Health System Research In Perak 2006 – 2009

Health System Research

㻾㼑㼟㼑㼍㼞㼏㼔㻌

㼀㼛㻌㼙㼍㼗㼑㻌㼍

Difference

2006 - 2009

July 2013 Health System Research

Research

To make a

Difference

Perak

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

© 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 HSS Ooi Qing Xi

Lionel Chia Dick Hua Lim Wei Yin

Lina Hashim

Arvinder Singh Harbaksh Singh

Advisors

Datin Dr Ranjit Kaur Praim Singh

Deputy Director of Perak State Health Department (Public Health)

Sondi Sararaks

Head Health Outcomes Research Division, Institute for Health Systems Research (IHSR)

Dr Asmah Zainal Abidin

Head 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 publish these reports.

Contents

Home 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

1

Home Safety Practices for Prevention

of Poisoning in Young Children

Health Systems Research 2008/2009

Authors

Shoba Pathmanathan

Paediatric Department,

Hospital Raja Permaisuri Bainun Ipoh, Perak

Lina Hashim

Clinical Research Centre Perak

Affendi Yusuf

Manjung District Health Office

Vishanthri Kulasingam

Greentown Health Clinic

Hooi-Meng Puah

Kinta District Health Office

Amar-Singh HSS

Clinical Research Centre Perak, Department of Paediatrics,

Hospital Raja Permaisuri Bainun Ipoh, Perak

Sondi Sararaks

Institute for Health Systems Research

Ranjit Kaur Praim Singh

Perak State Health Department

Asmah Zainal Abidin

Perak 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)

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 Speciic 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 indings

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

ABSTRACT

Home Safety Practices for Prevention of Poisoning in Young Children

Shoba Pathmanathan¹, Lina Hashim², Affendi Yusuf³, Vishanthri Kulasingam4_{, Hooi-Meng}

Puah5_{, Amar-Singh HSS}¹,²_{, Sondi Sararaks}6_{, Ranjit Kaur Praim Singh}7_{, Asmah Zainal Abidin}7

1 Paediatric Department, Hospital Raja Permaisuri Bainun Ipoh 2 Clinical Research Centre Perak

3 Manjung District Health Office 4 Greentown Health Clinic 5 Kinta District Health Office

6 Institute for Health Systems Research 7 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 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 1

Child operates device without guidance

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

Activity 2

Child 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 3

Adult 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

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

Evaluation of the effectiveness of intervention package in terms of

1. Safe storage

2. New changes by parents eg

use child resistant device Nurses administered questionnaire

Evaluation of the effectiveness of intervention package in terms of

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

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

1

Relationship of caregiver to child/ children

Relationship between respondent and young children at home as obtained by a direct question to the respondent 1. Father 2. Mother 3. Grandmother 4. Grandfather 5. Others

2 Age of the caregiver

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

Years

3 Ethnicity of

caregiver

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

1. Malay 2. Chinese 3. India 4. Others

4 Education level of

caregiver

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

1. No education 2. Primary 3. Secondary 4. Tertiary

5

No. of children aged 1-4 years in household

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

No Variables Operational Definitions Scale of Measurement

6

No. of other children in household

Respondent other children obtained from direct question to the respondent

Number

7 No. of adults in

household

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

Number

8 Furniture

availability

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

Yes

9

Self 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. Safe

2. Partially safe

3. Partially dangerous 4. 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. Safe

2. Partially safe

3. Partially dangerous 4. Dangerous

11

Self reported practice of safe disposal of medication

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

Correct Incorrect

(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

No Variables Operational Definitions Scale of Measurement

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 years

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.

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

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

4.0 RESULTS

4.1 Results of Evaluation of Safety Device

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)

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 92

0.72 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 level

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 year 4

(2.8%)

6

(4.0%) –

Number of poisoning in children in past year 4

(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.

Efective Implementation of a

Structured Psychoeducation

Programme among Caregivers

of Schizophrenia Patients in the

Community

Health Systems Research 2008/2009

Authors

Paranthaman Vengadasalam

Jelapang Health Clinic

Satnam Kaur Harbhajan Singh

Bahagia Ulu Kinta Hospital

Jean-Li Lim

Slim River Health Clinic

Amar-Singh HSS

Clinical Research Centre Perak, Department of Paediatrics,

Hospital Raja Permaisuri Bainun Ipoh, Perak

Sondi Sararaks

Institute of Health Systems Research

Nafiza Mat Nasir

Tanjung Malim Health Clinic

Ranjit Kaur Praim Singh

Perak State Health Department

Asmah Zainal Abidin

Perak 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”:

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)

Contents of Report

page

Abstract 43

1.0 Introduction 48

2.0 Objectives 48

2.1 General objective

2.2 Specific objectives

3.0 Methodology 49

3.1 Overview of research design

3.2 Study type

3.3 Ethical considerations

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

6.0 Conclusion & Recommendations 67

Acknowledgement 68

References 68

ABSTRACT

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

Paranthaman Vengadasalam1_{, Satnam Kaur Harbhajan Singh}2_{, Jean-Li Lim}3_{, Amar-Singh}

HSS4,7_{,Sondi Sararaks}5_{, Nafizah Mat Nasir}6_{, Ranjit Kaur Praim Singh}8_{, Asmah Zainal Abidin}8

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, Perak 8 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

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 illness

2. Understanding your treatment

3. Helping yourself prevent relapses

4. Avoiding and handling crisis

5. 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.

1.4 Problem analysis

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 of long term sustainability Defaulters/ dropout rates Programme implementation 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

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

2.1 General objective

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.

2.2 Specific objectives

1. To determine if the use of a structured psychoeducation programme will

significantly:

a. improve the knowledge about schizophrenia among caregivers

b. 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

3.0 METHODOLOGY

3.1 Overview of research design

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

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).

3.3 Ethical considerations

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 caregiver Age 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 patient Answer 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 patient

Single/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 status Formal education received by respondent

No Education/Primary/ Secondary/Tertiary Pretest Standard designed test regarding

knowledge about schizophrenia

Marks obtained: 0-20 marks

Post test Standard 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)

E

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

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

E

MODULE 2

INSPECTING FOR YOUR FEET

Look for:

1. Colour changes

a. redness with streaks means sign of infection b. pale / blue toes means poor circulation

c. darkened sign means tissue has died

2. Swellling

a. swelling with colour changes means sign of poor sirculation or infections b. symptoms include tenderness & an increase in the size of your foot

3. Temperature changes

a. warm areas means your feet are infected

b. cold feet means feet aren’t getting enough blood

4. Sensation changes

a. “ods sensations” like pin pricks,numbness,tingling,burning,or lack of feeling means nerves are damaged

5. 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 skin

b. they are signs that skins is breaking down which could lead to ulcers

7. Ingrown Toe Nails

a. often caused by tight fitting shoes or incorrect nail trimming

b. symptoms include nails that are growing into the skin,swelling,redness or pain.

8. Drainage & Odour

a. may develop from untreated ulcers

b. white or yellow moisture,bleeding & odour are often signs of infections or dead tissue

9. Call your doc immediately if you notice

a. redness or steaking b. swelling

c. increased heat d. fever & chills

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:

E

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 YUNUS

Jurupulih Carakerja U29, KK Kamunting