an average of 20 min to perform. This will greatly affect the waiting time. There are 3 Mas and 2 M&HO in Pendang HC as compared to one M&HO and 2 Mas in K.Panjang HC.

The tangible benefit that was obtained in this study was the waiting time has reduced tremendously and achieved 87.1% in Pendang HC. There were no complaints of long waiting time for the last 3 months of implementation. The consultation time with Dr. was used to use for clinical management of the case. There was defined work process and job division between staffs. Innovation on colour coding was able to reduce the inappropriate cases seen by Dr.

Special thanks to:

Dr.Hayati Mohd. Radzi, Dr.Baizury Bashah, Dr.Hazik Jamil Khan, Dr.Loh Leh Teng, Ishah Rashid, Faisol Abdul Rahim, Hussein Abdul Rahim, Zainol Man.

 ABSTRACT

To reduce the waiting time of patients with chronic diseases at Pendang HC and Kubur Panjang HC at Pendang District, Kedah, 2002 

Dr.Hayati Mohd. Radzi, Dr.Baizury Bashah, Dr.Hazik Jamil Khan, Dr.Loh Leh Teng, Ishah Rashid, Faisol Abdul Rahim, Hussein Abdul Rahim, Zainol Man. 

Long waiting time has been one of the components of client’s satisfaction. It is important as it influences the health seeking behaviour of clients, compliance to treatment and fostering good relationship with provider. Client satisfaction survey has been conducted in all the HCs in Pendang since 1997 and it has achieved 83% clients satisfied with the services.  

The indicator selected to measure the performance of remedial measures taken is the percentage of patients with chronic diseases waiting more than 90 min from registration to obtaining medication from pharmacy. Model of good care was formulated with certain process, criteria and standard. The remedial measures taken were colour coding for cards, filing system, retrieval of cards, appropriate referral for Dr. and promotion on keeping to appointment date. After implementation of the remedial measures, the waiting time improved for Pendang HC by 87.1% of clients waited less than 90 min but 82.2% of clients in K.Panjang HC waited more than 90 min.

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SAFE MOTHERHOOD INITIATIVE DAERAH PENDANG  

Hayati Md. Radzi, Baizury Bashah, Ishah Rashid, Maimunah Md Noor, Azizah Ramli, Saliha Hashim, Che Olah Zakaria

TAJUK: Meningkatkan pengamalan perancang keluarga di kalangan ibu berisiko tinggi di daerah Pendang dari 45.8% ke 80 %  menjelang tahun akhir tahun 2004

1.0 PENDAHULUAN  LATAR BELAKANG

  Daerah Pendang dengan keluasan 626.14  km persegi dengan jumlah penduduk sejumlah 97,850 yang terdiri dari  80% Melayu, 7.9 % Cina , 7.7 % Siam dan 1.4 % India dan lain-lain bangsa. Pekerjaan utama penduduk di daerah Pendang adalah dalam sektor pertanian, penoreh, pesawah, berniaga, pekerja kilang, peniaga dan kakitangan kerajaan.  

Fasiliti kesihatan di daerah Pendang adalah terdiri dari 3 buah klinik Kesihatan serta 17 buah Klinik Desa yang memberi kemudahan kesihatan kepada masyarakat di daerah ini. Hospital terdekat iaitu Hospital Alor Star adalah terletak 30 km dari Pendang.

  Perkhidmatan kesihatan mudah diperolehi dengan terdapatnya kemudahan jalanraya yang menghubungi  hampir 90%  kampong-kampong di daerah ini. Rata-rata di kawasan pendalaman masyarakat menggunakan kenderaan bermotor sebagai pengangkutan untuk perhubungan. Bekalan air dan tandas mencapai hampir 100%.

  Masalah kesihatan yang dikenalpasti di daerah Pendang  bagi bahagian Kesihatan Ibu dan anak ialah seperti  masalah anaemia  yang masih di pantau dalam Projek SMI  tahun 2002 dan adalah berterusan, masalah kedua adalah liputan imunisasi booster rendah di kalangan toddler dan ini telah di buat kajian DSA bagi tahun 2004. 

Masalah kekurangan amalan perancang keluarga di kalangan ibu berisiko adalah masalah yang juga di kenalpasti dan telah di pilih sebagai projek Safe motherhood Initiative bagi daerah Pendang bagi tahun 2004. 

2. PENYATAAN  MASALAH

  2.1       PEMILIHAN MASALAH  

JK Kualiti telah bermesyuarat pada bulan Oktober 2003 dan menyenaraikan beberapa masalah kualiti bagi semua unit. Antara masalah yang dikenalpasti untuk Program Pembangunan Keluarga. Pemilihan masalah ini dilakukan dengan menggunakan Kaedah “Nominal Group Technique”.

  Antara masalah Kualiti yang dikenalpasti ialah:

  2.2.1 Kurang kelahiran di ABC di ketiga-tiga Klinik Kesihatan

2.2.2 Kadar kematian perinatal yang tinggi di daerah Pendang

2.2.3 Keciciran yang tinggi di kalangan toddler

2.2.4 Liputan pelalian di kalangan toddler yang tidak mencapai sasaran 98%

2.2.5 Liputan pap smear yang tidak mencapai sasaran 2,300 yang ditetapkan

2.2.6 Kadar unsatisfactory pap smear yang tinggi iaitu > 5%

  2.2       MENGUTAMAKAN MASALAH

            Ahli mesyuarat telah menjalankan pengundian mengikut kriteria SMART dan masalah yang    

             mencapai markah tertinggi dipilih untuk projek safe motherhood initiative ini.

Berdasarkan kepada kajian dan analisa kes-kes ibu berisiko yang telah bersalin tahun 2002 terdapat penurunan sehingga 2.3% pengamalan sejak tahun 2001 adalah 72.4%. Paling ketara di KK K. Panjang perbezaan adalah sehingga 4.4 %. Sasaran yang di tetapkan bagi daerah Pendang ialah 80%, manakala pencapaian daerah bagi tahun 2001

ialah 75.7% dan 72.4 % pada tahun 2002 seperti dalam  carta 1:

  Pencapaian  prestasi pengamalan P/Keluarga  di kalangan IHBT di Daerah Pendang dari Januari hingga Oktober 2003 ialah 45.8% sahaja dan dianggarkan pencapaian pada tahun 2003 ialah 54.96%. Ini menunjukkan sasaran tidak tercapai sebanyak 25.1% berbanding dengan sasaran yang telah ditetapkan iaitu 80%.

Jadual 1: Jumlah kes Ibu Berisiko  yang mengamal perancang keluarga mengikut Kelinik Kesihatan tahun 2001 –2002

  Perkhidmatan  penjagaan ibu bermula  dari semasa mengandung, semasa proses kelahiran dan  ketika postnatal selama 42 hari. Ibu mengandung yang dikenalpasti mempunyai masalah obstetrik semasa, perubatan atau mempunyai sejarah masalah obstetrik yang lalu akan dikodkan berisiko tinggi berdasarkan senarai semak yang dikenalpasti. Senarai semak faktor risiko ini meliputi penjagaan semasa tempoh antenatal, intrapartum dan postpartum. Ibu hamil berisiko tinggi ditakrifkan ibu yang diberikan tag bewarna kuning dan merah sahaja.

  Jadual 3: Kadar kematian ibu daerah Pendang bagi 2001 –20002  

  2.3 MAGNITUD MASALAH

  Terdapat  17.96 % (297/1653) kes ibu berisiko yang telah dikenalpasti  di daerah Pendang sepanjang tahun 2002. Daripada jumlah tersebut 72.4 % ibu yang mengamal perancang keluarga. Peratus ini adalah lebih rendah jika dibandingkan  dengan pencapaian tahun 2001 iaitu 19.96 % (375/1878) adalah ibu berisiko tinggi dan hanya 75.7% ( 284/375 ) mengamal Perancang Keluarga.

Penurunan ketara dikesan berlaku di KK K. Panjang iaitu 4.3%. Daerah Pendang menunjukkan penurunan peratus pengamalan perancang keluarga sebanyak 3.3%. (Sila rujuk Jadual 1)

  Jadual 4: Jadual frekuensi kematian dan amalan perancang keluarga di kalangan IBT di daerah Pendang, 2002  

  2.4 KESAN MASALAH  

Dengan projek safe motherhood ini adalah diharapkan, daerah akan dapat meningkatkan amalan perancang keluarga di kalangan ibu berisiko tinggi dan dapat mengurangkan masalah yang berlaku berikutan dari masalah IBT. IBHT meningkatkan morbiditi dan mortaliti ibu dan bayi. Dengan mengamalkan perancang keluarga yang berkesan, morbiditi dan mortaliti akan dapat dikurangkan. Dengan menjalankan tindakan penambahbaikan / pemulihan adalah diharapkan peratus pengamalan perancang keluarga akan meningkat bagi daerah Pendang.  

3.0 METODOLOGI  

3.1 Jenis kajian  

Satu kajian retrospektif telah dijalankan pada bulan November 2003 melibatkan ketiga-tiga Klinik Kesihatan di daerah Pendang.  

3.2 Kaedah sampling dan unit sampel  

Sampel yang dipilih ialah ibu postnatal yang berisiko yang bersalin dari Januari – Disember 2002 di ketiga-tiga Klinik Kesihatan. Systematic random sampling telah dilakukan untuk pemilihan sampel. Sejumlah 108 ibu postnatal yang berisiko telah dipilih untuk kajian awal ini.  

3.3 Metodologi kajian  

Kajian dilakukan menggunakan borang soalselidik yang telah direka dan dilakukan pretest di kalangan ibu mengandung. Pengubahsuaian dilakukan mengikut maklumbalas dari pretest. Kajian dilakukan oleh JK dan JD yang telah diberikan taklimat mengenai pengisian borang soalselidik. Ibu postnatal yang berisiko tinggi yang terpilih dibuat lawatan ke rumah untuk kajian mengenai temubual.  

3.4 Kriteria inklusi  

Semua ibu postnatal berisiko tinggi yang didaftarkan di daerah Pendang dan berada di daerah semasa tempoh kajian dilakukan.  

3.5 Kriteria eksklusi  

Ibu yang telah berpindah atau tiada dalam kawasan semasa kajian dilakukan.

  3.6 Definasi  

3.6.1 Mengamalkan perancang keluarga  

Ibu postnatal yang mengamalkan kaedah perancang keluarga yang berkesan iaitu meliputi kaedah-kaedah pil, kondom, IUCD, norplant, injection, BTL, vasektomi dan lain-lain kaedah.

  3.6.2 keciciran perancang keluarga

  Ibu yang gagal datang ke klinik untuk perkhidmatan perancang keluarga mengikut tarikh temujanji yang diberikan.

  3.6.3 Pengesanan keciciran perancang keluarga

  Setiap kes yang tercicir perlu dikesan dalam 48 jam selepas sessi klinik samada melalui lawatan ke rumah, surat atau telefon.

3.6.4 Kesan sampingan perancang keluarga

  Kesan sampingan seperti loya, muntah, pening, gemuk, break through bleeding, irregular bleeding, amenorrhoea, dan lain-lain. Kesan sampingan ini akan berhenti / hilang apabila ibu berhenti menggunakan kaedah tersebut.

  3.6.5       ibu berisiko tinggi  

Ibu postnatal yang dikesan berisiko semasa mengandung dan ditagkan dengan kod bewarna kuning dan merah.

  3.6.6       Ibu merisiko tinggi

  Ibu yang menerima salah satu kaedah perancang keluarga sekurang-kurangnya selama 6 bulan.

  4.0 ANALISA MASALAH  

Sessi percambahan fikiran telah dijalankan dan beberapa masalah yang dikenalpasti yang menyumbang kepada kurang amalan perancang keluarga (PK) di kalangan IBT.

  Kurang pengetahuan anggota dalam pengendalian perancang keluarga di kalangan IBT mungkin disebabkan oleh kurang latihan mengenai pengendalian PK di kalangan IBT, kurang penyeliaan anggota semasa mengendalikan sessi perancang keluarga, kurang pendedahan kepada kaedah PK yang sediada dan sikap anggota dalam mengendalikan kes IBT.  

Kelemahan dalam pengendalian PK bagi IBT mungkin disebabkan oleh kurang pengetahuan mengenai pengendalian PK, tiada pengesanan kes tercicir dan tiada pengesanan kes IBT disebabkan oleh kurang penyeliaan dan semakan senarai semak.

  Kurang pilihan kaedah perancang keluarga kerana pilihan kaedah yang terhad, kurang promosi tentang kaedah PK dan kurang pengetahuan mengenai kaedah yang dipilih.  

Ibu kurang komplians dalam mengambil kaedah PK kerana kurang pengetahuan ibu/suami mengenai kaedah PK, suami tidak izinkan, kesan sampingan PK dan pendidikan kesihatan yang kurang berkesan serta sikap ibu. Sikap ibu mengenai amalan PK dipengaruhi oleh budaya/kepercayaan persepsi mengenai PK dan pengalaman buruk yang lalu.  

5. OBJEKTIF

  5.1 OBJEKTIF UMUM

  Untuk memastikan amalan perancang keluarga di kalangan ibu berisiko tinggi dari 45.8% ke 80% menjelang akhir tahun 2004 di daerah Pendang.  

5.2 OBJEKTIF KHUSUS

5.2.1 Untuk mengenalpasti sebab-sebab kurang amalan perancang keluarga di kalangan ibu berisiko tinggi.  

5.2.2 Menyediakan pelan tindakan dan langkah pemulihan.

  5.2.3 Membuat penilaian berkala ke atas pencapaian indikator.  

6.0 HASIL KAJIAN

  Kajian awal telah dijalankan di kalangan ibu berisiko tinggi (IBT)di ketiga-tiga Klinik Kesihatan. Jumlah responden ialah 108 orang IBT telah ditemuduga untuk bagi ibu yang telah bersalin dari Januari – Disember 2002. Kajian telah dijalankan pada November 2003.

  6.1 Hasil kajian  

  6.2 Pengetahuan ibu mengenai kaedah perancang keluarga  

ANALISA  MASALAH KURANG AMALAN  PERANCANG KELUARGA  

DI KALANGAN IBU BERISIKO TINGGI DI DAERAH PENDANG

  7.0 JADUAL  INDIKATOR  PENILAIAN PENCAPAIAN SMI 2004 DAERAH PENDANG

1.HEALTH INDICATOR

PROJEK INOVASI
 EAS 2000 (EPID AUTO SPOT 2000) 

SEBUAH PETA MAYA YANG BERFUNGSI SECARA INTERAKTIF DAN DAPAT MENGHASILKAN INFORMASI EPIDEMIOLOGI DENGAN PANTAS 

PePendahuluan 

Dalam pengurusan Kesihatan Awam, aspek survaillance dan pencegahan penyakit merupakan tonggak utama yang dijalankan. Berbagai cara telah dipraktikkan dalam menjalankanaktiviti tersebut seperti penyimpanan rekod dalam buku rekod besar, reten-reten, laporan-laporan dan sebagainya.
Bagaimana pun, dalam era IT ini, cara-cara yang dipraktikkan sekarang boleh dipertingkatan lagi dengan bantuan komputer dalam beberapa aspek supaya ianya menjadi lebih mudah, ringkas, kemas dan efektif serta dapat dimanafaatkan oleh semua kategori anggota kesihatan. 

2. Rationale

2.1. Situasi Semasa

Mengikut cara penyimpanan rekod yang diamalkan sekarang, maklumat-maklumat yang didapati seperti maklumat kes, maklumat rawatan, maklumat kontak, sosiodemografi dan lain-lain lagi akan direkodkan pada buku rekod atau peta kawasan operasi secara manual. Bagi menganalisa atau membuat surveillance kejadian sesuatu penyakit bagi tujuan membuat tindakan bersepadu yang lain seperti kawalan berkala, ACD dan pendidikan kesihatan, ianya agak rumit kerana rekod-rekod tersebut tidak begitu nyata tentang kedudukan kes–kes diseluruh daerah Pendang. Ianya mungkin terpaksa disemak dari beberapa rekod dan fail yang berlainan untuk mendapat maklumat yang lengkap. Kaedah ini tidak kemas, boleh hilang dan sukar untuk mendapt maklumat yang lebih terperinci dalam masa yang singkat.

2.2. Sistem yang dicadangkan

Menyedari hakikat ini,  anggota dari Pejabat Kesihatan Daerah Pendang telah cuba untuk mengwujudkan satu sistem yang lebih sistematik, mudah serta cepat untuk mengesan kedudukan setiap kes dengan semua data berkaitankes dipaparkan secara multimedia.

Memandangkan kejadiana kes TIBI merupakan antara masalah kesihatan utama di daerah Pendang dimana kadar insidennya merupakan antar yang tertinggi di negeri Kedah, maka satu sistem surveilance yang lebih mudah dan lengkap diperlukan bagi merangka strategi pencegahan dan kawalan penyakit tersebut.

Dengan terciptanya “Epid Auto Spot 2000’ (EAS2000), kedudukan serta maklumat kes dapat diperolehi  dan dilihat serta merta tanpa perlu membelek beberapa fail. Adalah diharapkan dengan adanya EAS 2000 ini, diharapkan program surveillance akan dapat ditingkatkan dan diperkemaskan lagi dan seterusnya memberi kesan yang lebih positif kepada program-progran kawalan dan pencegahan. Memandangkan EAS 2000 agak mudah untuk dipelajari dan difahami, maka dirasakan lebih banyak unit dapat menggunakan sistem ini  termasuk MCH, BAKAS dan lain-lain. 

3.  Objektif 

3.1. Objektif Umum 

Mewujudkan satu sistem surveillance kejadian penyakit berjangkit menggunakan multimedia supaya memudahkan aktiviti kawalan dan pencegahan dapat dijalankan dengan lebih cepat dan tepat. 

3.2.Objektif Khusus

3.2.1.  Bagi mengenalpasti kedudukan kes-kes penyakit diseluruh daerah Pendang. 

3.2.2.  Memudahkan proses penyemakan maklumat pesakit dimana maklumat dapat diperolehi pada skrin yang sama dengan skrin yang menunjukkan kedudukan pesakit pada peta.  

3.2.3.  Mengenalpasti faktor sosiodemografi untuk setiap kes bagi membuat persediaan yang bersesuaian untuk tindakan kawalan dan pencegahan. 

3.2.4.  Menggalakkan/memahirkan Anggota Kesihatan dengan penggunaan IT dalam kerja seharian. 

3.2.5.  Mengurangkan kos dan menjimatkan masa kerana maklumat yang direkodkan dapat diperolehi dengan serta-merta apabila dikehendaki.

4. Metodologi

Masalah utama yang sering timbul didalam menjalankan aktiviti kawalan dan pencegahan penyakit berjangkit adalah berkaitan pengurusan data mengenai kes, kontak, maklumat klinikal, faktor sosiodemografi dan lain-lain yang mana selalunya hanya direkodkan dalam buku rekod dan fail-fail tertentu. Melalui kaedah ini kita tidak dapat melihat dengan jelas kedudukan kes, maklumat-maklumat kes ataupun hubungan dengan kes lain dimana maklumat asas ini sangat diperlukan untuk menjalankan aktiviti pencegahan dan kawalan.

Sehubungan itu, satu pasukan telah dibentuk yang mana terdiri dari IK CDC, dan sebilangan PKA bagi membincang, mengenalpasti masalah dan cuba mencari kaedah terbaik bagi menyelesaikan masalah tersebut.

Didapati satu kaedah yang sering dipraktikkan di bilik gerakan semasa kejadian sesuatu wabak penyakit iaitu peta lokasi (selalunya peta daerah) yang menunjukkan kedudukan kes sesuai digunakan untuk projek ini. Dengan kaedah ini ‘map pin’ akan dicucuk diatas peta bagi menandakan kedudukan setiap kes. Tetapi, pada kebiasaannya hanya nama-nama kes sahaja dipamerkan pada peta tersebut. Maklumat-maklumat lain berkenaan kes seperti maklumat klinikal, kontak, sosiodemografi dan lain-lain tidak dapat dipamerkan pada peta tersebut kerana keadaan ini akan menyebabkan peta itu kelihatan terlalu padat dan berserabut.

Setelah mengetahui permasalahan asas, tugasan utama adalah bagaimana menyediakan satu peta yang dapat menunjukkan kedudukan kes dan juga mempunyai segala butir-butir lengkap mengenai kes dengan kemas tanpa berselerak diatas peta tadi. Akhirnya, setelah beberapa percubaan dijalankan,  sebuah peta maya (EAS 2000) yang berkonsepkan intraktif dan dapat memenuhi segala aspek yang dibincangkan telah dihasilkan dengan menggunakan perisian Macromedia Authorware Professional Attain 5. 

5. Perlaksanaan 

Sebuah peta daerah Pendang dipaparkan pada skrin komputer dengan ditanda bulatan-bulatan putih kecil bagi mewakili kedudukan kes-kes TIBI di seluruh daerah Pendang. Di peta itu juga dipaparkan keadaan geografi daerah. Segala maklumat mengenai setiap kes dimasukkan tetapi pada program ini tetapi tidak kelihatan pada skrin komputer. Hanya apabila cursor diklik diatas penanda kedudukan kes diatas peta, maklumat berkenaan kes tersebut akan dipaparkan dengan serta merta. Dengan kaedah ini, banyak penanda kedudukan kes boleh diletakkan diatas peta tersebut tanpa membuatkan ianya nampak penuh dan berserabut.

Semua maklumat mengenai kes, kontak, klinikal, sosiodemografi dan lain-lain boleh didapati pada satu paparan skrin komputer sahaja dengan serta merta. Dengan ini,  persediaan untuk membuat langkah-langkah kawalan dan pencegahan dapat disediakan dengan lebih teratur dan sempurna berdasarkan maklumat-maklumat yang dipaparkan. 

6. Kesimpulan 

EAS 2000 dihasilkan bersesuaian dengan seruan kerajaan agar semua jabatan lebih melibatkan bidang IT bagi membantu kerja seharian. ESM 2000 dicipta dengan harapan dapat membantu memudahkan urusan-urusan survaillance, pencegahan dan kawalan didalam program Kesihatan Awam. Selain dari memudahkan, ianya juga membolehkan kerja-kerja dilakukan dengan lebih cepat, kemas dan effisien berbanding cara lama yang terpaksa menyemak rekod-rekod yang ditulis di kertas, sekali gus dapat meningkatkan produktiviti jabatan serta mengurangkan kos operasi. Disamping itu, ianya juga dapat mendorong kakitangan Kesihatan lebih memahirkan diri dengan dunia IT. 

7. Cadangan Penambahbaikan 

EAS 2000 yang menggunakan aplikasi program Macromedia Authorware Profesional Attain 5 senang dipelajari, difahami dan digunakan. Segala penambahan maklumat yang difikirkan perlu senang untuk dilaksanakan. Sebagai contohnya, penambahan maklumat-maklumat Klinik Desa pada peta daerah Pendang. Apabila diklik pada penanda klinik di peta tersebut, satu paparan yang mengandungi semua maklumat mengenai klinik tersebut seperti JM yang menyelia, liputan kawasan operasi dan lain-lain akan muncul diskrin.

Cadangan pada masa depan, EAS 2000 akan dimajukan lagi dengan menambahkan semua maklumat daerah seperti bilangan penduduk, jumlah liputan BAKAS( air bersih, tandas, air limbah dll), bilangan kedai makan/restoren, bilangan kilang dan sebagainya hanya dalam satu skrin.

Maklumat pesakit akan terpapar disebelah kanan (kotak biru) apabila diklik pada bulatan putih diatas peta yang mewakili kedudukan kes.