Jurnal Kesihatan Johor Volume 10 2012

EDITORIAL COMMITTEE

PRINCIPAL ADVISER

DR MOHD KHAIRI BIN YAKUB
DIRECTOR OF HEALTH JOHOR,
JOHOR STATE HEALTH DEPARTMENT
TEL: 07-2245188 FAX: 07-2232603
EMAIL: [email protected]

ADVISER

MRS ROSIDAH MD DIN
STATE DEPUTY OF HEALTH ( PHARMACY ) JOHOR,

JOHOR STATE HEALTH DEPARTMENT
TEL: 07-2272800FAX: 07-2236146
EMAIL: [email protected]

CHIEF EDITOR

DR BADRUL HISHAM BIN ABDUL SAMAD
SENIOR PRINCIPAL ASSISTANT DIRECTOR (PUBLIC HEALTH)

JOHOR STATE HEALTH DEPARTMENT
TEL: 07-2245188 FAX: 07-2277577
EMAIL:[email protected]

EDITORS

DR HJH. MORNI BT ATAN DR SHEILA RANI RAMALINGAM

DEPUTY DIRECTOR (MEDICAL) SENIOR PRINCIPLE ASSISTANT DIRECTOR (ORAL HEALTH)

HOSPITAL SULTAN ISMAIL JOHOR STATE HEALTH DEPARTMENT

TEL: 07-3565000 FAX: 07-3565034 TEL: 07-2245188 FAX: 07-2230467

EMAIL: [email protected] EMAIL: [email protected]

MRS KAMALIAH BT MAT SAMAN

CHIEF PHARMACIST

HOSPITAL PAKAR SULTANAH FATIMAH

TEL: 06-9521901 FAX: 06-9526003

EMAIL: [email protected]

SECRETARY

MR ALI BIN ISMAIL
SENIOR PRINCIPAL ASSISTANT DIRECTOR (PHARMACY)

JOHOR STATE HEALTH DEPARTMENT
TEL: 07-2272800FAX: 07-2236146
EMAIL: [email protected]

MEMBERS

MS LEE CHING YAN MR JEGATHESWARAN PANDERENGEN
ASSISTANT DIRECTOR (PHARMACY)
PRINCIPAL ASSISTANT DIRECTOR JOHOR STATE HEALTH DEPARTMENT
TEL: 07-2272800FAX: 07-2236146
(TRADITIONAL COMPLEMENTARY MEDICINE) EMAIL: [email protected]

TEL: 07-2211787 FAX: 07-2212787

EMAIL:[email protected]

MRS FAIZAH BINTI JURAIMI
PRINCIPAL ASSISTANT DIRECTOR (HEALTH PROMOTION UNIT)

TEL: 07-2224784FAX: 07-2238426
EMAIL: [email protected]

Volume 10

2012

Contents

1 Assessment Of Insulin Adherence And Insulin-related Knowledge Among Diabetic
Patients In Hospital Sultan Ismail, Johor Bahru
Teoh L.R, Lee C.Y, Wasli M.

5 A Pilot study of Drug Administration Errors In A Male Medical Ward At Batu Pahat
Hospital
Ng Xin Yi, Nur Amalina Nasis, Nur Ezzati A. Rahman, Lee Chern Chyi, Chua Pei Ling

13 Analysis On Evaluation Of Quality Of Life In Hypertensive Patients By Using Short Form
36 In The Muar District, Johor
Mohd Anuar AR, Khadijah Ismail, Amran Maarof1

17 Study On Use Of Kaletra® (lopinavir/ritonavir) Among HIV Patients In HSAJB
Ong M.P.

19 Implementing Fly Control – Kluang Experience 2009, North Macap Rest & Relax Area
(R&R)
Norzihan MH, Zuhaida AJ, Mohd Zaki

23 Evaluation Of Molars Restored With Glass Ionomer Cements In The School Dental
Service In Kota Tinggi District
Muz'ini M . Premaa S

28 A Study Of Obesity Among Health Staff At Kulaijaya District Health Department
(2012)
Dr. Mohd Shaiful Ehsan B Shalihin, Poh Lin Chin, Misringaton

33 Evaluation of laboratory outcomes of patients (INR) between clinician-managed
Warfarin therapy and pharmacist-managed Warfarin Medical Adherence Therapy
Clinic (W-MTAC) in HBP over 1 year
Ali Umar Bin Ibrahim, Yvonne Koh Li Ling, Pn. Siti Khairaini Binti Rahim

42 Polypharmacy Of Antihistamines In Cough And Cold Products Used Among Children
Aged Below 6
Wong L.Y., Fajaratunur A.S, Zakiah A.R., Hazlinda A.H.,Goh P.T., Zakaria M.S., ZulRamli Z

47 The Prevalence Of Hearing Impairment Among The Dental Staff In Kota Tinggi
District, Johor
Muz'ini M Thilaka C

52 Prescription Intervention and Prescribing Errors Detected by Inpatient Pharmacy Unit
in Hospital Segamat
Mohd Syahrizam bin Ta'at, Lau Kok Hou

60 A Pilot Study To Assess Patient's Knowledge, Metered-dose Inhaler (mdi) Techniques
And Compliance To Treatment After Medication Therapy Adherence Clinic (mtac)
Asthma
Low Y.B., Tan W.L., Patricia Lim M.H., Yeo L.P

64 A Study of The Effect of Home Water Filtration Systems On Fluoride Content of
Drinking Water in Johor
Loh KH, Yaacob H, Adnan N, Omar S, Jamaludin M

69 Traumatic Abdominal Wall Hernia : A Johor Case Report
YJ Lee, TT Yew, AC Chan

71 Waterborne Bacillus Cereus Gastroenteritis Outbreak In Johor Bahru, Malaysia
Badrul H.A.S., Roslinda A.R., Mohtar A., Siti Khatijah A.R., Zuraidah M., Shamshulbahrin S.,
Norazema S., Mustafa A., Mohd. Ghazali S., Zulfahmi K., Akmalina H., Zaiton Y.,
Maziah M.N.

Assessment Of Insulin Adherence And 1

Insulin-related Knowledge Among Diabetic
Patients In Hospital Sultan Ismail,
Johor Bahru Volume 10

Teoh L.R1, Lee C.Y2, Wasli M.3 2012

1,2,3 Hospital Sultan Ismail, Johor Bahru.

BACKGROUND Insulin is one of the most commonly prescribed
Diabetes mellitus is an important public health concern medications in the hospital as it can be the most effective
both nationally and internationally, due to the increase in drug to achieve glycemic control and prevent long-term
its prevalence and its social and economic results, such as comorbidities. The invention of insulin pen devices (ie
impairment in productivity, quality of life and survival of HumaPen) offers safety, convenience and flexibility, with
individuals, early retirement, high treatment costs and higher acceptability by the patients especially among the
complications.1,2 The World Health Organization elderly. The Joint Commission on Accreditation of
(WHO) reported that 171 million people were living with Healthcare Organizations identified insulin as one of five
diabetes mellitus in the year 2000, and that amount is “high alert” medications that have the greatest risk of
estimated to double by the year 2030.3 In Malaysia, the causing injury to patients because of medication errors.13
prevalence of type 2 diabetes for those aged above 30 Insufficient knowledge of insulin and diabetes
years was 14.9% in the year 2006. The overall prevalence management on the part of health care providers
of diabetes increased by 80% over a decade (8.3% in contributes to errors in insulin use. Consequently, it may
NHMS II year 1996 vs 14.9% in NHMS III year 2006) lead to dangerous but preventable adverse patient
representing an average 8% rise per year.4 outcomes such as hyperglycemia and hypoglycemia.14
The present study focuses on patients' medication
According to World Health Organization Adherence adherence level and insulin-related knowledge; with the
(2003) and Koneru et al. (2008), medication adherence ultimate goal of promoting effective and safe use of
can be defined as the situation to which a person's insulin therapy by improving patients' insulin-related
behavior corresponds exactly with medical or health knowledge, minimizing insulin-related adverse effects,
advice as directed. Noncompliance with prescribed and identifying important criteria to be concerned before
treatment, especially medications, by patients increases running up Diabetes Medication Therapy Adherence
the cost of healthcare and the likelihood of admission to Clinic Hospital Sultan Ismail, Johor Bahru.
the emergency room and hospital, and can lead to
additional illnesses or exacerbation of underlying disease METHODS
(Jean et al., 2006). Poorly controlled diabetes is A descriptive cross-sectional study of insulin-related
associated with development of macro- and micro- knowledge among diabetic patients was conducted in
vascular complications. Therefore, intensive glycaemic Hospital Sultan Ismail, Johor Bahru from 1 May 2011
control is important in decreasing microvascular and until 30 June 2011. The inclusion criteria were diabetes
macrovascular complications in type 1 and type 2 mellitus patients (either type I or type II diabetes mellitus)
diabetes.5-7 Patients' adherence to medication regimens aged 18 years old and above, who had been using
is vital to achieve good glycaemic control. However, HumaPen (Humulin® R, Humulin® N or Humulin®
adherence is still a challenge and many patients are 30/70) and who was able to read and answer the
noncompliant with their oral hypoglycaemic agents and questionnaire independently. The exclusion criteria were
insulin.8 patients aged below 18 years old, patients who was
unable to read and answer the questionnaire
Evidence has proven that patient education improves independently, and mentally impaired, individuals with
patients' adherence and subsequently improves significant cognitive impairment and psychiatric
glycaemic control.9 Pharmacists play a significant role in comorbidity.
educating patients through routing counseling, which A questionnaire consisted of 2 parts was prepared. Part I
helps to improve patient adherence.10 Several studies was designed is to obtain insulin adherence level by using
have shown that collaboration of pharmacists with Morisky Scale. Morisky Scale consists of four-item
physicians in diabetes care improved glycaemic validated adherence predictor scales, using close-ended
control.11,12 In Malaysia, pharmacists collaborate with questions with answer 'YER' or 'NO'. Part II consisted of
physicians in diabetes care through Diabetes Medication 16 multiple-choice questions with a single best answer,
Therapy Adherence Clinic (DMTAC). Penang Hospital is designed to evaluate patient's level of knowledge.
the first centre to start the DMTAC program, which has Questions addressed topics including characteristics of
been operating since 2006 in a specialized diabetes different insulin (Humulin® R, N or 30/70) formulations,
endocrine clinic. storage conditions, causes, symptoms and management
of hypoglycemia or hyperglycemia. In addition, patients

1

were asked for information about their age, gender and and for those that answered partially correct and /or
ethnicity. incorrect were considered as presenting knowledge
Pilot tests were then given to 5 patients in out-patient deficit.
department and 5 patients in medical or surgical wards of
Hospital Sultan Ismail. Questions that appeared to be RESULTS
ambiguous during pilot testing were either corrected or Study population
removed from the final version of the questionnaire. The A total of 85 completed questionnaires were received and
questionnaires were then distributed to the diabetic analyzed; 60 from out-patient department, 21 from
patients who came and refilled their prescriptions at medical wards and 4 from orthopedic wards. All of the 85
outpatient department, as well as those admitted to participants, 2% (n=2) were of age 18-29 years old, 12%
medical or orthopedic wards of Hospital Sultan Ismail (n=10) aged 30-39 years old, 9% (n=8) aged 40-49 years
during the period of research study after informed old, 48% (n=40) aged 50-59 years old, and 29% (n=25)
consent was obtained. Participants were not permitted to aged 60 years old and above. 54% (n=46) were females
ask questions or refer to reference materials such as and 46% (n=39) were males. As for the ethnicity, 46%
product leaflet. A total of 85 questionnaires were (n=39) were Malays, 33% (n=28) were Chinese, 21%
distributed and collected. (n=18) were Indians.
By using Morisky Scale, the participants can be Level of insulin adherence
categorized as low, moderate or high adherence. Score 1 Table 1 showed the results for each item in the Morisky
was given for every 'YES' answer and score 0 was given Scale. 36% (n=31) of the patients reported that they had
for every 'NO' answer. Total score of 0 indicated high been forgotten to take insulin, 32% (n=27) reported
adherence; 1 to 2 indicated moderate adherence whereas careless at times about taking the insulin, 15% (n=13)
3 to 4 indicated low adherence (Guilera et al., 2006). For reported stop taking medication sometimes when they
those participants that answered all categories correctly feel better and 5% (n=4) sometimes stop taking
were considered as having acquired knowledge on insulin medication when they feel worse.

4-items in Morisky Scale Yes (%) No (%)
36 64
1. Do you ever forget to take your insulin? 32 68

2. Are you careless at times about taking your 15 85
insulin?

3. When you feel better do you sometimes stop
taking your insulin?

4. Sometimes if you feel worse when you take 5 95
the insulin, do you stop taking it?

Table 1 : Morisky Scale to Evaluate Level of Insulin Adherence

Results from Morisky Scale showed that 64% (n=54) of Level of insulin-related knowledge
the diabetic patients were classified as high adherence,
followed by 35% (n=30) as moderate adherence; and 1% For the 16 knowledge-based questions, results
(n=1) as low adherence. showed that 11% (n=9) of the patients scored 100%,
where all of the questions were answered correctly; 50%
Level of insulin adherence (n=43) scored 75-99% and 39% (n=33) scored 50-74%.
None of the patients scored less than 50%.
1%

35% Overall scoring marks

64% 39% 0% 11% 100%
50% 75-99%
High adherence Moderate adherence Low adherence 50-74%
< 50%
Figure 1: Proportion of Patients with High,
Moderate and Low Adherence Figure 2: Overall Scoring Marks for Level of
Insulin-Related Knowledge

2

Knowledge on insulin characteristics frequency of administration; and promote patients'
adherence to insulin therapy. Self-recognition of
68% of the patients were able to differentiate hypoglycemia or hyperglycemia through monitoring of
their insulin based on the colour of the strip at the bottom symptoms and blood glucose measurement; as well as
of Humulin® cartridge whereas 78% were able to proper management of hypoglycemic symptoms is
differentiate their insulin based on the appearance of important to decrease the risk of hospitalization and
Humulin® formulations. 58% of the participants mortality.
presented adequate knowledge on the appearance of
Humulin® formulations which indicates of instability. Upon collecting each completed questionnaire,
brief explanation and discussion around the rationale
Knowledge on insulin storage and its expiry date behind each correct answer were given. This helps to
increase participant attention and interest, achieve
Majority of the patients (85%) understood the effective and safe use of insulin therapy, and decrease
proper storage conditions for unopened and opened incidence of insulin-related reactions besides improving
Humulin® cartridge. However, Only 37% (n=31) of the patient adherence to insulin therapy, clinical outcome and
participants presented with knowledge that Humulin® quality of life. However, there are some limitations in this
cartridge may be used for up to 28 days once in use. study. Study sample and data were obtained from a single
hospital and may not be representative of the whole
Knowledge on symptoms and management of Malaysian population with diabetes mellitus. Reliability
hypoglycemia or hyperglycemia of Morisky Scale was compromised because of the
dichotomous of the response scale and the small number
76% of the patients understood that of items in the questions (Voils et al., 2005).
hypoglycemia is brought about by taking too much
insulin and hyperglycemia is brought about by stop taking Using this study as a pre-test may be effective to
insulin or taking less insulin than prescribed. 85% evaluate the level of insulin adherence and insulin-related
reported that hypoglycemic symptoms may include knowledge among diabetic patients in Hospital Sultan
sweating, hunger and dizziness. Majority of the Ismail before establishment of Diabetes MTAC.
participants 93% reported that mild to moderate Moreover, it can be used to identify important criteria to
hypoglycemia can be treated by eating or drinking sugar- be concerned while running up Diabetes MTAC in
containing foods. All of the participants claimed that Hospital Sultan Ismail and understand how diabetes
blood glucose monitoring helps patients to confirm education can best be optimized. In this sense, future
hypoglycemia or hyperglycemia immediately. studies should be carried out to assess the impact of
established Diabetes MTAC towards diabetic patients'
DISCUSSION therapeutic outcome.

Lack of knowledge on the medication has had a The present study showed that majority of the
strong impact in health and quality of life of people patients showed high adherence to insulin therapy and
especially those with one or more chronic health most of them were presented with insulin-related
conditions.16 Clear and accurate information regarding knowledge as none of the patients scored less than 50%.
insulin therapy to control diabetes mellitus provided by Therefore, the future establishment of pharmacist-
qualified health professionals may encourage patients to managed Diabetes Medication TherapyAdherence Clinic
self care and adherence to insulin therapy besides in Hospital Sultan Ismail may aim to improve patients'
promoting safe and effective use of insulin. Therefore, glycaemic control and therapeutic outcome via HbA1c
pharmacists play vital role in educating patients on ways and fasting blood glucose (FBG) monitoring.
to differentiate various types of Humulin® formulations,
proper storage conditions for unopened and opened CONCLUSION
Humulin® cartridge, possible insulin-related reactions In summary, 64% of the diabetic patients were reported as
such as hypoglycemia and hyperglycemia and how to high adherence, followed by 35% as moderate adherence;
treat these effectively. A well-structured Diabetes and 1% as low adherence. Majority of the patients were
Medication Therapy Adherence Clinic may fill the gaps presented with insulin-related knowledge. Health care
in knowledge of patients with diabetes mellitus for better professionals including physicians, pharmacists, nurse
therapeutic outcome. practitioners and endocrinologists play vital role in
educating diabetic patients regarding insulin-related
Knowledge on the appearance of Humulin® knowledge to improve their insulin adherence level. The
cartridge and formulations helps patients to differentiate future establishment of pharmacist-managed Diabetes
their insulin type without affected by the problem of poor Medication Therapy Adherence Clinic in Hospital Sultan
visual acuity as diabetic retinopathy is one of the common Ismail may aim to improve patients' glycaemic control
diabetes complications associated with long-standing and therapeutic outcome via HbA1c and fasting blood
diabetes mellitus.15 Besides that, knowledge on the glucose (FBG) monitoring since majority of the diabetic
appearance of Humulin® formulations which indicates of patients showed high adherence to insulin therapy and
instability and proper storage conditions for unopened were presented with insulin-related knowledge.
and opened Humulin® cartridge is required to ensure
effective and safe use of insulin therapy for positive
therapeutic outcome. Information on the causes of
insulin-related reactions may improve patients'
awareness on insulin therapy regarding the dose and

3

REFERENCES 9. Goudswaard AN, Stolk RP, Zuithoff NP, de Valk HW,
Rutten GE. Long-term effects of self-management
1. Sociedade Brasileira de Diabetes. Tratamento e education for patients with Type 2 diabetes taking
acompanhamento do diabetes mellitus: diretrizes da maximal oral hypoglycaemic therapy: a randomized trial
Sociedade Brasileira de Diabetes. Rio de Janeiro: in primary care. Diabet
Diagraphic; 2006. Med. 2004;21(5):491-496.

2. White paper on the prevention of type 2 diabetes and 10. Lindenmeyer A., Hearnshaw H., Vermeire E., Van
the role of the diabetes educator. Diabetes Educ. Royen P., Wens J., Biot Y. Interventions to improve
2002;28(6):964-8, 970-1. adherence to medication in people with type 2 diabetes
3. Wild S, Roglic G, Green A, Sicree R, King H. Global mellitus: a review of the literature on the role of
Prevalence of Diabetes. Estimates for the year 2000 and pharmacists. J Clin PharmTher. 2006;31(5):409-419.
projections for 2003. Diabetes Care. 2004;27:1047-1053.
11. Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk
4. Mafauzy M. Diabetes Mellitus in Malaysia. Med J Van JT, Assendelft WJ. Interventions to improve the
Malaysia. 2006;61(4):397-398. PREVALENCE OF management of diabetes in primary care, outpatient, and
DIABETES MELLITUS IN MALAYSIA IN 2006– community settings: a systematic review. Diabetes Care.
RESULTS OF THE 3RD NATIONAL HEALTH AND 2001;24:1821-1833.
MORBIDITYSURVEY (NHMS III)[cited 2011 Feb 12].
Available from: 12. Ramser KL, Sprabery LR, George CM, Hamann GL,
Vallejo VA, Dorko G.S, Kuhl DA. Physician-pharmacist
5. The DCCT Research Group. The effect of intensive collaboration
treatment of diabetes on the development and progression
of longterm complications in insulin-dependent diabetes 13. JCAHO suggests ways to prevent medical errors.
mellitus. N Engl J Med. 1993;329(14):977-986. Healthcare Risk Man 22:19 –20, 2000

6. U.K. Prospective Diabetes Study Group. Association 14. Smith WD, Winterstein AG, Johns T, Rosenberg E,
of glycaemia with macrovascular and microvascular Sauer BC: Causes of hyperglycemia and hypoglycemia in
complications of type 2 diabetes (UKPDS 35): adult inpatients. Am J Health Syst Pharm 62:714 –719,
prospective observational study. BMJ. 2005
2000;321(7258):405-412.
7. U.K. Prospective Diabetes Study Group. Intensive 15. The Wisconsin epidemiologic study of diabetic
blood-glucose control with sulphonylureas or insulin retinopathy. III. Prevalence and risk of diabetic
compared with conventional treatment and risk of retinopathy when age at diagnosis is 30 or more
complications in patients with type 2 diabetes (UKPDS years.[cited 2011 May 5]. Available
33). Lancet. 1998;352(9131):837-853. from:http://www.ncbi.nlm.nih.gov/pubmed/6367725/

8. Cramer JA. A systemic review of adherence with 16. Williams B. Medication education. Nurs Times.
medications for diabetes. Diabetes Care. 1991;87(29):50-2. (Acta)
2004;27(5):1218-1224.

4

A Pilot study of Drug Administration 2
Errors In A Male Medical Ward Volume 10
At Batu Pahat Hospital
2012
Ng Xin Yi, Nur Amalina Nasis, Nur Ezzati A. Rahman,
Lee Chern Chyi, Chua Pei Ling

1.1 Background of Study 1.3 Significance of Study
According to the National Coordinating Council for This study is significant because administration errors are
Medication Error Reporting and Prevention more likely to reach patients and they have a high
(NCCMERP), medication error is defined as “any potential for causing patient harm. Drug administration
preventable event that may cause patient harm or lead to errors appear to be a major source of iatrogenic harm to
inappropriate medication use while the medication is in hospitalized patients [16]. Drugs are prepared and
the control of the health care professional, patient, or administered to in-patients by the nurses in the wards.
consumer. Such events may be related to professional This study will increase the awareness of ward staff
practice, health care products, procedures, and systems especially nurses concerning such problems.
including prescriptions; order communication; product
labeling; packaging; and nomenclature; compounding; 1.4 Aim of Study
dispensing; distribution; administration; education; The aims of the study are to quantify the type and
monitoring; and use” [1,2]. The occurrence of the frequency of drug administration errors committed at the
medication errors is not a new issue. In fact it is a common medical wards and to identify contributing factors
occurrence faced by health care teams globally. In the towards this blunder.
United States of America (USA), there were
approximately 1%-2% of patients harmed by such errors 1.4.1 Objectives
[4] whereas 3.7% hospitalization in New York, USA in 1. To identify the frequency of drug
1991 was caused by such medication errors with 13.6%
leading to death [5]. Medication errors can be classified administration errors at Medical Ward No. 3
into prescribing, dispensing and administration errors. 2. To identify the drug administration error
Among these errors, administration mistakes account for 3. To identify factors which contribute to drug
the majority of events.
Drug administration errors are the second most frequent administration error
type of medication errors after prescribing errors. A drug 4. To identify the types of drug commonly
administration error is a discrepancy between the drug
therapy received by the patient and the drug therapy wrongly administered
intended by the prescriber [9]. Administration error is the
administration of a dose of medication that deviates from 2.1 Definition
the prescription, as written on the patient medication Drug administration is an activity that is prone to errors
chart, or from standard hospital policy and procedures. due to rapid development in medical technology because
This includes errors in the preparation, and of different types of drugs and increasing complexity of
administration of intravenous medicines in the ward. medical devices as well as the number of medications
These errors can be further classified into wrong drugs; being introduced into the market [9, 12]. There are also
wrong route; wrong dose; wrong patient; wrong timing of various routes of administration, different dosages,
drug administration; a contra-indicated drug for that dosage forms and dosing regimens which are often
patient; wrong site; wrong drug form; wrong infusion changed according to patient's clinical condition and
rate; expired medication date; or prescription error. diagnostic test results. Lack of awareness for those
various route, dosage and regimen of medication by the
1.2 Statement of Problem staff or nurses during drug administration can lead to
Medication errors (prescribing, dispensing and errors.
administration errors) were an important cause of patient Drug administration error is “defined as a discrepancy
morbidity and mortality [1]. Administration errors are a between the drug therapy received by the patient and that
common sub-type of medication errors and accounted for intended by the prescriber or according to standard
34% of errors in the study carried out by Bates et. a.l, hospital policies and procedures” [5, 9, 13] . Haw et al.,
1995. [23] 2007 also defined drug administration error as a
In the study carried out by Leape and his colleagues, “deviation from a prescriber's valid prescription or the
administration errors were found to account for 38 hospital's policy in relation to drug administration,
percent of drug-related errors. [6] [7] including failure to correctly record the administration of
a medication”.

5

2.2 Incidence of DrugAdministration 2.4.1 Incorrect Time
The study of drug administration that was conducted at An incorrect time error was defined as the administration
St. Andrew's Hospital, Northampton, United Kingdom of drugs more than 60 minutes before or after the
had shown a total of 369 errors committed per 1423 doses scheduled administration time by Barker et al, 2002 [5].
(25.9%). The independent pharmacist who reviewed the Some studies count a drug delivered 30 minutes late and if
medication charts detected 148 administration errors. The the drug delayed until the next dose is due as a wrong-
types of errors detected were as follows: 133 omissions, 9 time error [9].
unauthorized extra doses, 5 wrong times and 1
administration of a discontinued item [17]. 2.4.2 Incorrect Dose
Barker et al, 2002 conducted a study on hospitals Incorrect dose was defined as any dose of preformed
accredited by the Joint Commission on Accreditation of dosage units (such as tablets) that contained the wrong
Healthcare Organizations, non accredited hospitals, and strength or number. Incorrect dose for an injectable
skilled nursing facilities in Georgia and Colorado. In the product means any dose that is ±10% or more different
36 institutions, 19% of the doses (605/ 3216) erred. The from the correct dosage and if any other dosage form, then
most frequent errors by category were wrong time (43%), any dose that was ±17% or more of the correct dose [5]. In
omission (30%), wrong dose (17%), and unauthorized the case of ointments, topical solutions, and sprays, an
drug (4%). Seven percent of the errors were judged error occurs only if the medication order expresses the
potential adverse drug events. dose quantitatively for examples 1 inch of ointment or
In a local study by S.S.Chua et al, 2009 which was two 1-s sprays [13]. Medications must be administered at
conducted at the hematology ward of a teaching hospital the correct time to ensure therapeutic serum levels [15].
in Malaysia, an error rate of 11.4% (95% CI 9.5–13.3)
was established. Of the 127 doses with errors, eight had 2.4.3 Unauthorized or Unordered Drug
two types of errors, giving a total of 135 administration Unauthorized or unordered drug defined as the
errors. administration of a dose of medication that had never
been ordered for that patient [5]. This category includes a
2.3 Classification of Medication Error Severity drug given to the wrong patient, administration of an
Haw et al, 2007 rated the error severity based on a five- unordered drug, duplicate doses and extra doses not
point scale which had previously been used in a ordered but administered, and a dose given outside a
medication error research and entails the following :- stated set of clinical parameters [8, 13].
Grade 1—errors or omissions of doubtful or negligible
importance; Grade 2—errors or omissions likely to result 2.4.4 WrongAdministration Technique
in minor adverse effects or worsening condition; Grade Wrong administration technique errors comprised all
3—errors or omissions likely to result in serious effects or errors concerning the administration technique: crushing
relapse; Grade 4—errors or omissions likely to result in errors (crushing a tablet that should not be crushed
fatality; Grade X—unreadable (due to lack of clinical and because it is enteric coated),unsupervised intake of
other information). medication by the patient (for example patient with
Administration errors were classified into 9 classes of Alzheimer's disease need to be supervised to take
seriousness from the National Coordinating Council for medication), wrong technique for administering
Medication Error Reporting and Prevention inhalation preparations (not shaking the pressurized
(NCCMERP) taxonomy of medication errors: A—an metered inhaler before use), wrong technique for
error has been made but the medication does not reach the dissolving effervescent tablets (crushing instead of
client; B—an error has been made and the medication dissolving in water and administering after all bubbles
reaches the client, but no harm is done because the have disappeared) [14]. Wrong administration technique
medication is not administered; C—medication is a situation which a drug is given via the correct route
administered but no harm; D—an error has been made and site but improper technique is used [13].
which results in an increased frequency of monitoring,
but no harm is done; E—an error has been made resulting 2.4.5 Omission Error
in temporary harm necessitating treatment; Van Den Bemt et al, 2009 stated that omission errors
F—temporary harm resulting in an increased length of consisted of errors regarding not giving the medication to
hospital stay (in hospitalization of the client); the patient, which can arise by forgetting the
G—permanent damage; H—client nearly dies; I—an administration or by giving the medication to the wrong
error has been made which results in the death of the patient. However, if the patient refused to take the
client [19]. medication, no error has occurred. Likewise, if the dose is
not administered because of recognized
2.4 Types of Drug Administration Errors Usually contraindications, no error has occurred. (Greengold et al,
Occur 2003). Omissions were detected by comparing the
Drug administration errors can be classified into 11 medications administered at a given time with doses that
categories which are incorrect time, incorrect should have been given at that time based on the
administration technique, unauthorized or unordered physician's written order and protocols (Barker et al,
drug, incorrect preparation, incorrect dose, omission 2002).
errors, incorrect rate, incorrect drug, deteriorated drug,
extra dose, incorrect drug and other errors which were not
specified [5, 12].

6

2.4.6 Incorrect Rate drug administration errors. Individual staff characteristic
Incorrect rate defined as administration of a drug at the (knowledge and skills) is one of the reasons that can cause
wrong rate, the correct rate being that given in the drug administration errors. Wakefield et al stated that
physician's order or as established by hospital policy. The individual staff characteristics such as lack of knowledge
cytarabine to infuse over 3 hours but infused for 2 hours of the patient, or the patient's diagnosis, and the names,
and also vancomycin to infuse over 2 hours but infused purposes, and correct administration of the medication
over 30 minutes were the result of incorrect rate in the are the factors that contribute to medication errors for
study of drug administration error by S.S.Chua et al, example, knowledge of pharmacology will allow the
2009. The most common type of administration error in nurse to correlate it with the disease, diagnostic test
the ward was wrong rate error (73 out of 83 injections) results and clinical status [9]. Thus it will improve the
which were given faster than recommended [20]. detection errors and promote the detection of
contraindications and adverse effects.
2.4.7 Incorrect Preparation Lack of attention to safeguards intended to prevent errors
Incorrect preparation is also one type of administration in medication administration procedures as a result of
error. Greengold et al, 2003 stated that incorrect failure to comply with policies and procedures is the main
preparation of the medication dose include incorrect factor in drug administration errors [8, 9]. For example,
dilution or incomplete reconstitution, not shaking a staff did not check patient identification, allergy
suspension and mixing drugs that are physically or identification wristbands, medication against the
chemically incompatible. For example, when medication administration record (MAR) and receiving
Amphotericin B is not properly diluted, some powder is medications late from the pharmacy [9]. When a nurse
still left in the vial and thus, when a nurse bends the needle administers the medication, they must sign the
to syringe the drug out of an ampoule, it will cause a spill medication chart to provide evidence that the medication
onto the floor [12]. has been administered to the patient. Signing the
medication chart before the medication has been
2.4.8 Incorrect Drug administered is a risk, as the patient may refuse their
Incorrect drug is an error in which medication was medication or forget to take them. Similarly, failure to
wrongly given to the patient and totally different from the sign when a medication has been administered creates the
prescribed medication [10, 15]. This type of errors seems risk that another nurse may assume that it has not been
to have high potential to cause harm to the patient. For administered, and repeat that dose [15]. Drug
example, hydrochlorothiazide instead of spironolactone administration errors can also be caused by the lack of
[18] given and mefenamic acid 500 mg given instead of standard protocols for the administration of high-risk
tranexamic acid 500 mg [12]. These situations happened medications such as chemotherapeutic drugs and
because nurses misread drug names and misread antiarrhythmics [8].
medication file [12, 18] Failure or breakdown in communication is another factor
that contributed to the drug administration errors. (Pepper
2.4.9 Deteriorated Drug GA, 1995; Wakefield et al, 2005). These may include
Use of expired and unusable drugs in administration illegible handwriting, oral orders, transcription errors,
drugs are errors in which deteriorated drugs can cause less use of abbreviations, incorrect interpretation of
or no effectiveness towards the treatment. physician's orders, failure to document medications given
or omitted and unclear MARs. In spite of how accurate or
2.4.10 Extra Dose complete a prescription is, it may be misinterpreted if it
Barker et al, 2002 defined an extra dose as an error in cannot be read. The prescriber is the one who has a
which any dose given in excess of the total number of professional responsibility to issue a safe and legible
times ordered by the physician i.e. it can be a dose given prescription. However due to haste, fatigue or a lack of
based on the expired order, or after a drug has been understanding of the importance of clear prescribing, it
discontinued, or after a drug has been put on hold. may contribute to illegibility. In addition, poorly written
prescriptions may delay administration of medications.
2.5 Types of Drug Contribute To Error System issues such as workload and type of care delivery
S.S.Chua et al stated in their study that intravenous (iv) system can also cause drug administration errors. These
drug administration is significantly more likely to be include number of consecutive hours worked, staff mix
associated with medication errors than the oral routes and numbers, nurse-to-patient ratios, distractions and
(21.3% vs. and 7.9%). An i.v. dose was defined as an interruptions while administering to perform other duties,
administration of a drug directly into the vein via rotating shifts, assignment of floating nurses to
injection or infusion and included preparation of the drug unfamiliar units and hospital-and pharmacy-design
dose. Errors associated with i.v. administrations were features. Information resources, such as published drug
mainly caused by wrong administration rate and guides, may not be readily available or up to date. Drug
technique, similar to that reported by Wirtz et al [20]. manufacturers also contribute to medication errors by
Wrong i.v. administration rate was the second most producing look-alike and soundalike drug names,
frequent clinical error with 35.7% of these errors rated as confusing and unclear labeling, and confusing packaging
being of major severity [21]. of doses for example multidose vials which similar
packaging for different medications [8]. Pharmacies
2.6 Factors that Contribute To Error processes also can cause drug administration errors by
There are some possible reasons or factors that can cause delivering incorrect doses, not preparing the medications

7

correctly and not labeling the medications correctly 3. The observer would tag the nurse responsible for
(Wakefield et al, 2005). the drug administration on that shift.
4. Registration number of the particular patient was
METHODOLOGY recorded on an observational sheet.
3.1 Study Design 5. The process of drug preparation until
This study was of a cross sectional design using (i) direct administration to the patient by the nurse would be
observation and (ii) medication chart review (CMR). It observed.
was conducted at the medical male ward (no. 3) at the 6. Any drug administration errors would be
Batu Pahat Hospital from 10 May to 23 June 2011 during recorded. The 'near miss' error would also be recorded
the working hours on weekdays. The observers observed in the observational sheet as an error.
the drug administration in the morning (8.00 a.m.) and 7. The observers would intervene upon the nurse for
evening shifts (4.00 p.m.). The nurses were unaware of the 'near miss' error prior to drug administration.
the objectives of the study. They were only informed that
there will be provisionally registered pharmacists to tag 3.3 Outcome Measure
with them to observe and study the medication The types of administration errors used in this study are
distribution system. Patient's registration number and based on The Guidelines on Medication Error Reporting
observational data such as name of the medicine, dose, by Ministry of Health, Malaysia. The administration
frequency, and route were taken from CMR and recorded errors are categorized into 13 types of errors which are
in the observational sheet. The observers recorded all the prescribing, omission, wrong time, unauthorized drug,
errors that occurred during drug administration. dose, dosage form, drug preparation, routes of
administration, administration technique, deteriorated
3.2 Study Population drug, monitoring, compliance and other medication
The male medical ward can accommodate up to 50 errors.
patients. The ward consists of Malay, Chinese, Indian and
patients of other races whose ages range from 12 to 80 3.4 DataAnalysis
years old and above. At the time of the study, 5 nurses Descriptive statistics are used to explore the data
were working in this ward. There were three working collected in this study. The frequency distribution and
shifts for the nurses, which were 7.00 a.m. to 2.00 p.m. measures of central tendency and variability (mode,
(morning shift), 2.00 p.m to 9.00 p.m. (evening shift) and median or mean) of data collected has been analyzed by
9.00 p.m to 7.00 a.m.(night shift). The drug using SPSS version 15.0 for windows. Drug
administration on morning and evening shifts were administration errors data were analyzed using
observed. The nurses were responsible for the preparation descriptive measurement which compared the percentage
and administration of the medicines for each patient error of oral administration versus intravenous (i.v.)
according to the prescriptions. administration.
All the observational data and medicine were compared
with the written medication orders by the observers. The RESULTS
observers will intervene and inform the nurse prior to 4.1 Frequency of DrugAdministration Error
drug administration when they detect an error which was A total of 400 doses was observed throughout the two
about to be committed by the nurse, known as a 'near miss' weeks of study period. Most of the observed doses were
error but was also recorded in the observational sheet as oral (131 errors, 81.37%) and the rest were i.v doses (30
an error. errors, 18.63%). The total number of errors was 161 (SD:
1.907). Thus, the error rate was at 40.25%.
The study procedures are listed as below:
1. Two observers would be stationed in the ward 4.1 Types of DrugAdministration Errors
during the study period. The types of drug administration errors are shown in
2. The observers would follow the drug Figure 4.1 and the percentage of drug administration
administration for two working shifts of the nurse errors are shown in Figure 4.2.
which comprised the morning and evening shifts.

T yp es o f Dru g A d min i s tratio n E rro rs

In c orrec t tim e 28 89
O m is s ion e rro r 90 100
T yp es o f E rro rs Inc orrec t do s e 14 Figure 4.1
Inc orrec t prep aration 13 Types of Drug Administration
Unordered/u nauth oriz ed drug Errors
6
O thers 4
In c orrec t drug 2
D eteriorated drug 2
1
E x trado s e 1
Inc orrec t rate 1
Inc o rre c t adm in is tration tec hn iq ue

0 10 20 30 40 50 60 7 0 80
Fre q u en cy

8

Figure 4.2 Percentage of Drug
Administration Errors

Amongst the types of administration errors, incorrect timing was highest (89 doses; 55.28%), followed by omission
errors (28 doses; 17.4%). The four errors under 'Others' included the usage of the same cup to administer medications
to all patients, without cleaning it.

4.3 Factors Which Contribute to Drug Administration Error

Table 4.1 shows the error rate of drug administration errors according to the route and the time of administration.

Table 4.1 Factors Which May Be Associated With Drug Administration Errors

Factors Number of doses with errors Total number of % errors
doses
Route of administration 30 69.77
.v route 131 43 36.69
Oral route 357
Time 102 34.93
Morning shift 59 292 54.63
Evening shift 108

4.4 Types of Drug Contribute to Drug Administration Error

T y p es o f D ru g C o n trib u te to D ru g A d m in is tratio n
E rro r A c c o rd in g to A T C C la s s if ic a tio n

40 37 35
Frequ enc y of Drug
nue tarir,ctiaonrnodisaoevngaadasnabscldtnorutieloiooainrndronfdtsepodeicchysstirasitoitvrAnnreenedadsymlexrm ini s tratio n E rro r35

an alges ic3024 21
gdeennrietmouarutorilolnooaggryyy25
emerg enc y

ps yc hiatry
re spiratory
20 16

15 10 9
10
5 32 1 11 1

0

A TC C la ss ific a tio n

Figure 4.3 Types of Drugs Contribute to Drug Administration Error According to ATC Classification System
Figure 4.3 shows that most errors were committed during administration of the antiinfectives class (37 errors),
followed by cardiovascular system class (35 errors) and nutrition and blood disorder class (24 errors).

9

DISCUSSION giving medication at the prescribed time, the medication
5.1 Frequency of DrugAdministration Error trolley can then be returned to the satellite pharmacy for
The results showed that drug administration errors were the next ward order/ indents/drug requirements.
common in male medical ward in Hospital Batu Pahat. Intravenous drug administration is a complex process that
The error rate was 40.25% which included incorrect time usually requiring the preparation of the medication in the
error. clinical areas before administration to the patient [20, 22].
In this study, i.v. drug administration was more associated
5.2 Type of DrugAdministration Error with medication errors than the oral route (93.3% vs. and
Incorrect time errors were the most common type of 37.05%). Wirtz [20] also reported i.v. drug administration
errors in this study but many of these errors were not error rate of 34%. Errors associated with i.v.
likely to cause patient harm except for drugs that require administrations in this study were mainly caused by
close serum concentration monitoring especially incorrect time and incorrect drug preparation, similar to
antibiotic. Incorrect time errors consisted mainly of that reported by Cousins et al [22]. Incorrect drug
medications not given at the time ordered on the preparation was mainly related to wrong suitable diluents
medication lists which mostly within a 60 minute margin. being used to dilute certain medicines. For examples, i.v.
But other examples from this category concern wrong Amikacin 250 mg was supposed to be diluted with normal
time of intake in relation to meals (before, with or after saline instead of sterile water for injection while i.v
meal) which is more clinically relevant. In other study Meropenem 1 g should be diluted with 20 mL of sterile
stated that when medication given too early and too late or water for injection instead of 10 mL normal saline.
when intake before and after meal, it falls into class C Sometimes the reconstitution of dry powder injections
seriousness which not give harm to the patient [14]. also incompletes. Other errors included administered the
intravenous doses at the wrong rate and usually too
Omission errors were the second error that mostly quickly and administering the product too late or too early
occurred in these four week period of our study. There are after mixed with diluents. For example, the
some reasons why the medications were not given to the administration of i.v. bolus Gentamycin should take
patients during administration from our observation. about 2 to 3 minutes instead of a minute.
Omission occurs because there were no stock of
medication during administration and nurses forgot to Aseptic methods for preparation intravenous medications
indent medication from pharmacy. Sometimes the nurses were also observed in this study. The preparation process
also rushed to do other task in the ward and did not aware include cleaning the preparation area and washing hands
about patient's medications. The omission occurs because or wearing gloves, disinfecting vials, ampoules and
the nurse did not see the dose that should be given, the additive ports with alcohol impregnated swab [22]. Most
drug could not be located in the trolley, or the drug was of the time, the preparation area was cleaned with alcohol
not available. Usually they were omitting to give but not with a proper technique. Hands were washed and
medication when it was unavailable [10]. non-sterile gloves were worn during drug preparation.
The tops of vials were never wiped with alcohol
5.3 F a c t o r s W h i c h C o n t r i b u t e t o D r u g impregnated swabs in all preparation during our study.
Administration Errors The techniques of reconstitution of parenteral medication
One of the most possible causes of incorrect time errors in and of handling needle and syringe by the staff nurse were
the ward was heavy staff workload [8, 12]. The scheduled not followed the proper method. Training in drug
time for drug administration in the ward was the busiest administration technique and preparation as well as
time when nurses have to make the patient's beds, monitor awareness programmes should be conducted.
patients' physical signs, indent and prepare medications
in the ward and also assist the doctors on their ward 5.4 Types of Drug Which Contribute to Drug
rounds. From this study, there was usually only one nurse Administration Error
in charge of three cubicles to dispense medication to all Anatomical Therapeutic Chemical (ATC) classification
patients. Sometimes the other nurses will help to give systems provide a global standard for classifying medical
medication in which each of them will be assigned to one substances and serves as a tool for drug utilization
cubicle to ensure that medication was dispensed in time. research. The WHO recommends the ATC system for
Some nurses were also engaged in less important work international comparisons. In this study, ATC
rather than give medication on time to the patient. Nurses classification has been used to categorize the type of drug
may wonder how close to the prescribed time a that contributes to drug administration errors.
medication should be administered. There is no absolute Anti-infectives (antibiotics) followed by the
answer to this question. Practical or system factors will cardiovascular system drugs commonly contribute to
influence the actual time of administration. The guiding drug administration errors. The correlation of antibiotics
principle is that medications should be administered as with administration errors was most pronounced which
closely to the prescribed time as possible [15]. This may can be explained by the fact that antibiotics are given in
be achieved when the drug administration schedule was short courses and thus are not part of the long-term
planned such that not all patients take their medication at medication of the patient. The nurse attendant builds up
8.00 am. One other possible solution is to increase the routine with long-term medication but is more likely to
number of ward staff especially the number of nurses who make administration errors with medication that is given
give medication to patients [12]. When the nurses finish for short-term courses [14].

10

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12

3

Analysis On Evaluation Of Quality Of Life In
Hypertensive Patients By Using Short Form Volume 10

36 In The Muar District, Johor

Mohd Anuar AR1, Khadijah Ismail2, Amran Maarof1 2012

1Muar District Health Office
2Hospital Pakar Sultanah Fatimah, Muar

Summary Key words: Hypertension, Quality of Life, SF-36,
Physical Component, Mental Component, Correlation
Objective: Hypertension is one the most common chronic test
disease in Muar. This study was done to determine the
impacts on quality of life among hypertensive patients Introduction
using SF-36.
High blood pressure disease is a silent killer. It can cause a
Materials and Methods: Patients' quality of life using SF- lot of serious complications and lead to an early or sudden
36 was generated from a cross sectional study of 460 death. The normal complications of high blood pressure
hypertensive patients who had came for treatments at the or hypertension are strokes, kidney failure, and heart
government health clinics in Muar district. The data of attack. According to the World Health Organisation
SF-36 was collected by interviews from November 1st (WHO) 13% of deaths in the world are contributed by
2010 until January 31st 2011. The data was tabulated and hypertension and it is expected that the weightage ratio on
analyzed using SPSS software. Quantitative data was unseparated disease especially hypertension will be
described using median value and interquartil range. increasing to 57% by the year 2020 worldwide (WHO,
Meanwhile, a correlation test was performed to show the 2002).
correlation between variables studied.
In Malaysia, hypertension is one of the main public health
Results: The study showed that among the hypertensive problems. In the year 1996, the disease prevalence of
patients, the physical component (Median=72.50, blood pressure (BP) >140/90mmHg among adults aged
IQR=56.50-80.75) were more affected compared to the 30 years old and above is 29.9% and equivalent to 2.1
mental component (Median=73.63, IQR=65.00-80.50). million people. The research showed that hypertension is
Among domains in physical component the lowest score the highest among Malay adults aged 25 years old and
was general health (Median=62.00, IQR=52.00-72.00), above which is 15% followed by Chinese with 14.1% and
bodily pain (Median=62.00, IQR=52.00-74.00), physical Indian with 12.3% (MOH, 1996).
functioning (Median=80.00, IQR=55.00-90.00) and the
best score was physical role (Median=100.00, Hypertension is one of the most chronic diseases suffered
IQR=50.00-100.00). Whereas, for mental component the by the population. The numbers of average cases (old and
lowest domain score was energy (Median=65.00, new) annually is 8316.6 people a year from the year 2000
IQR=55.00-75.00), mental health (Median=72.00, to 2005 of which the average for the new cases is 1572.6
IQR=64.00-80.00), social functioning (Median=75.00, people a year. Until the end of year 2005, out of 10,631
IQR=62.50-87.50) and the best score was emotional role screened, there were 3,601 (33.87 %) people suffering
(Median=100.00, IQR=100.00-100.00). The correlation from hypertension and 21,229 people still receiving
test showed the association between physical and mental treatments (JKN, 2005). Since the disease is affects a
component (r = 0.695, p<0.001), the association between large number of people, it gives impact on the cost of
duration of having hypertension to mental component (r = health care. Additionally, the effects on family and
- 0.245, p<0.001) and the association between duration of society will surely affect the quality of health among
having hypertension to physical component (r = - 0.218, those patients with hypertension.
p<0.001).
Since the last two decades, patients' perspectives on their
Conclusion: The longer duration of hypertension will health conditions especially connected to psychosocial
lead to a higher deterioration on the quality of life. aspect have been taken into consideration as a main
Secondly, better physical components help in controlling component in evaluating health level instead of only the
the blood pressure, thus avoiding them from clinical aspect (Hopman WM, 2003). The change has
complications such as strokes and heart attacks, which in created a research scope known as quality of life where
turn contribute to patients' better mental health. These both aspects on physical and mental (psychosocial)
factors will be able to directly help hypertensive patients' health of the patients are given consideration.
compliance to treatment and medication.

13

According to Gill TM, 1994, the evaluation on quality of function, 5 on mental health, 5 on public health, 4 on
life in clinical investigations, in addition to determine physical roles, 4 on energy, 3 on emotional role, 2 on
different group of patients, predicting the end result of social functions, 2 on body pain and 1 on Health Changes
one's patient, but also for evaluating the health and
treatment programmes implemented. The evaluation of Statistical Analysis
quality of life normally affects patient's physical aspects,
psychological and social life. Data have been analyzed using the SPSS software version
12.0. The significant value is p<0.05. Meanwhile, for the
As hopefulness to the disease's condition and ability to descriptive analysis on quantitative data, the median
overcome limitations or disease problems can influence value and interquartile range have been used. Correlation
patients' perceptions and life satisfaction, therefore it is test have been used in order to show the relationship of the
possible for two patients of the same disease to have quantitative data.
different level of quality of life.
Results
Based on the research by Hassan NB et al.2005, it is found
that, patients' failure in adhering to treatment needs can From the total number of 460 respondents, the research
affect their quality of life besides making them results showed that the median score for mental
impossible and much more tougher to be cured and also component is higher with the value of 73.63 (65.00-
inviting complications such as cardiovascular system 80.50) when compared to the score of physical
problems, kidney diseases and as well as increasing the component with the value of 72.50 (56.50-80.75) (Table
treatment costs. Hwee-Lin et al.2005 has also found that 1).
hypertension have same level of impacts as diabetes,
cancers and serious respiration diseases on the quality of When the mental component is being divided into four
life. main domains, it is found that the emotional role domain
has the highest score with the median value of 100.00
Therefore, this research is very important since there was (100.00-100.00), followed by the social function domain
no research on quality of life among hypertensive patients with the median of 75.00 (62.50-87.50), the mental health
in Muar before. Besides, the findings will provide base domain with the median score of 72.00 (64.00-80.00),
data on the quality of life for hypertensive patients in and energy domain with the median score of 65.00
Muar for further studies. It is really important since it can (55.00-75.00) (Table 2).
increase the adherence level among hypertensive patient
thus preventing complications and decreasing morbidity As for the physical component, out of the four main
and mortality (Kyngas, 1998). Furthermore, this research domains, it is found that the highest score goes to the
is also important as the majority of the patients in physical role domain with a median score of 100.00
Malaysia are in the range of productive age that (50.00-100.00), followed by physical function with a
contributes to the country's huge important resources of median of 80.00 (55.00-90.00), the body pain domain
manpower (MOH, 1996). 62.00 (52.00-74.00) and the general health domain with a
median score of 62.00 (52.00-72.00) (Table 3).
Methods
Corelation test found a significant, good and positive
This descriptive research is a result from a cross sectional relationship exist between physical and mental scores (r
study where the respondents were 460 patients with =0.695, p<0.001). Meanwhile from the aspect of
relationship strength, 48.3% of the physical score can be
confirmed high blood pressure disease (Systolic ≥ 140 defined by the mental score (Table 4).
mmHg, Diatolic ≥90 mm Hg) . The respondents came to
On the other hand, the corelation test on the period of time
the government clinics for treatments and were faced by the hypertensive patients and mental component
interviewed from 1st November 2010 to 31st January score shows that there exist a significant relationship,
2011. negative but is too weak between both time period and
mental component score with ( r = -0.245, p<0.001 )
Sampling Size where only 6% was defined by the period of time
suffering from hypertension and the mental component
The total sampling size used in this descriptive analysis is score (Table 5).
the Software EpiCalc 2000, whereby basing on the
prevalence of 44.2 percent of hypertensive patient Hassan It is the same when a corelation test was done on the
NB et al.2005. relationship of time period suffering from hypertension
and the physical component score, negative but weak in
Study Instrument between the time suffering from hypertension and
physical component score ( r = -0.218 , p<0.001).
Quality data is measured using the standard questions of However, only 5% can be explained by the time period
SF-36 (Short Form-36) which have been translated into suffering from hypertension and the physical component
Malay. The SF-36 questions consist of 36 questions score (Table 6).
where 10 questions related to the domains of physical

14

Discussion (subjectively) including energy and exhaustness has the
lowest domain score. This is followed by the mental
This main purpose of this study is to see in details the level health domain score which intended to evaluate on over
of quality of life among patients with hypertension. By worried, depression, lost control in emotion and
using SF-36 as an instrument, the results of this study behaviour and physcological and harmony pressures. The
have shown that there existed a difference in the scores second highest score is the social function domain which
between physical and mental components among the intended to evaluate on the qualiy and quantity of one's
respondents with hypertension with a lower level of interaction with another individual as well as the
quality of life in the physical aspect compared to the limitations of social activities due to physical and
mental aspect. This can be explained based on the earlier emotional problems. The highest score goes to emotion
studies where it is known that hypertension is one of the role domain which intended to evaluate on the limitations
increasing chronic diseases globally contributing to of one's occupational function due to emotion problems.
approximately to 46% (WHO,2002) and it is a main risk
factor for other chronic diseases such as coronary heart Just like the physical component, the mental component
disease, strokes and heart failure (Mac Gregor GA,2003). can also vary with the time period suffering from
hypertension. Correlation test showed a significant
Apart from that, hypertension is also identified as can negative relationship between the time period suffering
lead to kidney failure and give a big impact in managing from hypertension and the mental component. This
the cost of health which complications is more of a burden means that a longer time period suffering from
on the physical aspect compared to mental (Hayes hypertension will decrease the quality of life mainly in the
RB,1997, Hammond SL,1994). This is similar to the mental aspect. This is an important benchmark since
study results by Lim et al.1998), where complications previous studies have shown that psychosocial factor is
from failing to control blood pressure properly has given one of the main factors leading to non-adherence to
a limitation on the level of life for a hypertensive patient medications among hypertensive patients (Zyczynski
to increase up to 75%. TM, 2000, Rahman ARA, 1995). It will impact on the
quality of life and lead to failure in their treatments
This can be further explained by corelation test which (Jones, 1996).
showed a significant relationship between the time period
suffering from hypertension and the physical component Finally, there is a difference between physical component
score. A negative relationship had been shown score and mental component score among the
eventhough it can only defined 5%. However, what can respondents, the results have shown that when a person
be analysed is that a longer time suffering from manage to take care of his or her physical quality aspect, it
hypertension will further affect the quality of life from the will indirectly help in his or her mental health. This can be
physical aspect. shown by the relationship of the physical score and
mental score using a correlation test whereby there is a
Besides, the lower scores among the four domains are significant relationship, positive and good between the
general health domain score which fits the evaluation of physical score and the mental score (r =0.695, p<0.001).
one's physical health status and body pain domain which
fits the evaluation of the body's pain level and how much Meanwhile, from the relationship strength, 48.3% of the
it affected daily routines. Meanwhile, for the physical physical score can be defined by the mental score. This
function domain which evaluates on the limitations of shows that a better physical of the patients or in other
physical activities due to health problems faced, highest words if the patients manage to control their hypertension
scored domain is the physical role domain. The physical and avoid from complications such as strokes will
role domain has the highest score, it is mainly to evaluate directly helps in improving the quality of mental health
on the limitations of occupational function which was where for example they will have no problems in their
affected by the physical health problems. social aspects. Eventually, this will help the patients to
stay in the better quality of life eventhough suffering from
The results have indicated that patients with hypertension chronic diseases that need treatments and medications.
have a better mental aspect score compared to the Conclusion
physical component and it depicts that the respondents
have a better quality of life in the mental aspect generally. As a conclusion, this descriptive research has two
This is further explained by monitoring all the four main important findings. The first one is that the longer the
domains in the mental component where the average patient suffers from hypertension, the lower will be his or
scores are better than the physical domains. The mental her quality of life either from the physical or the mental
component is important as previous study has showed aspect. Secondly, the better level of physical well being
that most of the patients with hypertension who adhere to will contribute to a better mental well being.
their medications have a positive relationship with their Hypertensive patients with good physical well being
emotional pressure (Wang PS et al.2002). would adhere more to scheduled treatments. Thus, good
physical attributes help in controlling the blood pressure
However, in the mental component, the energy domain thus avoiding them from complications such as strokes
which intended to evaluate on the harmony feelings and heart attacks.

15

References parts? 3:2http//www.google.com [20 Ogos
2006]20Kyngas, Helvi R N, Lahdenpera, Tiina MA RN.
1World Health Organization. Reducing risks, promoting 1998. Journal of Advanced Nursing .Compliance of
healthy life. World Health Organization Report. patients with hypertension and associated factors. 24
2002.2Ministry of Health Malaysia: National Health and (5):997-1005http://202.186.179.7/ovidweb.cgi [19 Julai
Morbidity Survey Report II.1996.3Jabatan Kesihatan 2006]21Hennekens, C.H, Buring, J.E, Mayrent,
Negeri Perlis: Laporan tahunan penyakit adrah tinggi. S.L.1987. Epidemiology in medicine. Boston: Little
2005.4Hopman WM, Jane Vernar: Quality of life during Brown & Co.
and after inpatient stroke rehabilitation. American Heart
Association. http//www.google.com .(July 2010).5Gill Please indicate date of access
TM, Feinstein AR: A critical appraisal of the quality of
life measurements. The Journal of the American Medical Appendixes
Association. 1994.6Testa MA, Hollenberg NK, Anderson
RB, Williams GH:Assessment of quality of life by patient Table 1: Mental and Physical Components Score in SF-36
and spouse during antihypertensive therapy with atenolol
and nifedipine . Am J Hypertens.4:363-373.1991.7Ware SF-36 Component Descriptive Analysis
JE, Snow KK, Kosinski M, Gandek B: SF-36 Health Median
Survey Manual and Interpretation Guide.Boston. New IQR
England Medical Center, The Health 25-75
Institute.1993.8Jenkinson C, Layte R, Lawrence K:
Development and testing of the Medical Outcome Study Mental Component 73.63 65.00 - 80.50
36-Item Short Form Health Survey summary scale score
Physical Component 72.50 56.50 - 80.75
in the United Kingdom. Med Care.35:410-
416http//www.yahoo.com (July 2010).9Ware JE, Table 2: Mental Component Domain Score in SF-36
Kosinski M, Keller SD: SF-36 physical and mental health
summary scales: A user's manual. New England Medical Component Domain Score in Descriptive Analysis
Center, The Health Institute.1994.10Mac Gregor GA, He
FJ: Cost of poor blood pressure control in the UK: 62,000 SF-36 Median IQR
unnecessary deaths per year. J Hum Hypertens 25-75
(PubMed). 17:455-457 http//www.google.com. (July
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in health care. John Hopkins University Press Baltimore
MD.1997.12Hammond SL, Lambert BL: Social Function 75.00 62.50-87.50
Communicating about medications .Directions for
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251http//www.google.com. (July 2010)13Lim LL,
Johnson NA O'Connell, RL Heller, RF: Quality of life and Energy 65.00 55.00-75.00
later adverse health outcomes in patient with suspected
heart attack. Aus N Z J Public Health 22(5):p 540- Table 3: Physical Component Domain Score in SF-36
546http//www.google.com.(July 2010)14Wang PS,
Bohn RL, Knight E, Glynn RJ, Mogan H, Avorn J: Non Physical Component Domain Descriptive Analysis
compliance with antihypertensive medications: The
impact of depressive symptoms and psychosocial Score in SF-36 Median IQR
factors. J Gen Intern Med.17(7):504- 25-75
511.2002.15Zyczynski TM, Coyne KS: Hypertension
and current issues in compliance and patient outcomes. Physical Role 100.00 50.00-100.00
Curr Hypertens Rep.2(6):510-514.2000.16Rahman
ARA, Hassan Y, Abdullah I: Admissions for severe Physical Function 80.00 55.00-90.00
hypertension: Who and why. Rim Hypertension
Conference.Tokyo Japan.1995. 17Jones, D.A. West, RR: Body Pain 62.00 52.00-74.00
Psychological rehabilitation after myocardial infarction:
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(7071); p.1517-21.199618Hassan NB, C I Hasanah, K
Foong, L Naing, R Awang, S B Ismail, A Ishak, L H Table 4: Correlation Test
Yaacob, M Y Harmy, A H Daud, M H Shaharom, R
Conroy, A R A Rahman.2005. Journal of Human Variable Correlation
Hypertension. Identification of psyshosocial factors of
noncompliance in hypertensive patients.20: p23-29 Physical Score And Mental r r2
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Cheung YB, Li SC, Fong KY, Thumboo J. 2005. PubMed Score 0.695
Central Journal List. The impact of diabetes mellitus and r2
other chronic medical conditions on health –related P<0.001 0.06(6.0%)
Quality of Life: Is the whole greater than the sum of its
Table 5: Correlation Test r2
0.05(5.0%)
Variable Correlation

Time Period Suffering High r

Blood And Mental - 0.245

Component

P<0.001

Table 6: Correlation Test

Variable Correlation

Time Period Suffering High r

Blood And Physical - 0.218

Component

P<0.001

16

Study On Use Of Kaletra® 4
(lopinavir/ritonavir) Among Volume 10

HIV Patients In HSAJB. 2012

Ong M.P.1
1Hospital Sultanah Aminah, Johor Bahru.

Summary of HIV patients was obtained from MTAC RVD HSAJB.
Kaletra®, a combination of lopinavir and ritonavir which Finally after taking into account inclusion and exclusion
are relatively well tolerated and provide potent antiviral criteria (those not initiated Kaletra® in HSAJB), 32
activity in human immunodeficiency virus (HIV) patients were included in this study. All relevant data
patients. The purpose of this study is to assess the were collected from patients' case notes. As suggested by
indication of use of Kaletra® and to study the tolerance of several recent National Institutes of Health-sponsored
Kaletra® among HIV patients in Hospital Sultanah conferences on aging and acquired immune deficiency
Aminah Johor Bahru (HSAJB). A retrospective cross syndrome, we adopted the age of 50 years as a cut-off
sectional study was conducted in Medication Therapy point to define 'older' subjects.2 Using that cut-off point
Adherence Clinic (MTAC) Retroviral Disease (RVD) 28% of subjects (n=9) were classified as older. Data
HSAJB. 32 patients were included in this study. Kaletra® extracted were managed with Microsoft Excel and
was being prescribed mostly due to intolerable side Statistical Package for the Social Sciences (SPSS) 16.0
effects (59%) caused by previous HAART regimen. For system. chi-square and the p-value were calculated using
those taking Kaletra®, it was well tolerated, with 82% of SPSS system. Comparisons between groups were made
patients without showing any undesirable side effects. with independent t-test. A p-value of less than 0.05 was
considered significant. Descriptive statistics were
INTRODUCTION. adopted to present the data such as mean ± standard
Antiretroviral drugs which are more effective with more deviation, frequency, range and percentage.
convenient administration have been developed in order RESULTS
to improve quality of life in patients infected with the The mean age of the sample was 44.8 years (SD 12.53)
human immune-deficiency virus (HIV).1 Kaletra®, a with a range of 18-77 years. More than half was male and
combination of lopinavir which is an HIV protease majority of them was Chinese. 31.3% of the patients aged
inhibitor with ritonavir, which acts as a pharmacokinetic over 50 years old. The reasons of starting Kaletra® were
enhancer used for patients who are new as well as for 40.6% patients due to treatment failure where the HIV
those experienced with HIV therapy.1 At present, most of RNA more than 400 copies/mL after 24 weeks or 50
the antiretroviral-experienced patients attending HSAJB copies/mL by 48 weeks in a treatment naïve patient
and failing their current therapy have been exposed to initiating therapy and 59.4% patients changed their
both protease inhibitors and ono-nucleoside reverse regimen to Kaletra® containing regimen due to
transcriptase inhibitors. Therefore, Kaletra® was intolerable adverse effects of previous HAART regimen.
prescribed for those who had treatment failure as well as The table show mean duration to attain desire CD4 count
for those experienced intolerable adverse effects. There is and suppress viral load.
no wide information about the use of lopinavir/ritonavir Table: Mean duration to attain desire CD4 count and
(Kaletra®) among HIV patients. This study intended to suppress viral load
obtain information of HIV patients who had been taking
Kaletra® as HIV therapy from date of their initiation up to Table: Mean duration to attain desire CD4 count and
December 2010 in order to provide better counseling suppress viral load
based on collected data. The purpose of this study is to
assess the indication of use of Kaletra® and to study the Age group N Mean Duration
tolerance of Kaletra® among HIV patients in HSAJB.
The results of this study were expected to assist the Duration for VL attain <50 < 50 years 19 5.74 months (SD 6.35)
educational practices regarding Kaletra® therapy and to
assist doctors, pharmacists and other healthcare HIV RNA copies/mL = 50 years 9 8.44 months (SD 11.43)
providers. The information can aid in the management of
HIV patients after their previous highly active anti- p=0.035*
retroviral therapy (HAART) regimen failure.
MATERIALSAND METHODS. Duration for CD4 count <50 years 19 4.11 months (SD 5.23)
A retrospective cross sectional study was conducted to >200 cells/mm³ = 50 years 10 7.40 months (SD 11.25)
review all Kaletra® treated HIV patients in HSAJB. A list
p=0.104

* significant at p<0.05

17

DISCUSSIONS. REFERENCES
The mean duration for CD4 count attained more than 1. Fazil AM and Newton GO. Lopinavir/Ritonavir
200cells/mm3 was 7.4 months for older patients while (Kaletra) Journal of Gynecology Surgery. 2001; 35-36.
only 4.11 months for younger patients (p=0.104). The 2. MaMercedes N, Gemma N, Esperanca A, et al.
mean duration for viral load to be suppressed to less than Epidemiological and clinical features, response to
HAART, and survival in HIV-infected patients diagnosed
50 HIV RNA copies/mL for older patients (≥ 50years) at the age of 50 or more. BMC Infectious Disease 2006,
6:159.
was 8.44 months (11.43) which is significantly (p=0.035) 3. Charles HH, David JH, Karen IM, et al.
longer than younger patients (5.74 months). Duration of Medication adherence in HIV-infected adults: effect of
survival is significantly shorter for older people due to patient age, cognitive status, and substance abuse. AIDS.
deficiencies in immune system related to age.2 However, 2004 January 1; 18(Suppl 1): S19-S25.
in the study done by Charles HH. et al, the older patients

(≥ 50years) showed better medication adherence

compared to younger patients but cognitive impaired
occur in older people do affect the medication
adherence.3 This may suggest that adherence might not
be factors affecting duration of success viral load
suppression. There was 93.8% (n=30) of patients
continue taking Kaletra®, only 6.2% (n=2) discontinue
Kaletra® due to down grade of regimen to reserve
Kaletra® as salvage regimen and another patient died
caused by lymphoma. Only 18.8% (n=6) reported
adverse effects during treatment of Kaletra®, these
reported side effects may not be solely due to Kaletra® as
patients were given combination regimen. Reported
adverse effects among these patients were increase
triglycerides, cholesterol; muscle weakness and pain;
facial lipodystrophy; dryness of legs and lips, numbness
of limbs; and leg edema. The study is a retrospective cross
sectional survey. Descriptive studies do not lead
themselves to causal inferences. This should be kept in
mind when evaluating the results of our study. As all
information collected were based solely on the
documentation in patients' case notes, data may be
incomplete with some missing data due to lack of
documentation. Incomplete information in the medical
records might lead to underreporting of some adverse
effects experienced by patients but not recorded. A
prospective study to follow the patients may be carried
out to overcome this problem.
CONCLUSION.
Kaletra® was being prescribed mostly due to intolerable
side effects (59%) caused by previous HAART regimen.
Kaletra® was well tolerated, with 82% patients show no
undesirable side effects after starting it.

18

Implementing Fly Control 5
– Kluang Experience 2009, Volume 10
North Macap Rest & Relax Area (R&R)
2012
Norzihan MH, Zuhaida AJ, Mohd Zaki I

EXECUTIVE SUMMARY and passing through this is the North-South Expressway,
The fly problem in North Macap Highway Rest & under the purview of PLUS. North Macap R&R is
Relaxation area (R&R) was mainly due to breeding of provided for the convenience of travelers and it is a
flies in nearby poultry farms. Control measures were facility comprising of food & beverage outlets,
staged in 3 steps to assess the effectiveness of each of the restrooms, prayer rooms, playground, souvenir shops and
recommended interventions. It was found that despite petrol station.
physical restructuring of the R&R, the problem did not
decrease as was also noted with the use of pesticides. There is a scheduled garbage collection though
Though there was a direct reduction of the fly index with indiscriminate disposal of food leftovers was found to
pesticide usage, the fly density went back to pre- contribute towards attracting adult flies to food premises.
intervention levels within 7 days of last spraying. The use However no source of breeding was identified within the
of probiotics showed itself to be an excellent method of area. Bearing in mind its flying distance, its tendency for
control through source reduction with fly index homing effect and breeding preference, a wider search for
decreasing from 18.8 to 1.2 at the end of intervention and source of housefly breeding was carried out.
maintained at that low level for a longer time period. It is
recommended that the use of probiotics be introduced to The source of breeding was found to be from surrounding
poultry farm industries to suppress fly population and estate areas, with poultry farms. In the Macap area, there
indirectly reducing flies problem in nearby R&R. are 24 poultry farms with a capacity of 346,000 million
chickens at a time. Eleven (11) of these farms were
INTRODUCTION situated within 6 km from the Macap R&R, the nearest
In 2008 the issue of fly problem in Kluang became a (FarmA) being 1.3 km away.
major concern when it was highlighted through
complaints in the media, involving food premises, Farm A comprised of 12 chicken coops with a capacity of
especially in the Kluang North Macap R&R (Figure 1). It 30,000 chickens. At time of investigation, fly density was
was a serious problem, where it marred the image of high under the chicken coops, though the coops were
tourism industry as well as being a threat to public health empty and in the process of cleaning and disinfection. The
as flies are mechanical vectors for food borne diseases soil beneath the coops was wet and warm from faeces.
such as food poisoning, typhoid, cholera, Hepatitis A etc There is a 2 month period for each cycle, from the first day
1. chicks are introduced to the farm till clearance and
cleansing of coops (46 days breeding + 14 days cleaning)
The fly species identified in this case were the common The high-density, confined housing systems used in
housefly (Musca domestica), which tended to breed in poultry production create conditions that favor the
warm, wet places where its' larvae can feed on upon development of manure-breeding flies.
hatching. Typical breeding grounds include garbage,
rotting food, exposed faeces of any type, and An integrated approach towards controlling flies
decomposing animal carcasses. They have a high problems consists of four basic management strategies
preference to poultry farms rather than domestic (mechanical, cultural, biological, and chemical) that can
surroundings 2, where a single female fly can lay 75 to be strategized into a successful fly control or integrated
150 eggs every 3 to 4 days. Life-cycle for a housefly from pest management program 4 (Table 1).
egg stage to adult takes about 10 days. In this study, 3 types of fly control interventions can be
Houseflies possess sensory receptors for smell and taste, carried out, that is:
important in the search of food, as far as 5 to 7 km away, 1) Mechanical intervention involving renovating
though they have a tendency to return to breeding sites physical attributes of food premises to discourage adult
(homing effect) 3. flies, as in screening, air conditioners with automatic door
closer, fly swatter or fly traps etc and ensuring a sanitary
Problem area establishment
Macap area is situated about 30 km from Kluang Town 2) Chemical intervention using adulticides or
larvicides both at problem areas (North Macap R&R) as

19

well as at breeding sites (FarmA). by product) (Table 3). Intervention monitoring was done
3) Biological intervention using beneficial from December 2008 until January 2009.
predators (macrochelid mites; hister beetles) or
microorganisms that can suppress fly populations. One Impact of each intervention were assessed through
such method is the use of probiotics to create an measurement of fly index, that is the number of flies
unsuitable environment for fly development. The use of landing on the grill within 30 seconds 7 using the 'Scudder
probiotics in fly control is a relatively new endeavor and it Grill' (Figure 3) at the North Macap R&R area. Reading
is known to reduce smell from poultry farm faeces as well of index was carried out at the same time (10.00 am) at 6
as reducing its potential to breed flies. different locations (index point), and the average reading
is calculated as index value. Proposed fly index threshold
As a step towards reducing the fly problem and thus the 6 were used throughout as a standard (Table 4).
number of complaints from travelers, Kluang district
Health Office convened a committee, which included the RESULTS
veterinary department, plantation department, PLUS and The fly index reading in 2007 prior to any intervention of
the local poultry farms, to discuss the possible and viable 3.8 is considered to be above accepted value for food
methods available. It was decided that the various premises, according to the fly index threshold.
interventions were to be carried out separately so that
analysis of effectiveness of each method could be
undertaken.

OBJECTIVE Chemical spraying
1) To identify the most effective & efficient control
measure available in the long term control flies at the 1) Physical intervention - physical restructuring:
North Macap R&R, Kluang. Pre-intervention reading for physical intervention was
2) To make recommendations towards reducing 3.8. Fly index reading after renovation was carried out at
flies in the Macap area. the North Macap R&R showed a continuously high
3) To strengthen inter-agency cooperation towards index, averaging 18.3, which is an increase of 381% of
reducing flies density. pre-intervention reading.
METHODOLOGY
Three types of interventions were carried out in three 2) Chemical intervention: Pre-intervention
phases, startingApril 2007 – March 2008 (1st phase), July reading for chemical control was 18. The overall fly
2008 – August 2008 (2nd phase) and December 2008 – index reading showed a 10 day interval where spraying
January 2009 (3rd phase) involving the North Macap schedule was carried out. Low readings were always on
R&R and Farm A. Interventions undertaken were the 3 days of spraying; the lowest being 3.3 and fly index
staggered with a 3 months pause in between each, to start to increase when spraying stopped on day 4 onwards,
allow for impact assessment and for the return of normal reaching 13.3 by day 7. Subsequent fly index readings
situation of flies population in both R&R Macap and maintained above 15, similar to pre-intervention. The
Farm A before the next intervention starts. The 3 months pattern was seen throughout the 46 day cycle of chicken
period was also taken in view of the poultry cycle from rearing in FarmA.
chick introduction to marketing and coop disinfection (46
days for poultry rearing + 14 days cleaning up) 3) Biological intervention: Pre-intervention fly
index was 18.8 (day -1). Post-intervention readings
The 3 types of interventions carried out in 3 phases were: showed a steady decline in fly density at the North Macap
1) First phase - Physical intervention: renovation R&R reaching as low as 1.2 at day 46. This low reading
was made to the Macap R&R by PLUS from an open was noted up to day 60 intervention, sustained even
premise to a fully air conditioned, closed area (with though the intervention had ended.
automatic door system) to discourage adult flies from
entering the food court (Figure 2). Renovation was DISCUSSION
carried out from June 2007 and resumed operation on Having a sanitary establishment is still the best way to
December 2007. Intervention monitoring was done for a avoid fly problems. Areas that are damp and warm
month before renovation started, in April 2007 and after (standing water, drains, and unchanged mop buckets)
resume operation, in March 2008. encourage flies infestation. Indiscriminate disposal of
2) Second phase - Chemical intervention: Use of
water–base insecticide via thermal fog and ULV (Ultra
Low Volume) spraying to control adult flies. Fogging is
carried out between 6 – 7 am at the R&R , while 'Spot
Spray' is carried out in Farm A. Fogging / spraying was
done at 10 day intervals: 3 days of spraying followed by 7
days of rest (Table 2). Intervention was done from July
2008 toAugust 2008.
3) Third phase - Biological intervention: Spraying
with probiotics using dilution ratio of 1: 100 is carried out
in Farm A every day 3, with 2 days rest (as recommended

20

food waste will always be an attraction to flies and is Probiotics has given a new dimension to Malaysia's
actually a great drawback to fly control. As such a agriculture towards farming systems that are productive,
physical barrier from flies in itself does not go a long way environmentally sound, energy and resource conserving,
in reducing the problem. This can be seen from the also ensure food safety and quality. Probiotics consists of
increase in fly index reading despite a major and mixed cultures of beneficial and naturally-occurring
expensive renovation carried out. PLUS needs to take microorganisms. Selected species of microorganisms
more effective measures in controlling flies in their food including lactic acid bacteria, yeasts and photosynthetic
establishments through regular cleaning and maintaining bacteria creating the probiotic are mutually compatible to
of problem areas. coexist in liquid culture 8.

PROPEL (Projek Penyelenggaraan Lebuhraya Berhad) a The use of probiotic in food and drinking water in poultry
company responsible for maintaining PLUS expressways farms reduce the foul smell in chicken dung, conserve the
including R&R Macap facility, has daily scheduled environment and at the same time increase the immunity
cleaning tasks. This includes mopping of floor, cleaning of chickens for better growth 9. Beneficial bacteria is also
of toilets and other facilities, also ensure that waste be a form of biological control of flies population in poultry
disposed off daily and not left overnight. Food Quality farm 10. The beneficial bacteria nitrifies toxic gases like
Control Unit, Kluang Health Office conducted 8 series of ammonia and hydrogen sulphide into less harmful
inspection of food premises, hygiene and cleanliness at organic acids, reduce foul smell and become less
the North R&R Macap areas throughout May to August attraction to flies and other winged insects 5. A study in
2008 involving 10 food premises. All food premises in Thailand by Sritoomma, S shows that flies population can
operation found to be in satisfying condition with above be reduced up to 60%, BOD (36%) and solid waste
80% score according to Food Premise Score sheet. sediment of 68% 11.

Though there was a marked increase in fly index reading CONCLUSION.
despite PLUS efforts, this could be attributed to increased The use of probiotic is shown to have positive effect in
fly problem at breeding sites rather than failure of any reducing flies population. However, proper handling and
physical interventions carried out. During this phase no technical advice is highly needed to ensure its
control measure had yet been carried out at source of effectiveness. The most important in dealing with
breeding. Usually, fly control measures by local probiotic is to stop the usage of pesticides and antibiotics
industries relied mostly on pesticides to keep pest that can render probiotic microbes killed and becomes
populations below economic injury levels or nuisance ineffective. Continuous usage of probiotic is also
thresholds. The fact that major renovations were carried essential to reach stability of beneficial bacteria
out through continuous discussions by various agencies population in chicken farm environment thus controlling
showed a success itself in terms of promoting interagency foul odour and fly population in a long term period.
relationship. This positive findings hope to widen the acceptance and
use of probiotics in the poultry industry. As a start,
Insecticides can play an important role in integrated fly recommendations were made to the relevant agencies to
management programs. However, extensive or improper integrate the use of probiotics in poultry industry as an
use of pesticides results in the destruction of biological alternative to pesticides.
control agents and the development of pesticide
resistance. Improper timing and indiscriminate ACKNOWLEDGEMENT
insecticide use, combined with poor manure Authors would like to thank all the agencies involved
management, poor moisture control, and poor sanitation throughout this study period, namely; Veterinary Services
practices, will increase fly population and the need for Department of Kluang, Plantation Department of Kluang,
additional insecticide applications. Space sprays or mist Section S3 PLUS Highway Berhad, Leong Hup Farming
sprays can be effective for a rapid knockdown and kill of and JB Kim Farm.
adult flies, but does not provide long-lasting control as
there is no residual effect. While larvicide application will
only give a short-term fly control and kill natural
biological control agents that are present, initiating a
repeated schedule of treatments 4. Chemical control is
proven to be highly effective at the point of usage but its
effectiveness is not sustained longer than 7 days.
Repetition of application is needed weekly involving
cost, raising concerns of insecticide resistance as well as
destruction of biological agents that naturally exist in the
environment.

Biological agents co-exist in the environment in various
forms ranging from beneficial predators such as hister
beetles or microorganisms that can suppress fly
populations. In Malaysia, microorganisms is widely used
by farmers to increase the quality and quantity of crops.

21

REFERENCES 7. Scudder, H.I. (1996). Use of the Fly Grill for
assessment of house fly populations: An example of
1. Arbain, Kadri (1990). Entomologi Perubatan. sampling techniques that creates rough fuzzy sets.
Dewan Bahasa dan Pustaka, Kementerian Pendidikan Journal of Vector Ecology 21(2):167-172.
Malaysia. Pp. (144-152).
8. Reduction Of Flies Index Number At Chicken
2. Robert, Lamb. "How Houseflies Work." How Farm By Using Effective Microorganisms (Em)
Houseflies Work. 7 Dec. 2008 Technology, A. K. Khamis1, M.R. Sarmidi1, N. 'A.
<http://animals.howstuf fworks.com/insects/housefly2.h Sabri1, N. F. Abd. Rahman1, H. Nohani; 1Chemical
tm> Engineering Pilot Plant (CEPP), Universiti Teknologi
Malaysia (UTM)
3. Nazni, WA et al. (2005). Determination of the
Flight Range and dispersal of the house fly, Musca 9. Ni, Y. and Li, W. (2002). Effects of Effective
domestica (L.) using mark release recapture technique. Microorganisms (EM) on Reduction of Odour from
Tropical Biomedicine 22(1): 53-61. Animal and Poultry Dung. 5p.

4. Stafford, K. Fly Management Handbook A 10. Kapongo, J. P. and Giliomee, J. H. (2000). The
Guide to Biology, Dispersal, and Management of the use of Effective Micro-organisms in the biological
House Fly and Related Flies for Farmers, Municipalities, control of house flies associated with poultry production.
and Public Health Officials, Connecticut. 2008. Afr. Entom, 8: 289-292

<http://www.ct.gov/caes/lib/caes/documents/p 11. Sritoomma, S. (1995). Application of EM for
ublications/bulletins/b1013.pdf> Improved Management of Swine and Poultry Wastes in
Thailand. Proceedings of Kyusei Nature Farming
5. Baustista, E. M. (2002). Use of Effective Conference in Paris, p193
Microorganisms (EM) to Eliminate Foul Odor in Meat
Processing Units. 3p.

6. Nazni, WA et al. (2003). Guidelines for Flies
Control. Tropical Biomedicine; 20(1):59-63.

22

Evaluation Of Molars Restored With Glass 6
Ionomer Cements In The School Dental Volume 10
Service In Kota Tinggi District

Muz'ini M1. Premaa S2. 2012

1Oral Health Division, Johor State Health Department
2Clinical Research Centre (CRC) Johor, Hospital Sultanah Aminah, Johor Bahru

Summary uncooperativeduring conventional restorative
treatment3. Recently, dental nurses in Johor generally
Use of glass ionomer cements (GIC) by dental nurses in utilised modified ART technique when restoring teeth of
the school dental service is well accepted due to its schoolchildren in mobile dental squads. Initially dental
anticariogenic potential. Its poor mechanical properties nurses used glass ionomer cements for restoring primary
limit their extensive use as a filling material in stress- teeth but this practice has been extended to permanent
bearing areas. The objective of this retrospective study is teeth as well. Electrically driven handpieces were used
to determine survival rate of glass ionomer cements for cavity preparation, caries excavated using excavators
(GIC).In 2006, dental nurses retrieved all dental records and tooth restored with GIC.
of Standard 6 students with posterior GIC restorations. GIC has similar mechanical properties to dentine. With
Status of tooth at each year after restoration was recorded. the important benefits of adhesion and release of fluoride,
Survival rates of GICs were estimated cumulative it is an ideal material in many restorative situations.
survival rates using the Kaplan-Meier method. The However, it's relatively poor mechanical properties must
median survival duration was 5.00 years (s.d. 0.28). be considered4. A study showed no significant difference
Survival rate of amalgam restoration at 5 years was in overall failure rates after two years but follow-up of the
86.21%whereas the findings from this study indicates restorations up to five years showed that glass ionomer
cumulative survival rate of 84.36%. The quality of restorations had significantly inferior survival time to
posterior Class 1 glass ionomer restorations is amalgam5
competitive with that of amalgam restorations.
There is a need to evaluate teeth restored with glass
Key words: glass ionomer cement, survival analysis, ionomer cements in the school dental service in view of
posterior restorations its relatively poor mechanical properties. Several studies
showed that GIC is not recommended for Class II cavities
1. Introduction due to unacceptable high fracture rates. Class I cavities
The use of glass ionomer cements (GIC) by dental nurses may be restored in the permanent dentition. Retrospective
in the school dental service is well accepted due to ease of trials reported unsatisfactory clinical performance in
manipulation. It also tolerates moisture and this property Class II cavities.Reviews indicated that the annual failure
is useful in mobile dental squads where moisture control rate with GIC is estimated to be around 8%6.The aim of
poses a problem.GICs are esthetically more attractive this study is to evaluate the outcome of restoring posterior
than amalgam restorations. In addition, by incorporating cavities with GIC in permanent molars in the school
fluorine, they exhibit an anticariogenic potential, and dental service in Kota Tinggi district.
they have good biocompatibility and chemical adhesion
to mineralised tissue. On the other hand, poor mechanical Objective
properties, such as low fracture strength, toughness and To determine survival rate of glass ionomer cements as
wear, limit their extensive use in dentistry as a filling dental restorations in posterior cavities
material in stress-bearing areas. In the posterior dental
region, glass-ionomer cements are mostly used as a 2. Materials and Methods
temporary filling1. 2.1 Design
Retrospective study
A study conducted in 1993 found that the Atraumatic 2.2 Sampling
Restorative Treatment (ART) approach using GIC All Standard 6 students in the school incremental dental
performed equally well as conventional restorative care system in Kota Tinggi district in year 2006with
approaches using electrically driven equipment and history of GICmolar dental restorations in their dental
amalgam for treating dentinal lesions in occlusal surfaces records were included in this study. Parents of students
after 6 years2.The procedure is gaining acceptance in involved in this study had given written informed consent
developed countries forthe treatment of caries, especially 2.3 Data collection
in young children with rampant caries who are Dental nurses in mobile dental squads and school dental
clinics retrieved all dental records of Standard 6 students

23

during annual dental screening in the school based dental Failure rates after 12 months, 24 months, 36 months, 48
programme. After routine examination, all dental records months, 60 months were 8.2%, 20.0%, 9.38%, 33.2%,
with posterior GICrestorations were retained and status of 38.8 and 66.0% respectively as shown in Figure 1.
tooth at each year after restoration was recorded.The
investigator entered the data on spreadsheets and analysed Survival Function
them using statistical software SPSS version 17.0.
Survival rates of GICs were estimated cumulative 1.1
survival rates using the Kaplan-Meier method.
1.0
3. Results
The following table shows the distribution of all restored .9
teeth included in this study.
.8
Table 4.1: Distribution of Restorations According to Cum Survival
Location and Tooth Type .7

Maxilla Mandible .6

First right First left First left First right Second left Second right .5
molar
molar molar molar molar molar .4 Survival Function
.3 Censored
1 24 4 0 0
0 12 3 45 6
5 9 14 16 0 1
duration
8 8 19 26 1 0
Figure 1 : Kaplan Meier Survival Curve

18 16 31 28 1 1 Table 4.3: Cumulative survival of GIC restorations in
permanent molars
32 35 68 74 2 2

Follow-up period No of Class 1 No of restorations No. of Survival (%)
restorations at that require redo extracted
A total of 213 molars restored with glass ionomer cements start of study teeth
were included in this study. Majority (68.54%) of molars
restored with GIC at all clinics in Kota Tinggi district were 0-12 months 196 16 0 91.83
lower molars. A total of 196 restorations were placed in
Class I and 17 in Class IIcavities.Records of all teeth 13-24 months 180 19 1 88.88
restored with GIC showed outcomes as shown in Table 4.2
25-36 months 160 13 2 90.62

37-48 months 145 2 1 97.93

49-60 months 142 8 0 84.36

Table 4.2 : Status of molars restored with GIC

Status Type of cavities Total The median survival with censored data was 3.099 years
as shown in Table 4.4
Class I Class II n (%)
58 (27.2)
n (%) n (%) 4 (1.9) Table 4.4: Kaplan MeierAnalysis
5 (2.3)
Indicated for redo 54 (27.6) 4 (23.5) Kaplan Meier analysis (with censoring)

Restored with amalgam 4 (2.0) 0 (0.0)
restoration
Class 1 Survival time Standard error 95% C.I.

Extracted 4 (2.0) 1 (5.9)

Median 5.00 0.28 (4.45, 5.55)

Among 5 teeth that were extracted, 4 were restored with 4. Discussion
Class I restoration and 1 with Class II. The tooth with Retrospective survival analysis of dental amalgam
Class II restoration failed at 24 months while those with restorations showed 96.29% survival at one year7.
Class I restoration failed between 24 to 48 months. No Percentage survival for glass ionomer cements after 12
further analysis was done for Class II restorations as data months in this study was 91.83% at one year.
were too few.
Survival rates of GICs were estimated cumulative The longest duration of study in this sample is five years
survival ratesusing the Kaplan-Meier method as shown in after placement of GIC restoration in the school dental
Table 4.3. service. Percentage survival of amalgam restorations at
five years using Kaplan Meier method from a previous
Table 4.3: Kaplan Meier estimate of survival function study was 86.21% 8. Findings from this study shows that
Survival Table cumulative survival of GIC restorations at five years was
84.36%
Follow-up period Cumulative proportion surviving
at end of Interval. (s.e)

0-12 months 0.92 (0.02)

12-24 months 0.80 (0.03)
24-36 months 0.67 (0.04)
36-48 months 0.61 (0.05)
48-60 months 0.34 (0.08)

24

5. Conclusion 3. Nazan Kocatas Ersin, PhD, DDS, Umit Candan,
DDS, Arzu Aykut, DDS, Özant Önça , PhD, DDS, Cemal
From a total of 142 restorations, the median survival Eronat, PhD, DDS and Timur Kose, PhD, DDS . A
duration was 5.000 years (s.d. 0.114). Survival rates of clinical evaluation of resin-based composite and glass
amalgam restoration at 5 years was 86.21% whereas the ionomer cement restorations placed in primary teeth
findings from this study indicates cumulative survival rate using the ART approach Results at 24 months . J Am Dent
of 84.36% Assoc, Vol 137, No 11, 1529-1536.
The quality of posterior Class 1 glass ionomer restorations
is competitive with that of amalgam restorations for the 4. Martin John Tyas. Clinical evaluation of glass-
same duration of 5 years. ionomer cement restorations. J Appl Oral Sci.
2006;14(sp.issue):10-3
Acknowledgement
5.
The author expressed her gratitude to dental nurses in http://en.wikipedia.org/wiki/Glass_ionomer_cement
Kota Tinggi district for their assistance in data collection
and special thanks to Clinical Research Center (CRC), 6. Roland Frankenberger,Franklin Garcia-
Hospital Sultanah Aminah, Johor Bahru for her advice on Godoy,,Norbert Krämer4. Clinical Performance of
statistical analysis. Viscous GlassIonomerCement in Posterior Cavities over
Two Years. Int J Dent. 2009; 2009: 781462. Published
References online 2010 February 22.

1. Ulrich Lohbauer. Dental Glass Ionomer 7. Bogacki RE, Hunt RJ, del Aguila M, Smith
Cements as Permanent Filling Materials? —Properties, WR.Survivalanalysis of posteriorrestorations using an
Limitations and Future Trends. Materials 2010, 3, 76-96; insuranceclaimsdatabase. Oper Dent. 2002 Sep-
doi:10.3390/ma3010076 Oct;27(5):488-92.

2. Mandari GJ, Frencken JE, van't Hof MA. Six- 8. Bonsor SJ,Chadwick RG. Longevity of
year success rates of occlusal amalgam and glass-ionomer conventional and bonded (sealed) amalgam restorations
restorations placed using three minimal intervention in a private general dental practice.Br Dent J. 2009 Jan
approaches.Caries Res. 2003 Jul-Aug;37(4):246-53. 24;206(2):E3; discussion 88-9. Epub 2009 Jan 16.

25

26

The Prevalence Of Hearing Impairment Among The 8. Acknowledgements
Dental Staff In Kota Tinggi District, Johor (Draft 1)2010 The authors expressed their gratitude to Kota Tinggi
District Dental Officer, Kota Tinggi Senior Health
The study also found that the three categories of staff who Officer, Director of Sultan Ismail Hospital, staff of ORL
suffered hearing impairment were working in high noise Clinic Sultan Ismail Hospital and all dental personnel in
area (Kota Tinggi Main Dental Clinic, Sening Dental Kota Tinggi districts who had contributed to the conduct
Clinic) and with high noise equipment such as of this study.
compressor, high speed handpiece and ultrasonic scaler
(Table 5.6). References
1. Act 514 Occupational Safety And Health Act 1994
6. Discussion [Reprint 2002]
Hearing impairment of two dental surgery assistants
(DSA) may be attributable to past job experience. One 2. Leggat PA, Kedjarune U, Smith DR. Occupational
attendant worked in a glass factory with exposure to loud health problems in modern dentistry: a review. Ind
noise for about 14 years before joining the dental Health. 2007 Oct;45(5):611-21.
services. He has been working in the dental clinics for 4 3.http://www.dosh.gov.my/doshV2/phocadownload/Re
years. Another attendant worked as a heavy vehicle driver gulations/AKJ/pua0001y1989s0005.pdf accessed at
and claimed that he was exposed to loud noise during his 13:51 7 May 2011
5 years of service before joining the dental services. 4. Noise and hearing loss - Noise, Regardless of Source,
Exposure to noise level at 90dBA is quite common in the Can Lead To Hearing Loss Henry P. CIH Robert E.
dental environment. Although the duration of exposure Sheriff; Shotwell Courtesy of Atlantic Environmental,
does not reach the permissible exposure limit, dental Inc. Jan. 1, 2002
personnel experienced distraction and annoyance during 5. Szymanska J. Work-related noise hazards in the dental
the exposure. surgery.AnnAgric Environ Med 2000 (7): 67-69
6. C.E. Wilson T.K. Vaidyanathan W.R. Cinotti S.M.
7. Conclusion Cohen S.J. Wang.Hearing-damage Risk and
Hazard from noise in dental working environment cannot Communication Interference in Dental Practice Journal
be underestimated. Hearing problems can occur due to of Dental Research, Vol. 69, No. 2, 489-493 (1990)
dental field noise due to prolonged exposure. Hence, 7. Bali N, Acharya S, Anup N, An assessment of the effect
proper monitoring and Hearing Conservation programme of sound produced in a dental clinic on the hearing of
is required for early detection and management of these dentists. Oral Health Prev Dent. 2007;5(3):187-918.
cases. Dental staff working in high noise area above Guidelines for hazard identification, risk assessment and
90dBA are advised to wear ear plugs. Regular medical risk control. Department of occupational safety and
surveillance of staff exposed to high level of noise must health, Ministry of Human Resources, Malaysia. 2008
be complied as per Factories and Machinery (Noise
Exposure) Regulation 1989. This can ensure early
detection and management of the patient hence
preventing hearing impairment among the dental staff.

27

A Study Of Obesity Among 7
Health Staff At Kulaijaya District Volume 10

Health Department (2012) 2012

Dr. Mohd Shaiful Ehsan B Shalihin
Poh Lin Chin, Misringaton

Kulaijaya Health District Johor

OBJECTIVE: To study and report prevalence of the environment which include education background,
occupation, household income, culture and lifestyle
overweight and obesity among health staff at Kulaijaya (Azmi, et al., 2009; Moy & Atiya, 2003-2005; Richard,
Andrew, & Rodolfo, 2012; Shashikiran, Sudha, &
District Health Department and describe their association Jayaprakash, 2004; Speakman, 2004). Globally, around
12% of adults aged 20 and above were obese in 2008
with gender, marital status, respective job scope and (World Health Organization (WHO), 2004). This figure
is increasing in developing countries including Malaysia
working environment, using standardized international (Caballero, 2001; Moy & Atiya, 2003-2005; Nor, et al.,
2008; Shashikiran, Sudha, & Jayaprakash, 2004). Based
definitions. METHODS: This cross on the National Health Morbidity Survey (NHMS) III
(2006), the national prevalence of obesity (BMI 18.5-
sectional study studied body mass index of all the health 24.9 kg/m2) was 14% compared to 4.4% in NHMS II in
1996 (Nor, et al., 2008). Rapid pace of industrialization
staff of Kulaijaya Health Department except expectant and urbanization in recent decades in Malaysia had
brought in changes in the lifestyles of Malaysians (Moy
mothers and females in their first three months FM, 2003-2005). These include reduction of physical
activities, changes in dietary habits and food preferences.
postpartum period. Body mass index (BMI:kg/m2) was Generally, Malaysians acquired a taste for high in fat,
processed fast food and high calorie diets. Furthermore,
calculated from measured weight and height, using housewives showed the highest prevalence of obesity at
20.3% (CI 0.19–0.21), compared to working mums who
calibrated weighing scales and body meters. Body weight engage in regular physical activity (Nor, et al., 2008).
Obesity has also reached an alarming level at the southern
classifications were defined as follows: According to region of Peninsular Malaysia, specifically Johor, as the
prevalence is highest in this state compared to other
WHO Expert Consultation 2004 for Asian BMI: states. According to the findings of the Malaysian Adult
Nutrition Survey in 2009, prevalence of obesity in Johor
underweight (BMI < 18.5), normal weight (18.5 to 24.9), is at 13.81% (CI: 0.12-0.16) (Azmi, et al., 2009). The
mean body weight was also significantly higher in the
pre-obese/overweight (BMI 25.0-29.9), obese (BMI > or southern region (64.42 kg) (CI: 63.46), compared to those
in Sarawak (60.66 kg) (CI: 59.43, 61.88)] and Sabah
= 30.0). Otherwise, 100% respondent's rate was achieved. (58.93kg) (CI: 57.86, 60.01) (Azmi, et al., 2009). Even
though obesity is higher in females 17.4% (CI 0.17-0.18),
Descriptive and correlation analysis were performed it is unequally distributed by comparing regional factors
and ethnic groups. This finding was attributed to
using SPSS version 15. A significance level of p-value underlying individual socioeconomic role (Nor, et al.,
2008)(Richard,Andrew, & Rodolfo, 2012).
less than or equal to 0.05 was considered statistically Currently, obesity and overweight are serious emerging
global issues among healthcare personnel. A study of 760
significant (p < 0.05). nurses across 6 different states of United States found
54% to be overweight or obese (Miller, Alpert, & Cross,
RESULTS: The prevalence were found to be 5.8% for 2008). In addition, there were hospitals which implement
policies barring the employment of obese candidates
underweight (CI 0.03-0.10), 40.2% for normal BMI (CI (Miller J. R., 2012). In Johor, the prevalence of
overweight and obesity among health staff was even
0.33-0.47), 33.9% for overweight (CI 0.27-0.41) and higher than national prevalence of 60% (Harian Metro,
2009).
20.1% for obese (CI 0.14-0.26). Higher prevalence of

obesity was found in males (20.1%) (CI 0.13-0.32), those

confined in office settings (23.3%) (CI 0.14-0.35) and in

married employees (20.6%) (CI 0.15-0.27). There was a

significant association between marital status and

overweight (P 0.023). Among all job scopes, medical

doctors had the highest prevalence of obesity (38.5%)

(0.18-0.64). Prevalence of normal weight and

underweight are higher in those working in clinical

setting (46.5%)(CI 0.38-0.55) compared to office staff

(45.0%) (CI 0.33-0.58).

CONCLUSION: There was higher prevalence of obesity

and overweight amongst male staff, office and

inspectorate personnel and medical officers at Kulaijaya

District Health Department in relation to national and

state figures. Regular weight management program

should be implemented to all staff regardless of gender,

marital status, job scope and working environment.

KEYWORDS: Obesity, health staff.

INTRODUCTION:
Obesity is a complex chronic disease that results from
multi factors such as interaction between genotype and

28

There are many ways to measure body fat content in answer. It was mandatory that all staff partook in this
which the body mass index (BMI) (defined as study and respondents' rate was set and achieved at 100%.
weight/height² [kg/m²]) is the most widely used This study is used to measure the prevalence of body mass
compared to other weight-for-height indices. BMI is easy index status and their related factors. Weight and height of
to calculate and has been recommended as the measure of adults were taken by trained personnel working in pairs
obesity for adults to be used in all studies. BMI generally using standard procedures and standardized digital
correlates highly with adiposity, although it can weighing scales and body meters which were calibrated
sometimes misclassify total body fat content (Caballero, every morning. Subjects were measured at clinic.
2001; Shashikiran, Sudha, & Jayaprakash, 2004; Body weights were measured in light clothing, without
Speakman, 2004). The classification of overweight and shoes as done in previous studies (Ismail, Zawiah, Chee,
obesity in adults as proposed by WHO includes: & Ng, 1995). Body weight was measured to the nearest
underweight (BMI < 18.5), normal weight (18.5 to 24.9), 0.1 kg while height was measured to the nearest 0.1 cm.
pre-obese/overweight (BMI 25.0-29.9), obese (BMI > or All readings were taken and recorded in triplicates. The
= 30.0) in which obese further subdivided into obese I BMI was calculated by dividing weight in kilograms by
(BMI 30-34.9), obese II (BMI 35-39.9) and obese III height in meters squared. The calculation of the BMIs
(BMI >40) (Malaysian Association for the Study of was carried out using SPSS version 15.
Obesity; World Health Organization , 2004). Despite Using the BMIs, subjects were assigned to various weight
previous attempts and suggestion to change this categories based on a modified WHO Classification
international BMI classification to interpret BMI cut-off which includes underweight (BMI < 18.5), normal (BMI
points for Asia population, the WHO Expert Consultation 18.5 to 24.9), preobese (BMI 25 to 29.9) and obese (BMI
2004 recommends retaining the current international > 30) (World Health Organization (WHO), 2004). The
BMI classification for adult regardless where the BMIs were analysed according to the different working
population is (Malaysian Association for the Study of areas at Kulaijaya Health District Office. The prevalence
Obesity; World Health Organization , 2004). was reported with confidence intervals (CI) and its
The present study focuses on the BMI index among health relations with variables of gender, workplace, job scope
staff of Kulaijaya Health District Office in Johor. The and marital status were analysed at 5% level of
objectives of this study are to describe the prevalence of significance using SPSS statistical software version 15.
overweight and obesity among the staff using
standardized international definitions. It will compare the RESULTS
prevalence in relation to the working environment, job Profile
scope, gender and marital status. All health workers (n=189) at Kulaijaya District Health
Department except for pregnant mothers and 3 months or
METHODOLOGY: less post natal were involved in this study. This study was
A cross sectional study was carried out in June carried out within the month of June 2012. Most of the
respondents were married (89.9%), females (64.6%) and
2012 among the the health staff of Kulaijaya District paramedics (43.9%). The mean BMI of the staff was
Health Department except expectant mothers and 25.73 kg/m². The respondents were equally distributed
females in their first three months postpartum period. among office and two clinics.
This study design was chosen since it was the best method
for this study due to its simplicity and rapid execution of

Figure 1-4 depict the descriptive profile
of staff of Kulai District Health Office.

Figure 1: Gender

Figure 2: Marital status Figure 3: Job Scope

Figure 4: Work area

29

Prevalence and relations
The prevalence of overweight (BMI > 25kg/m2) and obesity (BMI>30kg/m²) among the health staff was 33.9% (CI
0.27-0.41) and 20.1% (CI 0.14-0.26) respectively. Out of 20.1% of obese staff, 36.8% work in the office whereas 31.6%
served at the main Kulaijaya District Health facilities. All in all, the obesity prevalence was higher among office staff
(23.3%) (CI 0.14-0.35), males (20.1%) (CI 0.13-0.32), medical doctors (38.5%) (0.18-0.64) and married personnel
(20.6%) (0.15-0.27).

Prevalen Confidence Interval
ce
CATEGORY 5.8 Lower border upper border
UNDERWEIGHT 40.2
NORMAL 33.9 3.3 10.1
OVERWEIGHT 20.1 33.5 47.3
OBESE 100.0 27.5 40.9
TOTAL 14.1 25.2

Table 1: BMI prevalence and confidence interval of health staff of Kulaijaya Health District Office.

Bar Chart

PEJABAT BMI status
KK KULAI
underweight
normal
preobese
obese

w o rk p la c e

KK KULAI BESAR

0 10 20 30 40

Counts

Figure 5 Bar chart BMI status and workplace

OBESITY overweight
-.165(*)
Marital Status Pearson Correlation -.036 Marital status Pearson Correlation .023
Gender Sig. (2-tailed) .623 Jawatan Sig. (2-tailed)
Jawatan N 189 189
Workplace Pearson Correlation -.015 N
Sig. (2-tailed) .842 .118
N 189 Pearson Correlation .105
Pearson Correlation -.096 Sig. (2-tailed)
Sig. (2-tailed) .191 189
N 189 Gender N
Pearson Correlation .036 -.054
Sig. (2-tailed) .620 Pearson Correlation .460
N 189 Sig. (2-tailed)
189
Workplace N
.089
Table 2: Obesity and its correlations with studied factors Pearson Correlation .226
Sig. (2-tailed) 189
N

* Correlation is significant at the 0.05 level (2-tailed).

Table 3: Overweight and its correlations
30

DISCUSSION: or emergency department. Thus, less physical activity is
The mean BMI for staff of Kulaijaya District Health involved in their routine job. This explanation is true as if
Department (KDHD) was 25.73 kg/m², which is higher we add the prevalence of overweight and obesity,
than mean BMI of Malaysian adult which is 24.37kg/ m² paramedics had the highest prevalence at 55.4%
based on The Malaysian Adults Nutrition Survey (CI0.447-0.656). Paramedics share the same working
(MANS) (Azmi, et al., 2009) The prevalence of environment and similar job scope as medical doctors in
overweight (BMI 25-29.9 kg/m²) and obesity the clinic. Furthermore, 80% of these obese medical
(BMI>30kg/m²) among the health staff was 33.9% (CI doctors, 93.5% of overweight and obese paramedics are
0.27-0.41) and 20.1% (CI 0.14-0.26) respectively which married, in which marriage lifestyle is related with
were higher than the national overweight and obesity obesity-prone lifestyle (Hough, 2010).
prevalence of 29.1 (CI 0.286-0.297) and 14.4%
respectively (Nor, et al., 2008). The overweight and obese Males had higher prevalence of obesity and
were also higher than MANS (Azmi, et al., 2009); overweight (58.2%) (CI0.463-0. 693) compared to
whereby overweight prevalence was at 26.71% (CI: females (51.6%) (CI 0.429 - 0.603)in this study. Most
0.255 – 0.280) and obesity was at 12.15% (CI: 0.113 to males were (87.2%) married which could explain the
0.131). The local (KDHD) prevalence was even higher underlying reason for the higher prevalence.
than the overall southern region overweight prevalence of Furthermore, studies have shown that marital status is an
29.4% (0.266-0.324) and obesity prevalence at 13.8% (CI important predictor of obesity in males (Lipowicz,
0.118-0.161). Gronkiewicz, & Malina, 2002).

These figures can be attributed to the location of CONCLUSION :
Kulaijaya itself which is just next to Johor Bahru, a fast There was higher prevalence of obesity and
growing urbanized and developed capital city in
Malaysia (Noorsidi, 2009). Urban food environment, overweight amongst male staff, office and inspectorate
built environment and technology advancements can lead personnel and medical officers. Nevertheless, these
to poorer diets and less physical activity (Harvard School findings were found to be insignificant. However, there
of Public Health) (Reid Ewing, et al., 2008), which result was significant association between marital status and
in obesity (Caballero, 2001;Moy & Atiya, 2003-2005; overweight prevalence. Obesity and overweight
Speakman, 2004). Furthermore, working in a health prevalence of Kulaijaya District Health Department
community clinic is associated with less physical and (KDHD) was also higher than the national and southern
energy requirement compared to working in a hospital zone prevalence figures. There is a need for
setting. (Chris G., 2009). implementation of effective weight management
program for all the staff at Kulaijaya Health District
This study also showed that obesity prevalence Department, regardless of gender, marital status,
was higher in those working in office surroundings respective job scope and working environment.
compared to clinical settings. This is probably due to
higher physical activity required to run clinics rather than ACKNOWLEDGEMENTS
offices. Furthermore,office work is mostly related with In The Name of Allah, The Most Gracious and Merciful.
paper work and entails prolonged sitting rather than We are so blessed with all the courage and strength that
standing (Ariënsa, et al., 2001). Office workers also has been bestowed upon us.
spend lots of time sitting in front of their computers. The deepest appreciation and gratitude toward Dr Badrul
Studies have showed strong association between Hisham Bin Hj. Abd Samad for his great comments,
computer use and obesity due to physical inactivity (CBC guidance and assistance in the preparation of this writing.
NEWS, 2008;Kautiainen, Koivusilta, Lintonen, We extend our gratefulness to Dr Abdul Rahim Bin
Virtanen, & Rimpelä, 2005) Abdullah, Head of Kulaijaya District Health Department,
Kulaijaya, Johor for his support and advice.
Higher prevalence of obesity and overweight Special thanks to our beloved staff for giving good
among married staff was also significant (p=0.023). The cooperation and assistance during data collection. We
findings are similar with previous studies (Jeffery & pray that Allah will reward your benevolence and
Rick, 2002; Lipowicz, Gronkiewicz, & Malina, 2002; cooperation in this world or the hereafter.
Sobal, 2008). This might be due to significant changes in
lifestyle as a couple automatically cease to monitor or
control their weight gain or body shape after marriage.
Married couple spend more time eating together and
often order takeaway ready meals while exercising less
(Hough, 2010).

Surprisingly, medical doctors have the highest
prevalence of obesity among all categories in this study.
This might be due to their job scope in clinical setting
which were most likely related with counseling patient,
establishing long term relationship with patient and
family members, emphasizing disease prevention and
health promotion (American Academy of Family
Physicians, Wikipedia) rather than attendance or
involvement in acute or emergency cases as in a hospital

31

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CBC NEWS. (2008). TV viewing, computer use linked to
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Chris G. (2009, September 14). Hospital or Clinic: Which
is Better to Work In? Retrieved from Yahoo Contributor Overweight and obesity in nurses, advanced practice
Network: http://voices.yahoo.com/hospital-clinic-
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ml

32

Evaluation of laboratory outcomes of patients (INR) 8
between clinician-managed Warfarin therapy and

pharmacist-managed Warfarin Medical Adherence Volume 10
Therapy Clinic (W-MTAC) in HBP over 1 year

Ali Umar Bin Ibrahim, Yvonne Koh Li Ling, Pn. Siti Khairaini Binti Rahim 2012

Pharmacy Department, Hospital Batu Pahat, Johor, Malaysia
June 2011

Abstract Introduction

Evaluation of laboratory outcomes of patients (INR) Warfarin is the most widely used oral anticoagulant agent
between clinician-managed Warfarin therapy and worldwide, especially in the prevention of
pharmacist-managed Warfarin Medical Adherence thromboembolic events such as deep vein thrombosis
Therapy Clinic (W-MTAC) in HBP over one year (DVT), chronic atrial fibrillation, pulmonary embolism
I.Ali Umar1, Y. L .L Koh1, R. Siti Khairani1 and valvular heart disease [1]. Warfarin acts by
1Department of Pharmacy, Hospital Batu Pahat, Johor. interfering with the cyclic interconversion of vitamin K
Background: The clinical quality of warfarin therapy and vitamin K epoxide and subsequent modulation of the
relies on how successful healthcare professionals and gamma carboxylation of the terminal regions of
patients are in achieving and maintaining levels of vitamin K proteins. This results in the reduction of
anticoagulation capable of preventing thromboembolic clotting factors II, VII, IX, and X [2]. Carboxylation of
events without increasing the risk of hemorrhagic the regulatory anticoagulant proteins C and S also is
complications. The purpose of this study is to compare inhibited, potentially contributing to a procoagulant
the clinical outcomes of patients (INR) between effect early in therapy.
clinician-managed Warfarin therapy and pharmacist-
managed warfarin Medication Adherence Therapy Clinic Warfarin has its established role in anticoagulation
(W-MTAC) in HBP over one year (April 2009-March treatment for decades. But a number of challenges have
2010) and (April 2010-March 2011) respectively. been identified in managing warfarin therapy practically
Methods: The retrospective study was carried out by and clinically. These include the need for frequent
measuring the percentage of patient time spent within laboratory monitoring and dose adjustment, drug and
targeted INR therapeutic range. The percentage of time food interactions, presence of concomitant disease, the
spend within the therapeutic range was calculated by the influence of co-morbidities on anticoagulant control and
method described by Rosendaal and colleague. All data the fear of adverse events [6]. Besides, the variable
collected will be entered into Microsoft office Excel 2003 biological effect and drug response in patient due to
(Microsoft Corp., Redmond WA, USA) and analysed variant alleles of the CYP2C9, the hepatic enzyme
using Statistical package for the Social Sciences (SPSS) responsible for oxidative metabolism of the warfarin S-
version 17TM (SPSS Inc., Chicago, IL, USA). isomer, can also influence the optimal dosing of warfarin.
Results: It was found that there was an increase of Several genetic polymorphisms in this enzyme have been
percentage of patient-time in therapeutic range which described that are associated with lower dose
about 10% after W-MTAC managed by pharmacists was requirements and higher bleeding complication rates
started at HBP. compared with the wild-type enzyme CYP2C9 [6,9].
Conclusion: The management model for anticoagulation Besides, daily adherence to warfarin is both a persistent
therapy by clinical pharmacist as the primary care and potentially modifiable contributor to INR instability
provider with clinician consultation is more effective and warfarin efficacy [6,7].
than a model of care managed solely by clinicians in
achieving target INR control. The clinical quality of warfarin therapy
Keywords : Warfarin therapy, Warfarin Medical relies on how successful healthcare professionals and
Adherence Therapy Clinic (W-MTAC) patients are in achieving and maintaining levels of
anticoagulation capable of preventing thromboembolic
Correspondence: Mrs. R. Siti Khairani events without increasing the risk of hemorrhagic
Full correspondence address: Hospital Batu Pahat, Jalan complications [8]. Successful anticoagulant management
Korma, 83000 Batu Pahat requires careful monitoring of the INR, ongoing patient
Tel: 07-4363000 ext. 3136 education and good communication between patient and
Fax: 07-4345810 healthcare professionals. It also requires an educated and
Email: [email protected] skilled personnel as well as a well-organized framework
of services [8,9]. Poor patient compliance and lack of
patient education is often cited as an explanation for out-

33

of-range INR measurements [10]. Past studies had underwent follow-up at Medical Outpatient Department
suggested that patient education which highlight the side- (MOPD) HBP from year April 2010 to March 2011 are
effects of warfarin, the potential for drug–drug and recruited in this study. Before April 2010, outpatient
drug–food interactions, advice on birth control, the anticoagulation management in HBP patients was
importance of compliance and the need for regular managed solely by doctors. For the purpose of this study,
monitoring, is associated with better clinical outcomes. this model was named as 'usual medical care' (UMC). In
Prior knowledge about warfarin has been associated with April 2010, pharmacists took over the management of
a decreased risk of bleeding [11]. Written and verbal warfarin therapy, working closely with Medical
information have been shown to improve control of the Department doctors, hence the formation of W-MTAC. In
level of anticoagulation [12]. This shows that counselling W-MTAC the pharmacist sees all new patients at their
patients with respect to their anticoagulant treatment is first visit for information and counselling regarding
fundamental and significantly improves patient's warfarin therapy. In the subsequent visit, the clinic's
knowledge and quality of anticoagulation. Many studies standard procedure is for patients to have their blood
[15-20] had proven that pharmacist-managed taken for an international normalized ratio (INR) test
anticoagulation clinics had showed improved care in at the time of arrival. INR results were determined via
patient receiving warfarin therapy compared to usual venous blood samples and tested hospital laboratory staff
medical care, in which the patient showed improved INR using a fully-automated, high productivity analyzer
control, improved patient education, decreased warfarin- (ACL 7000; Instrumentation Laboratory, Milan, Italy).
related hospitalisation, lowered the incidence of When the INR results are received later the same day, they
haemorrhagic and thromboembolic events, decreased are written in the patient's record book and case note
health care cost or more cost effective therapy. along with dosage instructions, and subsequent review
date will be given to patient.
Because there is a strong association between
INR levels and adverse outcomes, the efficacy of warfarin Study Design and Selection Criteria
depends not only on defining the target INR but also the This is a retrospective medical record review,
maximal length of time the patient's INR maintained observational study. The historical control group
within the designated therapeutic range or time in consists of patients received warfarin therapy from 1st
therapeutic range (TTR) during warfarin therapy as there April 2009 to 31st March 2010, who were managed by
is an increased risk of haemorrhage at INRs > 3.0 and clinicians. The intervention group consists of patients
thromboembolic complications at INRs < 2.0 [19]. White under followed-up W-TAC from 1st April 2010 to 31st
et al., 2007 [20] reported that the INR value in the March 2011. Demographic data, indications for warfarin
therapeutic range for more than 75% of the time had therapy and the target INR ranges are collected for each
significantly fewer episodes of major and minor bleeding. patient. When multiple indications for warfarin therapy
Thus patient's INR must remain stable within their were recorded, the indication requiring the highest target
therapeutic range in order to minimize the complications INR range or the longest duration of anticoagulation
associated with anticoagulation therapy. Therefore, the therapy is chosen as the primary indication. A W-MTAC
aim of this study is to evaluate the clinical quality and audit form is designed to collect the data, and a pilot study
effectiveness of warfarin clinic managed by the was conducted to review the final audit form (Appendix
pharmacists - also known as Warfarin Medical Adherence 1).
Therapy Clinic (W-MTAC), in Hospital Batu Pahat
(HBP) by measuring the percentage of patient time spent Inclusion criteria
within targeted INR therapeutic range in a cohort of • Aged > 18 years at initiation of warfarin therapy
patient participated in this studies. • At least two INR test values measured during
any of the evaluation periods
Research Objective • Have been stabilized on warfarin therapy
The objective of this research is to compare the laboratory (minimum of 1 month).
outcomes of patients (INR) between doctor-managed
Warfarin therapy and pharmacist-managed Warfarin Exclusion criteria
Medical Adherence Therapy Clinic (W-MTAC) in HBP • INR tests performed as inpatient tests
over one year (April 2009 – March 2010) and (April 2010
– March 2011) respectively. Outcome
Percentage of time in the therapeutic range in each time
Research Hypothesis period was first calculated overall; that is, by considering
all days of follow-up. The outcome is the percentage of
Alternative hypothesis, H1 : The laboratory patient time spends within the target INR range. The
percentage of time spend within the therapeutic range is
outcomes of pharmacist-managed W-MTAC in HBP, calculated by the method described by Rosendaal and
colleague as described in Appendix 2 [22]. The method
Johor has improved over one year. utilized is Rosendaal's linear interpolation. The majority
of recent studies utilize Rosendaal's linear interpolation
Null Hypothesis, H0 : The laboratory methodology which assumes that a linear relationship
exists between two INR values, given that not more than 8
outcomes of pharmacist-managed W-MTAC in HBP, weeks has elapsed between the two. It allocates a specific

Johor has not improved over one year.

Methodology
Setting
Patients who were treated with warfarin therapy and

34

INR value to each day between tests for each patient, Statistical Analysis
allowing one to calculate INR specific incidence rates of All data collected will be entered into Microsoft Office
adverse events, such as bleeding complications. Linear Excel 2003 (Microsoft Corp, Redmond WA, USA) and
interpolation is the only method that incorporates time. analysed using Statistical Package for the Social Sciences
(SPSS) Version 17 ™ (SPSS INC., Chicago, IL, USA).

Results
Demographic Characteristics
Table 1 shows the demographic characteristics of warfarin patients of HBP from April 2009 until March 2011. The
proportion of male to female was about 1:1 (46.5 % male vs 53.5 % female). About three quarter of the W-MTAC
patients are made up of Malay, followed by Chinese. The mean age was around 59.62 years old, with standard
deviation of about ±13.71 years old. The youngest patient was 34 and the oldest patient was 91 years old.

Table 1: Demographic characteristics of warfarin patients of HBP from
April 2009 – March 2011

Year April 2009 – March 2011

No. of Patient (n) 43

n (%)

Gender

Male 20 46.5

Female 23 53.5

Races

Chinese 11 25.6

Melayu 32 74.4

Age

Mean age 59.62±13.71
± SD a

Age 34 to 90
Range

aSD=Standard deviation

Figure 2: Indication of warfain at HBP from 2009-2011

AF=atrial fibrillation, HVR= heart valve replacement,
DVT= deep vein thrombosis, included pulmonary embolism

35

Figure 2 shows the warfarin indication at HBP. Most of the warfarin was indicated for atrial fibrillation (AF) 81.4%,
followed by heart valve replacement (HVR) 14% and deep vein thrombosis (DVT) 4.65%. Warfarin was not used for
cardiac ischaemic events such as ischaemic cardiomyopathy (ICMP), dilated cardiomyopathy (DCMP) and other
events such as antiphospholipid sndrome (APS), and coronary artery bypass graft (CABG).

Figure 3: Mean percentage of patient-time in
therapeutic range. Results were expressed as the
mean percentage, significantly different from
the control group; Doctors at P < 0.05

Figure 3 shows the mean percentage of patient-time in medical care [23,24]. In the present study, the warfarin
therapeutic range between doctors and pharmacists. patients studied in the pharmacist-managed group spent
Overall, the mean percentage of patient-time in more time in the therapeutic INR ranges when compared
therapeutic range of W-MTAC managed by pharmacists with those in the clinician-managed group. This showed
was superior (58.1%) than MOPD managed by doctors that the patients managed by pharmacist-managed group
(48.2%). There was an increase of percentage of patient- from April 2010 to March 2011 achieved a better INR
time in therapeutic range which about 10 % after W- control as shown in Figure 3. Such achievement is
MTAC managed by pharmacists was started at HBP. perhaps due to the intense education provided to patients
and their caregivers by clinical pharmacist in the
Discussion pharmacist-managed group, patients' adherence or
Once the targeted intensity of oral anticoagulation is compliance are checked more thoroughly and, as a drug
achieved, it must be maintained, as this is directly related expert, pharmacist provides extra attention to the
to its derived benefit. The most recognized way to potential warfarin–drug and warfarin–herb interactions at
measure the therapeutic effectiveness of warfarin over each clinic visit. Besides, the use of standardized
time is to measure time spent in therapeutic range (TTR). anticoagulation monitoring template and separate case
TTR has been shown to strongly correlate with the note also makes monitoring of patient's INR become
principal clinical outcomes of hemorrhage or thrombosis easier and more easily retrievable. All these may
and, thus, TTR is a reliable measure of the quality of W- contribute to the improved INR control in the patients
MTAC. Increased TTR has also been associated with managed by the clinical pharmacist [27].
decreased mortality, myocardial infarction and stroke
rates. Clinical studies show that under-coagulation and The percentage of patient time spent in therapeutic range
over-coagulation enhance the risk of adverse clinical managed by pharmacist in WMTAC since April 2010 to
outcomes such as thromboembolism and bleeding March 2011 is higher than that of conventional medical
respectively. Literatures have proven that specialized care. A likely explanation is that, in 2008, the new
anticoagulation management with pharmacist's warfarin protocol has been implemented. The new
intervention has resulted in outcomes at least equal, and protocol came with more detailed information and
sometimes superior in term of time spent in therapeutic directions, with a clear dosage adjustment guideline and
range. Furthermore, there is also reduction in therapy- also with the list of possible drug-drug or drug herb
related complication by 50-90% compared to those interaction that may help pharmacist in warfarin dosing
managed through standard care. adjustment. Patient satisfaction with pharmacist
managed anticoagulation clinics was invariably high and,
Time in the therapeutic range has been shown to correlate in comparative studies, higher than that reported for
well with hemorrhagic and recurrent thromboembolic clinician-managed anticoagulation clinics. Physicians
events [25]. It can be measured by a number of methods surveyed also expressed satisfaction and frequently
(Rosendaal method, the percent (fraction) of INRs in acknowledged that such a service would save them time
range, and the point-in-time or cross-section of records [32,33]. Clinicians considered pharmacists capable of
methodology) and no standardized consensus exists as to monitoring and maintaining warfarin therapy, considered
which is the best measure. It was proven that the Pharmacist managed anticoagulation clinics an asset,
anticoagulation management service (WMTAC) and did not feel that it infringed upon their control of
improves time in the therapeutic range for patients on patient management [36].
chronic oral anticoagulation compared with usual

36

There are some limitations to this study. First was related Not only that, a continuous medical education (CME)
to the problems inherent in a retrospective analysis and with the Head of Department, Specialists, Medical
have been described in detail elsewhere [1]. Next Officers (MO) and Housemanship Officers (HO) should
limitation was due to the possibility of incompleteness or be conducted regularly, preferably once per year, this due
data loss, this is the common drawback of retrospective to the rapid staff movement in the hospital. The doctors
study and not only the problem in this study. Besides, the were introduced to W-MTAC in hope of providing better
warfarin complications such as thromboembolic events warfarin management and care to patients. Moreover, the
and bleeding risks, which were considered as the ideal existing warfarin book should be amended to provide
end points study of therapeutic efficacy, were not carried more comprehensive information including indication,
out in this study. Furthermore, many environmental tablet identification, drug-drug and drug-food
factors, such as medications, diet and concomitant interactions and other precautions. Besides, ongoing
disease states can alter the pharmacokinetics of warfarin, education, counsel in case of sustained dysregulation of
thus contributing to the limitations of study. Other factors anticoagulation, or advice on interruption of therapy in
that may affect therapeutic outcome such as patient case of bleeding or the need to undergo an invasive
compliance, transient fluctuations of comorbid procedure are, among others, issues that need to be taken
conditions, the addition or discontinuation of care of is also need to be addressed to all warfarin patient
medications, the quality of dose-adjustment decisions to improve better warfarin management control [37].
and whether the patient has demonstrated a stable dose
response and many others are not considered in this study. Conclusions
Overall, the mean percentage of patient-time in
In future studies assessment of the major complications therapeutic range of W-MTAC managed by pharmacists
of warfarin in this hospital, such as thromboembolic was superior (58.1%), more than that of MOPD managed
events, bleeding risks, and rate of hospitalization should by doctors (48.2%). In summary, the management model
be conducted. Besides, the future studies should also for anticoagulation therapy including a pharmacist as the
correlate the therapeutic efficacy with the compliancy, primary care provider with doctor's consultation is more
drug-drug, drug-food interactions, patients' knowledge effective than a model of care managed solely by doctors
and education levels. in achieving target INR control.References

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2460–4.

39

Appendix 1 Age: Indication: Target INR:

Name: Doctors

Visit Date INR Days since INR difference % in range

Visit Date Pharmacists
INR Days since INR difference % in range

40

Appendix 2

Rosendaal Method for % INR in range - method which INR-specific person-time is calculated by incorporating the
frequency of INR measurements and their actual values, and assuming that changes between consecutive INR
measurements are linear over time
Example: Patient has INR reading of 2.4 on October 1st, then reading of 3.2 on October 17th. Assuming the patient
gradually moves towards a reading of 3.2 throughout the 16-day period between Oct 1st and Oct 17th, then we can
estimate that the patient was within their INR therapeutic range [2 - 3] for a majority of that time period. To calculate the
value
1. calculate amount of the total shift (2.4 to 3.2 = 0.8 increase) that is within the therapeutic range (0.6 of shift is within
range, [3.0 - 2.4 = 0.6])
2. calculate percent of total shift within therapeutic range (0.6/0.8 = 75%)
3. estimate number of days since last visit that were within range (75% x 16 days since last visit = 0.75 x 16 = 12 days
within range, 4 days out of range). Percentage for that time period is 75% in range, and 12 total days in range.
To calculate overall % in range, add total days in range for each time period, and divide by total therapeutic days

Sample Patient

Visit Date Type INR Days INR Pred% In
Since Diff Range

12/20/2005 8:29:19 AM Prior Visit 3.3 50%
100%
1/17/2006 8:32:38 AM Onsite Training 2.7 28 -0.60 100%
100%
2/7/2006 8:32:38 AM Prior Visit 2.3 21 -0.40 67%

3/7/2006 8:32:38 AM Prior Visit 2.4 28 0.10 0%
0%
4/4/2006 3:54:57 PM Scheduled Visit 2.2 28 -0.20 48%
0%
4/12/2006 10:48:08 AM Telephone Contact 1.9 8 -0.30 0%
56%
4/25/2006 4:31:10 PM Scheduled Visit 1.2 13 -0.70 57%
100%
5/2/2006 3:18:50 PM Scheduled Visit 1.8 7 0.60 71%
71%
5/15/2006 3:51:58 PM Scheduled Visit 3.9 13 2.10 100%

5/22/2006 3:39:23 PM Scheduled Visit 3.7 7 -0.20

5/30/2006 3:42:20 PM Scheduled Visit 3.5 8 -0.20

6/14/2006 2:42:54 PM Scheduled Visit 1.7 15 -1.80

6/23/2006 3:09:33 PM Scheduled Visit 2.4 9 0.70

7/25/2006 2:50:16 PM Scheduled Visit 2.5 32 0.10

8/22/2006 2:49:09 PM Scheduled Visit 3.2 28 0.70

8/29/2006 3:07:13 PM Scheduled Visit 2.5 7 -0.70

9/19/2006 3:03:26 PM Scheduled Visit 2.3 21 -0.20

INR In Range % (Traditional) = 47.06%
[8 visits within range out of 17 total visits]

INR In Range % (Rosendaal) = 71.05%
[194 days in therapeutic range out of 273 total therapeutic days]

41

POLYPHARMACY OF ANTIHISTAMINES IN COUGH 9

AND COLD PRODUCTS USED AMONG CHILDREN Volume 10
AGED BELOW 6

Wong L.Y.1, Fajaratunur A.S1, Zakiah A.R.1, Hazlinda A.H.1, 2012
Goh P.T.1, Zakaria M.S.1, ZulRamli Z.2

1Pejabat Kesihatan Muar, Johor, 2Institute Health System Research

Summary (USFDA) that cough and cold medicines that contain one
or more decongestants, antihistamines and/or anti-
There are high incidences of concurrent use of two or tussives do not work and should not be used by children
more antihistamines in cough and cold treatment among aged below 61-7. In the meantime, the FDA's
children at Klinik Kesihatan Maharani, Muar. This study Nonprescription Drugs and Pediatric Advisory
aims to reduce the polypharmacy of antihistamines in committees voted to ban over-the-counter cough and cold
common cold treatment among children below 6, and to products that are intended for children who are younger
evaluate its magnitude and characteristic prior to and than 6 years,17 and the FDA is currently considering the
following pharmacist intervention. This was a cross- committees' advice. Beside, the Drug Control Authority
sectional, quasi-experimental, two-phase (pre/post) (DCA) recommends all healthcare professionals to take
study. All prescriptions of cough and cold product(s) for note that many products contain the same medicinal
children below six were recruited during these periods. ingredient(s) and combined use in children may lead to
Incomplete and indecipherable prescriptions were overdose1, 8.
excluded. The endpoints were total number of
polypharmacy in Phase I and II, in different category of Recently, attention has focused on the potential harmful
prescribers, and different combinations. The result effects of these medications18. The adverse events
showed total polypharmacy of antihistamines in Phase II reported with these products include death, convulsions,
(Npre=559) was significantly reduced to 82 from 238 in rapid heart rates and decreased levels of conciousness12,
Phase I (Npost=605, p<0.01). The incidences of 13, 22. Concerns about these toxicities, especially in light
polypharmacy prescribed by doctors, Medical assistants of data that cough and cold products have not been proved
and staff nurse were 10.3%, 34.4% and 0% respectively in effective in treating symptoms of cough and the common
Phase II compared to 46.6%, 37.4% and 17.2% cold in young children, it is advised not to give more than
respectively in Phase I (p<0.01). The most common one cough and cold product to children as they can
polypharmacy occurred appears to be combination of recover in time on their own. In addition, common cold is
diphenyhydramine and chlorpheniramine in both phases, a mild, viral infection that can be managed by rest,
which were 21.5% and 7% respectively (p<0.01). The sufficient fluid intake and comfort measures1, 2.
reduction in polypharmacy of antihistamines in cough There is high incidence (42.6% of total prescriptions
and cold products used among children below 6 can be given to children aged below 6 diagnosed with URTI) of
achieved by means of a systematic and comprehensive concurrent use of two or more antihistamines in cough
intervention and collaboration between healthcare staffs and cold treatments among chidren aged below 6 at
though there were limitations. Klinik Kesihatan Maharani (KKM), Muar. The
antihistamines used are promethazine, diphenhydramine,
Keywords: Polypharmacy, antihistamine, children, chlorpheniramine and triprolidine. The polypharmacy of
cough and cold antihistamines may lead to anticholinergic intoxications
such as heat intolerance, jerking movements,
Introduction disorientation and hallucinations and other adverse
events mentioned above4,9,10,11.
Cough and cold is the most common symptom for which
patients seek medical attention15 and cough mixtures are ___________________
frequently prescribed in primary care. However, the
clinical value of many cough mixtures is debatable16, 23, a Cough and cold: Symptoms of upper respiratory tract
24 and their use in children and the elderly is infection19.
controversial.
b Cough & cold products: Products that contain
In August 2007, US Federal Health advisors antihistamines, antitussives and/or decongestants to treat
recommended to U. S. Food and Drug Administration cough and cold symptoms1,20.

42

Objectives 31 January 2009 (20 working days) to aware the
prescribers about the polypharmacy that may occur if
The aims of this study are to reduce polypharmacy of more than one antihistamine given to the children aged
antihistamine(s) in cough and cold products and to study below six and hence the adverse events. The interventions
the magnitude and characteristic of polypharmacy of were conducted by providing short lecture, and
antihistamine in the management of couh and cold in distribution of published circular and protocol on rational
PKBM, Muar. prescribing cough and cold product(s) that contains
antihistamine(s) to all prescribers. The protocol
The specific objectives are: circulated was approved by Family Medicine Specialist
Ÿ To calculate the incidences of polypharmacy of and Pharmacy Department of the clinic. This is to
improve the physicians' confidence in handling URTI
antihistamine prior to and after intervention. cases among children without prescribing polypharmacy
Ÿ To identify the combinations of cough and cold and to reduce the suspicions on the reliability of protocol
circulated. Beside, all prescribers who were detected to
products in polypharmacy. prescribe two or more antihistamines for children aged
Ÿ To identify the categories of prescribers involved in below 6 in a single prescription were contacted by phone
for awareness and clarification purpose.
polypharmacy.
Ÿ To compare the incidences of polypharmacy prior to Phase 2 was conducted from 2 Februari 2009 to 31
Mac 2009 for another 48 working days. Every
and after the intervention. prescription and particulars as stated in Phase 1 will be
Ÿ To estimate the cost of polypharmacy prior to and identified after the intervention (Npost= 605), to compare
the incidences of polypharmacy of antihistamines with
after the intervention. respect to category of prescriber, and to estimate the cost
of polypharmacy prior to and after the intervention. The
Methodology endpoints were total number of polypharmacy in Phase I
and II, in different category of prescribers, and in
This is a 2 phases cross-sectional, quasi-experimental different combinations of polypharmacy.
cohort study that involved the prescribers and
pharmacists at Klinik Kesihatan Maharani, Muar. The The raw data were processed and entered for data analysis
study comprised all prescriptions given to children aged according to the different phases. Data were analysed
below 6 who diagnosed with upper respiratory tract using SPSS 15.0 programme.
infection (URTI) during November 2008 to March 2009
(N = 1164). The data was collected by pharmacists at Results
pharmacy counter.
A total number of 1164 prescriptions were enrolled
Phase 1 was conducted during the period from 3 during the study period. Of these, 559 prescriptions were
November 2008 to 31 December 2008 for 48 working recruited in Phase 1 and 605 patients for Phase 2. In Phase
days. Every prescription that contains cough and cold 1, 238 (42.6%) prescriptions were detected to comprise
product(s) to be given to children aged below six were polypharmacy compared to 82 (13.6%) in Phase 2. The
identified and recruited in the study (Npre= 559). The difference was found to be significant (p<0.01).
inclusion criteria were prescriptions, which URTI as the
diagnosis and antihistamine as one or more of the items A total of eight different combinations of polypharmacy
prescribed. Prescriptions which were incomplete, in antihistamines were identified in this study. There were
indecipherable, given to children aged 6 and above, not combinations use of (1)diphenhydramine and
diagnosed as URTI were ineligible. chlorpheniramine; (2)diphenhydramine and triprolidine;
(3)chlorpheniramine and triprolidine; (4)promethazine
Each prescription was described by a series of and diphenhydramine; (5)promethazine and
characteristics, which were analysed as possible chlorpheniramine; (6)promethazine and triprolidine;
explanatory variables for the prevalence of (7)diphenhydramine, chlorpheniramine and triprolidine;
polypharmacy of antihistamines: (8)promethazine, diphenhydramine and
Ÿ the category of prescribers (family medicine chlorpheniramine. In both phases, the combination of
diphenhydramine and chlorpheniramine was found to be
specialist, medical officer, medical officer assistant the most common polypharmacy which was 55.9% and
and staff nurse), 59.8% respectively, followed by diphenydramine and
Ÿ types of antihistamine prescribed (promethazine, triprolidine (35.3% and 34.2% respectively).
diphenhydramine, chlorpheniramine, and
triprolidine),
Ÿ types of combination use of antihistamines in one
prescription, and
Ÿ cost of antihistamine(s) used for every prescription.

___________________ Out of 382 prescriptions by doctors in Phase 1, 178
(46.6%) were detected with polypharmacy and this was
Polypharmacy: Concurrent use of two or more reduced to 50 (10.3%) in Phase 2 (npost= 486, p<0.01).
medications from the same chemical class21. However, only 3% polypharmacy of antihistamines was
decreased from Phase 1(55, 37.4%, npre=147) to Phase 2
Remedial action was carried out by means of pharmacist (32, 34.4%, npost=93) in population of medical assistants
interventions following phase 1, from 1 January 2009 to (p>0.05). Only 5 (17.2%) out of 29 prescriptions were

43

found to contain polypharmacy by staff nurse in Phase 1 polypharmacy from Phase 1 (238, 42.6% of 559
and were decreased to 0% in Phase 2 (npost=25, p<0.05). prescriptions) to Phase 2 (82, 13.6% of 605
Family medicine specialist did not prescribed prescriptions). A possible explanation for the reduction
polypharmacy of antihistamines during the study period. was an increase awareness and emphasis for concurrent
This study showed a drastic decrease in the total number use of more than one antihistamine should be avoided in
of polypharmacy among all prescribers (p<0.01). children and hence, the related adverse reactions.

The total cost of antihistamine(s) used (559 prescriptions) In addition, greater awareness of the health care
in Phase 1 was RM 1019.64 and RM 945.68 (605 professionals on the incidence of polypharmacy in
prescriptions) in Phase 2. The mean antihistamine (s) cost antihistamines used may have resulted in the reductions
per prescription in Phase 1 was RM 1.82 and reduced of seven combinations use of antihistamines among
significantly to RM1.56 in Phase 2 (p<0.01) . children in term of total number of polypharmacy, except
the combination use of chlorpheniramine and
Table 1: The Comparisons between Phase 1 (Before triprolidine, none in Phase 1 but detected one in Phase 2.
Intervention) and Phase 2 (After Intervention) in Terms of
Number of Prescriptions, Total Costs and Mean Cost of Among all prescribers(family medicine specialists,
Antihistamine(s) per Prescription medical officers, medical assistants, and staff nurses), the
polypharmacy of antihistamines prescribed by medical
Comparisons Phase I (before Phase II (after P value officers, decreased drastically from Phase 1 (178, 46.6%
intervention) intervention) p<0.01 of 382 prescriptions) to Phase 2 (50, 10.3% of 486
Total prescriptions with prescriptions). This reflects that medical officers respond
antihistamine(s) Npre=559 Npost=605 perceptively to medical information provided and react
Number of prescriptions with rapidly for the sake of patients. Besides, this further
antihistamine polypharmacy 238 (42.6%) 82 (13.6%) explains that the interventions taken were effective and
Total costs comprehensive in inducing and increasing the awareness
RM 1019.64 RM 945.68 among health care professionals on the incidence of
polypharmacy of antihistamines used in URTI treatment
Mean cost of antihistamine(s) per RM 1.82 RM 1.56 p<0.01 and the related adverse reactions. The polypharmacy of
prescription antihistamines prescribed among medical assistants
appear to be similar in Phase 1 and Phase 2. This explains
Table 2: The Comparison of Polypharmacy in that the interventions may not give an impressive impact
Antihistamines by Different Categories of Prescriber to the medical assistants. According to time captured by
between Phase 1 and Phase 2 using Queue Management System (QMS), most of the
polypharmacy prescribed by medical assistants were
Phase I (before intervention) Phase II (after intervention) found after office hour, which is from 5pm to 9.30pm.
During this time, most of the covering medical assistants
Comparisons P value were from other Klinik Kesihatan, who do not aware of
the remedial actions taken by pharmacists.
npre Polypharmacy npost Polypharmacy
(%) (%) The total cost of antihistamine(s) used was similar
between two phases. This was anticipated as the total
Family medicine specialist 1 0(0) 1 0(0) prescriptions recruited in Phase 2 were higher than that in
Phase 1 although the incidence of polypharmacy was
Medical officers 382 178(46.6) 486 50(10.3) p<0.01 contrary between both phases. However, accompany with
the fall in the total number of polypharmacy in
Medical assistants 147 55(37.4) 93 32(34.4) p<0.05 antihistamines across the phases, the mean cost of
antihistamine(s) per prescription decreased significantly.
Staff nurse 29 5(17.2) 25 0(0) p<0.05
Several limitations exist with this study. The assessment
Table 3: The Comparison of Different Combinations of of this study was over a relatively short period, and so
Polypharmacy in Antihistamines between Phase 1 may not truly reflect the long term impact of these
(Before Intervention) and Phase 2 (After Intervention) interventions. Therefore, it is suggested that another
phase should be performed in this study for another 48
Combinations of polypahrmacy in Phase 1 (before Phase 2 (after working days to reassess the magnitude and characteristic
antihistamines of polypharmacy 6 months after Phase 2, and hence the
intervention, n =238) intervention, n=82) effectiveness of the remedial actions.
chlorpheniramine + triprolidine As with any unblinded study of this type, the potential for
0 (0%) 1 (1.2%) investigator assessment bias existed. As the evaluation of
polypharmacy in antihistamines was undertaken
diphenhydramine + triprolidine 84 (35.3%) 28 (34.2%) sequentially across phases, potential bias may have been
introduced as the investigators who were the pharmacists
diphenhydramine + chlorpheniramine 133 (55.9%) 49 (59.8%) in this study, gained experience during the process.
Similarly, Hawthorne effect may have been introduced as
diphenhydramine + chlorpheniramine + 1 (0.4%) 0 (0.0%)
triprolidine

promethazine + triprolidine 2 (0.8%) 1 (1.2%)

promethazine + chlorpheniramine 11 (4.6%) 1 (1.2%)

promethazine + diphenhydramine 6 (2.5%) 2 (2.4%)

promethazine + diphenhydramine + 1 (0.4%) 0 (0.0%)
chlorpheniramine

Discussion

The objective of this study was to assess the relative
magnitude and characteristic of polypharmacy of
antihistamines in the management of cough and cold
among children aged below 6 subsequent to the remedial
actions.

The result showed a reduction of 29% in the number of

44

the respondents who were the prescribers, knowing that References
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Penggunaan Ubat untuk Rawatan 'Cough and Cold' Pada
The difference in sampling size between Phase 1 (559) Kanak-kanak. Pekeliling Pengurusan Farmasi BIL.
and Phase 2 (605) seemed to affect the comparisons of the 1/2008.
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both phases in term of the total number of polypharmacy. of Acute Respiratory Infections In Young Children.
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for Acute Cough in Children and Adults in Ambulatory
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46

The Prevalence Of Hearing Impairment 10
Among The Dental Staff Volume 10

In Kota Tinggi District, Johor.

Muz'ini M1 Thilaka C2 2012

Oral Health Division, Johor State Health Department, Malaysia1
Public Health Division, Johor State Health Department, Malaysia2

Summary from these equipment was too loud and affecting their
Sources of dental sounds can cause potential damage to hearing.
the hearing. The objective of this cross sectional study
was to determine the prevalence of hearing impairment Noise-induced hearing loss is caused by damage to inner
among dental personnel and also to identify the sources of ear nerve cells due to exposure to both loud and high
noise in the working environment and associated dental pitched sound. These cells never regenerate and they die
equipment. Noise levels during dental procedures and which results in irreversible hearing impairment. One
laboratory procedures were measured using a sound level may not hear faint sounds, or one may hear people
meter. Audiometric test was conducted to assess the speaking normally, but cannot make out or understand
hearing status of all dental personnel in the clinics what is being said. This type of deafness is permanent
involved. Only 7.7% (n=4) was identified had noise and irreversible and is called “Noise Induced Hearing
induced hearing impairment. The study also found that Loss” (NIHL).4
the three category of staff suffered hearing impairment
were working in high noise area which is dental Sources of dental sounds that can cause potential damage
surgery(Kota Tinggi Main Dental Clinic, Sening dental to the hearing are high speed and low speed handpieces,
Clinic) and with high noise equipment such as high velocity suction units, ultrasonic instruments and
compressor, high speed handpiece and Ultrasonic scaler. dental laboratory engines. Risk of noise induced hearing
Hazard from noise in dental working environment cannot loss among dental practitioners depends on personal
be underestimated. Hearing problems can occur due to susceptibility, total daily exposure to the instrument and
dental field noise. Proper monitoring and hearing patterns of use. Noise increases in a direct ratio as the
conservation programme is required for early detection bearing of handpieces become worn5.
and management of these cases. Dental staff working in Sound energy contribution of a typical dental practice is
high noise area above 90dBA is advised to wear ear plugs about 8% to 12% of the dentist's average 24-hour noise
during the procedures. exposure. Noise levels during dental procedures result an
articulation index of 0.21 to 0.37 which corresponds to
Keywords; noise, dental procedures, hearing impairment understanding of about 18% to 48% of nonsense syllables
and 52% to 90% of sentences. It appears that hearing-
I. Introduction damage risk is slight among dentists using modern
Under Act 514, Occupational Safety and Health Act equipment. However, further noise control in handpieces
1994, all employees must be protected from physical, is necessary so that error-free communication during
chemical and biological hazards1. It is the responsibility dental procedures can be ensured8.
for stakeholders to take preventive actions and provide a Condition of hearing of dental staff may be affected by
safe working environment in all aspects. Occupational smoking, medication (ototoxic drugs), rock music,
health risks among dental personnel includes needle prick personal stereos, CD players and other recreational
injury, musculoskeletal disorders, exposure to infectious sounds4. Factors influencing the risk of acoustic trauma
diseases, radiation, dental materials; dermatitis, are age, physical condition, existing hearing condition of
respiratory disorders, eye injuries and exposure to noise2. the individual, intensity or loudness of the equipment,
length of exposure and the time between exposures.
Under the Factories and Machinery (Noise Exposure) There is no way to undo damage caused by noise once it
Regulations 1989 Part II – Regulation 5 on Permissible has occurred, so prevention is essential.
Exposure Limit, no employee shall be exposed to noise
level exceeding equivalent continuous sound level of 90 2. Background
dBA and no employee shall be exposed to noise level There is need to conduct an evidence based study to
exceeding 115 dBA at any time3. Recently much hue and confirm the seriousness of exposure to noise hazard
cry was raised by dental technologists and dental nurses among dental personnel in Johor. Permissible limit of
in Kota Tinggi district on noise from compressors in exposure to noise level is not more than 90 decibels with
mobile dental squads, micromotors and polishing lathe maximum exposure time not exceeding eight hours as
machines in dental laboratories. They claimed that noise shown in Table 2.13.

47

Table 2.1 Exposure time limits at different sound levels 3. Objective

Sound level - Decibels (dBA) Exposure time 3.1 General
90 8 hours
95 4 hours To know the prevalence of hearing impairment among
100 2 hours dental personnel in Kota Tinggi Districts.
105 1 hour
110 30 minutes 3.2 Specific Objective
115 15 minutes
120 7.5 minutes To determine the sources of high noise in dental working
environment and its equipment.

A study conducted in a dental school in India documented 4. Materials and Method
that danger to hearing from dental clinic working
environment in a dental school cannot be underestimated 4.1 Design
There were statistically significant shifts of hearing Cross sectional study
threshold at 6 kHz and 4 kHz in the left ear and 6 kHz in
the right ear9. 4.2 Ethical considerations
Informed consent obtained from all respondents
Hence findings on effect of exposure to noise hazard in
the working environment would be of great importance to 4.3 Study population
all dental personnel involved. Other factors to be taken All categories of personnel working in dental clinics
into consideration are shown in Figure 2.1. Following this
assessment, the department would take remedial actions, 4.4 Sample
if necessary, to reduce hazard using appropriate Dental personnel working in dental facilities in Kota
measures. Otherwise, reassurance would be sufficient Tinggi district
following this evidence based study.

Figure 2.1: Factors influencing Hearing Impairment 4.4.1 Inclusion criteria
All personnel working in dental facilities in Kota Tinggi
Impacted ear wax Medication Poor district
control
4.4.2 Exclusion criteria
Location Ageing Hearing Underlying Family Past medical history of ear diseases
of home loss medical history Presence of impacted ear wax
problem
4.5 Data collection
Hobbies Exposure to Exposure to Poor Investigators used questionnaire for demography,
excessive excessive noise from maintenance of medical history and past exposure to noise hazard. All
respondents underwent audiometric test at the ORL/ENT
noise at home dental equipment equipment clinic, Hospital Sultan Ismail, Johor Bahru.

Duration
of work

Hearing OSHA Old equipment No
conservation workplace scheduling
programme standards
1

Previous
job

Job scope

5. Results
A total of 52 respondents from 4 dental clinics in Kota Tinggi district took part in this study. Age of staff ranged from
21 to 54 years and duration of service in the oral health division ranged from 1 to 32 years. The mean age and
duration of service is shown in Table 5.1.

Table 5.1 Characteristics of respondents

Category Dental Dental Dental Dental Attendant Driver Clerks Total
Surgery
officer nurse technologist Assistant 2 52
32.50 35.37
N 9 10 5 13 9 4 (9.19) (9.27)
1.00 10.47
Mean Age 29.22 37.90 34.60 36.00 34.44 45.25 (0.00) (9.20)
(SD) (8.38) (9.35) (10.50) (8.97) (9.33) ( 2.99)

Mean Years 6.28 15.30 11.80 10.15 8.56 16.25
of service (7.79) (9.62) (10.04) (9.33) (9.58) (4.86)
(SD)

48