Community Health Visit: Klinik Kesihatan

An Introduction to the Malaysian Healthcare System

Most of us have been exposed to the Malaysian healthecare system one way another, be it, private clinics or government ones, even hospitals at times. The Malaysian healthcare system can be said to consist of a broad umbrella structure that encompasses the provision of healthcare to both urban, not to mentioni also, the rural regions of our beloved country. In general however, it can be classified under the public or private sector, which is very obvious in our country. The public sector which is backed financially by the government, constitutes a whopping 80% of the total health services in our country, the remaining 20%, needless to say, is provided by the private sector.

The backbone, or in other words, basis of Malaysian Healthcare, is formed on the foundations of the complementary network of private and government clinics together with hospitals that are available to the public. Each state of our country have their respective General Hospitals located in the state’s capital. District hospitals will be present in most administrative districts. Health Centers (Klinik Kesihatan) will supplement these district hospitals. Under Health Centers, are the Rural Clinics (Klinik Desa).

Comparing the healthcare system in Malaysia with other first world countries such as the United States of America and the United Kingdom, the healthcare system in Malaysia is heavily subsidized by our government, in the aforementioned first world countries, treatment costs can rocket sky high. Our government has made sure that the price the people pay for treatment from the public sector his reasonable and affordable to the majority of citizens. At least 5% of the national budget is allocated to healthcare system expenditures.

Our government has listed the 8 elements of primary healthcare. To fulfill the 8 ELEMENTS, they provide these services as follows:

Maternal and Child Healthcare

Outpatient services

Basic Dental Health

Nutrition

Environmental sanitation

Essential drugs

Control of Communicable Diseases

Health Education

Laboratory services

Organization of Klinik Kesihatan Bukit Pelanduk

Klinik Kesihatan Bukit Pelanduk is located in the state of Negeri Sembilan, Port Dickson to be even more specific. There are 12 villages in the Jimah District area, and this Klinik Kesihatan is located there. On the 29th of July 1986, operations begin to go on in this clinic and the clinic has served as major centre for the treatment and recovery of the Japanese Encephalities and Nipah virus infected patients. The vaccination for the deadly Nipah virus. There are subsidiary clinics such as Klinik Desa Chuah under the jurisdiction of Klinik Kesihatan Bukit Pelanduk that provides the medical services such as maternal and child healthcare services.

Klinik Kesihatan Bukit Pelanduk is also located within the radius of 30 km from the Tuanku Jaafar Hospital and the Port Dickson Hospital in Negeri Sembilan

Oganisation Chart

Community nurse Public Health assistant U19 (6) U17 (1)

Altogether there are 33 staff workers.

Klinik Kesihatan Mantin is headed by an Administrative Doctor, who is directly responsible to the District Health Officer. Under the Administrative Doctor are two posts, which are the Assistant Medical Officer, and the Head Nurse. The Head Nurse is an authoritative figure, there are 7 components of the staff directly under her, which are the Assistant Pharmaceutical officer Medical Lab Technician, Assistant Medical officer, Senior Community nurse, Public Health nurse, Health nurse, and the Trained nurse. Under the Senior Community nurse would be the Community nurse, and the Public Health assistant.

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Components of Health Services.

The Klinik Kesihatan Bukit Pelandok has 6 main departments which are the Outpatient, Maternal and Child Health, Pharmacy, Laboratory, Dental Health, and Emergency Department. The outpatient department is by far the biggest service rendered to the public and can be broken down in the diagram below

The outpatient department consists of the diabetic, hypertension, mental health, healthy teen and out patient clinic. The out patient procedures of obtaining medical services is shown in the diagram on the left.

The outpatient department in other words, functions as the primary healthcare clinic. It is headed by an Administrator doctor( Medical Office). The out patient clinic sees an estimated 100 patients every single day. And the head nurse and assistant medical officers will do their utmost best to carry out their respective responsibilities to assist the Administrator doctor in any duties relevant to them.

The Maternal and Child Health Clinic is headed together by the administrator doctor and the head nurse. This helps in reducing the workload of the administrator doctor. The head nurse together with the staff under her will such as community nurses, will conduct frequent home visits and provide antenatal check-ups for pregnant women within that area.

Diagram on the left shows a brief summary of Maternal and Child Health services.

The Laboratory Department, which is headed by a medical lab technician. The medical laboratory is not as well equipped as those major hospitals, hence the Laboratory Department of Klinik Kesihatan will collaborate with the Laboratory Department of the Tuanku JaafarHospital such as urine protein tests, thyroid function tests, lipid profile and renal function tests.

Diagram on left shows a brief summary of services provided by the Laboratory Department of Bukit Pelandok.

Another important component of Klinik Kesihatan Bukit Pelandok. After consulting the medical officers, patients who are eligible for prescriptions, will have their medication prescriptions handed to the assistant pharmaceutical officer, who will then supply the patients and inform them of the usage of the medication.

Klinik Kesihatan Bukit Pelandok also has a dental department, the dental functions under the same operational hours of the clinic. Tooth extraction, filling, scaling, whitening are provided services. Major oral surgeries however would be referred to the Tuanku Jaafar and Port Dickson hospitals.

Last but not least, there is also an Emergency Department, this department is equipped to handle minor emergencies, it also has an ambulance and paramedics.

The bar chart on the left shows the ethnicity of the total number of patients in 2010.

Services Provided by Klinik Kesihatan Bukit Pelandok.

I have already stated the various departments of Klinik Kesihatan Bukit Pelandok in the Components of Health Services provided section.

The departments of this clinic provides a wide range of treatment modalities, hence allowing the clinic to ensure that patients enjoy effective treatment.

The outpatient department is the most busy of all the departments. The purposes of the outpatient department are to provide immediate treatment to patients who are acutely or chronically sick, and also to act as a control for the clinic against infective disease such as Tuberculosis. Klinik Kesihatan Bukit Pelandok also provides the Tuberculosis Direct Observed Therapy Short-course treatment.

Moving on to the Maternal and Child Health care department, the clinic mainly focuses on prenatal, antenatal, not to forget postnatal care of both the mother and foetus. There is a target to be achieved, which is the target of zero maternal deaths. They are accomplishing this target in a certain number of ways which include immediate diagnosis and treatment of pre-eclampsia, immunization of the mother and frequent antenatal check-ups up until the estimated delivery date. There are also activities scheduled by the department for disabled children on a case by case basis.

For the Laboratory Department, their main role is to enable the clinician in conducting relevant laboratory studies that will help in the diagnosis and management of the disease. The Laboratory Department allows the clinic to receive results much faster compared to the time it takes to receive results from a nearby hospital.

Some common tests conducted by this department are as follows:

Blood tests for HbA1c, lipid profile, platelet count, ESR

Light microscopy on blood smears to detect blood disorders such as anemia, or parasites in the blood smears.

Urinalysis for toxins, glycosuria, urea and red blood cell casts.

Pregnancy test

Other more intricate and complicated tests such as FTA-Abs for treponema pallidum, would require samples to be obtained and sent to the Tuanku Ja’afar or Port Dickson General Hospital for processing.

The pharmacy is responsible for dispensing medication in safe and legal amounts to patients, and to advise patients on practicing compliance in taking their medications. Patients will also be counseled on the side effects and contraindications of the drugs.

Reflections

From observing the complex structure of roles and responsibilities held by the different components and departments of Klinik Kesihatan Bukit Pelandok, it brings to light the vast value of this particular clinic in the provision and primary healthcare of the residents in Bukit Pelandok.

Many of the patients who visit this clinic are of the Malay ethnicity, I for particular, am one who is not fluent in Bahasa Melayu compared to the English language. I learnt that this could be a barrier in communicating with patients who can only speak the Malay language. I have decided that I will brush up my Bahasa Melayu, and master a few of the colloquial terms so that next time I would be able to communicate even better in the Malay language.

This clinic visit has taught me that every component of the staff has a part to play, and has managed to teach me invaluable lessons of becoming a team player.

Section II: Household Survey

Introduction

Bukit Pelanduk is most famous for the Nipah outbreak. Prior to the outbreak, during the 90’s, it contain the largest pig farming communities in Southeast Asia. In between October 1998 and May 1999, that was the darkest time in Bukit Pelanduk recent history, there were approximately 104 deaths out of 258 cases of Nipah infected patients.

Towards the Chinese new year in the middle of March 1999, a pig breeder from Sungai Nipah, which is located south of seremban, died suddenly triggering massive panic. Nearly half the population of the village migrated elsewhere out of fear towards the killer disease. The virus spread like a raging wildfire out of control causing many pig farmers not to mention villagers to abandon their farms and homes in panic. By March 1999, Bukit Pelanduk had become something like a ghost town due to the mass exodus.

The ministry of health then decided to raise the level of this epidemic to the level of national crisis. A Cabinet-level task force was set up, and then headed by the then Deputy Prime Minister Abdullah Ahmad Badawi. What was confusing was that at that time, the government adamantly insisted that it was right in tagging the disease as Japanese Encephalities, however both farmers and scientists opposed this theory and suspected that it was a different strain or virus altogether.

The virus then spread to Kampung Sawah, Kampung India and even Sepang. Farmers consulted temple mediums, and promptly put up red banners at the mediums’ advice in and around their houses to ward off the angel of death.

After months of futility in treating the outbreak as Japanese Encephalitis, the government finally decided to call in the Department of Medical Micribiology of University of Malaysa’s medical faculty for assistance in dealing with this disease. Dr Chua Kaw Bing was the doctor who managed to isolate the virus in five days. 12 days later, it was identified as a new Hendra-like virus and tagged as Nipah.

Over one million pigs, or half our contry’s pig population at that time, were culled. Around 36000 ppl suffered unemployment due to the destruction of farms. According to the United Nations Food and Agriculture Organization, it is estimated close to RM 500 million of pig production was lost.

Today, pig farming is no longer allowed legally in Bukit Pelanduk. Since the outbreak, the young had drifted elsewhere in search of a living. Only the old remain, to live out their days.

Objectives

The objectives of the study are

• To describe the social demographic of community
• To identify vectors and pests
• To comprehend health seeking behaviour
• To determine the housing conditions
• To understand food, nutrition and health awareness
• To determine working environment
• And to determine the knowledge, attitude and practices on dengue among the community.

Methodology (Methods and Materials)

The household group consisting of 15 members. We met up before going to Bukit Pelandok in IMU to discuss our strategies and to plan ahead before the Bukit Pelandok visit. Household questions and objectives for the Bukit Pelandok visit was meticulously discussed and great care was poured into the formation of our questionnaire. The questionnaire was in the English language and pretested to make sure no discrepancies arose when certain terms were used. After countless hours of discussion we finally agreed on a descriptive cross-sectional study upon the target population which were the residents of Bukit Pelandok.

Due to obvious time constraints, not to mention logistical ones, the art of the convenience sampling technique was called to the fore with households being identified as the basic unit of due analysis. The survey was conducted over 2 working days around the 7 housing areas within a five kilometer radius which are as follows

• Kampung Sawah
• Kampung Pachitan
• Kampung Jawa
• Kampung Cina
• Kampung India 
• Rumah Rakyat Taman Bayan

Most of us were well conversant in English as well as the Malay language, and we were able to translate all of the questions confidently into Mandarin as well. As names and specific home addresses were not included as part and parcel of the questionnaire, we managed to obtain consent of participants as well as guaranteeing their anonymity and confidentiality of their responses in the survey.

To display the results in an attractive and efficient manner, descriptive statistics were employed in the formulation of the results which would be put under the results chapter. Formulation of results in this survey was done with the SPSS 18 program together with the dedication of the data entry and analysis team.

The following is a brief summary of the study:

Study location: Bukit Pelandok, Negeri Sembilan

Study period: 17-18 February 2011.

Total population of Port Dickson: 90 000 people

Target population: Community in the 7 areas mentioned above.

Sampling technique: Convenience sampling technique

Sample size: 234

Basic unit of analysis: Household

Study design: Descriptive cross sectional study

Study instruments: Pre-coded and pretested questionnaires in the English language via face to face verbal interviews. Data entry and analysis: SPSS 18

Operational definitions

Results

Table 2.2 above shows the literacy level of respondents. For the male population, 50 out of 79 males ,63.29 % are literate whereas for the female population, 108 out of 155, 69.68% are literate. Women have a higher literacy level than men it appears.

Figure 2.3

Figure 2.3 shows that the most common occupation of respondents are housewives, 108 out of 234, or 46.15%. the second most common occupation is the skilled manual/clerical which stands at 38 respondents, or 16.24%. Only 5 of the respondents were students, representing only a meager 2.14%.

Figure 2.4

Figure 2.4 shows that the most of the respondents have a monthly household income of around RM 1000-RM1999 which was 84 out of 234, 35.90%. There were 11 respondents, 4.70% who were of the highest income bracket (>RM 5000)

Figure 2.5

Figure 2.5 above shows that majority houses in Bukit Pelandok are of the detached type, 65.81%.

Figure 2.6

Figure 2.6 shows that 53.2% of houses are made out of brick whereas 39.5% and 7.3% are made out of brick and wood, and wood respectively.

Table 2.3 : The Housing Characteristics of Respondents in Bukit Pelandok (n = 234)

Table 2.3 shows that 97.9% of the houses have 24 hour availability of electricity whereas 98.7 % have availability of piped water supply. Garbage collection facility was low as only 46.2% of the houses had that facility. Availability of a proper sewage system was high too at 85.9%.

231 out of 234 respondents did know where the nearest health clinic was, a 98.7% majority of them. 219, 93.7% of them claim they will seek medical assistance if sick. 70.5% would choose the government clinic for medical assistance whereas 26.9% will go to seek medical assistance from a private clinic.

Discussion

From Figure 2.3, the bar chart shows that a huge number of respondents are housewives. This is because the time we carried out the survey was during office working hours. Hence most respondents who were the most likely to be at home during this period of time tend to be housewives.

From Table 2.3 more than half of respondents claim that they do not enjoy proper garbage collection privileges. When we asked more about garbage disposal practices in that area, we found out that about once a week, rubbish is brought to a place designated by the village chief (ketua kampung). There the rubbish is either burnt or buried. If villagers feel that this is a complicated process, they would burn or bury their own rubbish in their own backyards.

From Figure 2.4, the majority of respondent’s household income can be appreciated to be below the RM 2000 mark. Most of the residents of this area belong to the skilled/ unskilled manual field of profession as stated in the operational definitions, hence their income is lower.

Limitations

While conducting the study, the survey team realized that we ran into several limitations. That was inevitable. And we will list it down below.

The first limitation encountered by our team was the coverage in the area of our study. A limited area makes it difficult for any study to be effectively correlated and to allow for generalizations to be made.

Certain questions in the survey were not specific for respondents such as the awareness of job related risks. If the head of household is not there to answer the questionnaire, the respondent might not be able to give a very accurate answer. Therefore certain conclusions about the population of Bukit Pelandok could not be accurately derived.

There were variations between the way interviewers would ask the questions. Hence there might be a slight discrepancy between explanations of questions and answers from one interviewer to another. This means that the standardized understanding of questions by respondents would have been slightly affected.

The reliability of the information provided by the respondents is very hard to verify also. We depend on truthful answers and had no concrete way to validate whatever the respondent answered. There were instances also where non responses were encountered.

During the survey there were also noticeable language barriers between interviewers and respondents. There was an instance where an Indian lady could only communicate well in Mandarin, hence the Malay interviewers would have had a real difficult time if not for his Mandarin-speaking partner.

Conclusion

Bukit Pelandok is an area where the residents put more faith in western medicine and most of them will seek medical treatment and advice from the Government Health Clinic. Local authorities need to beef up their services and improve garbage collection facilities among this area to prevent air pollution which results from open burning.

Reflections

I feel that this project has taught me some very important lessons and even practical skills, for example, in the entering and formulation of graphs and tables by the SPSS 18 program. This will help me in my future career as a medical doctor in the world of medical presenting, teaching and learning.

This project also gave me an experience of conducting a household survey together with my batch mates, we learnt how to delegate and carry out our respective responsibilities as a team. We also managed to learn from our mentors on how to facilitate this type of household survey research.

Section III-Research Report

Abstract

The objectives of this research survey conducted were to investigate the social status of the community and the knowledge, attitude and practices (KAP) on dengue among rural communities in Bukit Pelandok, Negeri Sembilan. Convenient sampling was used as time was a major limiting factor. 234 and 250 people participated in the household and research survey respectively. Participants age were 18 years old and above, had the ability to converse and communicate in the Malay, English, and Mandarin language, resided permanently in the area, and holding a Malaysian citizenship. In our survey, we used a pretested, precoded, and well structured questionnaire in the English language for data collection via a face to face interview with participants.

Introduction

According to the WHO, the Dengue virus is transmitted through infected Aedes mosquitos with any single one of four dengue viruses when it bites a human being. This virus is more prevalent in the tropical and sub-tropical areas on Earth. After an infective bite, symptoms start presenting within the next 3-14 days. As the name dengue fever implies, it is a febrile illness that affects humans in all stages of life be it infants, young children or adults.

The symptoms present with a wide range from a mild fever, to an immobilizing high fever, which is usually accompanied by severe headaches, muscle, joint pain and the occasional bout of rashes. Up to the present day, sadly, there are still no specific antiviral medicines to battle dengue. Hydration is of utmost importance when managing a patient with dengue fever. Aspirin or non steroidal anti-inflammatory drugs are not recommended for the treatment of dengue fever.

The most widely feared complication is the dengue haemorrhagic fever which is accompanied with fever, abdominal pain, bleeding and vomiting. It is potentially lethal and usually this complication affects children. Prompt clinical diagnosis and meticulous clinical management by experienced doctors and nurses usually increase the rate of survival of patients.

Over the past decade, dengue has emerged as one of the most common mosquito-borne viral disease among humans. On a global scale, an estimated 2.5 billion people reside in areas where the dengue viruse can be easily transmitted. From a geographical point of view, the spread of both the vectors (Aedes mosquito) and the dengue viruses has led to a resurgence globally of an epidemic dengue fever. Together with this epidemic, there is emergence of the dengue hemorrhagic fever (DHF) in the past quarter of the century.

The main vector of dengue is the Aedes aegypti¼Œ there are four different but related viruses that cause dengue. The recovery from infection by one type will provide lifelong immunity only against that particular serotype. In other words, it means a human being can be infected by another serotype of dengue virus for a subsequent time.

Dengue Hemorrhagic Fever was first identified during the 1950s in the Philippines and Thailand when those two countries experienced dengue epidemics. Around 1970, about nine countries had witnessed the DHF epidemic and continues to rise in our present day. All four dengue viruses are endemic in the Americas and Asia and has become one of the leading causes of hospitalization and mortalities among children in a few of their countries.

Until now, vector control is the most widely used method for the dengue and DHF prevention. Broad research on dengue vaccines are still being conducted.

Literature Review.

A number of literature reviews provided me with a very handy guide to the socio-demography and KAP regarding dengue among the community of Bukit Pelandok, Negeri Sembilan. Since i had limited time to conduct the research, the literature reviews gave me an overview and acted as a stepping stone to getting the research report together. Even for professionals, literature reviews are useful reports that keep them updated about what is current in their field.

4 journals from the internet and online journal communities were reviewed before writing this report. This included studies on KAP among the adult population in Malaysia, Thailand and Myanmar. The quality of the journals was merely acceptable as most of them used convenience sampling. Only one journal used a cross sectional multistage sampling, this was the journal regarding Dengue-related Knowledge among Caregivers in Myanmar.

From these journals, the group conducting the research managed to fine tune the questions in the questionnaire that was used so that the answers would be helpful and informative.

According to the journal by Dr Farizah Hairi, out of all of the 200 respondents surveyed in Kuala Kangsar, only one had never heard of dengue. And the main source of information came from the television or radio. 88.5 % of the of the respondents thought that the cause of dengue was mosquitoes whereas only 2.5% knew it was the dengue virus to be exact. Out of these 200 respondents, only 91 could name Aedes as the type of mosquito that could transmit the dengue virus.

The knowledge on the Aedes mosquito was quite poor. Only 25 percent of the respondents were able to mention that covering the stored water as a prevention method. The good news was that 192 (96%) of the respondents understood that presence of Aedes larvae in their residence was against the law. The practice of dengue control , the most common forms of prevention were using mosquito coils together with insecticides. Majority of respondents (96%) did consider the dengue virus as a very serious disease. All of the 200 respondents stated that they would seek treatment if they were infected with dengue. Out of the 200, 192 which is a large proportion felt that prevention was better than cure.

90.5% of the respondents support programmes or activities which are organized by the health authorities targeted at the elimination of Aedes mosquitoes. 91% of respondents too felt it was justified to punish those guilty of harbouring Aedes larvae in their residence. Based on the type of scoring system used which was described in the methodology of that particular journal, 68.5% of respondents possessed good knowledge of dengue and Aedes, whereas 91.5% had a positive attitude towards dengue control. What was disappointing was that only 51.5% of respondents actually adopted measures to prevent and control dengue and its vector.

Research Question

The following is the main research question that all the questions in the questionnaire are helping to answer.

What is the current level of knowledge, attitudes & practices for prevention of the Dengue virus among the semi-urban community?

Objectives

General objective

To assess the Knowledge, Attitude and Practice on Dengue among the Bukit Pelanduk community.

Specific Objectives:

To determine the level of knowledge of the local communities on Dengue

To appraise the attitude of the local communities towards Dengue

To describe the practices taken by the local community to prevent Dengue infection

Methodology

For the KAP of dengue research survey, we used a cross-sectional study in Bukit Pelandok. Type of sampling used was convenience sampling.

The sample size of the study was targeted at 250, we managed to hit that mark.

A pre-tested and well structured questionnaire on KAP of Dengue was used.

The household survey was carried out within the range of a 5 km radius around the Bukit Pelanduk Health Clinic which included

-Kampung Chuah

-Kampung Sawah

-Kampung Pachitan

-Kampung Cina

-Rumah Rakyat

-Taman Bayan

From the 14th to the 16th of February 2011, we did some brainstorming to finalise the topic and questions. After that we sent the questionnaires for printing. 2 members of the group were sent to Bukit Pelandok to check out the area before the day we went to conduct the research.

We then had to divide determine the criteria of interviewees which would be fit for selection to answer the questionnaires. The criteria the interviewees must fulfil is that they be above 18 years old, a resident of that household, and a Malaysian citizen.

Our questionnaire had 4 main components which included socio-demographics, knowledge, attitude and practices.

The medium used to conduct the interview were the Malay, English, and Mandarin language.

On the 17th to 18th of February 2011, we proceeded to the execution of the research study. We divided the research group into 13 pairs. On the 1st day, we covered areas within walking distance, which was as far as up to Kampung Cina and Kampung Sawah.

The 2nd day , we were dropped off by group members who had cars and managed to cover further areas as far as up to Taman Bayan and Chuah.

As like the previous household survey, there was a key emphasis placed on obtaining consent from respondents of the survey as well as maintaining their anonymity and confidentiality of any of their responses to the survey.

The descriptive statistics program, SPSS 18, was employed in the formulation of the results of the survey. The SPSS 18 greatly helped in data entry together with analysis. A P-value of less than 0.05 was used to prove the validity of the collected data unless otherwise stated.

The scoring system used is as follows.

Knowledge 10 vital questions ≥ 7 correct GOOD knowledge

Attitude 6 vital questions ≥ 4 Yes GOOD attitude

Practice 7 vital questions ≥ 4 Yes GOOD practice

There were some protocols that we followed to reduce bias or error while conducting the interview. We did our best to avoid suggestive questions, and the questionnaire was pretested among our own group members. There was a briefing held to convey the standardization of questioning. House allocations were done to prevent overlap and we tried our best to extensive coverage of Bukit Pelandok. Our group also double checked the SPSS data after input.

Results

Socio Demographic data

Gender

Figure 3.1 shows the gender of respondents .60.4% and 39.6% were female and male respectively out of 250 respondents.

Age group

Figure 3.2 shows the age group of the respondents, a majority, 40.4% were middle aged.

Ethinicity

Figure 3.3 shows the

Malay ethnicity is

59.6%, the majority.

Figure 3.4 shows the educa