AMINO AMSA-Indonesia Competition Archive
Pre-Conference Competition EAMSC 2021: Philippines
All the woks published in this volume are the submitted works of AMSA-Indonesia members in the Pre-Conference Competition East Asian Medical Students' Conference 2021: Phillipines
The EAMSC 2021 oral presentation videos can be accessed through: bit.ly/OralPresentationEAMSC2021
AMINO | PCC EAMSC 2021: Philippines
FOREWORD
Steven Millenio Widjaja Secretary of Academic AMSA-Indonesia 2020/2021
The AMSA-Indonesia Competition Archive or AMINO for short is a program by AMSA-Indonesia to facilitate all members to get inspiration on how to make a scientific masterpiece. AMINO acts as an archive where all the works submitted by participants in competitions in AMSA, including Pre-Conference Competition East Asian Medical Students’ Competition (PCC EAMSC), Indonesia Medical Students’ Training and Competition (IMSTC), Pre-Conference Competition Asian Medical Students’ Competition (PCC AMSC) and from AMSA International Competitions, are published. In the first volume of AMINO, all the scientific masterpieces of PCC EAMSC 2021: Philippines have been compiled, which consists of the following categories: Scientific Paper, Public Infographic Poster, White Paper and Videography. We hope that through this volume of AMINO, we are able to further motivate and inspire our members to construct more scientific masterpieces. On behalf of AMSA-Indonesia, I would like to extend my deepest gratitude to personal to all the participants of PCC EAMSC 2021: Philippines, the Academic Team of AMSA-Indonesia, Executive Board of AMSA-Indonesia 2020/2021, and other parties that have contributed to the creation of AMINO. Without each and every single contribution, AMINO would not have been possible. May the release of AMINO increase the academic enthusiasm and ignite the potentials of AMSA-Indonesia members. “Igniting Potentials, Unleashing Possibilities” Viva AMSA!
AMINO | PCC EAMSC 2021: Philippines
TABLE OF CONTENTS
AMINO | PCC EAMSC 2021: Philippines
AMINO | PCC EAMSC 2021: Philippines
SCIENTIFIC PAPER
TESTIMONY
AMINO | PCC EAMSC 2021: Philippines
Hasbi Nurrahim Nurrahim AMS AMSA A-Universitas -Universitas Jember 1st Winner of Scientific Paper Category
Initially, the reason that motivates us to join this competition was to look for a new experience and knowledge. It doesn't really matter about the result, but we just want to give it a try, we never know what future will prevail upon us and this might be our last chance to enter the competition. When you have no idea what to write about, observe your surroundings, even the smallest detail might spark an idea. It's better to start late than never. Writing and learning something new might seems difficult, don't hesitate to ask around for help from experienced people, as time goes by, you will feel the benefit. We didn't have any single clue on how to make a good paper back then. Writing while learning lot’s of things related to it at the same time together for a couple months. With the power of friendship and the internet, we learnt and finished our paper before the submission deadline of the competition. It took quite a lot of time but it worth the sacrifice.
AMINO | PCC EAMSC 2021: Philippines
Habsiyah Aini El Yafi AMSA-Universitas Brawijaya 2nd Winner of Scientific Paper Category
At first, I participated in the PCC EAMSC to get out of my comfort zone and challenge myself, so that I could learn a lot from the experience of participating in scientific paper at PCC EAMSC 2020. Some tips and tricks from me, we have to choose our teammates who have a huge motivation and have the same vision as ours. The initial things of creating something is an idea. Sometimes people waiting for the idea coming up over time, so it's just wasting time. In fact, idea will appear automatically when we start thinking about them. It's such a mindset that we should have. Previously, I had participated in several scientific writing competitions. However, participating in Scientific Paper of PCC EAMSC is a new thing for me because the writing mechanism is little different from scientific papers in general. Therefore, for those of you who don't have experience in writing scientific papers or anything else, don't be afraid to try because "experience is the best teacher".
AMINO | PCC EAMSC 2021: Philippines
Neville AMSA-Universitas Brawijaya 3rd Winner of Scientific Paper Category
Hello AMSA-Indonesia, I’m Neville from AMSA-Universitas Brawijaya. I would like to thank AMSA Indonesia and AMSA Brawijaya for giving me the chance to join the PCC EAMSC competition. I would also like to thank Pram, Hana, and Kak Martin for being good teammates in the process of the competition. PCC EAMSC is a competition to select one representative for AMSA Indonesia to compete in the international world. It is a rare and hard chance to join the international. By joining these types of competition, me and my friends could learn more about theory and practices in medical studies. It is a helpful activity to increase one’s knowledge about researching and the importance of it. Doctors are long life learners. We need to contribute to our environment and researching is one of the ways to do it. Being a good doctor don’t only need good theory and skills, but we also need to learn how to expand our knowledge and how to use it in a better way. Some tips and tricks that you can do to start are finding good teammates, finding fresh new ideas and try collaborating it in one new work. I don’t have a lot of past experiences in writing a full manuscript, but you have teammates than can help you and learn by doing it. Experiences are precious knowledge for the unknown. Try not to give cause no matter what, the fruits of your hard work will be useful.
The Role of SBAR Communication Tools Implementation for Clinical Handover Among Medical Personnel in Emergency Department: A Systematic Review and Meta-analysis of Hospital Setting Studies 1 Izza Amalia Putri , Yehuda Tri Nugroho Supranoto1, Hasbi Nurrahim1, Rifaldy Nabiel Erisadana1 1 Faculty of Medicine, University of Jember, Indonesia Asian Medical Students’ Association Indonesia Abstract Introduction: Clinical handover is a complex process that involves multiple roles. It contains information related to patients’ condition. Patient handover in Emergency Department (ED) plays an important role in the impact of patient safety with high-risk adverse events. To overcome this, The SBAR tool which is regarded as a communication checklist that increases patient safety, is needed to deliver information in critical situations. Objective: This systematic review and meta-analysis aimed to summarize and evaluate the outcome of SBAR tools implementation on patient handover in the Emergency Department. Materials and Methods: This meta-analysis was reported based on criteria from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A literature search was conducted with multiple electronic databases, such as PubMed, ScienceDirect, Cochrane Library, and Google Scholar. Mean Difference (MD) and Standard Deviation (SD) with the confidence interval (CI) of 95% were used to determine the association between SBAR tool implementation and the increase of total handover quality score. Key Findings: Twenty studies were included in the qualitative synthesis and six studies were included in the quantitative meta-analysis. The current study showed that the implementation of SBAR communication tool for clinical handover among medical personnel was very beneficial (Pooled MD= 1.79, 95% CI (1.59-2.00), p<0.00001, I2= 57%). It could also reduce the duration of clinical handover (Pooled MD= -1.74, 95% CI (-2.27, -0.67), p=0.0003, I2= 92%). Conclusion: This systematic review and meta-analysis provide valuable evidence suggesting the implementation of SBAR communication tool as a potential strategy for increasing the total handover quality. Keywords: SBAR, Patient’s handover, Emergency Department Communication, Systematic review, Meta-analysis
1
The Role of SBAR Communication Tools Implementation for Clinical Handover Among Medical Personnel in Emergency Department: A Systematic Review and Meta-Analysis of Hospital Setting Studies East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2021
Authors: Izza Amalia Putri Yehuda Tri Nugroho Supranoto Hasbi Nurrahim Rifaldy Nabiel Erisadana
Faculty of Medicine University of Jember, Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia 2020
2
The Role of SBAR Communication Tools Implementation for Clinical Handover Among Medical Personnel in Emergency Department: A Systematic Review and Meta-analysis of Hospital Setting Studies 1 Izza Amalia Putri , Yehuda Tri Nugroho Supranoto1, Hasbi Nurrahim1, Rifaldy Nabiel Erisadana1 1 Faculty of Medicine, University of Jember, Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia Abstract Introduction: Clinical handover is a complex process that involves multiple roles. It contains information related to patientsâ&#x20AC;&#x2122; condition. Patient handover in Emergency Department (ED) plays an important role in the impact of patient safety with high-risk adverse events. To overcome this, The SBAR tool which is regarded as a communication checklist that increases patient safety, is needed to deliver information in critical situations. Objective: This systematic review and meta-analysis aimed to summarize and evaluate the outcome of SBAR tools implementation on patient handover in the Emergency Department. Materials and Methods: This meta-analysis was reported based on criteria from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A literature search was conducted with multiple electronic databases, such as PubMed, ScienceDirect, Cochrane Library, and Google Scholar. Mean Difference (MD) and Standard Deviation (SD) with the confidence interval (CI) of 95% were used to determine the association between SBAR tool implementation and the increase of total handover quality score. Key Findings: Twenty studies were included in the qualitative synthesis and six studies were included in the quantitative meta-analysis. The current study showed that the implementation of SBAR communication tool for clinical handover among medical personnel was very beneficial (Pooled MD= 1.79, 95% CI (1.59-2.00), p<0.00001, I2= 57%). It could also reduce the duration of clinical handover (Pooled MD= -1.74, 95% CI (-2.27, -0.67), p=0.0003, I2= 92%). Conclusion: This systematic review and meta-analysis provide valuable evidence suggesting the implementation of SBAR communication tool as a potential strategy for increasing the total handover quality. Keywords: SBAR, Patientâ&#x20AC;&#x2122;s handover, Emergency Department Communication, Systematic review, Meta-analysis Introduction
patients and families in order to ensure the
Clinical Handover
patient's clinical care on a temporary or
Clinical handover is a complex process
permanent basis. (Eggins & Slade, 2015).
that involves multiple roles and responsibilities
Clinical handover occurs within and between
to provided clinical care. Clinical handover
teams constantly and is considered a time of
refers to the process of transfer patient-specific
risk for patients. Clinical handover also has a
information for some or all aspects of care from
main roles following patient transfers : to
one caregiver to another or from caregivers to
another unit/clinic; for a test, procedure or
3
appointment; to, from and within community
time of delivery are essential to ensure a safe
settings, including Residential Aged Care;
and effective treatment process. (5) Handover
involving other teams (e.g. Ambulance, patient
place: Face-to-face handover is preferred. If not
transport) (Clinical Excellence Commission,
possible, ensure the site for clinical handover
2019). International research has pointed to the
has minimal distraction. (6) Handover process:
following
clinicians
Include tools such as electronic clinical
communicate during handover: (1) lack of
communication tools, flow charts and scripts to
systematic structure, including incomplete
help keep clinical handover relevant, succinct
handovers; (2) lack of adequate explanations
and consistent. (7) Documentation: Document
about what has and will be done for the patient;
findings and include changes in clinical
(3) excessive reliance on memory without
conditions
reference to written documentation; (4) lack of
patient/family/career regarding ongoing care
patient involvement; (5) poor quality of written
requirements; update management / care plans.
medical
problems
records;
(6)
when
multiple
and
feedback
from
clinician
involvement in a patientâ&#x20AC;&#x2122;s continuity of care
Communication in Emergency Department
(Eggins & Slade, 2015).
Safety events in the Emergency
The Clinical Excellence Commission
Department (ED) are still of great concern and
(2019) present the following seven key
require a lot of improvement. Patient safety was
principles for safe and effective clinical
defined as the reduction of harm or adverse
handover:
Careers
events that occurred on the patient related to
involvements: Explain a moment in which
clinical healthcare systems. (Marra, 2020).
patients and families / caregivers are partners in
Patient handover in ED plays an important role
care in order to establish a motivation to engage
in the impact of patient safety with high-risk
during clinical handover. (2) Leadership:
adverse events. During the transfer of patients,
Nominate a leader at each clinical handover. As
both ambulance and hospital emergency
a decision maker, a leader must have a
services need to exchange necessary, precise,
comprehensive knowledge of the patient
and complete information. Epidemiological
handover process and its role as a leader. (3)
study showed that multidisciplinary teamwork
Handover
is
and communication error were responsible for
the
almost 40% of reported events resulting in
multidisciplinary team, so they should arrive
severe permanent harms of the patient (Marra,
prepared
2020; Pun, 2015; Gluyas, 2015).
attended
(1)
Patient/
participants: by with
relevant current
Family/
The
handover
members
of
information
and
knowledge of the patient's clinical situation
Patient Safety Incident (PSIs) represent
when handing over and was given the
a significant portion of the causes of morbidity
opportunity to ask questions also seek clarity.
and mortality in health care settings. In
(4) Handover time: Schedule an agreed time
addition, they are considered a significant
and duration for clinical handover to occur,
4
contributor to stress and psychological pressure
already implemented in different healthcare
for patients, their family members, and health
facilities. The SBAR tool is regarded as a
care providers. The high burden of PSIs holds
communication checklist that increases patient
particularly true in the emergency departments
safety and is current â&#x20AC;&#x2DC;best practiceâ&#x20AC;&#x2122; to deliver
(ED). EDs are fast-paced health care settings
information in critical situations (Muller,
with complex communication areas, and a high
2018).
rate of work distractions and disruptions. In
Outcome Measure
addition, health care providers are required to
The outcome measure in this study is
manage different types of patient care with
total handover quality score which is the
conditions of varying severity. Therefore, EDs
improvement
are characterized by a potentially challenging environment with a high risk of PSIs.
of
performed
by
handover
uses
the
handover
medical SBAR
quality
personnel.
This
communication
Although there were other aspects
standardization. Total Handover Quality Score
contributing such as the background of the
include four indicators: quality of verbal
clinicians, medication-related, high patient
information about the patient, the condition of
loads, and time limitation, communication was
the patient on admission, the professional
still included in each aspect, the components
behavior of the healthcare worker and the
and processes of communications are complex
satisfactory with the handover. Although the
and prone to misunderstanding. It is important
Total Handover Quality Score is a subjective
to improve healthcare worker performance that
observation of the handover quality, there is a
impacts communication (Marra, 2020; Pun,
positive
2015). Therefore, the strategies to overcome
performance with increased Total Handover
this situation are needed. Standardizing the
Quality Score.
correlation
between
higher
structure of communication could help both the speaker organize his thoughts and get prepared
Objective
with critical information, while the receiver focuses
on
filtering
which
This systematic review and meta-
important
analysis aimed to summarize the outcome and
information, leaving aside the less important
Implementation of SBAR tools on patient
ones (Kwok, 2019; Pun, 2015).
handover in the Emergency Department.
SBAR Handover Tool The SBAR (situation, background, assessment, recommendation) tools (see Table 1) and its derivatives ISBAR, SBAR-R, ISBARR and ISOBAR were widely used communication and handover tools that were
5
Table 1. SBAR communication technique, adapted table (IHI; Muller, 2018) Description
Question
Example
S
Situation
First, the speaker should introduce himself, What is happening to the patient? “Hello Dr Joo, this is nurse Cynthia, I’m calling from then state the patient’s identity before What is the situation you are ED with a report on Miss Paul, 42 years old. She came briefly explaining about the situation or talking about? with shortness of breath” problem.
B
Background
Relevant background of the patient What is the background of this “She was brought in by ambulance at 16.10 with including history about patient’s mental patient? shortness of breath and pneumonia. Her past history status, general condition, vital sign, includes infection of COPD.Her vital signs are stable. diagnosis, and reason for admission. The Low grade fever. No pain. Intact skin. O2 saturation patient’s chart is reviewed and questions 92%. Palpable pulses. Lung diminished bilaterally the other care provider may have are with elevated WBC” anticipated.
A
Assessment
The speaker determines or assumes the What is the assessment of the “The problem seems to be lung infection by patient’s condition according to the patient’s condition? microorganisms. The patient seems to be stable but quantitative or qualitative data such as vital still alert to get worse.” signs, background, laboratory data or other medical documents that are available. This section includes a provisional diagnosis or clinical impression.
R
Recommendation
The informed suggestion for the continued care that the patient may need immediately. It should be explained clearly, and specifically to address the patient’s problem. The speaker can ask for feedback to check that the transfer of information is going well
What is the recommendation for the patient’s management? What is the further examination needed?
6
“The team continues to monitor her temperature and oxygen saturation. I recommend checking her labs and giving broad spectrum antibiotics. Do you have any question or need clarification on any information”
Materials and Methods
ISBARR, and ISOBAR were included. Those
Study Methodology
studies without Total Handover Quality Score
This review followed the guidelines
mean difference and standard deviation were
provided by Preferred Reporting Items for Systematic
Reviews
and
included only in qualitative analysis
Meta-Analyses
•
(PRISMA).
Reference Standard The reference standard was a Hospital
Eligibility Criteria
or Nursing Home research performed by
The following criteria were considered
qualified
professional
clinicians’
for studies’ eligibility: type of studies,
implementation of SBAR, ISBAR, SBAR-R,
Handover tools, index test, and reference
ISBARR, and ISOBAR handover tools to the
standards.
Total Handover Quality Score.
•
Type of Studies Original research articles or research
Data Sources and Search
reports were included. Review, case report,
A literature search process was carried
case series, and conference abstracts were
out with multiple electronic databases, such as
excluded. Articles with full-text unavailability,
PubMed, ScienceDirect, Cochrane Library, and
non-English, and irrelevant topics were also
Google Scholar. Time restriction applied for
excluded.
this study. Only studies published between
•
2010 until 2020 were included. The keywords
Handover tools Background,
used in electronic databases were described
Assessment, and Recommendation), ISBAR
using Boolean operator as follow: (("SBAR"
(Identification,
Background,
OR "ISBAR" OR "SBAR-R" OR "ISBARR"
Assessment, and Recommendation), SBAR-R
OR "ISOBAR") AND "Communication" AND
(Situation,
Assessment,
("Emergency Department" OR "Emergency
Recommendation, and Read back), ISBARR
Case" OR "Emergency Patient")). All the
(Identification,
Background,
studies from these databases were stored in the
Assessment, Recommendation and Read back)
authors’ library in EndNote X9 (Clarivate,
and
USA) and Ms. Excel 2016 (Microsoft, USA).
SBAR
(Situation, Situation, Background,
ISOBAR
Situation, (Identification,
Situation,
Observation, Background, Assessment, and Recommendation)
handover
tools
Study Selection
were
included for this study. There was no limitation
After duplicates removal, retrieved
for the use or implementation for the type of
articles were screened based on their titles and
patient handover tools.
abstracts by four independent reviewers.
Index Test
Potentially eligible full-text articles were
Studies evaluating the Total Handover
thoroughly assessed using the eligibility criteria
Quality Score using SBAR, ISBAR, SBAR-R,
described above. Any emerging discrepancies
•
were resolved by consensus among the review
7
team. The study selection process was recorded
indicated by an I2 value less than 50%.
in the PRISMA flow chart.
Otherwise, we used REM. The pooled estimate was presented in a forest plot.
Risk of Bias in Individual Studies (Qualitative Synthesis)
Risk of Bias Across Studies (Publication Bias)
To evaluate the risk of bias in selection,
When a minimum of 10 studies was
performance, detection, attrition, and outcome
available for meta-analysis, the presence of
reporting, this study utilizes Review Manager
publication bias would be evaluated by
5.3. Result classified into high, low, or unclear
generating a funnel plot with RevMan v5.3. An
risk of bias. Four Authors (YTNS, RNE, HN,
asymmetrical shape indicates the presence of
and IAP) evaluate the risk of bias independently
publication
to form a summary. This review also is assessed
symmetrical shape indicates the absence of
for their quality by using A Measurement Tool
publication bias.
bias
potential
whereas
a
to Asses Systematic Reviews 2 (AMSTAR-2). Result Data Extraction
Study Selection
The following data were extracted from
A preliminary search obtained 3768
the included studies: first author, year, region,
journals. As many as 307 duplicate journals
study design, setting, SBAR implementation,
were removed. Then, the authors read the title
Measured Outcome, and Result of SBAR
and abstract of the remaining 3461 journals for
implementation.
preliminary
screening.
Authors
excluded
literature with reasons, including non-original research articles (case report, editor response,
Data Analysis All statistical test for this meta-analysis was
conducted
using
Review
review, scientific poster, and related meta-
Manager
analysis), literature without comparison and outcome. Finally, full texts were retrieved for
(RevMan) v5.3
81 papers, and 20 studies were included for qualitative analysis according to our eligibility
Quantitative Data Synthesis (Meta-analysis) Mean Difference (MD) and Standard
criteria. Our study selection process was
Deviation (SD) with the confidence interval
presented in the PRISMA diagram (Figure 1).
(CI) of 95% were calculated in this study. To present the effect size, we used the fixed-effect
Characteristics of Included Studies
model (FEM) or random-effect model (REM)
The full details of each study were
based on the level of heterogeneity result. FEM
displayed in Table 1. All included studies
will be used when the included studies
addressed the patient handover process in the
considered homogenous (low variability in
hospital. This handover process occurs when
studiesâ&#x20AC;&#x2122; results due to the random error),
the patient is moved from one room to another,
8
especially from the Emergency Department
patient safety (Dahlquist et al 2018, Smith et al
setting to another room. In qualitative analysis,
2018, Marmor et al 2017, Yik et al 2019, Usher
we highlight the implementation of SBAR
et al 2018 , Wilson et al 2017, Lee et al 2020).
communication training during the patient
In addition, from all studies, 6 studies included
handover process to improve the quality of the
Total Handover quality scores (Inanloo et al
handover (Thompson et al 2018, Randmaa et al
2017, Shalini et al 2015, Smith et al 2018, Uhm
2016, Pun et al 2019, Shalini et al 2015,
et al 2019, Usher et al 2018, Wilson et al 2017).
Beament et al 2018, Wilson et al 2017,
Even so, it turns out that there is a study that
Ramasubbu et al 2016, Uhm et al 2019, Lee et
illustrate the insignificance of the SBAR
al 2020, Campbell et al 2020). SBAR
application in several aspects such as length of
implementation also reduces the time or
stay of patients in emergency departments
duration of patient handovers between rooms so
(Dahlquist et al, 2018).
Included
Eligibility
Screening
Identification
that it can improve the quality of handovers and
Records identified through database searching • ScienceDirect = 297 • Cochrane library = 40 • PubMed = 241 • Google Scholar = 3190 (n = 3768)
Additional records identified through other sources (n = 0 )
Records after duplicates removed (n = 3461)
Records screened (n = 3461)
Records excluded (n = 3380)
Full-text articles assessed for eligibility (n = 81)
Full-text articles excluded, with reasons (n = 61)
Studies included in qualitative synthesis (n = 20)
Full-text articles excluded, with reasons (n = 14)
Studies included in quantitative synthesis (meta-analysis) (n = 6)
Figure 1 PRISMA Flow Diagram
9
Table 2. Qualitative Analysis of Included Studies Author
Year
Country
Design
Setting
How SBAR Was Implicated
Measured Outcome
Result After SBAR Implementation
O’Connor et al
2020
Australia
Naturalistic, Mixed Method Descriptive
Hospital
Capture data for the listen step in COLD (connect, observe, listen, delegate) observation tool by Telephone handover
Clear documentation by all health professionals
Tele handover provided to alternate nurse and increase the safety of patients transfer from one clinical setting to another
Randmaa et al
2016
Sweden
Prospective Cohort
Hospital
Evaluate the receiver’s information retention after postoperative handover in anaesthetic clinic
Percentage of recalled information sequences among receivers after the handover.
In the intervention group, the percentage of recalled information sequences by receivers increased from 43.4% preintervention to 52.6% postintervention (P=0.004) and the SBAR structure improved significantly (P=0.028)
Lee et al
2020
Korea
Prospective observational
Hospital
SBAR-R communication tool used in team training
Descriptive measures of team task performance and SBAR-R.
Team performance rate implementation was higher
Campbell et al
2020
USA
Pre- and Post-Test Study
Hospital
SBAR-R communication tool used in Nurse bedside patient handoff training
Nursing handoff quality based on questionnaire
Nurses and patients were satisfied with current handoff practices using SBAR tool
Potts et al
2018
USA
Hospital
Decrease handoff delays from the emergency department (ED)
Handoff time from the emergency department (ED) measured by ready to move (RTM)-to-occupied time.
RTM-to-occupied time was decreased to 49 minutes (a 41.4% decrease) 3 weeks after implementation of eSBAR communication tool
Trevino et al
2018
USA
Observational Descriptive
Hospital
Increase the quality of patient handoff by the nurses using educational video
Patient satisfaction, after nurse’s intervention
Positive improvement in patient satisfaction scores for nurse communication
Uhm et al
2019
Korea
Pre- and Post-Test Study
Hospital
SBAR was communication pedriatric nurse
implemented in training among
Handover confidence, practicum satisfaction, clinical practice selfefficacy
The SBAR communication program improves senior nursing students’ communication skill acquisition and handover confidence
Dahlquist et al
2018
USA
Prospective Cohort
Hospital
Workshop training to improve the quality of communication during handoff procedures
Patient length of stay in emergency department
No significant differences in patients length of stay between the communication methods employed
Pre- and Post-Test Study Design
10
after
SBAR-R
Author
Year
Country
Design
Setting
How SBAR Was Implicated
Measured Outcome
Result After SBAR Implementation
Smith et al
2018
USA
Pre- and Post-Test Study
Hospital
Increasing the composite handoff quality score for admission handoff communication between Emergency physicians (Eps) and Internal medicine (IM) physicians.
Composite handoff quality score in between Emergency department and Internal medicine department
SBAR communication tool improved handoff communication by facilitating targeted needs assessment of local handoff practices, data collection, and quality improvement intervention
Marmor et al
2017
Australia
Pre- and Post-Test Study
Hospital
ISBAR format handover was used in a bedside clinical handover procedure as an intervention medical personnel’s training to improve the handover’s quality
Perceived effect (improve, hinder, nil effect) of bedside handover on patient care among medical personnel
ISBAR format handover improve patient safety and patient reliability of communication.
Pun et al
2019
China
Pre- and Post-Test Study
Hospital
Healthcare communication training using CARE (Connect, Ask, Respond, Empathise) protocol combined with ISBAR tool
Nurses’ perceptions and practices score using Nurses Handover Perceptions Questionnaire (NHPQ)
All participating nurses exhibited significant improvements in their perceptions of effective handover from before to after training sssssssssss
Inanloo et al
2017
Iran
Pre- and Post-Test Study
Hospital
SBAR tool was used to investigate the medical personnel performances before and after communication training.
Total performances area of medical personnel
Using of SBAR tool by affecting different areas has been very effective in improving medical personnel’ performance in the work shift delivery report in the Hospital’s ICUs.
Shalini et al
2015
India
Pre- and Post-Test Study’
Hospital
SBAR protocol was used to increase nurses’ knowledge and practice of Clinical handover
Knowledge and Practice scores on SBAR technique during patients’ handoff ssssss
The protocol on SBAR technique of communication during patients; handoff among nurses was effective (increased score in knowledge and practice after intervention)
Yik et al
2019
Malaysia
Cross study
Hospital
SBAR tool was used for shift handover among nurses
Healthcare workers SBAR satisfaction score
Healthcare workers are found to be satisfied with SBAR for handover
Sectional
11
Author
Year
Country
Design
Setting
How SBAR Was Implicated
Measured Outcome
Result After SBAR Implementation
Sermersheim et al
2020
USA
Pre- and Post-Test Study
Hospital
SBAR tool was used in the electronic nursing handoff process
“assign to occupy” time in electronic nursing handoff
Patients are less delayed in the ED as a result of the significantly decreased assign-tooccupy time after the SBAR implementation
Usher et al
2018
USA
Pre- and Post-Test Study
Hospital
Evaluation a standardized bedside handoff process and its influence in a medical-surgical unit
Total communication scale scores from baseline to post project
Reducing the length of bedside handoff time and improvement in total communication scale scores.
Beament et al
2018
Australia
Pre- and PostTest Study
Hospital
SBAR clinical handover was used in an acute setting after education intervention
Participants understanding and confidence in handover
Education intervention was effective in increasing participants’ confidence in using the SBAR handover tool
Van der Wulp et al
2017
Netherlands
Prospective Observational
Hospital
Evaluating the previous handover process using SBAR-R handover tool
Handoff quality score based on questionnaire
Further increase in the quality of handovers with the implementation of the SBAR-R
Wilson et al
2017
USA
Pre- and Post-Test Study
Hospital
SBAR was implemented in communication training of real-life telephone handover among pediatric medical personnel.
Total item score in Clinical handover pre- and post-training groups
Standardized SBAR training was effective in improving total item score in telephone communication.
Ramasubbu et al
2016
UK
Pre- and Post-Test Study
Hospital
ISBAR was used in Cycle 2 (after ISBAR introduction) of handover process while it wasn’t in Cycle 1.
Total score
The introduction of a standardized handover template (ISBAR) has improved the quality and safety of the doctor-to-doctor patient information handover process.
12
patient
handover
Risk of Bias in Individual Studies (Qualitative
not assign subjects randomly to the intervention
Synthesis)
and control groups since matching the
We critically assessed the quality of
conditions is impossible. The study conducted
each study with the Review Manager tool.
by Smith et al. showed that the participants
Some of the studies did not provide adequate
were has already known that there will be an
information regarding the bias domainsâ&#x20AC;&#x2122;
handover scoring. Three studies did not report
judgment, leading to an unclear (moderate) risk
the outcome results clearly and significant
of bias. One study had a high selection bias
through the all presented data (Inanloo et al
caused
baseline
2017, Shalini et al 2015, Usher et al 2018). The
characteristics as it either has different outcome
summary of bias analysis was provided in
measure both handoff time or handover quality
Figure 2.
by
the
difference
in
score. The study conducted by Inanloo et al. did
Figure 2. Quality Assessment: Risk of Bias Summary using Review Manager (Review authorsâ&#x20AC;&#x2122; judgement about each risk of bias item for each included study.
13
the
Meta-analysis
handover
quality
for
each
studies
We compared the pooled effect size of
comparing the pre-intervention group. A
the implementation of SBAR communication
moderate pooled effect size was observed and
tool with the improvement of Total Handover
presented on the forest plot in Figure 3.
Quality Score. We used the total item score of
Figure 3. Forrest plot Meta-analysis of the effect of the implementation of SBAR communication tool on medical personnel seen from the total handover quality score. These
results
indicated
that
the
unpublished studies often contain neutral or
implementation of SBAR communication tool
negative data.
for clinical handover was more effective in
We also compared the pooled effect
increasing the total handover quality score
size
(pooled MD= 1.79, 95% CI (1.59-2.00),
of
the
implementation
of
SBAR
communication tool with the reduction of
p<0.00001, I2= 57%). This showed a promising
clinical handover duration. Patients’ handoff
effect of SBAR communication tool for clinical
can be influenced by the medical personnel’
handover in the hospital setting. Similar to
communication. So, moderate pooled effect
clinical research result, the unintentional
size about handoff duration are presented on the
exclusion of eligible studies in a systematic
forest plot in Figure 4.
review will usually result in an overestimation of the intervention effect size simply because
Figure 4. Forest plot Meta-analysis of the effect of the implementation of SBAR communication tool on medical personnel seen from the patients’ handoff duration.
14
Based on that forest plot, the mean
clinical handover duration also presented in
difference of duration in patient handover is
Table 3. It shows the median and interquartile
higher on control or pre-intervention groups
duration of handover process before and after
(pooled MD= -1.74, 95% CI (-2.27, -0.67),
the implementation of SBAR communication
p=0.0003, I2= 92%). It means that the
tool among medical personnel. It means the
implementation of SBAR communication tool
handover duration tends to decrease after the
can increase the effectiveness of clinical
implementation of SBAR.
handover management. The reduction of Table 3. Duration of Patients’ Handover Pre- and Post-SBAR Tools Implementation Studies
Year
Duration of patient handover (min) Pre SBAR Intervention Median
IQR
Post SBAR Intervention Median
IQR
Dahlquist et al
2018
12.5
7.5 – 12.5
7.5
7.5 – 12.5
Marmor et al
2017
29
21-37
21
14-27
p<0.00001, I2= 57%). This implied the fact that
Risk of Bias Across Studies (Publication Bias) A publication bias analysis with funnel
the implementation of SBAR tools was
plot was planned but could not be conducted as
effective for increasing the quality of clinical
less than 10 studies were included. However,
handover. This improvement was significantly
we recognized the possibility of publication
arise after the communication training process.
bias as we only included the studies reported in
Moreover the implementation of SBAR tools
English.
can decrease the duration of clinical handoffs including handover from ED to wards and
Discussion Our
wards to ED (pooled MD= -1.74, 95% CI (a
2.27,-0.67), p=0.0003, I2= 92%). Three studies
beneficial effect of SBAR implementation
suggest that the duration of handover can be
among medical personnel for have a high
reduced using SBAR implementation. So, this
quality patient’s handover. This review used the
handover can be more effective and beneficial.
participant data to examine the effect of SBAR
This systematic review assess the
tool on clinical handover among medical
effects of SBAR implementation on clinical
personnel. We found that participants that have
handovers. In the transfer of patients there is a
the SBAR intervention or post intervention
possibility of errors, one of which is the
developed significant handover quality score in
communication. SBAR is one of the crucial
all
management,
communication strategies in ED, to reduce the
handover knowledge, and handover quality
occurrence of communication errors that
score compared with control or pre-intervention
impact patient care. The patients care is one of
groups (pooled MD= 1.79, 95% CI (1.59-2.00),
the most important aspect from hospital value.
aspects
meta-analysis
including
time
suggested
15
Twenty studies, with various study
use of SBAR communication tool as a potential
design, met the inclusion criteria. SBAR was
strategy of clinical handoffs in ED.
implemented through different strategies in two different clinical settings (hospitals and nursing
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Randmaa, M., Swenne, C., Mårtensson, G., Högberg, H., & Engström, M. (2016). Implementing situation-backgroundassessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers. European Journal Of Anaesthesiology, 33(3), 172-178. doi: 10.1097/eja.0000000000000335
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Sermersheim, E., Moon, M., Streelman, M., McCullum-Smith, D., Fromm, J., Yohannan, S., & Powell, R. (2020). Improving Patient Throughput With an Electronic Nursing Handoff Process in an Academic Medical Center. JONA: The Journal Of Nursing Administration, 50(3), 174-181. doi: 10.1097/nna.0000000000000862
Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open, 8(8), e022202. doi: 10.1136/bmjopen-2018-022202 O’Connor, D., Rawson, H., & Redley, B. (2020). Nurse-to-nurse communication about multidisciplinary care delivered in the emergency department: An observation study of nurse-to-nurse handover to transfer patient care to general medical wards. Australasian Emergency Care, 23(1), 37-46. doi: 10.1016/j.auec.2019.12.004
Shalini, Castelino, F., & Latha, T. (2015). Effectiveness of Protocol on Situation, Background, Assessment, Recommendation (SBAR) Technique of Communication among Nurses During Patients’ Handoff in a Tertiary Care Hospital. International Journal Of
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18
The Effect of COVID-19 Hoax Busters on Public Knowledge and Attitude Regarding COVID-19 Hoaxes Habsiyah Aini El Yafi1a , Aurielle Annalicia Setiawan1 , William Wiradinata1 Undergraduate Medical Program, Faculty of Medicine, Brawijaya University
1
1a
habsi.elyafi@gmail.com
ABSTRACT Introduction : The COVID-19 pandemic that took the world by storm also brought another wave of health related hoaxes. Hoaxes and other forms of misinformation could distort and worsen public understanding and attitude in responding the pandemic. The existence of hoax busters utilized by the government and other organization aims to alleviate the detrimental effects of hoaxes and deliver valid information to the public. This paper aims to observe the effect of hoax busters as a countermeasure for hoaxes in the COVID19 era towards public knowledge and attitude regarding COVID-19 hoaxes. Methods : Data was collected from distributed online questionnaires regarding the viewing frequency of COVID-19 hoax busters, knowledge on COVID-19, and public attitude towards hoax. Data was analyzed statistically by the chi-square test. Results : The correlation between viewing frequency of COVID-19 hoax buster contents to knowledge on COVID-19 and public attitude towards hoax is statistically insignificant. Discussion : Due to the young demographics (mostly students), it is possible that they are exposed to more advances in science, and therefore have a more critical and scientific mindset, which is less prone to accepting hoaxes and therefore produce good attitude in countering hoaxes, even with low viewing frequency for hoax buster contents (due to low reading interest). Conclusion : There is no correlation between frequency of COVID-19 hoax buster dissemination and public attitude toward hoax.
Keywords: attitude, COVID-19, dissemination, frequency, hoax, hoax buster, knowledge
19
THE EFFECT OF COVID-19 HOAX BUSTERS ON PUBLIC KNOWLEDGE AND ATTITUDE REGARDING COVID-19 HOAXES
Authors: Habsiyah Aini El Yafi Aurielle Annalicia Setiawan William Wiradinata
AMSA-UNIVERSITAS BRAWIJAYA
20
INTRODUCTION The development of technology has brought society to this digital age, where it is more convenient than ever to communicate and access information. With this convenience comes its downsides, the spread of hoaxes being one of them. Hoax, as defined by the Cambridge dictionary, is a trick or something else that is intended to deceive someone (“Hoax”, n.d.). KBBI defines hoax as something that is untrue; a lie (KBBI, 2016). The spread of hoax is caused by the lack of knowledge regarding the source of information being spread and the concept of anonymity behind it. Hoaxes that are perceived as parallel with the beliefs and views that are held by the public are easier to digest and trust, thus the likelihood of ‘doublechecking’ the said information decreases. Affirmation of the said information drives the public to share them even further. Hoaxes are also thought to be the one of the examples of misuses for freedom of speech in digital era (Herawati, 2017). COVID-19 is a respiratory disease caused by SARS-CoV-2 that has taken the world in a storm as a pandemic. The rapid spread of the virus has forced many nations to take measures such as social distancing and lockdown to avoid the rise of case numbers. The drastic change of living conditions have driven the world to a state of worry and anxiety. Hoaxes, especially ones relating to COVID-19, are on the rise in this pandemic era and are more prone to influence the public, as there is increasing worry and anxiety. Hoaxes can influence public perception of COVID-19, health regulations, even perceptions towards healthcare workers and the government. Hoaxes have also been proven to increase anxiety among the public and can actually worsen the community’s psychological condition (Athbi and Hassan, 2019; Costa,2019; Evans,2020). This can lead to the rise of health protocol and social distancing violations, which in turn can cause the rise of case numbers. This presents as a serious threat for Indonesia, with high numbers of active social media users. According to the Cabinet Secretariat of the Republic of Indonesia, 132.7 million (52%) of Indonesians are internet users and 129.7 million of them have active social media accounts. There is also an abundance of hoaxes broadcasted around, with 44.30% of internet users in Indonesia reported to receive a hoax every day and 17.20% are reported to receive them more than once a day (Mastel, 2017). In the meantime, hoax busters serve as a countermeasure for this problem. Hoax busters are defined as fact-checkers that are conducted by organizations such as the Indonesian COVID-19 taskforce, Mafindo, and other organizations. But with the low literacy and education levels in Indonesia, it is questionable whether or not they have been effective. The PISA assessment held in 2018 showed Indonesia scoring much lower in literacy compared to the average OECD countries (OECD, 2018), and analysis by the World Bank has shown that 55% of Indonesians of complete school are functionally illiterate (Dilas, Mackie, &amp; Huang, 2020). Tertiary education levels are also very low, with just
21
under 9% of Indonesians over the age of 25 that had attained at least a bachelor’s degree (Dilas, Mackie, &amp; Huang, 2020). It is necessary for the public to have proper knowledge regarding COVID-19 facts, and for the public to have the proper attitude to recognize and combat hoaxes. Only by having both can the public as a whole make the right decisions and avoid this pandemic to worsen its effects in Indonesia. This problem needs to be assessed to strategize an ideal plan to combat hoaxes that are being broadcasted. There are still very few studies conducted to observe problems regarding hoaxes in COVID-19 era in Indonesia. This paper aims to observe the effect of hoax busters as a countermeasure for hoaxes in the COVID-19 era towards public knowledge and attitude regarding COVID-19 hoaxes.
METHODS Study design and setting This is a cross sectional study based on the frequency of COVID-19 hoax buster dissemination toward public knowledge about COVID-19 hoax buster and their attitudes in dealing with COVID-19 hoaxes. The data collected came from distributed online questionnaires. After the data collected, the data were processed and interpreted so that it can be seen the effect of hoax busters dissemination toward public knowledge and behavior regarding COVID-19 hoaxes. Participants All participants were Indonesian aged 12th – 60th years old. Samples were taken randomly with a valid sample of 202 people. Data gathering and scoring The required data were derived from the distributed online questionnaires (see Appendix). The main data collected were the frequency of COVID-19 hoax buster dissemination according to how often respondents receive the information about COVID-19 hoax buster, respondent’s scores in answering questions about the COVID-19 hoax buster were used to reference the level of public knowledge about COVID-19 hoax buster, the respondent’s attitudes scores in dealing with COVID-19 hoaxes, public attention to hoax buster dissemination, and where respondents usually receive COVID-19 hoax buster information. The supporting data collected were age, occupation, and the last education. The obtained data were classified based on the score level.
22
Table 1. Hoax buster dissemination frequency score Frequency of COVID-19 Hoax
Classification
Buster Dissemination Score
Very often
4
(>6x in a week) Often
3
(5–6x in a week) Rarely
2
(3–4x in a week) Very rarely
1
(1–2x in a week)
Table 2. Classification of knowledge, attitude, and total scores Scores Knowledge score
Attitude score
Total score
Continuous
Discrete Data
Data
Conversion
0 to 10
9-10
Very good
6-8
Good
3-5
Moderate
0-2
Bad
20-25
Very good
15-19
Good
10-14
Moderate
5-9
Bad
29-35
Very good
21 - 27
Good
13-19
Moderate
5 - 11
Bad
5 to 25
5 to 35
Classification
Coding The coding stage is carried out by coding the data. This stage aims to summarize the data and facilitate analysis. The coding stage was carried out by scoring on each element of the instrument. For positive answers, they were given a score from the largest to the smallest value (5-4-3-2-1), while the negative answers were given a score from the smallest to the largest value (1-2-3-4-5).
23
Table 3. Criteria for Alternative Attitude Score Answers
Positive Questions
Negative Questions
Score
Score
Strongly agree / always
5
1
Agree / often
4
2
Neutral / sometimes
3
3
Disagree / rarely
2
4
Strongly disagree / never
1
5
Data analysis In this study, two data analysis methods were used: descriptive data analysis and bivariate data analysis. Descriptive data analysis was used to determine the description of demographic data, public attention to COVID-19 hoax buster dissemination, media for society to receive COVID-19 hoax buster information, and the source of COVID-19 hoax buster received by the society. Meanwhile, bivariate data analysis was used to determine the relationship between the frequency of COVID-19 hoax buster dissemination toward public knowledge about COVID-19 hoax buster and their attitudes in dealing with COVID-19 hoaxes. The chi square test was used to test the correlation between two categorical variables: the frequency of COVID-19 hoax buster dissemination variable that has been categorized; and public knowledge about the COVID-19 hoax buster variable and their attitudes in dealing with the COVID-19 hoaxes variable that has been categorized.
RESULTS Demographic data Demographic data were obtained through distributing questionnaires to 202 respondents. Subjects in the study were individuals aged 12 - 60 years from Indonesia. The data collection process is carried out online because of the limitations of the researcher in reaching the subject for data collection. The data that has been obtained through questionnaires were then processed and arranged in a frequency distribution table. The following is the demographic data of 202 respondents who have been compiled in a frequency distribution table. Table 4. Demographic data of respondents Demographic Data
Category
Amount
Percentage (%)
Age
12â&#x20AC;&#x201C; 22
103
50,99
23 â&#x20AC;&#x201C; 33
14
6,93
24
34 – 44
49
24,25
45 – 55
32
15,84
56 – 60
4
1,98
TOTAL
202
100
The most recent
Elementary school
5
2,47
education
Junior high school
13
6,43
Senior high school
84
41,58
Diploma
6
2,97
Bachelor/proffesion
70
34,65
Postgraduate
22
10,89
Others
2
0,99
TOTAL
202
100
Government employees
38
18,81
Entrepreneur / trader
7
3,46
General employees
20
9,9
Profession
17
8,41
Housewife
18
8,91
Student
90
44,55
Does not work
12
5,94
TOTAL
202
100
Occupation
Based on the table above, the largest age group that participated as respondents aged 12-22 years were 103 people (50.99%). The most recent education demographic data recording of respondents was at the senior high school level as many as 84 people (41.58%). The largest respondent's occupational demographic data were students as many as 90 people (44.55%) from 202 subjects. Frequency of COVID-19 hoax buster dissemination, public knowledge about COVID-19 hoax buster, and public attitude toward hoax Based on the results of online questionnaires, 202 respondents were obtained. After that, the total score obtained by each respondent from each test variable was compiled. The following is a tabulation of the scores obtained by respondents on the variable frequency of the society receiving hoax buster information, public knowledge about COVID-19 hoax buster, and public attitude toward hoax. Table 5. Total score of frequency of COVID-19 hoax buster dissemination, public knowledge about COVID-19 hoax buster, and public attitude toward hoax
25
Variable
Classification
Frequency of COVID-19
Very often
hoax buster dissemination
(>6x in a week)
Total
Frequency
Percentage
4
18
8,91%
3
27
13,36%
2
54
26,73%
(1–2x in a week)
1
103
50,99%
Public knowledge about
Very good
9-10
50
24,75%
COVID-19 hoax buster
Good
6-8
128
63,36%
Moderate
3-5
21
10,39%
Bad
0-2
3
1,48%
Public attitude toward
Very good
20-25
144
71,28%
hoax
Good
15-19
50
24,75%
Moderate
10-14
6
2,97%
Bad
5-9
2
0,99%
score
Often (5–6x in a week) Rarely (3–4x in a week) Very rarely
Medias used for public COVID-19 hoax buster information Chart 1. Medias used for public COVID-19 hoax buster information
In this question, respondents are able to choose more than one option. Based on the chart above, out of the respondents who have stated to have seen COVID-19 hoax buster information, it is shown that the majority of them (153 respondents) receive COVID-19 hoax buster information from social
26
media, whereas only 30 respondents receive information from official government websites such as www.covid19.go.id. Ten respondents receive information from hoax buster tools/apps and eight respondents receive them from untrustworthy/ anonymous sources. The source of COVID-19 hoax buster received by the society Chart 2. The source of COVID-19 hoax buster received by the society
In this question, respondents are able to choose more than one option. Based on the chart above, out of the respondents who have stated to have seen COVID-19 hoax buster information, it is shown that the majority of them (182 respondents) receive COVID-19 hoax buster information sourced from mass media such as Kompas, detik.com, LINE TODAY, etc., whereas only two respondents receive information from official research organizations such as WHO, CDC, etc. Fourty-seven respondents receive them from untrustworthy/ anonymous sources and 31 respondents receive them from untrustworthy/ anonymous sources.
Public attention to COVID-19 hoax buster broadcasts Chart 3. Public attention to COVID-19 hoax buster dissemination
27
Based on the chart above, it is shown that the majority of the respondents (100 respondents; 49.5%) has seen and briefly read COVID-19 hoax busters which categorizes them as having moderate attention level, whereas only 40 respondents (19.8%) have seen and read COVID-19 hoax buster information carefully, which categorizes them as having good attention level. Twenty respondents (9.9%) have only seen them and 42 respondents (20.79%) have never seen them. Therefore it can be concluded that the majority of the public has moderate attention level towards COVID-19 hoax buster information.
Correlation of frequency of COVID-19 hoax buster dissemination and public knowledge about the COVID-19 hoax buster The chi-square correlation test was used to determine the correlation of frequency of COVID19 hoax buster dissemination and public knowledge about the COVID-19 hoax buster. Before processing, the data that had been grouped into four categories were regrouped into two categories for each variable. For the score categories of frequency of COVID-19 hoax buster dissemination in ‘seldom’ and ‘very seldom’ were considered as low frequency and scores in ‘often’ and ‘very often’ were considered as high frequency. For the score categories of public knowledge about COVID-19 hoax buster in the ‘moderate’ and ‘bad’ ranges were considered as bad and scores in the ‘good’ and ‘very good’ ranges were considered as good. In conducting the chi square correlation test, the SPSS application was used. Based on the research, the following results were obtained.
28
Table 6. Cross tabulation of the frequency of COVID-19 hoax buster dissemination and public knowledge about the COVID-19 hoax buster Knowledge Frequency
Good
Bad
Total
High
17
2
19
Low
161
22
183
178
24
202
Total
Table 7. Chi-square tests of the frequency of COVID-19 hoax buster dissemination and public knowledge about the COVID-19 hoax buster Chi-Square Tests Asymptotic
Exact
Significance Sig. (2Value df
(2-sided)
Pearson Chi-Square
,037a
1
,848
Continuity Correctionb
,000
1
1,000
Likelihood Ratio
,038
1
,846
Fisher's Exact Test N of Valid Cases
Exact Sig. (1-
sided)
sided)
1,000
,601
202
a. 1 cells (25,0%) have expected count less than 5. The minimum expected count is 2,26. b. Computed only for a 2x2 table Based on the table above, it was known that one cell has expected count less than five with the minimum expected count is 2,26. Therefore, the requirements of the chi-square test were not met so that decision making was based on fisher's exact value. Based on the table above, the fisher's exact value exceeds 0.05. This showed that the two variables do not have a significant relationship. Thus, the frequency of COVID-19 hoax buster dissemination and public knowledge about the COVID-19 hoax buster has no significant relationship. Correlation of Frequency of COVID-19 hoax buster dissemination and public attitude towards hoax The chi-square correlation test was used in determining the correlation of frequency of COVID19 hoax buster dissemination and public attitude toward hoax. Before processing, the data that had been
29
grouped into four categories were regrouped into two categories for each variable. For the score categories of frequency of COVID-19 hoax buster dissemination in seldom and very seldom were considered as bad and score categories in often and very often were considered as good. For the score categories of public attitude toward hoax in the moderate and bad ranges were considered as bad and score categories in the good and very good ranges were considered as good. In conducting the chisquare correlation test, the SPSS application was used. Based on the research, the following results were obtained. Table 8. Cross tabulation of the frequency of COVID-19 hoax buster dissemination and public attitude toward hoax Public Attitude Frequency
Good
Bad
Total
Good
19
0
19
Bad
175
8
183
194
8
202
Total
Table 9. Chi-square tests of the frequency of COVID-19 hoax buster dissemination and public attitude toward hoax Chi-Square Tests Asymptotic Value df
Significance
Exact Sig.
Exact Sig.
(2-sided)
(2-sided)
(1-sided)
1,000
,447
Pearson Chi-Square
,865a
1
,352
Continuity Correctionb
,097
1
,755
Likelihood Ratio
1,614
1
,204
Fisher's Exact Test N of Valid Cases
202
a. 1 cells (25,0%) have expected count less than 5. The minimum expected count is ,75. b. Computed only for a 2x2 table Based on the table above, it was known that one cell has expected count less than five with the minimum expected count is 0,75. Therefore, the requirements of the chi-square test were not met so that decision making was based on fisher's exact value. Based on the table above, the fisher's exact value exceeds 0.05. This showed that the two variables do not have a significant relationship. Thus, the frequency of COVID-19 hoax buster dissemination and public knowledge about the COVID-19 hoax
30
buster has no significant relationship.
DISCUSSION Based on the data above, it can be concluded that there is no correlation between frequency of COVID-19 hoax buster dissemination and public knowledge about the COVID-19 hoax buster and also there is no correlation between frequency of COVID-19 hoax buster dissemination and public attitude toward hoax. The majority of respondents shown low frequency in viewing COVID-19 hoax buster broadcasts, but had good knowledge and attitude towards them. This can be caused by multiple factors in the demographic. The majority of respondents are in the age range of 12-22 year olds, where most of the public in this age range are proficient in accessing technology and using it to attain information. The occupational majority in the respondents, students, are also known to have better educational background, and therefore have better skills in processing information and news that they receive. Students also have higher chances of having access to the most up-to-date advances in science, and are currently in an academic environment. Therefore, it is possible that they have cultivated a critical and scientific mindset towards most of the problems that they encounter. Based on the data above, it can also be concluded that the use of COVID-19 hoax busters is not effective to raise public awareness towards COVID-19 hoaxes, as can be seen from the majority of respondents admitting to be skim reading hoax buster articles. A study showed that Indonesia ranked 60 out of 61 countries in reading interest (Miller & McKenna, 2016). This shows that although the majority of respondents are currently in high school or college, apparently most of them tend to not thoroughly read articles that are presented. This could be even worse in demographics with lower levels of education. As mentioned above, tertiary education levels in Indonesia are very low, with just under 9% of Indonesians over the age of 25 that had attained at least a bachelorâ&#x20AC;&#x2122;s degree (Dilas, Mackie, &amp; Huang, 2020). This could potentially cause misinformation and misconceptions towards COVID-19 facts, especially in demographics with lower levels of education and socioeconomic background. This could be worsened by raising abundance of hoaxes from various untrustworthy sources. To counter this problem, forms of hoax buster information publicized can be adapted to more digestible and attention-grabbing forms, such as attractive poster design with explanations of words that are easily understood by all levels of society as well as videos that are attractive to the public so that the information conveyed can be digested properly. It can also be concluded that the use of social media to share hoax buster information is the most effective way, considering the massive ownership of social media in this era. As mentioned above, 132.7 million (52%) of Indonesians are internet users and 129.7 million of them have active social media accounts (Mastel, 2017). But it is important to keep in mind that social media is also the main source for hoaxes. Therefore with the presence of hoax busters, hopefully hoaxes can be countered
31
effectively, with the right content, distribution, and persuasive words. But with the low frequency of viewing hoax buster contents as reported above, strong collaboration and promotion is needed to attain public attention and gain competitive power and advantage towards existing accounts. Mass media a source for hoax buster information is reported above as more favorable compared to other sources, but it is important to keep in mind that information attained from news that are not thoroughly read by the public can lead to various misinformation. Again, this is especially worrying for Indonesia with low reading interest (Miller & McKenna, 2016) and low literacy levels (OECD, 2018 ; Dilas, Mackie, &amp; Huang, 2020). The limitations of this study includes the demographic properties of respondents that is dominated by a certain age demographic (12-22 year olds) and occupational background (students). In order to obtain a wider view of this problem, another study focused on other demographical factors such as an older demographic or different socioeconomic situation could prove to be beneficial. CONCLUSION The Indonesian society’s vulnerability towards hoax due to massive use of social media and low levels of literacy and education is a cause for worry in countering the abundance of COVID-19 hoaxes, as misinformation in the public was thought to cause anxiety and worry, and therefore cause distrust in healthcare workers and the government. This was thought to cause the rise of health protocol violations and therefore, the rise of case numbers. Henceforth, it is necessary to study the effect of COVID-19 hoax busters on public knowledge and attitude regarding COVID-19 hoaxes. Based on the results, here is no correlation between public knowledge and attitude towards COVID-19 hoaxes. A majority of respondents have good knowledge and attitude towards COVID-19 hoaxes, on the other hand the frequency of viewing hoax buster content is considered as low. RECOMMENDATIONS To raise public interest and attention, strong promotion, collaboration, and the use of other interactive forms of presentation might be required.
REFERENCES Athbi, H. A., & Hassan, H. B. (2019). Health Beliefs of Patients with Coronary Heart Disease toward Secondary Prevention: The Health Beliefs Model as a Theoretical Framework. Indian Journal of Public Health Research & Development, 10(1), 821-826. Costa, M. F. (2020). Health belief model for coronavirus infection risk determinants. Revista de Saúde Pública, 54, 47.
32
Dilas, D. B., Mackie, C., &amp; Huang, Y. (2020, July 14). Education in Indonesia. Retrieved October 19, 2020, from https://wenr.wes.org/2019/03/education-in-indonesia-2 Evans, G. (2020). Questions: COVID-19 Mortality, Conspiracy Theories, and the Mysterious Lack of Sick Children ‘Flu has a mortality of 0.1%–this has a mortality 10 times that.’. Hospital Infection Control & Prevention, 47(384). Herawati, D. M. (2016). Penyebaran Hoax dan Hate Speech sebagai Representasi Kebebasan Berpendapat. Jurnal Promedia, 2(2). Hoax.
(n.d.).
In
dictionary.cambridge.org.
Retrieved
from
https://diction-
ary.cambridge.org/dictionary/english/hoax KBBI. (2016). Kamus Besar Bahasa Indonesia ( KBBI ). In Kementerian Pendidikan dan Budaya. Mastel. (2017, February 13). Infografis Hasil Survey MASTEL Tentang Wabah HOAX Nasional. Retrieved June 15, 2017, from Mastel 4 Indonesia: http://mastel.id/infografis-hasil-surveymasteltentang-wabah-hoax-nasional/ Miller, J., & McKenna, M. (2016). World Literacy: How Countries Rank and Why It Matters. Routledge. OECD.
(2018).
Indonesia.
Retrieved
October
19,
https://gpseducation.oecd.org/CountryProfile?primaryCountry=IDN
33
2020,
from
APPENDIX
Personal identity
Name (initials allowed)
Age
The most recent education
Occupation
Part 1: Frequency of COVID-19 Hoax Buster Dissemination Hoax Buster is an antidote for hoax news or information that is spread to clarify hoax news. In this section, you will answer several questions that measure how often you see / read news about Hoax Buster related to COVID-19. Please answer according to your circumstances, because it will affect the results of the research. 1. Have you ever seen or read Hoax Buster's information about COVID-19? a. Has never been b. Just looking c. Look and read at a glance d. See and read the whole 2. Where did you see the Hoax Buster information?
Social media (Instagram, Line, Facebook, twitter, Whatsapp, etc.)
Official government website (covid19.go.id)
Hoax Buster Tools / applications used to get accurate and hoax-free news
Other
3. Where does Hoax Buster's information come from about COVID-19?
Government (Directorate General of Higher Education, Local Government, Regency / City, etc.)
4.
Mass media that usually share news (Kompas, Detik, CNN, Line Today, etc.)
Other
How often do you see / read Hoax Buster's information on social media in one week? a. About 1-2 times b. About 3-4 times c. About 5-6 times d. More than 6 times
34
Part 2: Public Attitude Toward Hoax
No.
Question
Strongly Disagree
Disagree Neutral Agree
Strongly Agree
I trust the information I receive 1 from the internet and other media for what it is 2
I donâ&#x20AC;&#x2122;t spread information which is not clear the truth I remind my family and / or
3
friends not to easily believe information from the internet or other media I rely on official sources from the
4
government or from WHO, CDC, etc. as main sources of information I am careful with news /
5 information with provocative headlines
Part 3: Knowledge Regarding Hoaxes Regarding COVID-19 1. Just sunbathing can prevent / cure COVID-19 a. Right b. Wrong 2. A mixture of coconut water, lime, and salt can kill COVID-19 a. Right b. Wrong 3. Can COVID-19 be cured with blood thinners? a. Yes, because COVID-19 can cause blood clots to occur b. No, because blood thinners only treat complications from COVID-19 4. Is it dangerous to use a mask while exercising (in the context of the COVID-19 pandemic) a. Dangerous, because it can make the body weak because it inhales CO2 again after
35
removing CO2 from the body. So don't wear a mask while exercising even during the COVID-19 pandemic b. It's dangerous, but in a COVID-19 pandemic like this, when exercising outside the home you must still wear a mask but still pay attention to the intensity of your exercise c. It is not dangerous because exercising using a mask does not affect the body 5. Cigarette smoke can transmit COVID-19 a. Right b. Wrong 6. A “Viral” necklace containing disinfectant / anti-microbial substances can prevent transmission of COVID-19 a. Right b. Wrong 7. Giving alcohol / hand sanitizer to masks can be dangerous to health a. Right b. Wrong 8. Eucalyptus oil can’t treat COVID-19 a. Right b. Wrong 9. Rapid Test / Swab Test is dangerous because it has the potential to transmit COVID-19 a. Right b. Wrong 10. When not sick, use the white side of the mask on the outside. Meanwhile, when sick, a blue / green mask is used on the outside a. Right b. Wrong
36
The Impact of Telemonitoring with Community-Based Cardiac Rehabilitation Intervention on Improving Quality of Life and Clinical Outcome of Stable Coronary Heart Disease Patients Neville1, Rachmad Pramuda Wardana1, Amandus Michael Martin1, Hana Devina Lesmono1 1 Undergraduate student at Medical Faculty of Universitas Brawijaya, Malang, East Java, Indonesia
Abstract (Introduction)Coronary Heart Disease has high morbidity and mortality rate. Combination of medicamentosa, revascularization, and community-based rehabilitation showed good outcomes and minimized rehospitalization in Europe. In Indonesia, decreasing the number of rehospitalizations will reduce the deficit of universal health coverage. Telemonitoring is an appropriate option to monitor CHD patients due to COVID-19. The study aims to know the impact of telemonitoring with communitybased cardiac rehabilitation interventions on stable CHD patients’ quality of life. (Method)This study was conducted at RSI Aisyah Malang from April 2019-2020. Subjects were taken by purposive sampling and divided into 2 groups(70 interventions,78 controls)who are>40 years old, diagnosed with stable CHD, and have been treated with medicamentosa and revascularization. Intervention patients are members of Malang Community of Cardiovascular Care(MC3), while control patients aren’t. We used characteristic data and clinical outcomes questionnaire, SF-36, Seattle Angina, IPAQS, DASH, and MMS-8. Telemonitoring is done using MC3 and WhatsApp application. (Result) MC3 patients had lower MACE(2.9%vs20.5%,p=0.002) and better quality of life(p=0.001). After 6 months intervention, SF-36 and SAQ parameters of MC3 patients increased(p=0,000). Clinical results showed lower rehospitalization rate in MC3 patients(p=0.012). The value of MMS-8 was different(7.5vs5.2,p=0,000). MC3 programs spent Rp93.600.000/year(100 patients) and it’s enough to reduce the number of CHD rehospitalization that cost 9.3 trillion/year. (Conclusion) Telemonitoring with community-based cardiac rehabilitation interventions must be considered in combination with medicamentosa and revascularization because it can improve quality of life and medication adherence, reduce the incidence of MACE, mortality, and BPJS cost due to rehospitalization. Keywords: Community Rehabilitation, Coronary Heart Disease, Telemonitoring
37
The Impact of Telemonitoring with Community-Based Cardiac Rehabilitation Intervention on Improving Quality of Life and Clinical Outcome of Stable Coronary Heart Disease Patients
Authors: Neville Rachmad Pramuda Wardana Amandus Michael Martin Hana Devina Lesmono
Faculty of Medicine Universitas Brawijaya Universitas Brawijaya Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia 2020
38
INTRODUCTION
trillion in 2016, and continues to reach Rp 9.3
The World Health Organization(WHO)
trillion in 2015(Atmirosev et al,2017). CHD is
stated that cardiovascular disease is the number
the largest contributor rehospitalization in
one cause of morbidity and mortality globally
Indonesia. Based on data from the Indonesian
and contributes in increasing healthcare costs
Ministry of Health in 2019, the total cost that
(WHO,2020). Coronary Heart Disease(CHD)
has been incurred by BPJS Health related to
is generally caused by atherosclerosis that
health services from 2014 to 2018 was Rp
narrow coronary arteries, reduce blood flow
345.75 trillion with an income of Rp. 317.04
and impair myocardial oxygen supply (Mann
trillion from BPJS participants(Kemenkes,
DL,et al,2019). CHD still becomes a problem in
2019). This indicates a deficit of Rp 28.71
both developed and developing countries. Data
trillion. If rehospitalization costs can be
from the World Health Organization(WHO) in
reduced, it can improve the quality life of
2020 stated that 17.9 million people worldwide
patients and decrease BPJS cost(AUR,2017).
die from heart and blood vessel disease every
Since 11 of March, WHO has stated that
year(WHO,2020). Based on data from the
novel coronavirus disease(COVID-19) has
Framingham
of
become an emergency pandemic(WHO,2020).
progression to symptomatic coronary heart
This outbreak has rapidly spread globally in
disease increase after the age of 40 years. In
128 out of 195 countries in the world with
2010, CHD caused 48% of deaths caused by
mortality rate of 1,064,838 people and high rate
cardiovascular disease in America(Mann DL et
of infection
al,2019).
Dokter
respiratory disease is primarily transmitted
Spesialis Kardiovaskular Indonesia(PERKI)
through droplets, direct and indirect contacts
stated that CHD contributes to the largest
between humans. These transmission highly
spectrum
worldwide,
occurs when individuals is in 1meter distance
amounting to 26.4% of all deaths. The death
by sneezing, talking, coughing(WHO,2020).
rate is five times higher than the death rate from
Due to COVID-19 pandemics, access to health-
cancer(6%) and has continued to increase
care centers are limited in order to reduce
rapidly in the last ten years. In other words,
COVID-19 transmission. However, regular
about one in four people who die in Indonesia
visits to the hospital are necessary for CHD
are caused by CHD. CHD in the next few years
patients
will continue to increase, reaching 23.3 million
management(Han et al,2020). This condition is
deaths
unfavorable for chronic patients, especially for
In
of
in
Heart
2019,
heart
2030
Study,
the
risk
Perhimpunan
disease
due
to
unhealthy
lifestyles(Windecker et al,2016).
to
since 17th October 2020. This
receive
adequate
clinical
CHD patients. Moreover, this disease can
The incidence of rehospitalization, the
increase the severity in patients infected with
return of patients to the hospital with the same
COVID-19. Therefore, it is important to
complaints, spent Rp 4.4 trillion in 2014, Rp 7.4
minimize risks of COVID-19 infection while
39
maintaining
adequate
treatment
Community-based heart rehabilitation
efficacy(Guo,2020).
intervention, which consists of modification of
More viable option which implement
risk factors and lifestyle behaviors, such as
physical distancing is needed in facing the
smoking cessation, diet changes, physical
terror of COVID-19. Telemonitoring can be
activity, weight loss, consumption alcohol, and
one of the best viable option for communication
psychosocial factors, a reduction in systolic
between health-care professionals and patients.
blood pressure, a decrease in serum cholesterol
Telemonitoring
the
are also said to reduce morbidity and mortality
observation of patients at a distance by using
rate in stable CHD patients(AUR,2017). The
telecommunication. Telemonitoring has a lot of
association
potential to be developed for monitoring
rehabilitation interventions based on length of
patients, patient self-care, disease management,
participation with better treatment adherence
treatment support, and also patients education
rates in stable CHD patients was observed. The
about their conditions to improve patientsâ&#x20AC;&#x2122;
impact of community-based heart rehabilitation
lifestyle or monitoring in health issues(Alves D.
on the prognosis of CHD patients are not only
et al,2019).
affected by the medication but also the
can
be
defined
as
The current CHD therapy uses optimal
of
community-based
heart
importance of communication to increase
medicamentosa because it has been shown to
motivation
improve symptoms and prognosis. If it still
Community intervention is the place for
shows poor results, it will be combined with
communicating
surgical therapy or revascularization, such as
professional and patients(Crues et al,2018).
PCI(Percutaneous Coronary Intervention) or
Moreover
CABG(Coronary
community-based
Artery
Bypass
Graft)
and
medication
adherence.
between
telemonitoring
healthcare is
heart
used
in
rehabilitation
(WHO,2020). Even though medicamentosa
intervention as one of the platform which is
with revascularization has been clinically
suitable in this pandemic era. However, there
tested, the morbidity and mortality rate of CHD
are no studies in Indonesia that assess the
patients remains high. This means that there are
impact
individual factors outside existing therapies that
rehabilitation interventions on the QoL of stable
affect clinical outcome of stable CHD patients.
CHD patients who receive optimal medical
In previous study, it is stated that medication
therapy
adherence in CHD patients regarding their
pandemic COVID-19 era.
of
or
community-based
revascularization
cardiac
therapy
in
treatment is very low.15 This is the important METHOD
aspect that can be evaluated for implementing a new interventions with the aim of improving the patient's quality of life (QoL) and clinical
This research is a prospective cohort
outcomes.
study to determine differences in clinical
40
outcomes in the form of quality of life (QoL)
presence training at least one year of attendance
and decreased MACE in patients with stable
before participating in research.
CHD who receive optimal medical therapy, as well
as
coronary
revascularization
Control Group
with
Percutaneous Coronary Intervention(PCI) or Coronary Artery Bypass Graft(CABG) with
Participants in the control group were all
interventional cardiac rehabilitation therapy.
stable CHD patients over 40 years of age with
Research
patients
who had received optimal medical therapy/a
undergoned revascularization-based therapy
history of PCI/CABG at least 1(one) year.
and optimal medical therapy, which were
Patients did not belong to any cardiac
divided into 2 groups(78 as a control and 70
community but receives a specific explanation
patients with community intervention). This
by the cardiologist in general about secondary
study used purposive sampling, where the
preventives(diet, physical activity, smoking
researcher chose patients who were determined
cessation).
subjects
were
CHD
as subjects who met the inclusion criteria as Research Platform
cases in patients who were involved in community intervention activities either with revascularization-based therapy or with optimal
We use telemonitoring in the form of an MC3
medical therapy and chose the patients who
application and WhatsApp group which can
were determined as controls who met both
only be accessed by MC3 members. The MC3
inclusion
application feature consist of reminder to take
criteria
based
on
therapy
revascularization and optimal medical therapy
medication,
and
reminders, doctor's appointment
not
being
involved
in
community
intervention activities.
MC3
programs
schedule schedule
reminders, and information about nutrition education. The WhatsApp group is involved to
Intervention Group
keep reaching out to community members in
Participant in this intervention group
undergoing cardiac rehabilitation programs.
were patients over 40 years diagnosed with
This group function as a forum for interactive
stable CHD who had been treated with optimal
discussion
medical conditions for a minimum of 6 months
member can share their successful therapies to
and take medication regularly and had
motivate other members and remind each other
undergone PCI/CABG. Patients are members
to increase the level of medication adherence,
of the Malang Community of Cardiovascular
also get the correct information about CHD.
Care(MC3) and routinely participate in the
Information about programs in the community
activities of the heart care community as
is also reminded through the group, so that
evidenced by membership and attendance
41
where every
individual MC3
members can find out and not miss participating
through a beneficial effect on reducing
in various activities in the community.
cardiovascular risk factors, morbidity and mortality in CHD patients. This program is
Community and Telemonitoring Programs
delivered by nutritionist.
1. Physical Activity
3. Psychological Counseling
Routine activities started with physical activity
MC3 provides psychological counseling which
in the form of cardiac gymnastic accompanied
aims to lower the threshold for psychosocial
by a physiotherapist. Based on the previous
stress and promote healthy behavior and
research, regular physical activity and aerobic
lifestyle. Interventions include counseling on
exercise will reduce the risk of fatal and non-
psychosocial risk factors, cognitive-behavioral
fatal coronary events in the individual health.
therapy,
By
meditation, autogenic training, breathing, yoga,
using
Intensity,
the Time,
FITT and
criteria(Frequency, Type),
activity
stress
management
programs,
and/or muscle relaxation. This program is
interventions on MC3 with a frequency of 5
carried
out
by
psychologists
times a week for moderate physical activity or
psychiatrists(Mann DL et al,2019).
and
2 times a week for cardiac gymnastic which held every Tuesday and Friday(Mann DL et
4. Routine Total Cholesterol and Blood
al,2019).
Pressure Monitoring This program is said to provide lifestyle
2. Nutrition Education
improvements(diet and physical activity) as
MC3 also provides education to its members
well as more effective control of risk factors for
about diet or nutrition intervention. Dietary
MC3
habits are known to influence cardiovascular
monitoring of blood pressure and serum
risk, either through effects on risk factors such
cholesterol. Through MC3 application, each
as serum cholesterol, blood pressure, body
patients the patient regularly deposits his blood
weight,
pressure.
and
diabetes,
or
through
the
members
by
conducting
routine
independent effects of risk factors(Mann DL et al,2019).
5. Seminar MC3 also conducts seminars that are held every
Through MC3 application, we have designed a
month which will be given by cardiologist. The
diet plan suitable and personalized for each
seminar materials contain information about
MC3 participant. DASH diet has long been
heart health on various topics to attract
reported as a diet for the prevention of non-
community members. The main purpose of
communicable diseases. DASH diet maintain
holding the seminar is to raise awareness of
health status and improve QoL, primarily
community members so that they are more
1
42
concerned about their heart health by changing
disease and in differentiating the health benefits
life style such as smoking cessation. This
generated by different interventions.
program is paid for voluntary. Seattle Angina Questionnaire Research Instruments All research instrument has been validated
The Seattle Angina questionnaire was
internationally.
developed for assessing QoL specifically on physical and emotional effects in CHD patients.
1. Basic characteristic data questionnaire Basic
characteristic
data
This questionnaire uses 19 questions that
used
a
indicate important clinical dimensions of CHD
questionnaire through face-to-face interviews
including: limited physical ability, stability of
and medical records.
angina, frequency of angina, satisfaction with therapy and perception of disease(Patel K.et al,
2. Patient's Clinical Outcome Questionnaire
2018).
Patient clinical outcome data were used to evaluate the Major Advance Cardiovascular Event(MACE)
and
the
4. Physical activity questionnaire
Patient-Oriented
Physical activity was measured using a
Composite Endpoint(POCE). The data was
short version of the International Physical
obtained based on face-to-face interviews and
Activity
medical record.
frequency and intensity of each activity were
Questionnaire(IPAQ-S).
The
used to calculate the total intensity category in 3. QoL questionnaire
METs / min / week units. These values were obtained by multiplying
Short Form-36 Questionnaire(SF-36)
average energy
expenditure(3.3 METs for walking, 4.0 METs for moderate intensity, and 8.0 METs for
Short Form-36(SF-36) as a measure of
vigorous intensity) by the min / week for each
QoL is a health survey questionnaire to assess
physical activity(Wanner,2016).
Quality of Life (QoL), consisting of 36 questions. This questionnaire produces an 8functional
scale
of
health
profiles
5. Diet Questionnaire based on the Dietary
and
Approaches to Stop Hypertension(DASH)
psychometric-based physical and psychological
score
well-being welfare score, and is a collection of
All participants completed a food
measures and index-based health preferences.
frequency questionnaire via a 22-item DASH
Therefore, the SF-36 has been shown to be
score(Tosseto,2017) which was conducted
useful in general and population-specific
face-to-face by the researcher. Participants
surveys, comparing the relative burden of
were asked to first indicate the frequency of
43
food intake, and record the exact amount
1. Univariate analysis which is a descriptive
consumed per month, week or day. The DASH
statistics to determine the characteristics of the
score, based on the scoring system developed
sample. The univariate analysis was the mean
by Fung et al. This assessment was chosen
value, standard deviation and prevalence to
because it is the only scoring system that
assess
includes the calculation of sodium, and
comorbidities of the research subject.
the
basic
characteristics
and
calculates the DASH score based on the reported food groups directly (Larsson et al,
2. Bivariate analysis on the subject of this study
2016).
used the independent t-test to determine the mean difference between the control group and
6. Medication adherence questionnaire
the intervention group, if the normality test
Patientâ&#x20AC;&#x2122;s medication adherence can be
obtained normal data distribution using the
defined according to the Modified Morisky
Kolmogorov-Smirnov test, whereas if the data
Scale(MMS-8) value for all cardiac drugs
distribution was abnormal it used the Mann
prescribed by cardiologists. MMS-8 is a
Whitney test. The independent t-test was
questionnaire consisting of 8 questions with yes
considered significant if p<0.05 was obtained.
and no answers, to measure the level of compliance
of
subjects
in
using
Subgroup analysis in this study examined
drugs
the mean differences between the treatment
(Zimmerman et al,2019).
subgroups(control group, MC3 1 year, 2 years,
Research location and time
3 years, and 4 years) and control. Subgroup analysis in this study used the oneway ANOVA
This research was conducted on the MC3
test if normal data distribution was obtained in
at the Cardiac and Vascular Polyclinic of
the Kolmogorov Smirnof test and using the
Aisyah Malang Islamic Hospital in the period
Kruskal Wallis test if the data distribution was
April 2019â&#x20AC;&#x201C;April 2020.
not normal. The p value is considered significant if p<0.05.
Data Analysis 3. Multivariate analysis to determine factors The data obtained were analyzed using
that affect POCE, MACE, and QoL using
SPSS 22 software to determine the relationship
logistic regression and linear regression. The
between MC3 groups with control on QoL,
degree of trust used is 95%(Îą=0.05).
POCE in the form of death, repeated rehospitalization in stable CHD patients who
4. Kaplan Meier analysis to analyze survival
underwent both PCI and CABG or optimal
analysis aimed at estimating the probability of
medical therapy.
survival, recurrence, death, and other events up to a certain time period. This analysis will
44
assess the difference in the proportion of POCE, MACE and mortality between MC3 and control patients with a span of 6 months before intervention up to 6 months after intervention. RESULT Analysis of Basic Characteristics(univariate) This study involved 148 patients, 74.3% of whom were male, mean patient age was 59.8Âą7.64
years,
mean
BMI
25.9Âą3.41
kg/m2where all patients were monitored by telemonitoring through MC3 application and WhatsApp groups. 88.5% of patients had undergone PCI. 48% had a history of hypertension, 12.8% had a history of DM, 52.7% had a history of dyslipidemia, and 10.1% had a history of heart failure. The results showed that 62.35% had received ACE-I therapy and 37.2% had received ARB. 73.4% had received statin therapy. 58% of patients received nitrate, 65.5% of patients received acetyl salicylic acid and 78.4% of patients received Clopidogrel. The results of the univariate analysis showed that there was no significant difference between the treatment group(MC3) and the control group on the basic characteristics. The results of the univariate analysis are presented in Table 1.
45
0.001, 0.001, 0.044, and 0.000, respectively). MC3 has a better QoL when compared to control
patients
based
on
the
SAQ
questionnaire value(physical limitation, angina stability,
angina
frequency,
treatment
statistification, and QoL) with the following significance values (p = 0.001, 0.001, 0.021, 0.003, 0.000 , respectively) The resultsof the bivariate analysis are described in Table 2
Bivariate Test Analysis Results The results of bivariate analysis showed that there was a significant difference in the value of the left ventricular ejection fraction(EF) between MC3 patients and controls(48.70±11.1 compared to 42.9±14.5,p=0.007 respectively). There was a significant difference in adherence to physical activity(IPAQ questionnaire) MC3 patients compared with controls based on IPAQ questionnaire, the proportion of MC3 patients with vigorous activity was 43.7%, while in control patients was 23.4%(p=0.000). The results of this study indicated that MC3 patients had a higher adherence score to the DASH diet than
the
control(32.41±2.4vs29.98±1.90,p=0.000). MC3 participants had a significantly lower incidence
of
MACE
than
control
patients(2.9%vs20.5%,p=0.002). There was a significant difference in the QoL between MC3 and
control
patients
based
on
SF-36
parameters(Physical Functioning, Limitation Physical health, Social functioning and General Health with several levels of significance(p =
46
Physical limitation and QoL, with a value of p = 0.00. On the other hand, on the parameters of angina frequency and angina stability, there was no significant difference in the mean increase in the mean SAQ value for both MC3 and control. The follow-up data after 6 months of intervention are presented in Table 3.
Follow Up After 6 Months In the follow-up results after 6 months after the intervention, MC3 patients had a significant increase in the mean SF 36 parameters compared to controls, including: Physical functioning, limitation to physical health, limitation to emotional problems, energy fatigue,
emotional
well
being,
social
functioning, pain, general health, and health change with a value of p = 0.00; 0.02; 0.02; 0.00;
0.00;
0.001;
0.026;
0.00;
0.00,
respectively. SAQ parameters also increased significantly compared to controls, including:
47
Differences
in
Clinical
Outcomes
of
in
Figure
1.
Rehospitalization The clinical outcome of rehospitalization showed that the proportion of rehospitalization of MC3 patients was significantly lower than control group with p value = 0.012(4.2% vs 16.9%). From the sub-group analysis, it was found that the most common cause of
Figure 1. Kaplan Meier Curve Predicted the
rehospitalization was heart failure and there
Absence of Heart Failure Symptoms between
was a significant difference(p = 0.018) between
groups
groups. Meanwhile, for the proportion of
There was no significant difference in the
angina and myocardial infarction, there was no
proportion of the occurrence of Angina pectoris
significant difference between groups.
and acute myocardial infarction in the MC3 and
Rehospitalization resulted from relapsed
control groups with a value of p = 0.187.
MI(p = 0.0187), heart failure(p = 0.018),
Predictions of acute myocardial infarction in the
angina(p = 0.187) and mortality(0% vs 3.9%, p
MC3 and control groups are depicted in Figure
= 0.09). The difference in rehospitalization
2.
outcomes is explained in table 4.
Figure 2. Kaplan Meier Curve Predicted the Absence of Symptoms of Acute Myocardial Infarction between groups
Kaplan Meier Curve
There were no mortality in MC3 patients
There was a significant difference in the
during the 12 months follow-up, whereas in
absence of heart failure during 12 months of
control patients there were 3 patients who died
follow-up between MC3 patients and controls
due to cardiac causes(2 patients had heart failure,
described according to the Kaplan meier curve
and 1 patient had myocardial infarction). There
48
were no significant differences in the occurrence
the other groups with p=0.000. The results of
of mortality between MC3 patients and controls
the sub-group analysis are described in Table 5.
with a p value = 0.09. The Meier Kaplan curve
Table 5. Sub Group Analysis
prediction of no mortality in MC3 patients and controls is illustrated in Figure 3.
Figure 3. Kaplan Meier Curves Predicted the Absence of Mortality between groups Subgroup Analysis In the subgroup analysis, it was found that the MC3 group who had been joined for 4 years had the highest left ventricular ejection fraction value compared to the other groups with
p=0.049.
There was a
significant
difference in diastolic dysfunction between the MC3 group and the other treatment groups, patients who had followed MC3 for 4 years had a smaller proportion of diastolic dysfunction than the other groups with p=0.006. The adherence to regular physical activity was higher in the MC3 group at 2 years compared to the other groups, p=0.000. There was a significant difference in the DASH diet score between the treatment groups, with the DASH diet adherence score in the 4th year MC3 group having the highest DASH value compared to
49
50
The impact of community-based heart rehabilitation intervention on medication adherence Patients who joined MC3 had different values of
MMS-8
with
control
patients
baseline(7.5Âą0.8vs5.2Âą1.1,p=0.000)
at with
MACE values (4.2%vs16.9%,p=0.00). Then an evaluation was carried out after 12 months and the MMS-8 value was 1.57vs0.2 with p=0.000. The differences between MMS-8 and MACE in intervention and control groups are described in Table 6. Tabel 6. Differences between MMS-8 and MACE in groups
Cost Effective Estimation
51
differences in terms of comorbid. Intervention data from the two groups were not statistically significant. Bivariate analysis showed that the EF of the intervention group was better than control which shows a good effect of physical activitybased cardiac rehabilitation, in accordance with a previous study conducted by Haddadzadeh et al that at an evaluation for at least one year provided an improvement in left ventricular EF were better in the intervention group than in the control group with the effect of improving stroke volume and myocardial contractility. However, this study collected the data from medical records when subject were recruited.
Note : * per patient **100
patients(member
of
In the intervention group, vigorous
the
activity was greater than control. This shows
community)
that adherence of intervention group is better
Other programme billed collectively
measured by the ability of resistance as
from the community
measured in METs than in control. It shows that the existence of the community has a positive
DISCUSSION
impact in increasing physical activity, with the support of each member of the community who
The study was consisted of 148 patients,
has the same way of thinking and fate, provides
74.3% were male, the patient's age was 59.8Âą7.64
years,
the
mean
BMI
motivation so that compliance with physical
was
activity is better than control.
25.9Âą3.41kg/m2. 88.5% where all patients were
The
monitored by telemonitoring through MC3 application
and
DASH
diet
intervention
also
provided better adherence in the intervention
groups.
group than in the control group. The
Anthopometric baseline data showed no
intervention diet and physical activity turned
statistical distribution, indicating that the two
out to provide a better QoL according to SAQ
groups had the same anthopometry.
and SF36 in the intervention group compared to
The baseline data for optimal therapeutic
the
drug use did not have statistical differences, so
control.
MC3
participants
had
a
significantly lower incidence of MACE than
that the two groups had the same distribution,
control patients(2.9%vs20.5%,p=0.002), thus
with the use of CHD drugs. History data from
consistent with previous studies.
the second group also had insignificant
52
There was a significant difference in
The
rehospitalization
data
in
the
QoL between MC3 patients and controls based
intervention group rate was significantly
on
smaller than the control group. After analyzing
SF-36
parameters
with
levels(p=0.001,0.001,0.044,
significance and
0.000,
subgroups, it was found that the most common
respectively). MC3 patients have a better QoL
cause of rehospitalization was acute heart
when compared to control patients based on the
failure, which differed significantly between
SAQ questionnaire value(Physical limitation,
the two groups,p=0.018, according to the study
angina stability, angina frequency, treatment
conducted by Sarah Canyon et al. gave the same
statistification, and QoL) with the following
results with a follow-up of 12 months.
significance
Telemonitoring
in
community-based
values(p=0.001,0.001,0.021,0.003,0.000,
cardiac rehabilitation intervention decrease the
respectively), followed up for 6 months and the
rehospitalization rate which lead to the decrease
QoL assessment of the intervention group was
of national universal health coverage in
better than the control group, and this is
Indonesia, known as Badan Penyelenggara
consistent with previous studies conducted by
Jaminan Sosial(BPJS),
Lixuan Zhang et al., Dabek et al. and the
community which consist of 100 people spent
ETICA trial which gave the same results with
93,6 billion IDR per year for all the operational
this study.
cost. Whereas with the current intervention,
MMS-8
data
showed
that
the
without
expenditure. This
community-based
cardiac
intervention group had a significantly better
rehabilitation interventions, the BPJS spent 9.3
level of medication adherence(p=0.000) than
trillion in 2018 for CHD rehospitalization.
the control group. In subgroup analysis, it
From the epidemiology data, there are 2
showed that the intervention group that had
million stable CHD patients in Indonesia.3 If
participated for 2 years had the highest score of
this community is implemented to all stable
MMS-8 compared to the control group with
CHD patients in Indonesia with the same
p=0.049.
amount of members, 100 person, there will be
Meanwhile, MACE data from the
20.000 communities and BPJS will spend 1,872
bivariate analysis showed that the intervention
trillion IDR. If the community sized is
group had a lower incidence of MACE than the
increased to 2 times or 3 times the initial
control group. In accordance with research
quantity,
conducted by Kashish Goel et al. who
rehospitalization could decrease more.
participate
in
community-based
the
total
money
spent
for
cardiac
Mortality is also shown in this study in
rehabilitation group with a subset of post-
the 12 months follow-up in the intervention
revascularization patients with PCI showed a
group there was no death, but in the control
lower MACE rate compared to control group.
group, it was found that 3 patients experienced death 2 due to acute heart failure, 1 patient
53
experienced reinfarction. However, statistically
considered in combination with medication and
it has insignificant significance, but has a better
revascularization because they can improve
trend than control. In accordance with the
QoL
systematic review conducted by O'Conor and
mortality and reduce BPJS expenditure due to
Olridge which stated a decrease in mortality
rehospitilization.
and
medication
adherence,
reduce
rates from all causes, both cardiac and nonRECOMMENDATIONS
cardiac. Community-based
heart
disease
Further studies with a longer follow up period
prevention programs are a widely advocated
and larger sample size are needed to reduce bias
strategy in public health. So far, no studies have
and improve the accuracy of measuring the
reported the impact of community-based
relationship between groups.
interventions on QoL. There are also limited
Acknowledgment
data on the effect of health promotion programs
We are grateful to our teacher and mentor, dr.
and QoL.
Syaiful Arifin, M. Biomed for the support and
An improvement in the QoL component
assistance during the process of creating this
has been reported after one-year cardiovascular
research.
lifestyle modification program. The initial program consisted of sports training, whereas
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56
Current
Scientific Paper Competition PCC EAMSC 2021 THE ASSOCIATION BETWEEN DOCTOR-PATIENT RELATIONSHIP AND MEDICATION ADHERENCE AMONG GLOBAL PATIENTS WITH CHRONIC DISEASES : A SYSTEMATIC REVIEW AND META-ANALYSIS Ayers Gilberth Ivano Kalaij*, Michael Sugiyanto**, Nathaniel Gilbert Dyson***and Gideon Hot Partogi Sinaga**** * **
Third Year Medical Student, AMSA-UI (kalaijayers@gmail.com)
Third Year Medical Student, AMSA-UI (michael.sugiyanto@yahoo.co.id)
*** Second Year Medical Student, AMSA-UI (nathanielgilbert88@gmail.com) **** Third Year Medical Student, AMSA-UI (gideonsinaga21@gmail.com)
Abstract Introduction : Chronic diseases are the leading causes of death and disability worldwide, in which 79% of them occur in the developing countries, including Indonesia. On the other hand, chronicdiseases related outcomes are significantly depended on patientâ&#x20AC;&#x2122;s medication adherence. In recent years, several studies have been done to investigate the association between doctor-patient relationship and medication adherence among patients with chronic diseases. Objective : This systematic review and meta-analyses aims to evaluate the association between doctorpatient relationship and patientâ&#x20AC;&#x2122;s medication adherence as an important factors to improve chronicdiseases related outcomes. Methods : This review selects cross-sectional studies found by database searching systematically using previously determined inclusion, such as assess doctor-patients relationship, chronic diseases patient samples, and exclusion criteria such as emergency settings studies and studies written in languages other than English or Bahasa Indonesia. This review was arranged based on PRISMA guideline. Results & Discussion : Ten cross-sectional studies were included in qualitative and quantitative analyses with the pooled OR of 0.74 [95% CI: 0.69-0.80]. The quantitative analyses showed that poor doctor-patient relationship significantly lower the medication adherence (p<0.00001). However, heterogeneity analyses revealed a substantial heterogeneity of the pooled studies, probably due to different type of chronic disease included. Conclusion : This study has proven that poor doctor-patients relationship is strongly associated with low medication adherence in chronic diseases patients significantly. Thus, it is necessary to enhance training about communication skills for healthcare providers in order to decrease the prevalence of chronic diseases medication non-adherence. Keywords : Doctor-patient relationship, Medication Adherence, Chronic Diseases
57
THE ASSOCIATION BETWEEN DOCTOR-PATIENT RELATIONSHIP AND MEDICATION ADHERENCE AMONG GLOBAL PATIENTS WITH CHRONIC DISEASES : A SYSTEMATIC REVIEW AND META-ANALYSIS Scientific Paper
Author : Ayers Gilberth Ivano Kalaij Michael Sugiyanto Gideon Hot Partogi Sinaga Nathaniel Gilbert Dyson
Faculty of Medicine Universitas Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia 2020
58
Introduction
medication adherence to several factors related to effective health communication, with doctor-
Chronic diseases such as heart diseases,
patient relationship as one of the most influencing
diabetes, and cancer are the current leading causes
one.
of death and disability worldwide. The term ‘chronic diseases’ actually refers to any conditions
The relationship between doctors and
that occur for 1 year or more and involve an
patients involves feeling of trust and vulnerability.
ongoing medical attention or limit daily acitivities
Nevertheless, it is believed to be one of the most
or both (CDC, 2020). In recent years, disease rates
moving and meaningful experiences shared by
from these conditions are accelerating globally,
human beings. Basically, by entering into the
advancing across every region and pervading all
relationship, the doctors agree to respect their
socioeconomic
example,
patient’s autonomy, maintain confidentiality,
cardiovascular diseases (CVDs) are the number
provide informed consent, serving the best
one cause of death, taking an estimated number of
treatment options, and promise to not abandon
17.9 million lives each year. Diabetes is another
them until they find a new doctor. However, this
global health issue which is currently acquired by
relationship are not always perfect. (Chipidza et
422
al., 2015)
million
classes.
people
For
worldwide.
Moreover,
according to the WHO, 79% of the deaths
Recently, accumulating evidences have
attributed to chronic diseases occur in the
shown
developing countries, including Indonesia. (WHO,
that
doctor-patient
relationship
and
patient’s medication adherence is significantly
2020).
associated. However, to our knowledge, there has On the other hand, medication adherence
been no systematic reviews and meta-analysis to
has been proved to be one of the most important
summarize and analyse all of these findings.
factor that can improve chronic-diseases related outcomes
(Balkrishnan,
2005).
Therefore, we thought that the evaluation
Medication
and analysis of this association could be a
adherence can be defined as whether patients take
breakthrough to further promote a better strategies
their medications as prescribed, or whether they continue
to
take
a
previously
towards enhancing patient’s medication adherence
prescribed
and
medication (Ho et al., 2009). This is a growing
thus,
improve
chronic-diseases
related
outcomes. Therefore, this systematic review and
concern to clinicians and healthcare providers as
meta-analysis aim to investigate the association
plethora of evidences have been found that
between doctor-patient relationship and patient’s
nonadherence is associated with adverse outcomes
medication adherence. Studies and reviews like
and higher costs of care (Desai et al., 2014).
this are needed due to urgency of current situation
Meanwhile, some studies have associated
59
as already stated above and finally to design an
Furthermore, duplicates removal was performed
appropriate solution.
using EndNote X9 software. Screening of titles and abstracts of studies was carried out according
Materials and Method
to criteria of accessibility by three independent
This systematic review was conducted
reviewers. Any disagreements were discussed into
based on the Preferred Reporting Items for
consensus. The planned procedure is illustrated in
Systematic
Figure 1.
Reviews
and
Meta-Analyses
(PRISMA) checklist which can be accessed
Quality assessment
through http://www.prisma-statement.org/
Each included study was assessed using
Search strategy
Strengthening the reporting of observational
A comprehensive literature search was
studies in epidemiology (STROBE) statement
performed by three independent reviewers with
checklist designed for cross-sectional studies. This
multiple electronic databases, such as PubMed,
tool consists of quality and risk of bias assessment
Scopus, Wiley, and EBSCOhost up to 18 October
based on every section of the included studies
2020. The keywords used in the pursuit were
including title and abstract, introduction, methods,
"Doctor-Patient Relationship” OR "Physician-
result, discussion, and fundings with a total score
patient
and
of 22. Studies with higher STROBE score
“Medication adherence”. Where applicable and
indicates better quality of studies which shown
available, appropriate advance search techniques
that the study has lower risk of bias (STROBE,
relationship”,
“Compliance”
were applied to narrow the search. Study eligibility criteria Studies were screened according to the following inclusion and exclusion criteria. Our inclusion criteria were (1) cross-sectional survey studies, (2) assess doctor-patients relationship, (3) chronic diseases (>1 year duration) patient samples, and (4) assess odds ratio towards medication adherence as the study outcome. Exclusion criteria: (1) emergency settings studies, (2) Studies that did not have a full-text version, and (3) written in languages other than English or Bahasa Indonesia were excluded from this review.
Figure 1. Literature search strategy
60
2009). The quality assessment was done by three
which are sufficient for quantitative analysis are
reviewers with each other blinded on othersâ&#x20AC;&#x2122;
admitted for meta-analysis.
scoring, then discussed until consensus was
Odds ratio (RR) with a 95% confidence
reached.
interval and p-value below 0.05 was used to determine the association between poor doctor-
Visual indication of publication bias was
patients
also done using funnel plot. An asymmetrical
relationship
and
low
medication
adherence in chronic diseases patients. If OR <1,
shape indicates the presence of publication bias.
poor doctor-patients relationship was associated
Additional sensitivity analysis was conducted
with low medication adherence. Factors were put
through Duval and Tweedieâ&#x20AC;&#x2122;s trim-and-fill
as study code, log of odds ratio, and standard of
analysis which are specific for situations that the
error which will be calculated for study weight,
heterogeneity is too large. This method was
fixed odds ratio, and its 95% confidence interval
conducted to re-ensure the pooled effect size after
(CI) which will be presented in forest plot. Studies
removing any studies to minimize the publication
were also assessed using the Cochraneâ&#x20AC;&#x2122;s chi-
bias (Higgins J, 2008, pp. 279-281)
squared test and the Higgins I-squared statistical
Similarly, as there was heterogeneous
test in terms of heterogeneity of the included
reporting of outcomes, we categorized them into
studies. If the p-value of the chi-squared test
two main groups for consistency if the study
results is >0.05 and I-squared statistic is over 50%,
included numbers are two and above. Those two
the study will be considered as heterogeneous.
main groups include: (a) hypertensive patients and
Thresholds for the interpretation of I-squared
(b) Inflammatory bowel diseases (IBD) patients
referred to Cochrane Handbook for Systematic
Summary measures and data analysis
Reviews of Interventions is as follows: 0% to 40% considered as not important; 30% to 60% represent
Evidence-based analysis was conducted in
moderate heterogeneity; 50% to 90% represent
this systematic review. Outcome assessment was
substantial
done by three reviewers independently, then
heterogeneity;
75%
to
100%
considered as strong heterogeneity (Duval &
discussed further into a table. Data was extracted
Tweedie, 2000) All forms of statistical tests of this
from the included studies based on following
study including heterogeneity were carried out
aspects: author and year of publication, study
using Review Manager (RevMan) v5.3.
location, study design, participants, study period,
Results
diseases, and outcomes stated in factors with its
Search results and study selection
respective odds ratio and p-value. The results of the study were stated as suboptimal and optimal
Initial search from PubMed, Scopus,
using odds ratio (p<0.05). Subsequently, factors
Wiley, and EBSCOhost using search strategy
61
mentioned above resulted a total of 1,128 studies.
chronic diseases with duration of illness >6
Among them, 9 were deduplicated, while the other
months
1,041 were excluded after screening the titles and
relationship more in number.
abstracts in terms of patients-doctor relationship
Quantitative
studies. In addition, 27 studies were excluded since
all
respective
studies
conducted
which
involved
analysis
of
doctor-patients
doctor-patients
relationship contributing to medication adherence
in
Our meta-analysis resulted that poor
emergency settings. Subsequently, 41 studies were further excluded since 4 were qualitative studies,
doctor-patients relationship was significantly
1 were non-original studies, 5 did not assess
associated with low medication adherence as it is
medication adherence, 24 did not assess OR, and
a suboptimal adherence factors and met minimum
lastly 7 were neither in English. The search yielded
requirements for meta-analysis according to
in a final ten studies, consisting of all cross-
Cochrane handbook (Higgins et al., 2011)
sectional studies to be included in qualitative and
although our study consists of studies with
quantitative synthesis.
considerable heterogeneity. This meta-analysis has also showed the cumulative fixed odds ratio of
Study characteristics and design
each study after calculated with its weight and
The data extracted and characteristics of
presented the final odd ratio of analysis with all
included studies are shown in Table 1. Overall,
respective study weight. According to this meta-
this review included a total of 7,064 subjects.
analysis, lack or poor doctor-patient relationship
Study locations varied across three continents:
decrease the odds of medication adherence in
Asia (n=4), America (n=2), Australia (n=2), and
chronic diseases patients (OR:0.74; 0.69-0.80).
Europe (n=2). Mean age of all included studies
Nevertheless, p value for the overall effect test
distributed >18 years. All studies enrolled include
(z=8.09) is p <0.00001 which shows a significant
Figure 2. Forest plot presenting relation of poor doctor-patients relationship with suboptimal medical adherence
62
Table 1. Study Characteristics Study Characteristics Studies, year
Location
Design
Participants
Range/Mean age (year)
Study Period
Cheiloudaki et al, 2019
Greece
Crosssectional
140
64.2 ± 9.0 years
Venkatesan et al, 2018
India
Crosssectional
328
>18 years
Ward et al, 2018
United States
Crosssectional
2,510
76.4 ± 6.88 years
Mahmoudian et al, 2017
Iran
Crosssectional
300
61.27 ± 9.97 years
Chou et al, 2017
Taiwan
Crosssectional
309
55.22 ± 12.71 years
Barfoed et al, 2016
Denmark
Crosssectional
1,398
NR
Mountfield et al, 2015
Australia
Crosssectional
473
50.3 years
Shigemura et al, 2010
Japan
Crosssectional
1,151
34.6 ± 7.1 years
Across 2009
Nguyen et al, 2009
United States
Crosssectional
235
41.2 ± 14.2 years
October 2005August 2007
Diseases
Factors
Odds ratio (95% CI)
P-value
November 2015-February 2016 November 2016-April 2017 2007-2008
Stroke
Doctor-patient communication
0.51 (0.351-0.74)
<0.001
Diabetes
0.303 (0.120-0.769)
0.006
0.746 (0.613-0.9079)
0.0035
August 2015September 2015 NR
Hypertension
0.16 (0.05-0.55)
0.003
0.196 (0.064-0.6003)
<0.05
November 2014December 2014 Across 2014
Hypertension
Lack of doctorpatient relationship Low overall patient perception of Physician scale Poor build off doctor-patient relationship Patient satisfaction with doctors’ barrier Lack of doctorpatient relationships
0.86 (0.77-0.96)
0.008
0.641 (0.535-0.768)
<0.001
0.65 (0.472-0.895)
0.008
0.735 (0.592-0.913)
0.003
63
Hypertension
Cancer
Inflammatory bowel disease (IBD) Depression disorder (> 2 years) IBD
Dissatisfied doctor-patients communication Negative Perceived doctorrelationship Low trust inphysician
Kerse et al, 2004
New Zealand
Crosssectional
220
41.3 Âą 15.8 years
NR
NR = Not reported
64
Chronic illnesses
Low physicianpatient doctor concordance score
0.75 (0.58-0.97)
<0.05
association between two factors. Forest plot is presented in Figure 2.
encountered poor patients-doctor relationship
Heterogeneity and sensitivity analysis
medication
have significantly decreased odds to adhere
odds to medication optimal adherence by 0.68
Those are indicating significant heterogeneity
considered
as
in
this
substantial
(0.59-0.78). Given the reduced heterogeneity in
handbook,
meta-analysis
times.
relationship was also significantly decreased their
freedom was 9, and the I-square test was 70%.
studies
(0.75-0.90)
patients which encountered poor patients-doctor
of chi-square test was 0.0005, the degree of
included
0.82
Furthermore, in another subgroup analysis, IBD
Included studies showed that the p-value
studies. According to Cochrane
by
sub-group analysis, the reason for the observed
is
heterogeneity in our study could be due to
heterogeneity.
different types of chronic diseases which may have
Moreover, sensitivity analysis using Duval and Tweedieâ&#x20AC;&#x2122;s trim-and-fill analysis revealed that one
different medications.
study is an outlier study (Barfoed, 2016). Upon
Publication Bias
removal of Barfoed et al. study on trim-and-fill
Critical appraisal was conducted using
sensitivity analysis, the outcome was OR of 0.67
STROBE for cross-sectional study criteria which
[0.61, 0.73], P < 0.00001; I2 = 51%.
were given in the appendix on the last part of this
Sub-group analyses
paper. This tool is used to assess the quality of each study with the maximum score of 22. The
In subgroup-analyses, this meta-analysis
higher STROBE score indicates the lower risk of
revealed that hypertensive patients which
Figure 3. Forest plot presenting hypertensive patients subgroup relation of poor doctorpatients relationship with suboptimal medical adherence
Figure 4. Forest plot presenting IBD patients subgroup relation of poor doctor-patients relationship with suboptimal medical adherence
65
Moreover, although the heterogeneity between studies
are
categorized
as
substantial
heterogeneity (70%), results shown a significant correlation between doctor-patients relationship and medication adherence. This could be due to various type of chronic diseases included in this study which have its own different characteristics. Sensitivity analysis also indicated one outlier study (Barfoed et al, 2016). This event could be
Figure 5. Funnel plot presenting heterogeneity
due to variability in the measurement of this study
analyses of doctor-patients relationship with
in terms of its adherence scoring as it used
suboptimal medical adherence calculated in
specialized scoring and analysis developed by
meta-analysis.
authors.
bias of the study. From our systematic review and meta-analysis, the highest STROBE score was
Association Between Doctor-patient Relationship
obtained by Barfoed et al (2016) with the score of
and Medication Adherence
21.8 and the lowest was obtained by Mahmoudian
A bad doctor-patient relationship is associated
(2017) with the score of 15.9. The average
with
STROBE score for those 10 studies is 18.277,
low
medication
adherence,
therefore
decreasing the medication efficacy. A study by
which indicated that this review included
Maguire et al stated that most of the doctors
relatively good studies. Funnel plot is presented in
surveyed were not inclined to persuade their
Figure 5. Overall, funnel plot yields a symmetrical
patients to ask questions, care about their patientâ&#x20AC;&#x2122;s
shape which indicates that included studies are
expectations, discuss their patientâ&#x20AC;&#x2122;s problem
considered as low publication bias.
together, elaborate information, and assess their patientâ&#x20AC;&#x2122;s
Discussion
perception.(Maguire,
Fairbairn,
&
Fletcher, 1986) Study by Ward, which assessed the
Doctor-patients relationship is one of the important factors associated towards medication outcome in terms of its adherence; however,
association
between
the
relationship
and
adherence
the
doctor-patient towards
antihypertensive medications, stated that more
remains neglected in health care facilities services.
than 30% of the patients admitted that they did not
This study proved that poor doctor-patient
discuss about their medications in the last 12
relationship did decrease the odds to adhere
months with their doctors. Among the non-
medication of chronic diseases patients by 0.74
adherence group due to skipping doses or non-
times, which explained the urgency of why
tolerant with the side effects, more than 25% of
medication adherence remains a major problem.
66
Figure 6. The illustration of the whole-person care concept them did not discuss this with their doctor. The
influence the patient satisfaction with their
same study also stated that patients with more
doctors, especially in geriatric patients as the
favorable perception to their doctor will be more
illness
likely
understanding, their trusting ability, and their
to
adhere
to
their
antihypertensive
medications.(Ward
&
Thomas,
have
can
influence
their
An
decision making ability.(Harbishettar, Krishna,
interesting study by Albaz in Saudi Arabia
Srinivasa, & Gowda, 2019; Li, Gong, Kong,
concluded that organizational variables (time
Mueller, & Lu, 2020) Other factors that can
spent with the doctor, doctor's continuity of
influence patient satisfaction with their doctors are
treatment, doctor's style of communication and
thorough anamnesis and the ability of the doctor to
doctor's interpersonal style) are much more
explain the disease to the patients. Thorough
important
variables
anamnesis and ability to explain are two of the
(gender, marital status, age, educational level and
indicators perceived as the attributes of a
health status) in patients' adherence. (Albaz et al.,
professional doctor, therefore increasing the
2007)
patientâ&#x20AC;&#x2122;s trust for their doctors.(Li et al., 2020)
than
2020)
they
socio-demographic
Studies have shown that a trusting doctor-
In a qualitative study by Thomas, a good
patient relationship, along with the length of
doctor-patient relationship is the foundation of the
communication between them, can significantly
whole-person care in general medical practices.
67
The concept of the whole-person care can be seen
respected. Empathy will enable the patient to share
in Figure 6. When involving a single doctor, the
their feeling and perception about their disease
base of the prism resembles the doctor-patient
therefore increasing their will to cope with their
relationship, the width and depth of the triangle
disease. Empathy also promote shared decision
resembles the ability to understand a patient in
making between the doctor and the patient,
biological, psychological, and social aspects, and
increasing the patient autonomy in managing their
the length of the prism resembles the length of the
diseases.(Wu, Zhang, Li, Liu, & Yang, 2020)
therapy. It can be inferred from the model that the
A good doctor-patient relationship is also
magnitude of the beneficial effects from a therapy
influenced by the patient’s satisfaction towards the
are influenced by those three factors. In that study,
doctor. Patients satisfaction correlates with the
which subjects are general practitioners, the
emotional response of the doctor, including eye
participants stated that a good doctor-patient
contact, empathy, and non-verbal communication.
relationship enabled them to understand their
In order to establish hope in the patient, the doctor
patients as a whole person. A trusting relationship
must implement a “positive psychiatry” approach,
between doctor and patient also enabled the doctor
which components are creating optimism, setting
to question and challenge the behaviors that might
goals,
affect the health of the patient without any
non-biased
approach,
non-judgmental
approach, and encouraging patients to change their
hesitation and promoted shared decision making
lifestyle.(Jeste, Palmer, Rettew, & Boardman,
between them. Participants also stated that a good
2015)
relationship with their patients will make them medication
Strategy in improving doctor-patient relationship
adherence.(Thomas, Best, & Mitchell, 2020) A
The overall health and success of managed care
return, therefore
increasing
the
good communication quality will increase bond,
plans depend on excellence in the medical
encourage patients to heal, and reduce the chance
interview, superior doctor–patient relationships,
of a doctor getting sued in case of unintentional
and
malpractice.(Tallman, 2007)
effective
management
of psychosocial
medical problems. Several strategies can be implemented
A study by Wu showed that patients
in
improving
doctor-patient
treated with empathic doctors showed lower IL-6
relationships that mainly include communication
level and better mental state than patients treated
skills, communication training, as well as health
by non-empathic doctors. The possible mechanism
beliefs (Ha & Longnecker, 2010). Attentive
for that is the perception of their doctor as an
listening skills, empathy, and use of open-ended
empathic person reduces their anxiety, increases
questions
self-efficacy, and promotes sleep. By showing
communication that may involve in adherence to
empathy, patients feel more loved and more
recommended therapy. (Clark et al., 2009)
68
are
some
examples
of
skillful
Communication skills may also be taught
relationship and medication adherence with the p-
for future physicians, mostly by observing their
value <0.00001 and its respective reliable OR with
seniors, teachers and mentors and then with
95% confident interval However, this meta-
practice (SabatĂŠ et al., 2003). A study by Yedidia
analysis presents several limitations. We have
et al stated that the effect of communications
included various types of chronic diseases which
training
may have different types of medication, which
on
improved
medical
student
third-year
significantly
students
overall
adds significant heterogeneity. However, Finally,
communications competence, as well as their
we included only papers published in the English
skills in relationship building, organization, time
language, which may have resulted in a lack of
management, as well as increased clinical
relevant work written in other languages.
competence. (SabatĂŠ et al., 2003; Goh et al.,
Conclusion and Recommendation
2017)
In conclusion, this systematic review and
Effective teaching of physicians will also
meta-analysis has proven that poor doctor-patients
improve physician behavior, medical outcomes, and
patient
satisfaction.
Learning
relationship is strongly associated with low
better
medication adherence in chronic diseases patients
interviewing skills, which include skills for
significantly. the application of continuous and
improving the doctor- patient relationship and for practicing
psychosocial
medicine,
can
intensive training about communication in daily
be
clinical practice is highly recommended for
accomplished by using an integrated model that
medical students, doctors, and other healthcare
teaches knowledge, skills, and attitudes together,
providers, including attentive listening skills,
by employing the learners' own problems as
empathy, use of open-ended questions, and better
motivation, and by the use of wellâ&#x20AC;&#x201C;trained
interviewing skills in terms of communication
teachers. (Ha & Longnecker, 2010). Using these
with patients which can be practiced during
approaches can improve medical interviewing
healthcare daily practices. Improvements on this
and doctor-patient relationships in a plan's
factor could increase medication adherence of
practices, improve efficiency and cut costs,
chronic diseases patients therefore decreasing the
decrease patient disenrollment, increase medical
prevalence of chronic diseases medication non-
adherence, and help retain satisfied physicians in
adherence and its adverse outcomes with higher
the practice group. (Clark et al., 2009)
costs of care.
Strength and Limitation To our knowledge, this is the first meta-analyses assessing the association between doctor-patient relationship and the adherence towards medcation. The results of this meta-analyses showed significant correlation between doctor-patients 69
Acknowledgement
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73
Appendix 1. Studies quality assessment based on STROBEâ&#x20AC;&#x2122;s criteria Item
Cheilouda ki et al
War d et al
Yes
Ven kates an et al Yes
(b) Provide in the abstract an informative and balanced summary of what was done and what was found
Yes
No Title and abstract
1
Recommendation (a) Indicate the studyâ&#x20AC;&#x2122;s design with a commonly used term in the title or the abstract
Cho u et al
Barf oed et al
No
Mah mou dian et al Yes
Shig emu ra et al Yes
Ngu yen et al
Kers e et al
Yes
Mou ntfiel d et al Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Introduction Background/rati onale
2
Explain the scientific background and rationale for the investigation being reported
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Objectives
3
State specific objectives, including any prespecified hypotheses
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Methods Study design
4
Present key elements of study design early in the paper
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Setting
5
Describe the setting, locations, and relevant dates, including periods of recruitment, exposure,
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
74
follow-up, and data collection Participants
6
(a) Give the eligibility criteria, and the sources and methods of selection of participants
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Variables
7
Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Data sources/ measurement
8*
For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Bias
9
Describe any efforts to address potential sources of bias
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Study size
10
Explain how the study size was arrived at
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Quantitative variables
11
Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
75
Statistical methods
Results Participants
12
13*
(a) Describe all statistical methods, including those used to control for confounding
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
(b) Describe any methods used to examine subgroups and interactions
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
(c) Explain how missing data were addressed
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
(d) If applicable, describe analytical methods taking account of sampling strategy
Yes
N/A
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
(e) Describe any sensitivity analyses
No
No
Yes
No
No
No
No
No
Yes
No
(a) Report numbers of individuals at each stage of studyâ&#x20AC;&#x201D;eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
(b) Give reasons for nonparticipation at each stage
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
(c) Consider use of a flow diagram
No
Yes
Yes
No
No
Yes
No
No
No
Yes
76
Descriptive data
14*
(a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
(b) Indicate number of participants with missing data for each variable of interest
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Outcome data
15*
Report numbers of outcome events or summary measures
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Main results
16
(a) Give unadjusted estimates and, if applicable, confounderadjusted estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
(b) Report category boundaries when continuous variables were categorized
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Report other analyses doneâ&#x20AC;&#x201D;eg analyses of
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Other analyses
17
77
subgroups and interactions, and sensitivity analyses Discussion Key results
18
Summarise key results with reference to study objectives
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Limitations
19
Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Interpretation
20
Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Generalisability
21
Discuss the generalisability (external validity) of the study results
No
No
Yes
No
No
Yes
Yes
No
Yes
Yes
Other information
78
Funding
22
Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based TOTAL
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
19.50
17
20
15.9
16.47
21.8
17.6
16.1
19.2
19.2
*Give information separately for exposed and unexposed groups. Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
79
PCC EAMSC MANILA 2021
THE IMPACT OF COMMUNICATION SUPPORT BETWEEN HEALTH CARE PROFESSIONALS WITH END-OF-LIFE CARE PATIENTâ&#x20AC;&#x2122;S FAMILY ON THE PRESSURE FELT BY THE FAMILY: A SYSTEMATIC REVIEW OF CURRENT RANDOMIZEDCONTROLLED TRIALS
Authors: Ketut Shri Satya Wiwekananda (21269) Kadek Egadia Calisto
(21268)
Rizqiko Pandai Hamukti
(21286)
Ketut Shri Satya Yogananda
(21270)
AMSA-UNIVERSITAS GADJAH MADA 2020
81
ABSTRACT Introduction: In the end-of-life (EoL) care settings, health-care professionals (HCPs) use communication as one of the main tools to achieve the treatment goals. However, there are several factors and problems that must be faced in this EoL care settings, especially from the patient's family. Therefore, this study aimed to describe and discuss the influence of communication support carried out by HCPs to the patient's family in EoL care settings. Method: A systematic review was conducted in four databases, e.g., PubMed, ProQuest, Cochrane Library, and EBSCOhost using PRISMA-P model. A total of 510 records were obtained in the preliminary search, and finally a total of 11 studies were included. This review used a critical appraisal checklist from the Joanna Briggs Institute's critical appraisal tool. Results & Discussion: A total of 6 studies showed positive results (reduced burden felt by families) from communication support between HCPs and EoL patientâ&#x20AC;&#x2122;s families, while the other 5 studies showed negative results (no decrease in the burden felt by families). The relationship between the characteristics of communication support provided with the impact on the family could be described from the literature. The characteristics of communication support that have a positive impact was different from that which have negative impact. Conclusion: Communication support interventions on family members of EoL care patients have a positive and negative impact depending on the characteristics of the communication support given. This study could be used for further research to improve the quality of communication in EoL care that is required.
82
PCC EAMSC MANILA 2021
THE IMPACT OF COMMUNICATION SUPPORT BETWEEN HEALTH CARE PROFESSIONALS WITH END-OF-LIFE CARE PATIENTâ&#x20AC;&#x2122;S FAMILY ON THE PRESSURE FELT BY THE FAMILY: A SYSTEMATIC REVIEW OF CURRENT RANDOMIZEDCONTROLLED TRIALS
Authors: Ketut Shri Satya Wiwekananda (21269) Kadek Egadia Calisto
(21268)
Rizqiko Pandai Hamukti
(21286)
Ketut Shri Satya Yogananda
(21270)
AMSA-UNIVERSITAS GADJAH MADA 2020
83
A. INTRODUCTION Health-care professionals (HCPs) communication skills are one of the most important components of their job. Good and effective exchange of information between HCPs and patients helps them see what others are thinking and how they are feeling. It used to be believed that the job of HCPs was simply to make a correct diagnosis by focusing only on the symptoms and relieve patient complaints by administering the right medication. They decided the treatment without even asking the opinion of the patient and accompanying family. The HCP did not need to communicate with the patient, asking how they feel or what they think about the whole procedure (Markides, 2011). However, we now know that things are not that simple. Patients are not machines that just need to be repaired and, in several condition, patients do not come alone but also come with their families where the family also plays an important role in decision making (Alden, 2018). The modern perspective emphasizes that the HCPs, the patient, and the accompanying patient's family need to work together as a team. This suggests that HCPs communication skills are strongly associated with satisfaction, decision making, treatment, and clinical outcomes in many clinical settings (Doyle, Lennox, & Bell, 2013). One example of clinical situations related to communication skills are in the end-oflife (EoL) care settings. EoL care is a treatment for EoL patients and also their families who have to accept the situation that one of their family members will die. The number or prevalence of EoL care is not small with an estimate that each year there are 40 million individuals who need EoL care, with 78% of this total coming from low- and middle-income countries (World Health Organization, 2020). EoL care is an approach that improves the quality of life of EoL patients who are facing life-threatening diseases and the families of patients who will be left behind. EoL care aims to prevent and reduce suffering through early identification, correct assessment, and treatment of pain and other problems whether physical, psychosocial, or spiritual (Odgers, Penney & Shee, 2018). In addition, EoL care also aims to help EoL patients live as actively as possible and help the patient's family readiness in various conditions. EoL care uses a team approach to support patients and their families. The forms of EoL care that are commonly used are discussion, advance care planning, and counseling (Bischoff et al., 2013; Gamino, 2016). From these forms of EoL care we know that communication is the main tool used by HCPs to achieve the goals of EoL care. In EoL care settings, several problems can be encountered especially those arising from the patient's family. When a patient is diagnosed with EoL, there will be sudden life changes that trigger several symptoms. Not only the patient's life, the life of family members and loved ones can also change. The visible changes include physical, psychological, and social (Benkel,
84
Wijk, & Molander, 2014). The patient may exhibit emotional problems such as sadness, anxiety, fear, depression, as well as physical problems such as fatigue that can affect the patient's family (Lee, 2005). Besides, when EoL care is carried out, family members must face new challenges that have the potential to exceed their ability to adapt in several factors, including financial factors, changes in family roles, and changes in the overall health condition of other family members (Hwang, 2000). These problems can lead to family dysfunction if family members are not properly prepared physically, emotionally, and economically. The family in this EoL care settings plays an important role as a caregiver and decision maker of the steps or procedures to be carried out (Yoo, Lee, & Chang, 2008). Therefore, with the combination of the above problems, in this EoL care settings, there can be a failure in decision making due to many factors to consider such as financial, patient and family psychological, and physical condition. This indicates that the role of HCPs is to become active participants and even leaders in facilitating family communication about EoL care (Omilion-Hodges, & Swords, 2017). With the existence of several potential problems that have been described and the goals to be achieved in EoL care settings, the communication carried out by HCPs to the patient's family is essential to be reviewed and given full attention. There is a demand to understand whether the communication that HCPs brought to the patient's family had a positive or negative impact on the patientâ&#x20AC;&#x2122;s family, the characteristic of communication support that influence these positive and negative results, and the effective communication approaches in the EoL care settings. Therefore, this study aimed to describe and discuss the influence of communication support carried out by health-care professionals to the patient's family in end-of-life care settings.
B. METHOD a. Data Collection Technique A systematic review was conducted to answer the research question above. Systematic review is capable of obtaining best evidence related to the research questions objectively. Systematic review is among research methodologies that possess high level of evidence (Burns, Rohrich, & Chung, 2011). This study applied PRISMA-P model (Shamseer, et al., 2015) to allow systematic and comprehensive literature search. Search Strategy A rigorous literature search was conducted in four databases, e.g., PubMed, ProQuest, Cochrane Library, and EBSCOhost. A set of keywords were used to find articles that
85
discuss the impact of health care professional communication with end-of-life care patient’s family on the distress felt by the bereaved family, for instance: ("end of life" OR palliative OR “intensive care unit”) AND (family OR caregiver OR "loved ones") AND (impact OR effect OR outcome) AND (discussion OR conversation OR communication OR facilitator) AND (anxiety OR stress OR depression OR "decisional conflict" OR satisfaction) AND ("randomised trial" OR "randomised controlled trial" OR "randomised clinical trial" OR "randomized controlled trial" OR "randomized trial"). Study Selection The included studies fulfilled several inclusion criteria. The object of studies must be about the family of the end-of-life care patient's; the intervention must be related to communication between the health care professional and the patient's family; the studies should be in the form of randomized controlled trials; and the aim of the research should be related to the pressure the bereaved family felt after the intervention. This review included randomized controlled trials (RCTs) only to minimize risk-of-bias since RCTs allow randomization and accurate comparison (Pati & Lorusso, 2017). The study would be excluded if the studies are not written in English; was inaccessible; and published later than 5 years ago. The authors applied a considerable time limit to find the most relevant studies. Risk of Bias Assessment This review assigned two reviewers to evaluate all included studies independently. This method was considered as reviewer triangulation, to avoid reviewer bias (Carter, Bryantlukosius, Dicenso, Blythe, & Nevile, 2014). Both reviewers also evaluate the journals using a critical appraisal checklist from the Joanna Briggs Institute's critical appraisal tools, a validated quality appraisal tool that consists of 13 criteria (The Joanna Briggs Institute, 2020). If in the journals there was an explanation of the criteria requested from the appraisal tools and these criteria are fulfilled, then 1 point is added for each of these criteria. When the total is ≥ 10 points, it was assessed as high quality and then the journal was included in data extraction and synthesis. b. Data Analysis Data from included studies were then extracted to obtain data about the impact of studies intervention toward the bereaved family. Subsequently, obtained data were analyzed using descriptive statistical methods. To summarize the results of each journal, the authors classified the studies into 2 groups based on the results. The first group was the studies group that showed positive results (reduced the burden felt by the bereaved family after the intervention). While the second group was the studies group that showed negative
86
results (did not significantly reduce the burden felt by the bereaved family after the intervention). In the discussion section, the causes of differences in the study results would be discussed so that the solution could be found to maximize the positive impact of the communication support provided by HCPs on the EoL patient's family. c. Literature Search Timeframe The literature search was conducted from September to October 2020. C. RESULTS AND DISCUSSION RESULTS a. Study Search Results The literature search and selection process are illustrated in Figure 1. A total of 510 articles were retrieved from four databases, 432 articles were screened based on inclusion and exclusion criteria after the duplicate has been removed. Subsequently, 30 full-text articles were screened for eligibility. Finally, 11 studies were included and analyzed in this paper, which met all of the inclusion criteria. b. Risk of Bias Assessment A total of 11 studies were collected using a randomized controlled trial method. The assessment of each study was carried out using appropriate appraisal tools for each research method. The results of the study assessment show that all studies are included as high quality. Table 1 (in appendix) shows critical appraisal results on studies using Joanna Briggs Institute's Critical assessment tools. c. Characteristics of Included Studies All studies obtained come from developed countries. The object of all these studies were the family of EoL care patients, while several studies also use patients as study objects. The general inclusion criteria of the studies that have been obtained are patients who are currently in EoL care with families who can speak the national language of the study location and were over 18 years of age. The length of follow-up time span from 5 days to 6 months. Outcomes measured from the obtained studies generally include the level of anxiety and depression in the family; level of satisfaction with EoL care services; level of communication quality; and reduced or increased conflict in patient care decision making. Table 2 (in appendix) shows the characteristics of the obtained studies in more detail and concise.
87
Figure 1. Literature Search and Selection Process b. Characteristics of Study Interventions Communication support intervention carried out from the studies obtained generally describes support in the form of communication between families of patients with HCPs, discussion forums for family led by HCPs, made a list of questions to facilitate families formulating questions on HCPs, as well as mental support provided to families. The timing of the interventions varied considerably from the studies obtained. Table. 3 shows the details of the interventions carried out from the studies obtained in a concise and detailed manner. c. Outcomes The author managed to collect 11 articles related to the topic discussed. The number of family members included from the 11 studies was 2,803. There are 6 studies that show positive results (reduced burden felt by families) from communication support interventions between HCPs and EoL patient families, while there are 5 studies that show negative results (no decrease in the burden felt by families) from communication support interventions between HCPs with the EoL patient's family.
88
Table 3. Intervention Characteristics of Included Studies Study
Curtis et al., 2016
Brazil et al., 2017
Communication support intervention
Control group
Used a communication facilitator to increase familiesâ&#x20AC;&#x2122; and Usual care only
Timing Every three months
cliniciansâ&#x20AC;&#x2122; self-efficacy expectations about communication in the ICU. Usual care with ACP intervention that included a trained Usual care only
Meeting for an average of 60
ACP facilitator, family education, family meetings,
minutes.
documentation of advance care plan decisions, and orientation of general practitioners (GPs) and nursing home staff
Chan et al., 2018
Houben et al., 2019
Home visits with advance care planning program was Home visits which mimics the administered by a trained nurse
Three times a week
inactive components in the intervention
Usual care with 1.5 hours structured nurse-led ACP- Usual care only
Conducted in one time that was
session.
conducted 4 weeks after discharge from the hospital with 1,5 hours in duration.
89
McDonald et
Standard palliative care with standard oncological care.
Standard oncological care only
support after a week of follow up.
al., 2016
Kissane et al., 2016
Monthly follow up, 24-h telephone
Standard care with 6 or 10 sessions of Family-Focused Standard care only
Once per week for the first two
Grief Therapy (FFGT).
meetings, then 2 weeks later, 1 month later, 2 months later, and 3 months later for the final session.
Johnson et al., 2018
Skorstengaard et al., 2019
White et al., 2018
The intervention was delivered in a structured meeting Usual care only
Every 2 weeks
between the patient, their family members and the ACP facilitator, Support communication using advance care planning Usual care only
Every 2 weeks, with 45 minutes
(APC) and usual care.
duration.
The trained nurses met with family according to a Usual care only
Clinicianâ&#x20AC;&#x201C;family meetings within 48
standardized
hours after enrollment and every 5
protocol;
intensive
support
for
implementation was provided to each ICU by a quality-
to 7 days thereafter.
improvement specialist, to incorporate the family-support pathway into cliniciansâ&#x20AC;&#x2122; workflow.
90
Carson et al., 2016
Azoulay et al., 2018
Support and information team clinicians conducted pre Provision of an informational
The first and second support and
meetings with ICU physicians; at least 2 structured family brochure and routine family meetings
information team meetings were
meetings led by palliative care specialists; and provision of conducted by ICU teams
separated by 10 days, targeting 2
an informational brochure.
key time points.
In the intervention group, the list of 21 questions was No list of question handed
Health care staff members were
handed to the relative who provided informed consent
encouraged to answer all questions
immediately after randomization.
asked by any of the relatives every day and during a formal conference held on day 3.
91
Studies with Positive Results A total of 6 of 11 studies (54.5%) showed positive results, with a total of 1,044 participating family members. A study conducted by Curtis et al. (2016) showed that facilitating communication between families of patients with HCPs and communication facilitators can reduce the level of depression of family members after 6 months compared to the control group as well as shorten the family stay in the hospital which shows increased family trust in HCPs. Interventions in the form of communication support between the patient's family and HCPs through discussions in advance care planning (ACP) are proven to be able to reduce the occurrence of conflicts between family members in making decisions regarding the care to be carried out so as to reduce doubts in making decisions (Chan et al., 2018; Brazil et al.., 2018); and able to reduce the level of anxiety and depression in the family significantly compared to the control group (Houben et al., 2019). A study conducted by McDonald et al., Showed that consultation and monthly follow-up from the palliative care team increased patient family satisfaction thereby reducing depression, anxiety, and stress levels in the patient's family compared to the control group (McDonald et al., 2018). In addition, conducting a family meeting in the form of FamilyFocused Grief Therapy significantly reduces distress, optimizes the adaptation process, and reduces the level of depression during mourning for family members left by patients after undergoing palliative care (Kissane et al., 2016). In general, interventions that increase communication between HCPs and the families of EoL patients can reduce levels of depression, anxiety, increase confidence in HCPs, and help families determine the treatment to be carried out. Studies with Negative Results A sum of 5 of 11 studies (45.5%) showed negative results, with a total of 1,759 participating family members. The study obtained shows that the communication support intervention in the form of advance care planning (ACP) does not significantly affect the anxiety and depression felt by the patient's family and also does not significantly increase family satisfaction with EoL care compared to the control group given usual care (Johnson et al., 2018; Skorstengaard et al., 2019). A study conducted by White et al., Showed that the intervention in the form of communication support provided by interprofessional HCPs to the patient's family did not significantly reduce the psychological burden on the family, but was shown to shorten the length of stay of the family and communication quality, indicating increased trust in HCPs compared to the control group (White et al., 2018). A study by Carson et al. (2016) suggested that communication support through meetings with families led by palliative care experts does not show a significant reduction in anxiety and
92
depression compared to the control group who holds family meetings only with their primary health team. A study conducted by Azoulay et al. (2008) reported that communication support through the creation of a list of questions to be asked by families to HCPs did not significantly affect the level of satisfaction and depression of the patient's family compared to the control group. In general, several interventions to improve communication between families and HCPs did not reduce anxiety, depression, and satisfaction with EoL care. However, communication support between HCPs and their families is still able to increase the trust of families to HCPs. DISCUSSION The studies that have obtained have had a result of positive and negative impact on EoL patient's family condition. The relationship between the characteristics of communication support interventions provided with the impact on the family could be seen. Therefore, the characteristics of communication support interventions that cause positive and negative impact of communication support on the EoL patient's family are described in this section based on the articles from the results section and other supporting articles. So that the authors can find optimal communication support interventions for EoL patientâ&#x20AC;&#x2122;s families. a. Characteristics of communication support interventions that have positive impacts on families 1. The use of facilitators The studies conducted by Curtis et al. (2016), Brazil et al. (2017), and Chan et al. (2018) showed positive results in improving decision making and the psychological condition of the patient's family as the effect of using facilitators. The facilitator is considered to have a role in connecting the communication gap between EoL patients with family. The study conducted by Chan et al. (2018) also added that nurse as the facilitator is better used in this EoL care setting. This happens because nurses are considered to have more contact with both patients and patientâ&#x20AC;&#x2122;s families (Izumi, 2017). In a study conducted by Brazil et al. (2017), also added that a better implemented facilitator is a facilitator who has already carried out training with an ACP setting, so that it is more suitable for EoL patient care. 2. The duration of EoL care was more than 6 months The longer of the EoL care is carried out, the more significant positive impact for the patient's family will be, compared to the EoL treatment that is carried out in a shorter time. In the study conducted by Curtis et al. (2016), a significant improvement
93
on EoL patientâ&#x20AC;&#x2122;s family psychological condition was found when EoL care had been carried out for 6 months, while when EoL care had only been carried out for 3 months it did not show any significant improvement. 3. High-frequency family meetings More frequency of planned family meetings, the better impact on reducing the level of distress and depression experienced by the patient's family. Based on a study conducted by Kissane et al. (2016), family meetings that were held in 10 sessions turned out to have a more significant impact in reducing distress and depression than family meetings which were held in 6 sessions. 4. The involvement of trained HCP experts HCPs with specific expertise in their fields who have undergone training on ACP including effective communication and procedures for conducting structuredACP have a positive effect in reducing anxiety of patients and their families. In a study conducted by Houben et al. (2018), ACP discussions with COPD patients led by trained respiratory nurse specialists make patients and their families feel more comfortable and confident when discussing EoL care. Doctors with effective ACP communication skills who perform ACP with patients and their families indicate topics of discussion that suit their needs. In addition, based on the study of McDonald et al. (2016), the ability of doctors to assess patient's symptoms and availability of nurses to the family are important factors for family satisfaction with EoL care. 5. A structured family meeting Based on a study conducted by Hudson et al. (2019), structured family meetings show a decrease in anxiety of the patient's family. EoL care discussion which is mediated by structured family meetings according to its procedures and guidelines can improve family-patient-team communication in palliative care inpatient settings (Cahill, Lobb, Sanderson, & Phillips, 2017). b. Characteristics of communication support interventions that have negative impacts on families 1. Redundancy in communication support A study conducted by Carson et al., were using interventions in the form of communication support from the primary health team and palliative care experts for the intervention group, and communication support from the primary health team only
94
for the control group. The communication support that is provided by the primary health team has sufficient information for family desires. Additional communication activities discuss about the prognosis that has been discussed with primary health team is unlikely to help the family and is likely to cause disappointment from depressed families, even when emotional support is also provided (Carson et al., 2016). 2. Less communication with primary health team In a study conducted by Carson et al., stated that decreasing direct participation from primary health team because it is replaced by intervention from support teams (such as palliative specialists) can reduce the suitability of communication with families. So that it will reduce the positive effects of the meeting between a patient's family with HCPs (Carson et al., 2016). 3. The use of question list restricted communication support In a study conducted by Azoulay et al., it was stated that communication support through a questions list has an insignificant result for the patient's family because it limits the patientâ&#x20AC;&#x2122;s family questions. This list prevents families from getting more time to ask questions and also explore more questions (Azoulay et al., 2018). 4. The intervention was not tailored to each type of diseases In a study conducted by Skorstengaard et al., the same communication support intensity for families of patients with malignant disease will be more difficult to get the positive effects than the families of patients with non-malignant diseases (Skorstengaard et al., 2019). It can be seen that the intensity of the communication support for the patient's family must be adjusted to the type of disease suffered by the patient. Therefore, families of the patients with malignant disease need more intense family support than families of the patients with non-malignant diseases. 5. Offering life expectancy was not based on the patient's wishes This is one of the characteristics that causes patients not to be interested in discussing end of life through ACP with family and HCPs. This issue should be delivered due regard to the wishes of the patient. Based on a study conducted by Johnson et al., the disclosure of life expectancy information was a factor causing reluctance on both the HCPs side and the patient, which patients did not expect to receive the life expectancy information. (Johnson et al., 2018).
95
6. Suboptimal timing of the conversations Suboptimal timing of the conversations means that the end-of-life conversations performed at inappropriate times, which is the conversion regarding the end of life was carried out by 5.5 months before the patient's death. End-of-life conversations performed at inappropriate times may be a factor for patients becoming unwilling to have ACP discussions with family and HCPs (Johnson et al., 2018). 7. Have had a medical wishes discussion before According to the journal by Johnson et al., and Jones et al., patients who already discussed their medical wishes, can be less satisfied with the overall treatment that was carried out, if the treatment doesnâ&#x20AC;&#x2122;t comply with their wishes. This causes the mental wellbeing of the patient to be worse in the ACP treatment than in the usual treatment (Johnson et al., 2018; Jones et al., 2011) 8. Discontinuation of intervention after discharged from intensive care The patient's family support intervention that was performed only while the patient was in the ICU had no effect on the long-term psychological burden of the patientâ&#x20AC;&#x2122;s families or surrogate. In fact, after the patient has been discharged from the ICU, the patient's family or surrogate could experience psychological stress, such as mourning, financial difficulties, and demands for care (White et al., 2018; Hebert, Prigerson, Schulz & Arnold, 2006). Strengths and Limitation of The Study The strength of this study is that there are no systematic review that discussed the topic about impact of communication between HCPs and the family of EoL patients in less than 5 years before, this systematic review also discussed the characteristic of communication support that has a positive or negative impact on the family of EoL patient that can help to designing the optimum communication support intervention. This study has several limitations namely all studies with methods other than randomized controlled trials were excluded to decrease study bias and find reliable result (Olofsgďż˝ rd, 2014); communication support interventions given to EoL patients, and their impact on patients were not discussed in this study. D. CONCLUSION AND RECOMMENDATION This review found that communication support interventions on family members of EoL care patients might have both positive (reduce the burden on the family) and negative (did not have an impact on reducing the burden on the family) impacts depending on the characteristics of the communication support given. Health-care professionals should endeavor more on
96
positive communication attributes; such as involving facilitators, optimal engagement duration, high-frequency family meeting, involving trained HCP experts, and structured family meeting. Ineffective attributes, namely redundancy in communication support, less communication with primary health team, the use of an inappropriate question list, offering life expectancy, suboptimal timing, disregarding previous medical wishes discussion, and unsustainable support, should be avoided to mitigate rejections, disappointments and distress among patients and their family members. Hence, communication support carried out by health-care professionals should include all of the effective attributes and minimize the ineffective attributes above. Furthermore, this study recommends further research on the impact of communication support to the families of EoL care patients using communication support interventions that are in accordance with the characteristics of positive communication support interventions. Hence, the optimum communication support intervention models for EoL care patientsâ&#x20AC;&#x2122; family can be proposed in the future. There is also a need to investigate the impact of different culture to the communication approaches in EoL care. Authors also offer authorities to implement the review results for managing communication supports by health professionals in EoL care settings. E. ACKNOWLEDGEMENT Authors thank to dr. Prattama Santoso Utomo, MHPEd (Gadjah Mada University) for the willing to give us suggestion and review to our study. This study did not receive specific grants from funding agencies in the public sector, commercial, or non-profit sector.
97
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Appendix Table. 1 Critical Appraisal Results Carson
White
Houben
Chan
Azoulay
Curtis
Johnson
Brazil
Skorsteng
McDonal
Kissane
et al.,
et al.,
et al.,
et al.,
et al.,
et al.,
et al.,
et al.,
aard et
d et al.,
et al.,
2016
2018
2019
2018
2018
2016
2018
2017
al., 2019
2016
2016
1
1
1
1
1
1
1
1
1
1
1
Was allocation to treatment groups concealed?
1
1
1
1
1
1
1
1
1
1
1
Were treatment groups similar at the baseline?
1
1
1
1
1
1
1
1
1
1
1
Were participants blind to treatment assignment?
0
0
0
0
0
0
0
0
0
0
0
Were those delivering treatment blind to treatment
0
0
0
0
0
0
0
0
0
0
0
Were outcomes assessors blind to treatment assignment?
1
1
0
1
1
0
1
0
0
0
1
Were treatment groups treated identically other than the
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Was true randomization used for assignment of participants to treatment groups?
assignment?
intervention of interest? Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?
102
Were participants analyzed in the groups to which they
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Were outcomes measured in a reliable way?
1
1
1
1
1
1
1
1
1
1
1
Was appropriate statistical analysis used?
1
1
1
1
1
1
1
1
1
1
1
Was the trial design appropriate, and any deviations from
1
1
1
1
1
1
1
1
1
1
1
11
11
10
11
11
10
11
10
10
10
11
were randomized? Were outcomes measured in the same way for treatment groups?
the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?
TOTAL
103
Table 2. Characteristics of Included Studies Study
Location
Inclusion criteria
Sample
Planned
size
follow-
Measured outcome
up
Curtis et al., 2016
Washington,
Family members included if age >18, able to complete consent process, and I = 78
United States
questionnaires in English, and have a family member who are in the ICU with
of America
criteria: in ICU for >24 hours; age >18; mechanically ventilated at enrollment;
1 month
symptoms of depression; anxiety; posttraumatic stress disorder (PTSD); length
C =60
of stay, and costs of care.
Sequential Organ Failure Assessment (SOFA) score >6 or diagnostic criteria predicting a >30% risk of hospital mortality; and legal surrogate decision-maker to consent for patient participation
Brazil et al., 2017
Northern
Family members most responsible for the care of relatives classified as having I = 61
Ireland,
dementia and assessed as having no decision capacity to complete ACP were
United
identified as study participants.
Kingdom.
C = 98
6 weeks
Awareness benefits and risks; perceived level of support in decision-making; respondentâ&#x20AC;&#x2122;s degree of confidence about the decision; satisfaction with the decision; family satisfaction measured by Family Perceptions of Care Scale (FPCS).
104
Chan et
Hong Kong
al., 2018
Patients from family members meeting one of the three triggers in the screening I = 115
6
The congruence between patients’ end-
tool (“Surprise Question”; general indicators of health deterioration; and specific
months
of-life care preferences and those
clinical indicators of cancer); were at least 18 years of age, were mentally
C = 115
predicted by the nominated fa- mily
competent, could communicate in Cantonese and lived at home. Patients who
member; patient’s decisional conflict
were eligible to the study and interested in the study were invited to nominate a
regarding end-of-life decision-making;
family member who would be involved in their end-of-life decision making.
and the presence of documentation of the end-of-life care preferences in medical records.
Houben et
Netherlands
al., 2019
Patients with advanced COPD (Global initiative for chronic Obstructive Lung I = 89
6
Quality of end-of-life care
Disease stage III, IV or quadrant D with a modified Medical Research Council
months
communication was assessed using the
(mMRC) dyspnea grade ≥2) discharged after a hospital admission for an acute
C = 76
end-of-life subscale of the QOC
COPD exacerbation. Patients were asked to identify one to four loved ones for
questionnaire; changes in symptoms of
participation in the study. Exclusion criteria were: unable to complete
anxiety and depression of patients and
questionnaires because of cognitive impairment or unable to speak and/or
loved ones; quality of death and dying.
understand Dutch.
McDonal d et al., 2016
Toronto,
Eligible patients had stage IV cancer (those with breast and prostate cancer had I = 94
4
Satisfaction with care and QoL assessed
Canada
hormone-refractory disease), or stage III advanced cancer with poor prognosis;
months
with FAMCARE scale; caregiver
an Eastern Cooperative Oncology Group (ECOG) performance status of 0–2; a clinical prognosis of 6–24 months (prognosis and ECOG were determined by the
105
C = 88
satisfaction with information giving, availability of care, and psychological
patient’s primary medical oncologist); and passed a cognitive screen (Short
and physical care of the advanced cancer
Orientation-Memory-Concentration test >20 or<10 errors). Each patient was
patient and caregiver; physical
asked to identify their primary caregiver from the family, who was approached
component score (PCS) and a mental
with the patient’s consent. Patients or caregivers were excluded if they were
component score (MCS).
under 18 years old or had insufficient English literacy.
Kissane et al., 2016
Memorial
Patients with a survival prognosis of less than 1 year (on the basis of judgment I (10
13
Complicated Grief Inventory (CGI) and
Sloan
of the treating oncologist) and their relatives for individual perceptions of session) =
months
the Beck Depression Inventory II (BDI).
Kettering
relational functioning using the Family Relationships Index (FRI). Eligibility 56 families
Cancer
criteria were perception by one family member of reduced relational functioning,
Center,
defined by an FRI of ≤ 9 out of 12 or a cohesion subscale < 4; geographic
Calvary Hospital,
accessibility to treatment; children age 12 years or older who were able to I (6 complete questionnaires; and willingness of at least three family members, session) =
Visiting
including the patient with cancer, to attend therapy.
59 families
Nursing Service of
C = 55
New York,
families
and Beth Israel Hospice Service
106
Johnson et al., 2018
Metropolitan
Family Member (FM) that has been nominated by the patient with eligibility I = 53
oncology
criteria included: age ≥ 18 years, diagnosis of incurable cancer, expected
centers in
survival time of 3–12 months (as estimated by the treating oncologist), prior
Victoria and
systemic anticancer therapy, and ability to complete questionnaires and have an
New South Wales,
6 weeks
Family perception that the patient’s wishes were discussed, and met;
C = 63
concordance between documented patient preferences for EoL care and care received at the EoL.
ACP conversation in English.
Australia
Skorsteng aard et al., 2019
Vejle
Patients have relatives; were above 18 years old; were able to speak and I = 79
4-5
Symptoms of anxiety and depression
Hospital,
understand Danish; were not expected to die within 1 month; cognitively able to
weeks
using Symptom Checklist, 92-item
Denmark
participate in the conversation.
C = 88
version (SCL-92); relatives’ satisfaction was measured using the 19-item FAMCARE scale.
White et al., 2018
Pittsburgh,
Ill family member aged 18 years or older; a lack of decision-making capacity; at I = 308
6
Surrogates’ mean score on the Hospital
Pennsylvania
least one of the following clinical characteristics: receipt of mechanical
months
Anxiety and Depression Scale (HADS);
ventilation for at least 4 consecutive days, an estimated chance of death during
C = 501
surrogates’ mean scores on the Impact of
hospitalization of at least 40% as judged by the patient’s attending physician, or
Event Scale (IES); the Quality of
an estimated chance of severe long-term functional impairment of at least 40%
Communication (QOC) scale; as well as
as judged by the patient’s attending physician.
the mean length of ICU stay.
Patients who did not have a surrogate decision-maker or were receiving only comfort-focused treatment at the time that they were eligible for enrollment, and
107
surrogates who were younger than 18 years old or were unable to read or understand English were excluded. Surrogate decision-makers were chosen from the family.
Carson et al., 2016
Northeastern
Patients from family members aged 21 years or older treated in medical ICUs I = 184
United State;
were eligible if they required at least 7 days of mechanical ventilation
Southeastern
uninterrupted for 96 hours or longer and were not expected to be weaned or to
United State
die within 72 hours. For the first year of the study, patients were eligible if they
90 days
C = 181
Hospital Anxiety and Depression Scale (HADS) symptom score; Impact of Event Scale-Revised (IES-R)
required at least 10 days of mechanical ventilation; not mechanically ventilated at an outside hospital for longer than 7 days or had chronic neuromuscular disease, trauma, or burns; surrogate decision maker was available and good English proficiency; the primary physician not refused to grant permission to investigators to approach the patient or family..
Azoulay et al., 2018
France
Patients were eligible if they received invasive mechanical ventilation within 48 I = 148 hours after ICU admission, were at least 18 years of age, received at least one family visit within 24 h following intubation, had a SAPS-II score less than 75,
C =154
5 days
Family comprehension on day 5; satisfaction (Critical Care Family Needs Inventory, CCFNI); and symptoms of
and were expected to survive for at least 5 days. For each patient, a single relative
anxiety and depression (Hospital Anxiety
(the designated health is proxy) was included. Relatives were eligible if they
and Depression Scale, HADS).
could speak and read French.
108
Communication in mechanically-ventilated patients: systematic review of current practices Andi Muhammad Zharfan, Arief Abdurrazaq Dharma, Dhiya Muthiah Gaffari, Richard Holman Matanta Medical Student, Faculty of Medicine Universitas Hasanuddin, Makassar, Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association Universitas Hasanuddin Introduction: Mechanically ventilated patients often find difficulties with communication. Behaviors such as nodding, gestures, and eye blinking may often not reliable, and can be misinterpreted. There are various kinds of communication aids from low to high technology. Objective: This review aimed to summarizes the available modes of communication for patients with mechanical ventilation. Methods: We used five searching tools including PubMed, NIH Clinical Trials, Directory of Open Access Journal, Epistemonikos, and ScienceDirect. We created a flow of study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) and assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Results: We reviewed 19 studies, then distinguished several communication intervention types which are: Augmented Alternative Communication (AAC) (n=9), Electrolarynx (n=3), Modified tracheostomy (n=5), and Multiple Intervention (n=2). For the most part, research results have improved communication using alternatives. Studies were considered moderate with QATSDD. Review of current literature returns a wide array of communication strategies to communicate with mechanically ventilated patients. These treatment options will be expected to improve the quality of care for the patients and family, as well as to relieve the communication barriers experienced by healthcare providers. However, more well-controlled and systematic studies are needed before these strategies can be implemented widely. Conclusion: Numerous communication alternatives for patients undergoing mechanical ventilation are presented in this study. However, further studies assessing the benefits of these treatments are needed in order for these choices to be implemented in respective healthcare facilities. Keywords: Mechanical ventilation, Communication intervention, Communication tools, Communication method.
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Communication in mechanically-ventilated patients: systematic review of current practices
Author: Andi Muhammad Zharfan Arief Abdurrazaq Dharma Dhiya Muthiah Gaffari Richard Holman Matanta
Medical Student, Faculty of Medicine Universitas Hasanuddin Asian Medical Studentsâ&#x20AC;&#x2122; Association Universitas Hasanuddin 2020
110
Methods Four reviewers (A.A, A.M, R.H, dan D.M) conducted systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA). The reviewers conducted a search on five onlinedatabase PubMed, NIH Clinical Trials, Directory of Open Access Journal (DOAJ), Epistemonikos, and ScienceDirect using queries as follow: ““communication intervention” OR “communication tools” OR “communication method”” AND “mechanical ventilation” AND “clinical trial”.
Introduction Mechanical ventilation is an artificial ventilation that have goals to provide adequate oxygenation and alveolar ventilation (Hess et al., 2011). Mechanical ventilation is one of the common interventions received by patients to maintain their condition and the necessity of mechanical ventilation will increase proportionally in line with the need of hospitalization in the future(Vincent & Creteur, 2019). One of the problems that Patient’s with mechanical ventilation has to face is communication barrier. The problem occurs due to the presence of an endotracheal tube or tracheostomy, that compromise the verbal ability of the patients to communicate. Thus, even mechanical ventilator can save a patient’s live, it also creates psychological distress such as frustration in patients (Karlsson et al., 2012; Khalaila et al., 2011). Different communication methods have been attempted to make it able to communicate such as head nods, spoken word, gesture, even blinking eyes. These strategies itself present significant disadvantages, as it can be interpreted inaccurately, inefficiently, and cause significant misunderstanding for both patients and healthcare providers (Grossbach et al., 2011). Miscommunication can lead to various negative outcomes: discontinuity of care, patient safety, dissatisfaction in patients and economic consequences (Vermeir et al., 2015). The use of Augmentative and alternative communication (AAC) could be an alternative to enhance the ability of patients to communicate properly to the healthcare provider. There is a wide range of communication aids from basic to high technology, and the reviewers want to summarize what type of communication that can be used for patients with mechanical ventilation based on their clinical condition.
Eligibility criteria Studies were considered eligible for systematic review based on the following criteria: 1) all randomized control trials, quasiexperimental studies, observational studies published in English or Indonesian; 2)The population under consideration are all adult patients in the ICU who were using mechanical ventilation; 3)The main focus of the studies had to be the use of communication techniques between healthcare professionals and patients; 4) The studies had to be published from 2010. Data Collection First, The reviewers screened the studies based on the titles and abstracts to identify eligible studies. Studies that did not meet the criteria were excluded. Studies that met the criteria would be further assessed. We discussed the studies that have incomplete data and exclude if it's not possible based on the agreement of the reviewers. Data Extraction The following data is extracted from the included studies: first author, publication tear, study design, sample size, intervention type, study population, measures, and found in each of these studies.
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al., 2015; Otuzoğlu & Karahan, 2014; C. Rodriguez & Rowe, 2010; C. S. Rodriguez et al., 2016), 4 were case-series(16–19) (Kunduk et al., 2010; Leder et al., 2013; Pandian et al., 2014; Pryor et al., 2016), 3 were case reports (Girbes & Elbers, 2014; Mitate et al., 2015; Shimizu et al., 2013), 3 were cohort studies (Maringelli et al., 2013; C. S. Rodriguez et al., 2012; Tuinman et al., 2015), and 1 was a randomized control trial (Pandian et al., 2020). From the studies, we distinguished several communication intervention types which are: Augmented Alternative Communication (AAC) (Eight Studies) (El-Soussi et al., 2015; Garry et al., 2016; Koszalinski et al., 2015; Maringelli et al., 2013; Otuzoğlu & Karahan, 2014; C. Rodriguez & Rowe, 2010; C. S. Rodriguez et al., 2012), Electrolarynx (Three Studies) (Girbes & Elbers, 2014; Shimizu et al., 2013; Tuinman et al., 2015), Modified tracheostomy (Five Studies) (Kunduk et al., 2010; Leder et al., 2013; Pandian et al., 2014, 2020; Pryor et al., 2016), and Multiple Interventions (Three Studies) (Mary Beth Happ et al., 2014; Hosseini et al., 2018; Mitate et al., 2015). The outcome was acquired within a broad spectrum of measures. Mostly, author-devised questionnaires and subjective assessments of improvement in communication were utilized.
Quality assessment The methodological quality and risk of bias of selected studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). The QATSDD is a 16‐item tool developed for use with varying research designs. The QATSDD shows good reliability and validity for use in the quality assessment of a diversity of studies, which included qualitative and quantitative methods, and clearly-defined scales (Sirriyeh et al., 2012). Synthesis of result Data that was considered eligible were collected by two reviewers (R.H and D.M) and were adjusted by two other reviewers (A.A and A.M) and inputted to the table. meta-analysis will be conducted if the data collection supports it. The data will be summarized in a narrative synthesis If the data collection has high heterogeneity. Results
The initial database search yielded 387 articles. Out of those articles, 367 articles were excluded after abstract screening due to 25 articles being published more than 10 Years Ago, 181 articles being focused on mechanically nonventilated population, 23 articles having their communication method non-specified, 73 articles were review article, 8 articles were research protocol, 4 articles having non-communication related intervention, 2 articles were conference reports, and 1 article was written in foreign language. Proceeding to the full-text screening, 1 article was excluded due to irrelevant patient assessment. In total, 19 studies are finally reviewed in our study. This process is summarized in Figure 1. The included studies were described based on their characteristics in Table 1. Among the included studies. 1 was a controlled clinical trial (El-Soussi et al., 2015), 7 were using quasiexperimental design (Dithole et al., 2017; Garry et al., 2016; Hosseini et al., 2018; Koszalinski et
Quality Assessment Using the QATSDD appraisal outline, the overall methodological varied from poor to moderate; score 9–40 out of 42 and 48, median 25 (Table 2). Overall, the studies were considered moderate, and considered poor on case series and case report (Girbes & Elbers, 2014; Kunduk et al., 2010; Mitate et al., 2015; Pandian et al., 2014; Shimizu et al., 2013). Only six studies that reporting an evidence of sample size considered in term of analysis (Mary Beth Happ et al., 2014; Hosseini et al., 2018; Otuzoğlu & Karahan, 2014; Pandian et al., 2020; C. Rodriguez & Rowe, 2010; C. S. Rodriguez et al., 2016). There’s no study in quantitative study that assessed the reliability of
112
analytical processes (Koszalinski et al., 2015; Kunduk et al., 2010; Mitate et al., 2015; Pandian
et al., 2014; Pryor et al., 2016; C. Rodriguez & Rowe, 2010).
Figure 1. Flow diagram of study selection procedure.
113
Table 1. Characteristics of the included studies (n=19)
114
115
116
117
Table 2. Critical Appraisal (QATSDD)
Criteria were scored on a scale from 0 to 3 (0 = not at all, 1 = very slightly, 2 = moderately, 3 = complete, # = no quantitative methods used, X = no qualitative methods used).
118
List of Item Reviewed: 1. Explicit theoretical framework 2. Statement of aims/objectives in main body of report 3. Clear description of research setting 4. Clear description of research setting 5. Representative sample of target group of reasonable size 6. Description of procedure for data collection 7. Rationale for choice of data collection tool(s) 8. Detailed recruitment data 9. Statistical assessment of reliability and validity of measurement tools (Quantitative only) 10. Fit between stated research question and method of data collection (Quantitative only) 11. Fit between stated research question and format and content of data collection tool e.g. interview schedule (Qualitative only) 12. Fit between research question and method of analysis 13. Good justification for analytical method selected 14. Assessment of reliability of analytical process (Qualitative only) 15. Evidence of user involvement in design 16. Strengths and limitations critically discussed
119
could communicate clearly after being unable to speak (Girbes & Elbers, 2014; Shimizu et al., 2013). Tuinman et al, through conducting a cohort study measuring the effectivity of electrolarynx using Electrolarynx Effectivity Score (EES) found that 6 /15 patients scored 4 and 5 in EES and 2/15 patients scored 3 in EES. Which indicates improvements among 8/15 of the patients (53,33%) (Tuinman et al., 2015).
Modified Tracheostomy Modified Tracheostomy Tube is a tracheostomy tube that underwent several methods of modification to produce audible phonation (Pandian et al., 2014). The Blom Tracheostomy Tube was reported to be used in each of these 3 studies in 2010, 2012, and 2016 which in total includes 36 case reports (Kunduk et al., 2010; Leder et al., 2013; Pryor et al., 2016). In 2010, reported by Pryor et al, the tube was successfully implanted in 2 out of 3 patients and they maintain audible phonation and high level of comfort(Pryor et al., 2016). In 2012, reported by Leder et al, all patients (n=23) were able to maintain audible voicing with significantly greater voice intensity than room noise by >10 dB SPL (p = .003) and also speech intelligibility scores improved from 80% to 85% (p = 0.03)(Leder et al., 2013). In 2016. Kunduk et al reported that, 9 out 10 patients were able to maintain audible phonation (Kunduk et al., 2010). The second type, The BLUSA Tracheostomy Tube was reported to be used in conducting two studies respectively in 2010 and 2019 (Pandian et al., 2014, 2020). In 2010, reported by Pandian et al, all patients (n=4) who were treated with this tube were able to proficiently speak under mechanical ventilation, though they cannot handle cuff deflation (Pandian et al., 2014). In 2019, Pandian et al conducted a randomized controlled trial which accounted 25 patients, which shows that the change of Quality of Life is significantly better in patients (n=25) treated with these tubes (Pandian et al., 2020).
Augmented Alternative Communication (AAC) Augmented Alternative Communication (AAC) is a system that helps people with difficulties in communicating. This system consists of Unaided and Aided systems. Unaided systems utilize only the skill (lip reading, mouthing) owned by individuals and it is unnecessary to use additional equipment. In other hand, Aided systems utilize additional equipment to help people encompass their difficulties in communicating, distinguished into two groups which are High-tech AAC (speech generating device, eye-tracker) and Low-tech AAC (communication board) (Mary Beth Happ et al., 2014). Our search showed three distinct types of AAC systems, unaided system, low-tech AAC, and high-tech AAC. In our review, we included two studies that utilized Low-tech AAC and six studies that utilized high-tech AAC. El-soussi et al conducted a controlled clinical trial using modified communication board and paper/pen and reported that level of satisfaction differs significantly (40% are Satisfied, compared to 6.66% in control group (p<0.001); 10% were Very Dissatisfied compared to 53,33% in control group) and there were no significant differences in mortality between the two groups (El-Soussi et al., 2015). Otuzoglu et al reported that using authordeveloped illustration in managing the difficulties in communication undergone by post open-heart surgery patient, there were significant differences between groups (Intervention group 2.2% vs.
Electrolarynx Electrolarynx is a device powered by battery that helps user to produce speech through generating vibration to the oropharyngeal cavity (Shimizu et al., 2013). We included 3 studies that involve the usage of EL, which 2 were case reports and 1 was a cohort study. Both Shimizu et al and Girbes et al reported success through their case reports that with the usage of EL, patients
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design using Speak for Myself Computer Pad Software Application and stated that all patients (n = 20) prefer to use the Speak for Myself software, only one patient had difficulty to operate the computer tablet (Koszalinski et al., 2015). Garry et al. using The Tobli C12 eye-tracking computer enable patient to communicate basic needs to nursing staff and family with a positive mean overall impact score (PIADS = 1.30; n = 12, p = 0.004), and in mean scores for each PIADS domain: competence = 1.26, adaptability = 1.60, and self-esteem = 1.02 (all n = 12, p < 0.01) (Garry et al., 2016).
35,6% Control group, p < 0.000) (OtuzoÄ&#x;lu & Karahan, 2014). Among the studies that utilize High-tech AAC, there were Maringelli et al. who demonstrates a gaze-controlled system that managed to mediate and improve the communication between mechanically ventilated patient and healthcare workers in ICU and there was a significant decrease in negative feeling and thoughts among all groups (p < 0.001) (Maringelli et al., 2013). Rodriguez et al. who conducted 3 researches in 2010, 2012, and 2016 with completely different characteristics but reported a similarity in outcomes (C. Rodriguez & Rowe, 2010; C. S. Rodriguez et al., 2012, 2016). Rodriguez et al. conduct a research with quasiexperimental design using The Springboard Programmable speech-generating device and reported that there were significant improvements in communication quality, mean satisfaction score was 4.18/5 indicating 'quite satisfied', importance level score was 4,5/5 indicating 'quite important', only that patients reported issues associated with accessibility of the device (C. Rodriguez & Rowe, 2010). In 2012, another study by Rodriguez et al using speech generating software in a tablet computer and reported that Intervention given to participant was considered high importance (a Kappa = 0,421, 95% CI (-0,243,1.00)), easy to use (a Kappa = 0,388, 95% CI (-0,011, 0,789)) and qualitatively high satisfaction among the participant (C. S. Rodriguez et al., 2012). In 2016, another quasi-experimental design study conducted by Rodriguez et al reported the use of Software incorporated within a touch-screen tablet (include pictorial hot-buttons with spoken message, handwriting using finger or stylus, typewriting) which demonstrate a significantly lower mean frustration level (-2.68; 95% CI -3.02 to -2.34, p=<0.001), and higher satisfaction level ((0.59, 95% CI 0.27 to 0.91; p<0.0001)) within the intervention group compared to the control groups (C. S. Rodriguez et al., 2016). Koszalinski et al. also conducted a study with quasi-experimental
Multiple Interventions Our search also returns 3 studies which implemented mixed communication strategies to the patients (Mary Beth Happ et al., 2014; Hosseini et al., 2018; Mitate et al., 2015). Mitate et al. reported findings on the usage of VocalAid tracheostomy tube in pairing with Modified mouthstick stylus for tablet and communication board (High-tech AAC) which indicated that speaking tracheostomy tube was found insufficient for the patient to communicate and mouthstick stylus left him fatigued by the constant biting. Until modification was made to the mouthstick stylus then the patient can communicate with his surroundings (Mitate et al., 2015). Hosseini et. al conducted a quasiexperimental design study using only routine nursing practices on control group and adding communication board (low-tech AAC) to the intervention group and stated that there was a significant difference in ease of communication scores between the two groups (z = â&#x2C6;&#x2019;4.69; p = 0.001)(Hosseini et al., 2018). Happ et al. through their three phase cohort-study stated that communication frequency and positive nurse communication behavior increased significantly in one cohort, successful communication rate is significantly better when being compared with control groups and patient
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voices, and may help the healthcare providers to help choose the best strategies for the patients (Ten Hoorn et al., 2016). A similar study was conducted by Ten Hoorn et al., which shows a wide array of communication methods available in the literature for patients undergoing mechanical ventilation. Hoorn et.al attempted to create an algorithm in order to help healthcare providers in choosing the best communication strategies for these patients(Ten Hoorn et al., 2016). However, with the limited data in proving the efficacy of these options, the strategies may be difficult to be implemented. In order to choose the best communication strategies for the patient, the assessment of cognition and functional status is an essential part to be done (Ten Hoorn et al., 2016). Patients who can maintain their vocalization and undergo mechanical ventilation may be benefitted by the modified tracheostomy tube. Modified tracheostomy tubes (such as the Blom tracheostomy tube or the BLUSA tracheostomy tube) may provide a good alternative to allow patients to vocalize their words. Similarly, the Electrolarynx, which works by augmenting the vibration from the patient’s oral or pharyngeal mucosa may provide a good phonation for the patients. However, for those who cannot maintain vocalization, other communication strategies may be more suitable. For such patients, communication may still be possible to be conducted with tools such as the Speak for Myself software, which translate the need of the patients into audible voice. Some attempt to provide alternative tools for patients to interact with the given technologies have been developed. Eyetracker devices may be useful to help the patients who cannot or are difficult to move, especially paraplegic patients. New modified stylus developed by Mitate et.al may also be useful for these patients. However, due to the energy exertion which may be caused by these devices,
with AAC and SLP has a lower difficulty in communication (Mary Beth Happ et al., 2014). Discussion Communication is an essential part of human life, and also a huge part determining the quality of care provided by the healthcare providers, and determines the treatment outcome by patients(M B Happ, 2001; Patak et al., 2004). Our search reveals numerous studies which have proven to positively impact the outcome of care provided to the patients (Koszalinski et al., 2015). A number of studies described the patient’s feeling when they cannot communicate with the healthcare workers, or their family(Koszalinski et al., 2015; Mazor et al., 2012). Repeatedly, the feeling of “loneliness”,“helplessness” or “trapped in their own head” are being described by these patients (Koszalinski et al., 2015). Due to this problem, assessments which may need subjective reports from the patient, such as pain intensity or the location of pain, may often be impossible to be done. This problem may affect how they perceive the treatment they went through, and will also determine their quality of life (Pandian et al., 2020; Patak et al., 2004). Similar to this, the healthcare providers are also having troubles in communicating with the patients, which will significantly hinder the assessments and alter the treatments provided (Patak et al., 2004). Our review may gives insights about the available technologies and alternatives to help overcome these situations. The emergence of new technology such as the Electrolarynx, the Modified Tracheostomy Tube, eye tracking devies or computer softwares (such as the Speak for Myself) may provide useful solutions for patients undergoing mechanical ventilation. New technologies such as eyetracking devices and novel softwares may help provide a mode of communication which is easy to use, and may cut unnecessary cost related to the need to purchase additional devices. With these technologies arises, the patients may regain their
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BMC Nursing, 16, 74. https://doi.org/10.1186/s12912-017-0268-5 El-Soussi, A. H., Elshafey, M. M., Othman, S. Y., & Abd-Elkader, F. A. (2015). Augmented alternative communication methods in intubated COPD patients: Does it make difference. Egyptian Journal of Chest Diseases and Tuberculosis, 64(1), 21–28. https://doi.org/https://doi.org/10.1016/j.ejcdt. 2014.07.006 Garry, J., Casey, K., Cole, T. K., Regensburg, A., McElroy, C., Schneider, E., Efron, D., & Chi, A. (2016). A pilot study of eye-tracking devices in intensive care. Surgery, 159(3), 938–944. https://doi.org/10.1016/j.surg.2015.08.012 Girbes, A. R. J., & Elbers, P. W. G. (2014). Speech in an orally intubated patient. In The New England journal of medicine (Vol. 370, Issue 12, pp. 1172–1173). https://doi.org/10.1056/NEJMc1313379 Grossbach, I., Chlan, L., & Tracy, M. F. (2011). Overview of mechanical ventilatory support and management of patient- and ventilatorrelated responses. Critical Care Nurse, 31(3), 30–44. https://doi.org/10.4037/ccn2011595 Happ, M B. (2001). Communicating with mechanically ventilated patients: state of the science. AACN Clinical Issues, 12(2), 247– 258. https://doi.org/10.1097/00044067200105000-00008 Happ, Mary Beth, Garrett, K. L., Tate, J. A., DiVirgilio, D., Houze, M. P., Demirci, J. R., George, E., & Sereika, S. M. (2014). Effect of a multi-level intervention on nurse-patient communication in the intensive care unit: results of the SPEACS trial. Heart & Lung : The Journal of Critical Care, 43(2), 89–98. https://doi.org/10.1016/j.hrtlng.2013.11.010 Hess, D. R., Macintyre, N. R., Mishoe, S. C., Galvin, W. F., & Adams, A. B. (2011). Mechanical Ventilation. In Repiratory Care Principles and Practice (2nd Editio, pp. 462– 492). Jones and Barlett. Hosseini, S.-R., Valizad-Hasanloei, M.-A., & Feizi, A. (2018). The Effect of Using Communication Boards on Ease of Communication and Anxiety in Mechanically Ventilated Conscious Patients Admitted to Intensive Care Units. Iranian Journal of Nursing and Midwifery Research,
more research is needed before these strategies are implemented. Apart from the technologies, the role of well-trained health providers is also an important issue. Healthcare providers trained for the communications may perform better in communicating with the patient, resulting in a better quality of care (Nilsen et al., 2014). Oftentimes, patients with mechanical ventilation are unable to convey messages other than simple syllables or behavior. With this in mind, the importance of proper consultation to the welltrained nurses or Speech Language Pathologist are crucial. The main limitation in providing the best communication method for the patient is the lack of recommendation and research in the field. Despite the importance of communication strategies in order to improve patients' treatment outcome, this matter is often under-appreciated. Our study shows that only one randomizedcontrolled trial is available in assessing the importance and effect of the available communication method. We suggest that proper trials which assess clear outcomes for the patients are needed in order for the new technologies to be implemented by the patients. Conclusion Numerous communication alternatives, such as Electrolarynx, the Modified Tracheostomy Tube, eye-tracking devices or computer software (such as the Speak for Myself), for patients undergoing mechanical ventilation are presented in this study. However, further studies assessing the benefits of these treatments are needed in order for these choices to be implemented in respective healthcare facilities. Reference Dithole, K. S., Thupayagale-Tshweneagae, G., Akpor, O. A., & Moleki, M. M. (2017). Communication skills intervention: promoting effective communication between nurses and mechanically ventilated patients.
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impact, and response. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 30(15), 1784– 1790. https://doi.org/10.1200/JCO.2011.38.1384 Mitate, E., Kubota, K., Ueki, K., Inoue, R., Inoue, R., Momii, K., Sugimori, H., Maehara, Y., & Nakamura, S. (2015). Speaking Tracheostomy Tube and Modified Mouthstick Stylus in a Ventilator-Dependent Patient with Spinal Cord Injury. Case Reports in Emergency Medicine, 2015, 320357. https://doi.org/10.1155/2015/320357 Nilsen, M. L., Sereika, S. M., Hoffman, L. A., Barnato, A., Donovan, H., & Happ, M. B. (2014). Nurse and patient interaction behaviors’ effects on nursing care quality for mechanically ventilated older adults in the ICU. Research in Gerontological Nursing, 7(3), 113–125. https://doi.org/10.3928/19404921-2014012702 Otuzoğlu, M., & Karahan, A. (2014). Determining the effectiveness of illustrated communication material for communication with intubated patients at an intensive care unit. International Journal of Nursing Practice, 20(5), 490–498. https://doi.org/10.1111/ijn.12190 Pandian, V., Cole, T., Kilonsky, D., Holden, K., Feller-Kopman, D. J., Brower, R., & Mirski, M. (2020). Voice-Related Quality of Life Increases With a Talking Tracheostomy Tube: A Randomized Controlled Trial. The Laryngoscope, 130(5), 1249–1255. https://doi.org/10.1002/lary.28211 Pandian, V., Smith, C. P., Cole, T. K., Bhatti, N. I., Mirski, M. A., Yarmus, L. B., & FellerKopman, D. J. (2014). Optimizing Communication in Mechanically Ventilated Patients. Journal of Medical SpeechLanguage Pathology, 21(4), 309–318. Patak, L., Gawlinski, A., Fung, N. I., Doering, L., & Berg, J. (2004). Patients’ reports of health care practitioner interventions that are related to communication during mechanical ventilation. Heart & Lung : The Journal of Critical Care, 33(5), 308–320. https://doi.org/10.1016/j.hrtlng.2004.02.002 Pryor, L. N., Ward, E. C., Cornwell, P. L.,
23(5), 358–362. https://doi.org/10.4103/ijnmr.IJNMR_68_17 Karlsson, V., Lindahl, B., & Bergbom, I. (2012). Patients’ statements and experiences concerning receiving mechanical ventilation: a prospective video-recorded study. Nursing Inquiry, 19(3), 247–258. https://doi.org/10.1111/j.14401800.2011.00576.x Khalaila, R., Zbidat, W., Anwar, K., Bayya, A., Linton, D. M., & Sviri, S. (2011). Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses, 20(6), 470–479. https://doi.org/10.4037/ajcc2011989 Koszalinski, R. S., Tappen, R. M., & Viggiano, D. (2015). Evaluation of Speak for Myself with Patients Who Are Voiceless. Rehabilitation Nursing : The Official Journal of the Association of Rehabilitation Nurses, 40(4), 235–242. https://doi.org/10.1002/rnj.186 Kunduk, M., Appel, K., Tunc, M., Alanoglu, Z., Alkis, N., Dursun, G., & Ozgursoy, O. B. (2010). Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed tracheostomy tube. Respiratory Care, 55(12), 1661–1670. Leder, S. B., Pauloski, B. R., Rademaker, A. W., Grammer, T., Dikeman, K., Kazandjian, M., Mendes, J., & Logemann, J. A. (2013). Verbal communication for the ventilatordependent patient requiring an inflated tracheotomy tube cuff: A prospective, multicenter study on the Blom tracheotomy tube with speech inner cannula. Head & Neck, 35(4), 505–510. https://doi.org/10.1002/hed.22990 Maringelli, F., Brienza, N., Scorrano, F., Grasso, F., & Gregoretti, C. (2013). Gaze-controlled, computer-assisted communication in Intensive Care Unit: “speaking through the eyes”. Minerva Anestesiologica, 79(2), 165– 175. Mazor, K. M., Roblin, D. W., Greene, S. M., Lemay, C. A., Firneno, C. L., Calvi, J., Prouty, C. D., Horner, K., & Gallagher, T. H. (2012). Toward patient-centered cancer care: patient perceptions of problematic events,
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Tuinman, P. R., Ten Hoorn, S., Aalders, Y. J., Elbers, P. W., & Girbes, A. R. (2015). The electrolarynx improves communication in a selected group of mechanically ventilated critically ill patients: a feasibility study. In Intensive care medicine (Vol. 41, Issue 3, pp. 547–548). https://doi.org/10.1007/s00134014-3591-2 Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., Hallaert, G., Van Daele, S., Buylaert, W., & Vogelaers, D. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International Journal of Clinical Practice, 69(11), 1257– 1267. https://doi.org/10.1111/ijcp.12686 Vincent, J.-L., & Creteur, J. (2019). Critical care medicine in 2050: less invasive, more connected, and personalized. In Journal of thoracic disease (Vol. 11, Issue 1, pp. 335– 338). https://doi.org/10.21037/jtd.2018.11.66
O’Connor, S. N., & Chapman, M. J. (2016). Establishing phonation using the Blom® tracheostomy tube system: A report of three cases post cervical spinal cord injury. Speech, Language and Hearing, 19(4), 227– 237. https://doi.org/10.1080/2050571X.2016.1196 035 Rodriguez, C., & Rowe, M. (2010). Use of a speech-generating device for hospitalized postoperative patients with head and neck cancer experiencing speechlessness. Oncology Nursing Forum, 37(2), 199–205. https://doi.org/10.1188/10.ONF.199-205 Rodriguez, C. S., Rowe, M., Koeppel, B., Thomas, L., Troche, M. S., & Paguio, G. (2012). Development of a communication intervention to assist hospitalized suddenly speechless patients. Technology and Health Care : Official Journal of the European Society for Engineering and Medicine, 20(6), 489–500. https://doi.org/10.3233/THC-2012-0695 Rodriguez, C. S., Rowe, M., Thomas, L., Shuster, J., Koeppel, B., & Cairns, P. (2016). Enhancing the Communication of Suddenly Speechless Critical Care Patients. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses, 25(3), e40-7. https://doi.org/10.4037/ajcc2016217 Shimizu, K., Ogura, H., Irisawa, T., Nakagawa, Y., Kuwagata, Y., & Shimazu, T. (2013). Communicating by electrolarynx with a blind tetraplegic spinal cord injury patient on mechanical ventilation in the ICU. Spinal Cord, 51(4), 341–342. https://doi.org/10.1038/sc.2012.170 Sirriyeh, R., Lawton, R., Gardner, P., & Armitage, G. (2012). Reviewing studies with diverse designs: the development and evaluation of a new tool. Journal of Evaluation in Clinical Practice, 18(4), 746–752. https://doi.org/10.1111/j.13652753.2011.01662.x Ten Hoorn, S., Elbers, P. W., Girbes, A. R., & Tuinman, P. R. (2016). Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Critical Care (London, England), 20(1), 333. https://doi.org/10.1186/s13054-016-1483-2
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Double-edged Sword : The Role of Social Media and Online News as Crisis Communication Platform during COVID-19 Pandemic Amalia Dwi Mulyani, Muhammad Abdurrahman Ar-Rizqi, Fildza Intan Rizkia, Satria Angga Widitama AMSA-Universitas Padjadjaran Amaliadwi67@gmail.com
COVID-19 is the disease caused by a new species of coronavirus named SARS-CoV-2, currently held status as a pandemic. Social media and online news play a major role in spreading information regarding SARS-CoV-2 and COVID-19, especially on the prevention strategies. Unfortunately not all information created equal, some of it could be constructed by people without prior knowledge on public health, infectious disease, and epidemiology. this issue could incite the endless wave of COVID-19 infection and hinder the prevention efforts that already been done before. Literature search was conducted through Google Scholar, Pubmed, and Science Direct using keywords : "Crisis communication" AND "covid-19" AND "social media" AND â&#x20AC;&#x153;online newsâ&#x20AC;?. We focused in analyzing 8 studies and found that social media and online news have a great impact in forming public perception and opinions so it is important to media platforms and authorities to deliver right informations and take serious actions to prevent spread of misinformations.
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Double-edged Sword : The Role of Social Media and Online News as Crisis Communication Platform during COVID-19 Pandemic
Amalia Dwi Mulyani, Muhammad Abdurrahman Ar-Rizqi, Fildza Intan Rizkia, Satria Angga Widitama Faculty of Medicine Universitas Padjadjaran 2020
Introduction
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COVID-19 is the disease caused by a new species of coronavirus named SARS-CoV-2, currently held status as a global pandemic (Johnson, 2020). The disease was first reported in Wuhan, Hubei Province, China. During the period from 31 December 2019 through 3 January 2020, the first 44 case-patients were reported as pneumonia without any known etiology. The Chinese authorities confirmed that the disease is caused by a new type of coronavirus that was called 2019-nCoV and later on named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Gorbalenya et al., 2020). The disease spread rapidly worldwide over the course of three month, then it was declared as pandemic by WHO. Based on the weekly epidemiology update, the global cumulative case until 4 October 2020 is more than 34 million people infected with almost half of the figures are from the Americas region. (World Health Organization, 2020) During the COVID-19 Pandemic, most of the region in the world imposed a lockdown or social restriction policy as infection control measures. This action directly minimized outdoor activity and as a consequence increased the digital screen time for some people worldwide. With almost all public activities and big gatherings being prohibited, people start to seek out entertainment and connection with one other people online. There is a surge of social media usage in several platforms, including Facebook and Youtube. From January to March 2020 the traffic numbers from Facebook and Youtube websites are rising to 27% and 15.3% respectively (The Virus Changed the Way We Internet - The New York Times, n.d.). In the early days of pandemic, a cross-sectional study conducted in Italy involving 1.310 participants concluded that there was an increase in digital media usage, up to 3% activities during lockdown (Cellini et al., 2020). Social media plays a major role as a platform to spread information and news during COVID-19 pandemic. Unfortunately not all information online comes from reliable and verified sources. Misinformation regarding COVID-19 and SARS-CoV-2 may happen, and it may affect public compliance on implementing prevention measures. In addition to misinformation, there is also some misleading and terrifying news from unverified theorists and scientific explanation deniers. These problems could lead to an uncontrolled transmission and a never-ending wave of infection. For example, improper health communication drawn from Nigeria, where some health workers found out cases of chloroquine, drug for malaria treatment, overdoses after the release of news that chloroquine may be effective to treat COVID-19 (Nigeria records chloroquine poisoning after Trump endorses it for coronavirus treatment - CNN, n.d.). This study will analyse the influence of social media on people's behaviour and perception on COVID-19 and SARS-CoV2 in several countries in the world.
Materials and Methods
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Literature search was conducted through Google Scholar, Pubmed, and Science Direct using keywords : "Crisis communication" AND "covid-19" AND "social media" AND â&#x20AC;&#x153;online newsâ&#x20AC;?.
Results Study Characteristic No.
Study
Sample
Location of Study
Time span of study
Misinformation (false)
3 053 Tweet
tweet was at peak at
IDs from 7 623 1
Shahi, et al
news articles and 163 096
Result
Twitter (Global)
random English
January-July 2020
March-April 2020 and it got more likes and has faster speed of propagation than partially
tweets
false tweet.
129
43,832 Twitter users and users
Tweets that contain
and 78,233 2
Park et al.
relationship such as tweet,
South Korea
February 29, 2020
retweet,
medically framed news are more popular than tweets that contain nonmedically framed news
mention, and replies
Information Seeking on 3
P. Liu
511 participants China
February 2020
digital media will increase preventive behaviours through worry COVID-19â&#x20AC;&#x201C;related GT
4
Sousa-Pinto et. al
Data from
17 European
google trends
countries
Jan-April 2020
data are more closely related to media coverage than to epidemic trends. Global media framing of
5
Ogbodo et. al
6145 news
8 media platforms December 2019 Covid-19 employed
items
(Global)
- April 2020
words that increase fear among public the majority of videos portrays death and informations that increase
6
Basch, C et. al.
431 Google videos
Global
January-
public fear, while
February 2020
important informations related to prevention of Covid-19 gained little attention Due to the high
Google Trends 7
A Rovetta et. al
and Instagram
Global
hashtags
February-May
prevalence of infodemic
2020
monikers, mass media regulators and health
130
organizers should be encouraged to take serious actions against spreading misinformation in social media. the use of social media platforms can positively influence awareness of public health behavioral 8
Hani Al-Dmour
2555 social media users
Jordan
March 15-30,
changes and protective
2020
measures against COVID19 depending on how informations are delivered to populations by the authorities
Discussion In this study, we describe the role of social media and online news during this pandemic. The availability of information and analysis of the data produced and consumed about health in online media is very important at this time because it can provide insights to public health officials in order to develop policies. Information that is widely circulated during a pandemic which is popular among the public is about health related to Covid-19. The information circulating in online media can cause worry in the community or can lead to preventive behavior among the public so that the spread of the virus can be minimized(Liu, 2020). Especially information such as the dangers of viruses, their impact on health and their impact on medical personnel. However, with this abundance of information, it is necessary to be aware of the validity of the information. Since the flood of information during the pandemic, misinformation has also appeared a lot. This is proved by the high level of misinformation in the early months of the pandemic (Fig.1). Misinformation should be watched out for because it can cause excessive panic which can cause people to
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behave like panic buying, or even vice versa, that the public does not care about the danger of Covid-19. Fig1 COVID-19–related web searches closely reflect media news coverage (Park, Park, & Chong, 2020). This is depicted from a study that shows the search for Covid-19 signs “anosmia and ageusia” peaked after March 16 (after the publication of an interview with Hendrik Streeck in the German newspaper Frankfurter Allgemeine Zeitung) (Sousa-Pinto et al., 2020). Unfortunately, the majority of news videos on the internet missed an opportunity to encourage and promote coping strategies and preventive behaviors, instead promoting fear and anxiety in public (Basch et al., 2020). Masses opinions and perception depend on public health crises from the media, so it is important for the media to inform messages in a way to inform the
public the right information, not just making the public scared and panic (Ogbodo et al., 2020). Social media usage in fact can influence individuals' awareness regarding public health issues positively, especially on preventive measures of COVID-19. The Ministry of Health or other related agencies could use social media as a platform to enhance public health awareness in short messages. (Al Dmour, 2020). With the high spread of misinformations, mass media regulators and health organizers should be encouraged to take more serious actions against spreading misinformation in social media because the misinformation is just as dangerous as the disease(Rovetta & Bhagavathula, 2020). Conclusion During the pandemic, the increasing indoor activities induce the use of social media and online news. It placed them as a major key factor in spreading information regarding SARS-CoV-2 and COVID-19, especially as the prevention strategies. Unfortunately not all information created equal, some of it could be made and spread by people without prior knowledge on public health, infectious disease, and epidemiology. This issue could incite the endless wave of COVID-19 infection and hinder the prevention efforts that have already been done before. However, social
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media and online news platforms can also provide benefits to increase public awareness of COVID-19. Both of that output is possible to be happening depending on the strategies that are being implemented. Public health experts, medical doctors, authorities, and epidemiologists should cooperate with each other and take the lead in social media and online news to dissipate any misinformations. More research is needed to find strategies on how social media and online news platforms can be best used to improve health knowledge and practice protective behaviors in public. References Cellini, N., Canale, N., Mioni, G., & Costa, S. (2020). Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy. Journal of Sleep Research, 29(4), 1–5. https://doi.org/10.1111/jsr.13074 Gorbalenya, A. E., Baker, S. C., Baric, R. S., de Groot, R. J., Drosten, C., Gulyaeva, A. A., Haagmans, B. L., Lauber, C., Leontovich, A. M., Neuman, B. W., Penzar, D., Perlman, S., Poon, L. L. M., Samborskiy, D. V., Sidorov, I. A., Sola, I., & Ziebuhr, J. (2020). The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nature Microbiology, 5(4), 536–544. https://doi.org/10.1038/s41564-020-0695-z Johnson, M. (2020). Wuhan 2019 Novel Coronavirus - 2019-nCoV. Materials and Methods, 10(JANUARY), 1–5. https://doi.org/10.13070/mm.en.10.2867 Nigeria records chloroquine poisoning after Trump endorses it for coronavirus treatment - CNN. (n.d.). Retrieved October 20, 2020, from https://edition.cnn.com/2020/03/23/africa/chloroquine-trump-nigeriaintl/index.html The Virus Changed the Way We Internet - The New York Times. (n.d.). Retrieved October 20, 2020, from https://www.nytimes.com/interactive/2020/04/07/technology/coronavirus-internet-use.html Basch, C. H., Hillyer, G. C., Erwin, Z. M., Mohlman, J., Cosgrove, A., & Quinones, N. (2020). News coverage of the COVID-19 pandemic: Missed opportunities to promote health sustaining behaviors. Infection, Disease and Health. https://doi.org/10.1016/j.idh.2020.05.001 Liu, P. L. (2020). COVID-19 Information Seeking on Digital Media and Preventive Behaviors: The Mediation
Role
of
Worry.
Cyberpsychology,
https://doi.org/10.1089/cyber.2020.0250
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Behavior,
and
Social
Networking.
Ogbodo, J. N., Onwe, E. C., Chukwu, J., Nwasum, C. J., Nwakpu, E. S., Nwankwo, S. U., â&#x20AC;Ś Ogbaeja, N. I. (2020). Communicating health crisis: A content analysis of global media framing of COVID-19. Health Promotion Perspectives. https://doi.org/10.34172/hpp.2020.40 Park, H. W., Park, S., & Chong, M. (2020). Conversations and medical news frames on twitter: Infodemiological study on COVID-19 in South Korea. Journal of Medical Internet Research. https://doi.org/10.2196/18897 Rovetta, A., & Bhagavathula, A. S. (2020). Global infodemiology of COVID-19: Analysis of Google web searches and Instagram hashtags. Journal of Medical Internet Research. https://doi.org/10.2196/20673 Al-Dmour, H., Masaâ&#x20AC;&#x2122;deh, R., Salman, A., Abuhashesh, M. and Al-Dmour, R., 2020. Influence of Social Media Platforms on Public Health Protection Against the COVID-19 Pandemic via the Mediating Effects of Public Health Awareness and Behavioral Changes: Integrated Model. Journal of Medical Internet Research, 22(8) Sousa-Pinto, B., Anto, A., Czarlewski, W., Anto, J. M., Fonseca, J. A., & Bousquet, J. (2020). Assessment of the impact of media coverage on COVID-19-Related google trends data: Infodemiology study. Journal of Medical Internet Research. https://doi.org/10.2196/19611
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EAMSC 2020
Teleconsultation As A Solution For Patient-Doctor Communication In COVID-19 Era: A Systematic Review Az Zachra Sanati Khodijah1, Aldona Akhira Susanto1, Ellen Josephine Handoko1 Third Year of Medical Student, Medical Department, Medical Faculty of Sebelas Maret University
1
[corresponding email: azzachras@student.uns.ac.id]
Abstract Introduction Teleconsultation is communication method used while participants don't have to be face-toface. After the emergence of COVID-19 pandemic, new protocol is made to limit direct contacts from person to person. Therefore, teleconsultation becomes a prominent solution for safe communication between patients and medical professionals. Material and Method This systematic review was carried out using PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) with search on PubMed, Google Scholar, and Science Direct database. Keywords used include teleconsultation, online consultation, communication, and COVID-19. Thirteen studies were appraised using CEBM (Centre for Evidence-Based Medicine) appraisal tools. Result Assessment of teleconsultation was based on satisfaction rate, feasibility, and efficiency from patients and medical professionals point of views. Teleconsultation presented a satisfactory rate above 86% based on seven studies. Two studies found that teleconsultation is feasible with a rate of completed appointments of 80% and 85%. Efficiency was evaluated in five studies, all of them stated teleconsultation can be used adequately to evaluate patients and prevent COVID-19 infection. Discussion Teleconsultation is considered effective and feasible in COVID-19 pandemic because it is proven to reduce COVID-19 transmission. Patients gave positive responses and high satisfaction rates. Communication between medical professionals and patients is slightly reduced because of technical issues. Teleconsultation is considered equal as face-to-face appointment to accommodate communication.
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Conclusion Teleconsultation made communication access between patientsâ&#x20AC;&#x2122; and doctorsâ&#x20AC;&#x2122; become easier. It could be said that telecommunications is a solution for communication problems between patients and doctors in COVID-19 Era. Keywords: Teleconsultation, Communication, COVID-19
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TELECONSULTATION AS A SOLUTION FOR PATIENT-DOCTOR COMMUNICATION IN COVID-19 ERA: A SYSTEMATIC REVIEW PCC EAMSC PHILIPPINES 2020
Az Zachra Sanati Khodijah Aldona Akhira Susanto Ellen Josephine Handoko
G0018039 G0018012 G0018062
AMSA-Universitas Sebelas Maret Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia (AMSA-Indonesia) 2020
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Introduction Communication between patient and doctor is crucial in clinical practice, to build a therapeutic relationship which is what the art of medicine itself. To gather information in order to provide accurate diagnosis, management, and education for the success of patient therapy, good and effective communication is required between the patient and the doctor so that there are no misunderstandings that will affect the patient's treatment. [1] A trust-based relationship between patient and doctor can be built by effective communication which in turn is able to improve patient satisfaction and adherence. [2] Poor communication can lead to misunderstanding and patient dissatisfaction. In addition, inadequate communication is the primary cause of patient complaints and malpractice claims. A study by Kee, J. W. Y. found what the nature of these errors are in communication between doctor and patient, which are divided into verbal communication errors, non-verbal communication errors, inadequate content of communication and poor attitudes. [3] Direct communication can minimize these problems especially in the theme of quality of information and non-verbal communication. Face to face communication is proven to increase the level of understanding, closeness, and self-disclosure of the communicants. [4] On a study conducted in 2017 by Tates, comparing the effect of screen to screen versus face to face consultation on doctor-patient communication, which showed no significant difference in patientsâ&#x20AC;&#x2122; satisfaction between screen to screen consultation and face to face consultation. Patientsâ&#x20AC;&#x2122; interpretation did not significantly differ between screen to screen and face to face consultation. In conclusion, there were no significant differences between Web-based and face-to-face consultation. In Web-based consultations, simulated patients may expect more information exchange and more affective behaviour or interpersonal building in face to face consultations. [5] At the beginning of 2020, the world was faced with a pandemic caused by the novel coronavirus SARS-CoV-2 (COVID-19). Globally, as updated on 8 September 2020, there have been 27,236,916 confirmed cases of COVID-19, including 891,031 deaths, reported to WHO. Since the coronavirus is highly contagious, the best way to reduce the spread is to limit direct (face to face) interaction and keep distance from others. This, of course, affects the consultation between doctor and patient which usually done in person. [6,7,8] Healthcare professionals must be equipped with standardized personal protective equipment including protective suits, masks, gloves, goggles, face shields and gowns especially during aerosolgenerating procedures such as tracheal intubation, aerosol inhalation, tracheostomy, and oral care. A cross-sectional study conducted in Wuhan, China in 2020, showed that despite frequent exposure to SARS- CoV-2 infection, 420 healthcare professionals showed negative test results for nucleic acids and specific IgM or IgG antibodies because using standardized personal protective equipment together
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with hand hygiene, social distancing and receiving proper training about how to put on and take off personal protective equipment. [9] Based on a study conducted by Umoren in 2020, the number of healthcare providers who needed to utilize PPE especially for providing care for patients in isolation can be decreased substantially with the use of telehealth. Nonacademic facilities may have fewer health care providers available to back up in case there is a shortage of staff due to COVID-19. It means it is very essential to reduce the risk of potential exposures and health care provider illness. Telemedicine can be a solution because it can reduce exposure risk and conserve PPE especially for smaller health care facilities with limited PPE. Telemedicine can be a way to preserve inpatient supportive services such as nutrition, occupational, and physical therapy. With telemedicine, health care providers can converse with the family without masks and other PPE. Telemedicine also mediate visits for families who cannot visit during the COVID-19 pandemic due to exposure concerns. [10] Various things have been tried to be done, one of which is telemedicine. Telemedicine is defined by delivery of health services at a distance, including the components of promotion, prevention, diagnosis, treatment, and rehabilitation, provided by health professionals who use information and communications technologies strategies such as telephone or video consulting. Teleconsultation is an effective way to determine patient priorities and reduce unnecessary visits to the emergency department. [11] The use of online consultation via video or telephone as an alternative to face-to-face consultation has been popular in current times, because it is considered to be more timeefficient and can be an option for patients who live far away and have difficulty getting access to primary health care. [12] Telemedicine sounds very promising for improving health care access, especially during a pandemic. however, not all regions have smooth internet access, some rural areas have limited internet access, so the benefits of telemedicine are still questionable. [13] In this systematic review with the title Telemedicine as a Solution for Patient-Doctor Communication in COVID-19 Era: A Systematic Review aims to know whether it provides a solution in this ongoing pandemic, through the point of view of medical professionals, medical students, and community.
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Materials and Methods The systematic review with the title Online Consultation as a Solution for Patient-Doctor Communication in COVID-19 Era: A Systematic Review was carried out using PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses). Studies search were conducted using PubMed, Google Scholar, and Science Direct database with keyword teleconsultation, online consultation, communication, and COVID-19. Inclusion criteria were paper published both in English or Bahasa, literature has five years range since it was published, and qualified literature dealt with Teleconsultation in COVID-19 Era. The selected studies were appraised using CEBM appraisal tools (Centre for Evidence-Based Medicine).
Figure 1. Journal searching takes time from September 8th, 2020 to October 14th, 2020. From the initial search obtained 1,302 studies from selected database. Journal selection processes through assessment on title and topic, assessment on abstract, assessment on eligibility, and full test assessment also devoted to inclusion and exclusion criteria. After the journal selection process, 13 qualified literature were obtained for this systematic review. Selection of journal shown in Figure 1.
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Result Tabel 1. Summary of Studies Related with Teleconsultation as Solution in Patient-Doctor Communication in Covid-19 Era References
Study design
Cases
Clinical setting
Study
Method
End point
Major findings
intervention Jiménez-
Observational
Rodrígue z,
Study
53
Follow-up care
In depth
Qualitative data was
To explore
By 96,2% of the
for patients after
discussion of
collected by online
healthcare
healthcare
D., et al.
surgery, chronic
video consultation
interview, comprising
professionals’
professionals regarded
(2020)
diseases, families
and all relevant
four closed-ended and
perceptions about
video consultations to
of children with
topics with health
four open- ended
the
be adequate for
cancer and
care professionals
questions using
implementation of
providing health care,
premature
Google Meet video
video
although 83% of the
newborns, mental
platform
consultations and
interviewed healthcare
health, and
its management in
professionals had not
dermatology
the provision of
provided video
examinations.
high-quality
consultation. 90,6%
health care.
considered training dan educating healthcare professionals in video consultation to be necessary
Shenoy, P., et al. (2020)
Audit Study
100
Rheumatology
Teleconsultation
Rheumatology
To find the
During 7 days of study,
patients
via WhatsApp for
patients were
feasibility and
975 out of 1469
eligible patients
screened twice using
acceptance of
appointments were
and taking
electronic medical
patients in
offered teleconsultation
feedbacks
records and interview.
switching to
of which 723 (74%)
Eligible patients
teleconsultation
agreed, while a total of
141
arranged
275 cancelled or
teleconsultation using
rescheduled
video calling feature
appointments.
of WhatsApp.
Median satisfaction
Feedbacks were taken
was 9 (IQR 8–10) on
after seven working
the NRS scale. In
days by random call
recommending the
up.
continuation of teleconsultation, he respondents scored median 9.5 (IQR 8–10) on the NRS scale .
Miguel,
Cross-
D’Haeseleer,
sectional
et al. (2020)
study
20
Multiple
Teleconsultation
Teleconsultation was
To explore
17 or 85% of
Sclerosis clinic
using
held using novel
whether planned
consultation were
communication
internet-based
real
completed. Two
platform obtained
communication
time
failures were due to
from Zebra
platform obtained
audiovisual
patients not responding
Academy and
from Zebra Academy
teleconsultation
while the other one was
feedback taking
then satisfaction rate
over the internet
because of technical
was evaluated at the
is feasible in
issues. Out of the total
end using 5-points
patients with
17 consultations, 17
Likert scales
multiple sclerosis
patients declared themselves to be satisfied or highly satisfied with the teleconsultation for technical quality, 15 patients for convenience, and 16 patients for overall quality of care
Rahman, N.,
Cross-
52
New and follow
Patients survey 142
Appointments were
To explore patient
Thirty-five patients
et al. (2020)
sectional
up appointments
conducted using
satisfaction, ease
attended the virtual
study
in dentistry
Attend Anywhere
of use, the
clinic and 17 patients
Telehealth system.
effectiveness
opted for telephone
Patients were asked to
including
consultation. 90%
complete
increasing access
patients felt satisfied.
questionnaire at the
to clinical
91% virtual clinic and
end of the
services,
100% telephone clinic
consultation.
reliability of the
patients felt they
teledentistry
understand and can use
system, and
the system while
usefulness for
maintaining good
patients.
communication. 100% telephone consultation and 97 % virtual clinic patients considered the system was effective.
Freud, et al.
Prospective
(2020)
study
100
ENT patients
Online
The
Patients
Overall satisfaction
who had
questionnaire.
questionnaire
satisfaction
was 87%. There were
was delivered at
point with ENT
no clinically relevant
end of
teleconsultation
predictive factors
consultation,
during the
signiďŹ cantly associated
using an online
lockdown due
with satisfaction.
website, SARA,
world pandemic
Sound
accessible to
COVID-19 and
and video quality was
health
finding factors
satisfactory for 76%
professionals
for satisfaction,
and 61% of patients
and patients at
and the
respectively, without
www.sante-
advantages,
signiďŹ cant impact on
ara.fr/teleconsultation.
drawbacks and
overall satisfaction
limitations
(respectively: OR =
teleconsultation.
143
during COVID-
3.40, P- value =.049;
19 situations
and OR = 3.79, P-value = 0.049). Lack of physical examination
Gu., et al.
Retrospective
(2020)
study
271
None
Data collection,
The data were
Aims that Covid-
No in-hospital COVID-
questionnaire
analyzed by
19
19 infections occurred
for patients
Prism 8.3.1
infection in
in obstetric unit, but
mental state,
(GraphPad
pregnant
higher prevalence of
analyzed using
Software, San
women can be
gestational
software.
Diego, CA,
avoided by
hypertension and
USA). The t-
teleconsultation.
psychological problem
test was used to
such as anxiety and
analyze changes
depression was
in patient flow.
reported.
The chi-square test was applied to evaluate obstetric outcomes, and the paired t-test was used to compare the psychological status before and after our intervention. Bourbon, et
Prospective
al. (2020)
500
Every patient
Data analysis of
Patients’
To assess the
There was a 96%
observational
who asked for an
patients using
characteristics were
efficiency and
sensitivity and 95%
cohort study
ophthalmic
software.
analyzed using
security of
specificity to properly
emergency
XLstat® and
teleconsultation
evaluate the indication
consultation.
Pvalue.io® software.
with only a laptop
of a physical
computer or
consultation and only
144
smartphone to
1.0% misdiagnoses that
manage the flow
lead to delayed care, it
of ophthalmic
means teleconsultation
emergencies, in a
should be considered as
specialized
a way to efficiently
emergency
regulate ophthalmic
ophthalmology
emergencies.
office in Paris. Ashry
Prospective
(2020)
Study
30
Post- operative
Virtual visits using Check wound status,
Evaluate the
The total number of
neurosurgical
treatment
effectiveness and
telemedicine visits was
patients
Messenger for 30
modification, the time
safety of
67 visits. We received
days
of return to work,
telemedicine
about 62 emergency
postoperative
visits in providing
calls. Pain
complications, and
postoperative care
management, seizures
the radiological data
of neurosurgical
control, wound
of the patients via
patients.
infection, and
virtual visits. The
hydrocephalus is
satisfaction of patients
among issues that were
and doctors was
evaluated and managed
measured with the aid
via telemedicine visits.
of two questionnaires.
The overall satisfaction rate among patients and doctors was 90% and 95%, respectively.
Orazem
Cross-
468
Radiation-
29-question
Two separate
Assess patients’
30,6% of patients
(2020)
sectional data
pati
Oncology
survey for patients
quantitative
and physicians’
expressed interest in
ents
patients
and 25-question
questionnaires for
perspectives on
more frequent usage of
and
survey for
physicians and
wider
telemedicine and
101
physicians
patients. And the
implementation of
23.3% would start
phy
distributed
result was reported
telemedicine in
using it. 67% of
145
sicia
electronically
ns
based on their
radiation
radiation oncologists
frequency distribution
oncology practice
expressed interest in
and to measure the
more frequent usage of
variety of statements,
telemedicine, and 14%
Likert scale was used.
would use it similarly
All statistical analyses
as in the past. Patients
were carried out using
treated with radiation
SPSS.
therapy, 59.9% and 63.4% acknowledged that video consultations would be an important addition to medical care. 61.1% and 63.9% of radiation oncologists believed video consultations would be useful for RT patients.
Mehta (2020)
Survey
51
Pediatric allergy
By completing
Patients who are
Explore the
Patient attitudes toward
and immunology
attitudes and
appropriate for HTH
clinical,
HTH were generally
patients
perception survey,
appointments were
operational, and
favorable. A total of 51
also satisfaction
approached to
financial
HTH appointments
survey
complete attitudes &
feasibility of a
were offered, and 46
perception survey.
home telehealth
appointments were
After that, were asked
(HTH)
made. Notably, 37
to participate in the
program in a
appointments were
pilot program. After
pediatric allergy
completed successfully
that, they complete a
and immunology
among 32 unique
validated satisfaction
clinic.
patients. Patients were
146
survey.
satisfied with the HTH
experience. A total of 36 of 37 encounters were reimbursed by 19 different public and private payers. Payers on average reimbursed ±6% of the expected allowable for an equivalent in- person visit. Sorensen (2020)
Survey
1827
Public’s
A public-facing
A 43-question survey
Determine the
Based on 1827
perception of
survey was
assessed respondents’
public's
analyzable responses,
telemedicine
developed on a
attitudes toward
perception of
we found that a
surgical
Qualtrics (Provo,
telemedicine for
telemedicine
majority (86%) of
consultations
UT) online
initial consultations
surgical
respondents reported
platform using a
with surgeons, both in
consultations,
being satisfied with
modified Delphi
the context of
during the
telemedicine
method
COVID-19 and
COVID-19
encounters.
during “normal
pandemic and
Interestingly,
circumstances.”
beyond.
preference for in-
Participants were
person versus virtual
recruited through
surgical consultation
Amazon Mechanical
reflected access to care,
Turk, an online
with preference for
crowd- sourcing
telemedicine
marketplace.
decreasing from 72% to 33% when COVIDrelated
147
social distancing ends.
Lai (2020)
Interviews
60
Older adults with
Video conference
The impact of
Evaluate whether
Supplementary
and question
neurocogni tive
and telephone
additional services
supplementar y
telemedicine had
naires
disorders and
delivered to both
telehealth via
averted the
their caregivers
care- recipient and
video-
deterioration in the
caregiver through
conferencing
Montreal Cognitive
video conference
platforms could
Assessment evident in
(n = 30) was
bring additional
the telephone-only
compared with
benefits to care-
group (ηp2 = 0.50). It
telehealth targeted at
recipient with
also reversed the
caregivers by
NCD and their
falling trend in quality
telephone only
caregivers at
of life observed in the
(n = 30), over 4 weeks
home.
telephone only group
in a pretest–post-test
(QoL-AD,
design. Interviews
ηp2 = 0.23). Varying
and questionnaires
degrees of
were conducted at
improvements in
baseline and study's
physical and mental
end.
health (Short-Form 36 v2), perceived burden (Zarit Burden Interview Scale) and self-efficacy (Revised Caregiving Self- Efficacy Scale) were observed among caregivers in the videoconferencing group, which were absent in the telephone-only group
148
(ηp2 = 0.23–0.51).
Umoren
Prospective
(2020)
study
-
Children in ICU
InTouch Vici
Telehealth cart was
Explore the
With telehealth, the
in strict isolations
telemedicine cart
places at the bedside.
feasibility of in-
healthcare providers
due to viral
with A Littmann
The nurse was
hospital
requiring PPE decrease
illness
3200 digital
oriented to the use of
telemedicine to
to 7, comparing to
bluetooth
the stethoscope. After
provide pediatric
without telehealth 21.
stethoscope
the patients was
care in strict
discharged or
isolation setting.
removed from isolation, InTouch recommend cleaning protocols for device contamination using isopropyl alcohol and quaternary ammonium germicidal wipes
149
Discussion The health systems in many countries had been modified because of COVID-19 pandemic, as the health care for patients that not primarily involved with COVID-19 were still needed, governments must modify the health system to reduce probability of COVID-19 nosocomial infection and protected both patients and doctors. One of the alternative methods for health care is teleconsultation. This method of health care doesn’t require medical professionals and patients in the same location which can prevent spreading of Coronavirus. Teleconsultation has been around for decades. The first recorded implementation was psychiatric consultation in the late 1950s.[27] From years of practice, it is easily seen that teleconsultation benefits healthcare systems regarding cost reduction, decreases workload of medical professionals, and prevention of mass waiting lists. Despite that,
because
patients and medical professionals are not able to make any physical contacts, teleconsultation still possesses some limitations. Those limitations are concerned to affect communication and health care performances. In this study, we found that patients' perspective on teleconsultation is on a positive note. Freud et al. (2020) [18] stated that implementation of teleconsultation received high satisfaction scores from patients (87%). Relationships between doctors and patients could still be well established, especially in teleconsultation via video, because empathy could be conveyed through doctors’ and patients’ expressions that were seen on screen, and the lack of physical examination didn’t really affect patients' satisfactory results. Based on a public survey conducted by Sorensen et al., (2020) [21], 1827 participants were satisfied with telemedicine encounters even though preference for telemedicine decreased from 72% to 33% when COVID-19 pandemic ends. In D'Haeseleer M et al. (2020) study [16], patients especially multiple sclerosis patients are considered benefited from teleconsultation because those with multiple sclerosis usually have physical disabilities that refrain them from mobility and commonly affect young people who are more familiar with technology. Moreover, Rahman et al. (2020) [17] found that the majority of patients, 100% telephone consultation patients and 97% virtual clinic patients, felt more at ease that they can communicate from home and perceive teleconsultation as effective as in person clinical services in terms of expressing themselves. Although satisfaction rate from patients is considered high, teleconsultation still has many obstacles to tackle from a medical professional perspective. These difficulties consist of lack of technical skills and refusal to use teleconsultation. [14] Teleconsultation requires the use of technology such as software or application. If both parties were not familiar with the operating system, it would lead to confusion and technological hindrance. Jiménez-Rodríguez, D et al. (2020) [14] suggest that before implementation of teleconsultation, it is best to train the medical professionals first. Aside from technical problems, medical professionals should be trained to communicate better with patients. Communication skills such as active listening, clinical interview skills, empathy, emotional support, patience, and problem solving will be restricted in teleconsultation. Training medical professionals is intended to maximize those skills through teleconsultation.
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Absence of physical contact also gives drawbacks. In the study by Shenoy et al. (2020) [15] regarding teleconsultation implementation on rheumatology, there are criterias for patients to make teleconsultation appointments such as patients should be able to get their blood tested in a nearby laboratory, patients didnâ&#x20AC;&#x2122;t plan for any procedure or diagnostic tests. These criterias lead to exclusion for a number of patients which indicates that teleconsultation still can not facilitate all medical problems. In one study using prospective observational cohort method conducted by Bourdon at al. (2020) [20], regarding teleconsultation in ophthalmic patients, there was 1% misdiagnosed which result in delayed treatments, but the sensitivity and successful indication of physical examination were still high, namely 96% and 95%. Thus indicates that teleconsultation could still be taken as consideration to regulate ophthalmic emergencies. Gu et al. (2020)[19] showed that no COVID-19 infection occured in pregnant women during the consultation (conducted online) until the delivery. However, the prevalence of gestational hypertension has increased, as psychological problems such as anxiety and depression, which means teleconsultation still need further evaluation. Nevertheless, teleconsultation is still an option for post operative neurosurgical patients. Ashry et al. (2020) [22] evaluate the effectiveness and safety to perform telemedicine using Facebook Messenger for 30 days. The total number of telemedicine visits was 67 visits and the overall satisfaction rate among patients and doctors were 90% and 95%. Not only in neurosurgery, in a study conducted by Lai et al. (2020) [23], was performed in older adults with neurocognitive disorders along with their caregivers. Video-conferencing groups improved physical, mental health and self-efficacy among caregivers rather than telephone-only groups. Another study by Orazem et al. (2020) [24] performed in 468 radiation-oncology patients and 101 physicians showed that 30,6 % of the patients expressed interest in more frequent usage of telemedicine and 23,3% showed interest to start using telemedicine. 67% of radiation oncologists were interested to use telemedicine more often. 59,9% and 63,4% of the patients agreed that video consultations would be an important addition in medical care. Telemedicine is also an option for pediatric setting. In a survey performed by Mehta et al. (2020) [25] for 51 pediatric allergy and immunology patients, 37 appointments were completed among 32 patients with satisfying results of the home telehealth (HTH) services. In addition, telehealth can help to reduce the use of PPE among healthcare providers especially in isolation settings due to viral illness in ICU. Before the use of telehealth, the amount of PPE needed by healthcare providers was 21 and with telehealth the amount of PPE needed by healthcare providers was only 7 [10]. Teleconsultation can be a solution to decrease the amount of PPE use among healthcare workers especially in small healthcare facilities with limited resources during the COVID-19 pandemic. Teleconsultation can be a way to prevent PPE shortage among healthcare workers. Teleconsultation also enables family visits that could not be conducted due to COVID-19 visit limitation policy. Support from family may improve patientsâ&#x20AC;&#x2122; prognosis.
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Application of teleconsultation becomes the most suitable healthcare delivery option in the middle of this pandemic. Recollecting from these studies, teleconsultation is well-accepted from patients. Although, for improvement, there should be regulation that arranges the mechanism and integration of teleconsultation into broader healthcare systems. Thus, patients data, privacy, and confidentiality will be safer. [26] Conclusion As we saw that telecommunications made communication access between patientsâ&#x20AC;&#x2122; and doctorsâ&#x20AC;&#x2122; become easier, it could be said that telecommunications is a solution to solve communication problems between patients and doctors in COVID-19 Era. Recommendation Further research is needed relating to evaluations of teleconsultation during COVID-19 pandemic in different fields of medicine, this could help to improve the system that has been implemented and could become an option for people who had difficulty accessing health services.
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Reliability of WhatsApp Messenger in X-ray Interpretation by Medical Doctors: A Systematic Review Elizabeth Marcella1, Angeline Tancherla1, Felix Wijovi 1, Jonathan Juniard Anurantha 1 1
Faculty of Medicine, Pelita Harapan University, Tangerang, Banten, Indonesia ABSTRACT
Introduction: WhatsApp Messenger is one of the most popular smartphone applications and is known as a messaging platform that does not reduce the quality of the images in their conversion from analogue to digital. Therefore, WhatsApp Messenger can provide sufficient details for diagnosis and the classification of fractures. However, the reliability of WhatsApp usage for radiograph interpretation is still unclear. The aim of this systematic review is to evaluate reliability of the diagnosis of plain radiographs through images sent via WhatsApp Messenger. Methods: Literature search for this systematic review is conducted in online resources, which includes PubMed, PMC and Science Direct using keywords related to the reliability of WhatsApp messenger usage for x-ray interpretation by medical doctors. Results: A total of 5 studies consisting of 353 X-Ray images were included. All studies reported that intraobserver agreement for determining fracture was good, with kappa scores ranging from excellent to perfect (k = 0.74 - 1.0). One study had reported that radiograph interpretation via WhatsApp Messenger had good sensitivity (72.7% and 78.2%) and specificity (75.2% and 77.9%) in assessing scaphoid fractures with no significant difference in sensitivity (p-value = 0.507) or specificity (p-value = 0.547). Conclusions: WhatsApp is a reliable technology to be used for x-ray interpretations by medical doctors. We hope that WhatsApp Messenger can be widely used as a platform for teleradiology. To improve the study validity, we recommend assessing studies that use evaluate the same type of x-ray images and smartphones with same specifications. Keywords: WhatsApp Messenger, X-Ray, Interpretation Reliability, Medical Doctors
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Reliability of WhatsApp Messenger in X-ray Interpretation by Medical Doctors: A Systematic Review Elizabeth Marcella1, Angeline Tancherla1, Felix Wijovi 1, Jonathan Juniard Anurantha 1 1
Faculty of Medicine, Pelita Harapan University, Tangerang, Banten, Indonesia
Introduction Smartphone technologies have played an important role of communication in the todayâ&#x20AC;&#x2122;s world.1 Mobile health, mobile computing and communication technologies in health care, is a rapidly developing domain within e-health, especially nowadays in this COVID-19 era. There is high interest for mobile-health interventions and it has been argued that there is huge potential for mobile-health interventions to have advantages on health and health service delivery processes, especially in resource-poor and remote settings.2 Health-related smartphone applications offer various features to facilitate patient care. On the other hand, some applications not produced for health-related purposes have become popular among healthcare professionals to facilitate communications related to the daily practice, such as radiological images, laboratory results, and even clinical pictures.3â&#x20AC;&#x201C;6 Ninety-nine percent of doctors own smartphones and 94% use them in work to communicate daily.7 Messaging applications are engrained into most clinical teams and are seen by many as essential to delivering the best possible standards of care.8 Healthcare professionals find that smartphone messaging applications may be effective for remote consultation of patients. However, verbal descriptions without the actual images or reports of these patients are unreliable and insufficient for consultation.9,10 Several studies have reported that smartphones usage has reduced the missed diagnosis of fractures in patients in a general practice or a rural hospital and helped to avoid unnecessary trips to a tertiary hospital to show X-rays to a consultant.11 This method of communication has lead to the emergence of teleradiology. Teleradiology helped general practitioners in viewing radiological images to treat simple dislocations and fractures after consulting orthopedic surgeons and radiologists.12 Such smartphone applications and their image-viewing functions have been shown to be effective, compared to standard workstation images.13,14 In the early stages, people were doubtful about teleradiology, not only due to its new and unconventional technology, but also due to the different characteristics of the smartphones, which may cause varied size and resolution of display.1As time passes by, the advancement of smartphones and transmission of data have open up more possibilities for teleradiology
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application in medical areas.15 However, recent studies have shown modest benefits for clinical diagnosis and other health interventions with use of SMS, due to the poor quality of images. Two studies using photos taken with mobile phone demonstrated a reduced accuracy in the diagnosis of fractures compared with the gold standard, the simple xray. Low camera resolution and loss of data quality due to the conversion from analogue to digital were the main problems found in these studies.1,16,17 WhatsApp Messenger is one of the most popular smartphone application and is known as a messaging platform that does not reduce the quality of the images in their conversion from analogue to digital. Therefore, WhatsApp Messenger has the ability to provide sufficient details for diagnosis and the classification of fractures.14 However, the reliability of WhatsApp usage for radiograph interpretation is still unclear. The aim of this systematic review is to evaluate reliability of the diagnosis of plain radiographs through images sent via WhatsApp Messenger. Materials and Methods Search Strategy Literature search for this systematic review is conducted in online resources, which includes PubMed, PMC and Science Direct. The literature search is done from October 15th to 16th using keywords related to the reliability of WhatsApp messenger usage for x-ray interpretation by medical doctors. The inclusion criteria included (1) an evaluation of the impact of WhatsApp Messenger as one of the primary outcome measurements, and (2) a conclusion containing clear indications for the use of the app. The exclusion criteria included (1) case reports or case series with fewer than 5 patients, (2) other reviews of the literature, (3) meta-analyses, and (4) letters to the editor. No study was excluded due to the original language in which it was written. The studies that we included are retrospective studies and cohort studies that evaluate the reliability of WhatsApp Messenger for xray interpretations. The studies must be in English or Indonesian language and published after year 2010. Unpublished manuscripts, abstracts or lectures, dissertations, books and book chapters, editorials, online articles, letters to the editor or opinion pieces, poster or conference presentations, case reports, case series, meta-analysis, animal study, cross-sectional, case-control studies, systematic reviews, and literature reviews were excluded. We also excluded studies with reported opinions or outcomes through nonstandardized questionnaire, or studies with other main outcomes. Data selection, extraction and analysis were conducted by three independent reviewers (AT, EM, and FW). Any dissimilarities were resolved through discussing with the third author
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(JJA) and reaching a general agreement between the reviewers. The reviewers evaluated the titles and abstract for all selected studies using PRISMA search strategy. Relevant titles and abstracts from each database were chosen. If there was limited information for the reviewers to determine the inclusion and exclusion criteria, the full texts will be evaluated. References that are found in the included and excluded manuscripts were reviewed to discover studies that were failed to be included through the primary search. Studies which met criterias were included in this study, as listed in Table 3. Data extraction Data regarding authorsâ&#x20AC;&#x2122; name; year of publication; study design; country of the study; inclusion and exclusion criteria; sample size; main outcomes (reliability). Collective manuscript reviews were performed on the 3 databases. Full-text manuscripts of the appropriate studies were read and assessed. The study selection process is illustrated in a flow diagram (Figure 1). Outcome Definitions Primary outcome includes intra- and interobserver agreement, intra- and interobserver reliability, specificity and sensitivity. Intraobserver agreement is defined as the degree to which an individual report the same observation of an event of behaviour at two or more intervals. Interobserver agreement is a commonly used indicator of measurement quality which measures the degree to which two or more observers report the same observed values after measuring the same events or behaviour. Intraobserver reliability is defined as the stability of an individualâ&#x20AC;&#x2122;s observation of an event or behaviour at two or more intervals of time. Interobserver reliability is defined as the extent to which two or more observers are observing and recording an event or behaviour in the same way. Results Literature search The initial search through online databases had identified a total of 168 studies, with 10 studies from PubMed, 94 studies from PMC, and 64 studies from Science Direct. The search process was followed by screening of title and abstracts, and the remaining studies were further assessed for eligibility. After a series of selection according to inclusion criteria and exclusion of duplicated studies, we acquired 5 studies for this systematic review. The selection process is shown in Figure 1.
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Characteristics of the Included Studies The characteristics of the included studies are presented in Table 3. A total of 5 studies were included in this systematic review. All studies were cross sectional and published between year 2014 - 2020 The countries of the studies are Israel, Turkey, United States, Brazil and India. There were 3 studies that evaluated intraobserver agreement, with one among them also evaluated interobserver agreement, and two studies also evaluated inter- and intraobserver reliability. Another study evaluated the intraobserver reliability, sensitivity and specificity. One study evaluated both intra- and interobserver reliability. Characteristics of the Studied Population The studies consisted of 353 xray images, Each studies evaluated different types of skeletal trauma, which are scaphoid fractures, pediatric limb trauma, distal humeral and elbow fractures, tibial plateau fractures and maxillofacial fractures. Primary outcomes Intra- and interobserver agreement A total of 3 studies had evaluated the intraobserver agreement. All studies reported that intraobserver agreement for determining fracture was good, with kappa scores ranging from excellent to perfect (k = 0.74 - 1.0). One study had demonstrated that interobserver agreement ranged from excellent to perfect (0.75 < k < 1.0). Intra- and interobserver reliability One study had reported that the intraobserver reliability was fair to moderate, with a kappa score of 0.436 (95% confidence interval 0.295â&#x20AC;&#x201C;0.577). Other study had shown that the intraobserver reliability was very good (kappa score = 0.8), moderate (kappa score = 0.55), and good (kappa score = 0.67). There was no significant difference in the intra- and interobserver reliability between the groups. One study had shown that both intra- and interobserver reliability ranged frim 0.85-0.98. One study shows a near perfect reliability to determining fracture level (kappa score = 0.94). Specificity and Sensitivity One study had reported that radiograph interpretation via WhatsApp Messenger had good sensitivity (72.7% and 78.2%) and specificity (75.2% and 77.9%) in assessing scaphoid
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fractures with no significant difference in sensitivity (p-value = 0.507) or specificity (p-value = 0.547). Discussion Stahl et.al. (2019)18 study, consist of X-ray images of 73 representative cases of pediatric limb trauma were captured and transmitted to 5 pediatric orthopedic surgeons by the Whatsapp instant messaging application on an iPhone 6 smartphone. Evaluators were asked to diagnose, classify, and determine the course of treatment for each case over their personal smartphones. Following a 4-week interval, revaluation was conducted using the PACS. The overall results indicate “near perfect agreement” between interpretations of the radiographs on smartphones compared with computerbased PACS, with κ of 0.84, 0.82, and 0.89 for diagnosis, classification, and treatment planning, respectively. Smartphone-based instant messaging applications are reliable for evaluation of a wide range of pediatric limb fractures. Study done by Stanley et.al. (2020)19 which consist of eleven orthopedic SPRs were recruited and agreed to take part in the study. One participant dropped out from the study, as they were unable to complete the second set of image interpretation on their second index test (desktop) before the study deadline. The sensitivity and specificity of phones compared with radiologist report when suspicious X-rays were classed as fractures were 72.7% (95% CI 56– 84.8) and 75.2% (66.7–82.1), respectively, with a false positive rate of 24.8% and a false negative rate of 27.2%. Adjusting for clustering due to some X-rays being assessed by more than one SPR, there was no significant difference between phone and desktop in sensitivity ( p = 0.317) or specificity (0.572). Suspicious X-rays classed as normal. The sensitivity and specificity for phones was 84.4% (95% CI 70.1–92.6) and 75.5% (67.2–82.2), respectively. The false positive and false negative rates were 24.5% and 15.5%, respectively. Comparing the phone and desktop with adjustment for clustering, there again was no significant difference in sensitivity ( p = 0.699) or specificity ( p = 0.781). Intra-observer agreement was 73.5%, with an expected agreement of 53% giving a kappa score of 0.436 (95% CI 0.295–0.577). This reflects moderate intra-observer agreement between phone and desktop interpretation within the same participant. Another study done by Kapıcıoğlu (2020)20, which consist of patients between 2 and 10 years of age who presented to the emergency department for elbow trauma were included. Only distal humeral Gartland type 1 and 2 fractures and soft tissue traumas at the elbow were included in this study. Those with elbow deformities (n=6), previous elbow trauma (n=15), and open elbow injuries (n=5) requiring medical treatment were excluded from the study. Lateral
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X-rays were captured using an iPhone 7S (Apple Inc., Cupertino, CA, USA) smartphone at a 30-cm distance from the monitor screen using a tripod to capture the entire monitor screen. All identifiers on the images were deleted from the photos before radiological assessment. All consultants made their diagnoses via an iPhone with the WhatsApp application (v2.17.323). Consultants were not informed about the patients' charts and did not have any conversations with the orthopedic surgeon over the phone. There was a good agreement between the first and second evaluations by the physicians via WhatsApp (k=0.74). There was a very good agreement between the first and third evaluations by the physicians (k=0.88), and there was a good agreement between the second and third evaluations (k=0.76). The intraobserver reliability was very good (k=0.8), moderate (k=0.55), and good (k=0.67). The reliability of the first, second and third evaluations was moderate (k=0.55), moderate (k=0.55), and very good (k=0.86) for all physicians, respectively. The reliability of the consultantsâ&#x20AC;&#x2122; diagnosis with the gold-standard diagnosis was almost very good for the first consultant (k=0.78), very good for the second consultant (k=0.92), and very good for the third consultant (k=0.96). The reliability of the median diagnostic value of the first, second, and third evaluations by all consultants with the gold-standard diagnosis was very good (k=0.86), almost very good (k=0.79), and very good (k=0.97), respectively. The images (plain radiographs) were obtained from Giordano et.al.21 obtained 13 images (plain radiographs) of tibial plateau fractures using the iPhone 5 (Apple Inc., Cupertino, CA, USA) and were sent to six observers via the WhatsApp Messenger application. The observers were asked to determine the standard deviation and type of injury, the classification according to the Schatzker and the Luo classifications schemes. The six observers independently assessed the images on two separate occasions, 15 days apart. The inter- and intra-observer agreement for both periods of the study ranged from excellent to perfect (0.75 < x < 1.0) across all survey questions. When asked if the inclusion of the CT images would change their final X-ray classification (Schatzker or Luo), the inter- and intra-observer agreement was perfect (k = 1) on both assessment occasions. Study done by Madi et.al.22 which consist of radiographs of 150 patients assessed by a senior maxillofacial radiologist was performed as the gold standard method for the assessment of fractures by using a workstation monitor. The radiographs were sent to the Gmail accounts of 2 other observers, who used their laptop computers to independently evaluate the radiographs for fractures. The same radiographs were sent to the smartphones of the observers via WhatsApp Messenger and were evaluated on the smartphone screens. In comparison with the gold standard, the reliability of the observersâ&#x20AC;&#x2122; diagnoses from both laptop computers and smartphones ranged from 0.96 to 1.00. Intraobserver and interobserver reliability ranged from
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0.85 to 0.98. Measures of diagnostic efficacy ranged from 93.5% to 100% for images sent by Gmail and from 95.2% to 99.9% for radiographs transmitted through WhatsApp Messenger. All studies included in this review show a reliable result for WhatsApp Messenger as one of the communication media for X-ray interpretation by medical doctors. The current studies demonstrated that the intant messaging application, which is WhatApp Messenger, is reliable for teleradiology implementation in this digital era. This finding may helped general practitioners to treat simple dislocations and fractures after consulting orthopedic surgeons and radiologists through the intant messaging application. Limitation There are several limitations in our study. Firstly, there were only 5 studies that were included in this review. The limited number of studies may cause limitation in assessing the reliability of WhatsApp Messenger for x-ray interpretation. Aside from that, there were differences in the types of radiographs and smartphone specifications, which may cause bias in the result. Strength The strength of our study is that we focused on the evaluation of a specific communication application, which is WhatsApp. Therefore, it is less likely to be biased. Conclusion From the systematic review, we found that WhatsApp is a reliable technology to be used for x-ray interpretations by medical doctors. We hope that, in the future, WhatsApp Messenger can be widely used as a platform for teleradiology. To improve the study validity, we recommend assessing studies that evaluate the same type of xray images and smartphones with same specifications.
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Table 1 Literature Search Strategy Database Pubmed
Keywords
Results
"whatsapp"[All Fields] AND ("diagnostic imaging"[MeSH Subheading] 10 OR ("diagnostic"[All Fields] AND "imaging"[All Fields]) OR "diagnostic imaging"[All Fields] OR "radiography"[All Fields] OR "radiography"[MeSH Terms] OR "radiographies"[All Fields] OR "radiographys"[All Fields])
PMC
"reliability"[All Fields] AND Whatsapp[All Fields] AND ("diagnostic
94
imaging"[Subheading] OR ("diagnostic"[All Fields] AND "imaging"[All Fields]) OR "diagnostic imaging"[All Fields] OR "x ray"[All Fields] OR "x-rays"[MeSH Terms] OR "x-rays"[All Fields]) Science
"Whatsapp" AND "Radiography"
64
Direct
167
Figure 1 PRISMA diagram of the detailed process of studies selection to be included in the systematic review
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Table 2 Summary of studies on reliability of WhatsApp Messenger in xray interpretation by medical doctors Authors
Study design
Country
(year)
Inclusion Criteria (IC)/ Exclusion Criteria (EC), Additional Information (AI)
Giordano, et
Cross
al (2014)
sectional
21
Kapıcıoğlu,
Retrospective
et al (2019)
study
20
Brazil
Turkey
X-ray
Findings
Primary Outcome
Imaging
IC: radiographs and CT scans of patients
P: Intra- and
The inter- and intra-observer agreement for both
who had tibial plateau fractures
interobserver
periods of the study ranged from excellent to
EC: N/A
agreement
perfect (0.75 < k < 1.0) across all survey
AI: N/A
S: -
questions.
P: Intraobserver
There was a good agreement between the first
and 2 fractures and soft tissue traumas at the
agreement, intra-
and second evaluations by the physicians via
elbow in patients between 2 and 10 years of
and interobserver
WhatsApp (k=0.74). The intraobserver reliability
age who presented to the emergency
reliability
was very good (k=0.8), moderate (k=0.55), and
department for elbow trauma
S: -
good (k=0.67). There was no significant
IC: xray of distal humeral Gartland type 1
n = 13
n = 90
EC: xray of elbow deformities, previous
difference in the intra- and interobserver
elbow trauma, and open elbow injuries
reliability between the groups.
requiring medical treatment
AI: N/A Madi, et al.
Cross
(2020)
sectional
22
India
IC: Radiographs of maxillofacial fractures
P: Intra- and
The reliability of the observers’ diagnoses for
EC: N/A
interobserver
both modalities ranged from 0.96 to 1.00
AI: N/A
reliability
compared with the gold standard. Intra- and
S: -
interobserver reliability ranged from 0.85 to
n = 150
0.98. Measures of diagnostic efficacy ranged from 93.5% to 100% for images sent by Gmail
169
and from 95.2% to 99.9% for radiographs transmitted through WhatsApp Messenger. Stahl, et.al
Cross-
(2019)
Sectional
18
Israel
IC: 73 pediatric limb trauma
P: Intraobserver
Intraobserver agreement for determining fracture
EC: Exclude children from their practice
reliability,
level was near perfect (κ=0.94). Intraobserver
and unnecessary referrals from an ED or
Intraobserver
agreement for AO classification, proposed
general practice without an on-call
agreement
treatment, neural canal penetration, and Denis
pediatric orthopedic specialist.
S: -
classification were substantial (κ values, 0.75,
n = 73
AI: N/A
0.73, 0.71, and 0.69, respectively). Intraobserver agreement
for
loss
of
vertebral
height
and kyphosis were moderate (κ values, 0.55 and 0.45, respectively) Stanley, et al
Prospective
United
IC: scaphoid X-rays taken between
(2020)
cross-sectional
States
19
study
P: Intraobserver
Phone and desktop interpretation had good
October and November 2017
reliability,
sensitivity (72.7% and 78.2%) and specificity
EC: second set of image interpretation on
sensitivity and
(75.2% and 77.9%) in assessing scaphoid
the second index test (desktop) that were
specificity
fractures with no significant difference in
unable to be completed before the study
S: -
sensitivity (p-value = 0.507) or specificity (p-
n = 27
deadline by orthopedic specialist registrars
value = 0.547). There was fair to moderate intra-
AI: N/A
observer reliability (kappa score 0.436; 95% confidence interval 0.295–0.577).
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The Potential of VDOT as the New Strategy in Tuberculosis Monitoring of the Non-Adherence Elvando Tanely, Hendri Tanjaya, Jacinda Phowena, Michelle Trisya
1
Undergraduate Medical Program, School of Medicine and Health Sciences, Atma Jaya Catholic
1
University of Indonesia Asian Medical Studentâ&#x20AC;&#x2122; Association Indonesia tanelyelvando@yahoo.co.id
1
ABSTRACT Introduction: TB is a disease caused by bacteria called Mycobacterium tuberculosis and it most often affects the lungs. Up to this point, there were a few methods such as DOT, VDOT, and DATs which proven to be effective as a TB treatment. Aim: To find the most acceptable and effective methods for TB monitoring in non-adherence patients. Methods: In this study, databases including PubMed, ScienceDirect, ProQuest were searched up to 2020. Keywords were: Tuberculosis, DOT, VDOT, SMS and Telemedicine. Study inclusion criteria were: studies from all over the world with general population; English and Indonesian articles. Articles that canâ&#x20AC;&#x2122;t be accessed full-text and published below range of years were excluded from the study. Results: A preliminary search obtained 12,323 articles. 9,633 duplicates were removed. Then, Authors filtered studies based on inclusion and exclusion criteria and finally retrieved 32 studies which were further assessed by full text articles. Authors excluded literature with reason, including a literature published below five years, other outcomes and compares. Finally, it comes with 11 studies include for qualitative and quantitative. Conclusion: All the three techniques show a positive respond, but VDOT appear to be the most acceptable and effective to the TB patients as for they give a more private documentary of the medical records.
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The Potential of VDOT as the New Strategy in Tuberculosis Monitoring of the Non-Adherence Scientific Paper
Author: Elvando Tanely Hendri Tanjaya Jacinda Phowena Michelle Trisya School of Medicine and Health Science Atma Jaya Catholic University of Indonesia Asian Medical Studentâ&#x20AC;&#x2122; Association Indonesia 2020
172
Introduction TB is a disease caused by bacteria called Mycobacterium tuberculosis and it most often affects the lungs. TB is spread through the air when people with lung TB cough, sneeze or spit. A person doesn’t need to inhale many of those TB’s germs to be infected by it. In 2018, an estimated 10 million people fell ill with tuberculosis (TB) worldwide. 5.7 million men, 3.2 million women and 1.1 million children were infected. Although there were cases in all countries, half of the infected people came from countries with low- and middle-income countries such as Bangladesh, India, south Africa, and Indonesia. WHO had been trying to develop various methods and strategies to push down the infection rate of TB. For years, DOT or Directly Observed Therapy has been used as a method of medication for TB. This method has been successful in decreasing the rate of TB’s infection. Unfortunately, DOT is often burdensome for some patient. Patients are required to bear the financial and logistic problem of frequent visit to and from the hospital for treatment monitoring. Time and money will be spent during this process and this has always been the problem of this “DOT” method. Recently, various kind of digital technologies has been developed to try to solve these problems. Digital technologies such as DATs (Digital adherence technologies) and VDOT (Video Directly observed therapy) has been used as an alternative way of curing tuberculosis. By using these methods, it will help to reduce the money and time spent during the curing process of tuberculosis Material and Method We conducted searching on three databases: PubMed, ProQuest and ScienceDirect using queries which could be seen in table Database
Queries
Findings
PubMed
“tuberculosis” OR “VDOT” OR 5,283 “DOT” OR “SMS” END
ScienceDirect
("tuberculosis" OR "TB") AND 4,280 ("vdot" OR "sms" OR "dot") END
ProQuest
("tuberculosis" OR "TB") AND 2,760 ("vdot" OR "sms" OR "dot") AND "telemedicine"
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Selection is made for duplication, then we filtered using inclusion and exclusion criteria. Inclusion criteria are: (study from all over the world, general population, English and Indonesian articles). Exclusion criteria are: (study that published below range of years, full text in other language,). The process of the literature search could be seen in figure 1.
Result A preliminary search obtained 12,323 articles. 9,633 duplicates were removed. Then, Authors filtered studies based on inclusion and exclusion criteria and finally retrieved 32 studies which were further assessed by full text articles. Authors excluded literature with reason, including a literature published below five years, other outcomes and compares. Finally, it comes with 11 studies include for qualitative and quantitative. Discussion DATs Digital adherence technologies (DATs) have the possibilities to give patients a better approach in handling TB. DATs have served a plethora of positive outcomes to TB patients such as reminding patients to take their medications through SMS, simplify digital monitoring of pill taking by the usage of digital pillboxes,
174
and also tracking doses via ingestible sensors. DATs collate patient dosing histories and allow TB medications to be tract simultaneously. SMS research has demonstrated a high degree of acceptability in Peru, Argentina, Uganda, Pakistan, and China. This result also prevails in the search for a digital pillbox in China. Notably, however, a study conducted in the USA revealed poor satisfaction with the SMS system with an efficiency of just 33 percent. Digital pillboxes do limit the mis-recording information through paper records, on the other do limit the accuracy as this tool allows dose to be taken without opening it. This goes for ingestible sensors, since the absence of control of the dose would be triggered by detaching the monitor. To minimize inaccuracy of patient reporting, prevention steps such as offering patient education on the proper use of the device may be used. DATs also transform TB surveillance to a patient-centered approach because DATs are interested in multiple types of devices that lead to their deployment and adoption in diverse sets. There is still a challenge to DAT surveillance, and further research is still needed to really ensure the efficacy of DATs in surveillance TB patients, considering the limited findings of this search. DOT Based on qualitative review of five reviews, three of the study compared effectiveness of DOT than selfadministered therapy (SAT) for TB patients, one of the systematic reviews compared treatment completion rates CB-DOT to clinic-DOT, and last one compared DOT treatment success rates compared to VDOT. One of the studies (Guo, 2019) observed 405 participants using VDOT and DOT. The cost incurred on VDOT was 34.3 (SD 3.8), which was statistically lower compared with 71.6 (SD 49.7) in the DOT group. Patients in the VDOT group had a better experience compared with those in DOT group. The study shows that VDOT saved time and is a cost-effective method. Another study (Jinbo, 2017) was comparing 405 participants with DOT group to non-DOT group. This study showed a significant increase in completion rates with the DOT group (94.6%) when compared to the non-DOT group (73%). Dobler (2015) study in Ulaanbaatar, Mongolia, with 1,769 participants comparing CB-DOT to clinic-DOT by treatment completion dan treatment success. The result showed that treatment completion and success rates were higher in the CB-DOT group compared to clinic-DOT. We also found the data for SAT compared to DOT on TB treatment outcomes (Alipanah, 2018). DOT has lower rates of treatment success, and adherence compared to SAT with not specified population.
175
Fig 2. Treatment Outcomes SAT vs DOT DOT should be the standard of care for all infectious tuberculosis cases (Singapore Ministry of Health, 2016. Good counselling of the patients by the doctor and TB health care worker can further minimize the risk of treatment default. DOT also decreases the rate of failure and defaulting. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone. DOT is a highly effective and efficient means of managing TB. Efforts should be made to increase treatment centres so as to make them available to patients in developing countries that bear a large burden of TB. VDOT This study review uses individual participant data to examine the acceptability and feasibility of VDOT as the standard strategy that was established to ensure adherence to the treatment of TB. Nearly half of the patients used a social networking site daily and were accessed the internet using a cell phone. We found that most of the participant that have been experienced by using VDOT in Uganda and India are very satisfied with the TB treatment monitoring using VDOT than DOT itself. To our knowledge, there is no published study on the use of VDOT in Indonesia.
176
Fig. 3. Participants experienced by using VDOT
The use of VDOT has increased among TB programs in recent years especially in US, Uganda, and India. VDOT has been the modality that most minimized cost, assuming with some equivalent treatment adherence, duration, completion, and adverse event across all of the DOT types, these based on the reported experience of patients using VDOT, from total of 50 patients, 49 patients were satisfied and 1 that dissatisfied. This is promising as a new treatment of TB, since DOT was officially launched as the RNTCP strategy in 1997. With the rapid expansion in mobile network coverage and smartphone ownership in resource-limited settings, such intervention is poised to become more feasible and scalable. Therefore, stigma and privacy issues when using digital technologies in TB management are potential concern that must be carefully considered. Based in our study, there are patients that were concerned about their family members, friends or neighbors finding out about their TB status, which can be underlying fear. This stigma has negative impacts on individuals, especially in seeking care, diagnosis and nonadherence to the patientâ&#x20AC;&#x2122;s status. These findings suggest that patients perceived using VDOT as more private as it relates to their TB status in which most respondents felt that the videophone service improved patientsâ&#x20AC;&#x2122; privacy. For future adoption and scale up of VDOT, this program should address the main reason that prevented video submission. TB program may need to set minimum requirement of the device to be used for VDOT
177
interventions, most of the participants suggest that benefit might have outweighed the difficulties faced from the patientsâ&#x20AC;&#x2122; perspective. Limitations There are a few limitations in the current study such as there might be excluded studies resulted from unpublished records, lack of data reviewed, and lack of long-term observations. Conclusion In conclusion based on the three-technique discussed, VDOT brings the most satisfaction to the people. VDOT main strength compared to other methods are the privacy. VDOT offer patients to keep their TB status stays in private. The findings also conclude that VDOT is the most effective and acceptable technique in TB monitoring. Recommendation Further research should be done to investigate the effectiveness of VDOT as an alternative of tuberculosis treatment. So far, VDOT has proven to be the most efficient in time and money spent during the treatment process of tuberculosis. We recommend to do more studies in Asian countries to further confirm the effectiveness of this VDOT method. References 1. Doshi, R., Falzon, D., Thomas, B., Temesgen, Z., Sadasivan, L., Migliori, G., & Raviglione, M. (2017). Tuberculosis control, and the where and why of artificial intelligence. ERJ Open Research, 3(2), 00056-2017. https://doi.org/10.1183/23120541.00056-2017 2. Istifada, R., Sukihananto, S., & Laagu, M. (2018). PEMANFAATAN TEKNOLOGI TELEHEALTH PADA PERAWAT DI LAYANAN HOMECARE (THE UTILIZATION OF TELEHEALTH TECHNOLOGY BY NURSES AT HOMECARE SETTING). Nursing Current Jurnal Keperawatan, 5(1), 51. https://doi.org/10.19166/nc.v5i1.1102 3. Nugraha, D., & Aknuranda, I. (2017). An Overview of e-Health in Indonesia: Past and Present Applications. International Journal Of Electrical And Computer Engineering (IJECE), 7(5), 2441. https://doi.org/10.11591/ijece.v7i5.pp2441-2450 4. Indria, D., Alajlani, M., & Fraser, H. (2020). Clinicians perceptions of a telemedicine system: a mixed method study of Makassar City, Indonesia. BMC Medical Informatics And Decision Making, 20(1). https://doi.org/10.1186/s12911-020-01234-7
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from
A Systematic Review of Telemedicine as a Communication Mode During the COVID-19 Pandemic: Cancer Patients’ Perspectives Fandi Hendrawan1*, Amandus Michael Martin2, Brenda Kristi2, Enrique Aldrin1 1 Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, AMSA Univesitas Gadjah Mada 2 Medical Faculty of Universitas Brawijaya AMSA Universitas Brawijaya, AMSA Universitas Brawijaya *hendrawanfandi4@gmail.com
Corresponding Authors: Adi Utarini1, Martina Sinta Kristanti2 1 Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia, Phone: +622133113322, Email: adiutarini@ugm.ac.id 2 School of Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Phone: +621227811976, Email: sinta@ugm.ac.id
ABSTRACT Background: COVID-19 rapidly spreads globally and puts cancer patients at higher risk due to limited access to care to minimize exposure. This systematic review focuses on the use of telemedicine as a potential method of routine care delivery and aims to explore communication with healthcare professionals using telemedicine from the patients’ perspectives. Method: A systematic search of key terms was conducted in "PubMed", "Medline", and "Web of Science" databases, and reported with PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) statements. Result: Among 211 articles screened, ten fulfilled our criteria. We found negative, moderate, and positive patients’ experiences. Telephone counselling is the most used method of telemedicine. Satisfaction due to convenience, reduced cost and travel were mentioned as positive experiences with similar clinical outcomes. Demotivation to continue therapy and preference not to use telemedicine in delivering bad news were considered as the negative experiences. Conclusion: Telemedicine is highly recommended to maintain communication and provide high quality routine care for cancer patients, and its use should be strengthened in the pandemic era.
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A Systematic Review of Telemedicine as a Communication Mode During the COVID-19 Pandemic: Cancer Patientsâ&#x20AC;&#x2122; Perspectives
Author Fandi Hendrawan Amandus Michael Martin Brenda Kristi Enrique Aldrin Corresponding Author Adi Utarini Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Phone: +622133113322, Email: adiutarini@ugm.ac.id Martina Sinta Kristanti School of Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Phone: +621227811976, Email: sinta@ugm.ac.id
Faculty of Medicine, Public Health, and Nursing Universitas Gadjah Mada Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia 2020
182
Introduction The World Health Organization (WHO) stated that there were 1.03 million mortalities worldwide due to novel coronavirus disease (COVID-19) until October 3rd 2020 (WHO, 2020). This outbreak has rapidly spread globally to reach 34.5 million people in more than 150 countries since it was identified as a public health emergency of major international concern (WHO, 2020). The emergence of COVID19 was first detected in Wuhan, China and reported on December 31st, 2019 with several cases of unknown etiology of pneumonia. This respiratory disease can easily be transmitted by droplet or airborne transmission through direct transmission by sneezing, talking, coughing, and also indirect transmission by contact made by infected people to external objects (WHO, 2020). Due to the COVID19 pandemic, access to health care centers are limited in order to reduce the risk of COVID-19 transmission. This condition is unfavorable for patients with chronic disease, especially those with cancer. Cancer contributes as the second most global non-communicable disease mortality with 9.07 million deaths (WHO, 2018). Moreover, patients with cancer are included as vulnerable groups with high morbidity and mortality rates in the COVID-19 pandemic era due to their immunosuppressive condition caused by its treatment (Zonghua et al., 2020). In a study of 1,524 patients with cancer, there was a twofold increased risk of SARS CoV-2 infection in patients with cancer compared to the healthy population (Yu et al., 2020). Even cancer patientsâ&#x20AC;&#x2122; case fatality rate was 5.6%, which is higher than the general case fatality rate (2.3%) from COVID-19 (Zonghua et al. 2020). Regular visits to the hospital are necessary for patients with cancer to receive adequate clinical management (Liang et al., 2020). Unfortunately, this was limited due to protocols including physical distancing. Therefore, in the COVID-19 pandemic era, telemedicine has become the best option to provide access to high quality care by the patients, including those who live in the remote areas (Latifi et al., 2020). Mobile health applications as part of telemedicine can give treatment support, patient selfcare, disease management, and also patient education about their conditions to improve their lifestyle. It can also prevent unnecessary patient transfers. Moreover, telehealth applications can further create an interconnected global health communication to improve global health (Kim et al., 2019). In oncology, communication is a key to achieve clinical outcome goals. Cancer management requires interprofessional collaboration, which generally consists of specialist surgeon, oncologist, pathologist, specialist nurse, palliative care specialist doctor, clinical psychologist, therapist, and dietician (Ruiz-Casado et al., 2018). Good communication is needed among the interprofessional team to diagnose and give high-quality patient care. Sufficient quality of communication is also needed to provide patient-centered care to increase patient knowledge and provide mutual understanding for patients and family to achieve behavioral changes (Ellington et al., 2018). Home hospice cancer care has been established to resolve the communication barrier toward patients with cancer. This program
183
requires nurse visits to give physical care in order to comfort the patients with cancer while living with their families, and also provide intense discussion about the patients’ care. This intervention can greatly affect patients’ outcome (Ellington et al., 2018). Several barriers to effective communication for oncology healthcare have been identified, including lack of communication among the interprofessional team, different expectations among clinical staff, lack of skills to provide empathic care to patients and family members, to assess patient expectations, and to initiate discussions about palliative care (Wittenberg et al., 2018). With the increased risk of SARS CoV-2 transmission, these barriers have escalated and care delivery strategies need to be modified in order to ensure both continuity of care and risk minimization. Telemedicine provides several advantages toward patients and healthcare. Several studies have shown the effectiveness of telemedicine intervention, such as teleconsultation for routine consultation of chronic disease, prevention of heart attack, prevention of coronary heart disease, virtual reality exposure therapy for anxiety disorders, telepsychiatry, robot-aided therapy of the proximal upper limb, as well as Internet and computer-based cognitive behavioral therapy for the treatment of anxiety (Ekeland et al., 2010). Reduced waiting time, limited exposure to others who might be carriers of COVID-19, close monitoring of oral therapy and reduced demands on the personal protective equipment (PPE) among healthcare were among the advantages of telemedicine in general (Audrey et al., 2020). We conducted a systematic review to explore cancer patients' perspectives in communicating with healthcare professionals using telemedicine. Findings from the current review are expected to encourage healthcare providers in implementing telemedicine for providing cancer care during this COVID-19 pandemic era. Material and Method Search Strategy PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement rules were used to report the journal selection process. We searched works of literature published in "PubMed", "Medline", and "Web of Science" databases with keyword “telemedicine OR telehealth OR mhealth OR teleconsultation'', “cancer OR neoplasm”, “COVID-19 OR SARS OR coronavirus OR SARS CoV-2”. The search was limited to human participants and no language restrictions were applied. Concept of the literature search strategy can be seen in Figure 1. Inclusion and exclusion Criteria We applied the following inclusion criteria: (1) empirical studies that show how telemedicine was used for patients with all types of cancer; (2) study was conducted during COVID-19 pandemic era; (3) studies were written in English; and (4) the studies were focused on patients’ perspective. We also set
184
the exclusion criteria: (1) study population of hospitalized or intensive care unit (ICU) cancer patients, and (2) unfound full-text articles. Selection of Studies Two reviewers (EA, FH) conducted the screening based on the titles and abstracts independently to examine eligibility. Any duplicate articles were listed and removed with EndNote X9 software. All reviewers retrieved the full texts of all papers identified as potentially relevant and also assessed these papers independently. Any disagreement was solved by discussion between authors. Data extraction and Evaluation of Studies We extracted all data from the articles including author’s name, years of publication, study design, population characteristic, intervention implemented, and outcome, such as cancer patients’ quality of life improvement, perspectives (obtained from patients, family, caregivers, and health professionals), and the effectiveness of the program, and other reported outcomes. Then, three subdomains were generated in order to simplify the outcomes (negative, moderate, and positive experiences). Quality Assessment All studies were evaluated by using Joanna Briggs Institute (JBI) Critical Appraisal Tools based on their appropriateness to the methodology for each article. No study was excluded based on quality. The assessment of included studies was conducted by all reviewers independently and discrepancies were resolved by consensus between reviewers. These appraisals were presented using a range of coding systems. Every “Yes” answer is counted as 1 point. A coding system of 1—8 was applied to three papers; 7—8 was considered high quality, 3—6 was considered moderate and below 3 poor. One paper was appraised using a coding system of 1—10; 8—10 was considered as high quality, 4-7 was considered as moderate and below 4 poor. The last one article was assessed by a coding system of 1— 11; 9—11 was considered as high quality, 5—8 was considered as low quality, and below 5 poor. Detailed information on the evaluation score is attached in Appendix 1. Results We identified 211 articles from the electronic primary databases of PubMed, Medline and Web of Science. After removal of duplicates, 130 articles were left. The remaining articles were screened by the title and abstract and 35 articles were selected for full-text review. Finally, we included 10 articles that met our inclusion criteria. Six articles were identified as moderate quality while the other four were considered as high quality articles based on our appraisal. The Characteristic of Studies
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The ten included articles are composed of 8 cross-sectional studies (Atreya et al., 2020; Kotsen et al., 2020; Orazem et al., 2020; Paleri et al., 2020; Rodler et al., 2020; Smrke et al., 2020; Yildiz et al., 2020; Younger et al., 2020), 1 cohort retrospective study (Klain et al., 2020), and 1 qualitative study (Triantafillou et al., 2020). In this review, 7 studies were conducted in Europe (Klain et al., 2020; Orazem et al., 2020; Paleri et al., 2020; Rodler et al., 2020; Smrke et al., 2020; Yildiz et al., 2020; Younger et al., 2020), 2 in the United States of America (Kotsen et al., 2020; Triantafillou et al., 2020), and 1 in Asia (Atreya et al., 2020) while there were no articles that were conducted in Africa and Australia. Due to cancer being a chronic and severe disease, either tertiary care hospitals or medical centers for cancer were the only possible places for research to be conducted. Most of the articles mention the specific type of cancer (Klain et al., 2020; Kotsen et al., 2020; Paleri et al., 2020; Rodler et al., 2020; Smrke et al., 2020; Triantafillou et al., 2020; Younger et al., 2020) while the others do not mention specifically the cancer type (Atreya et al., 2020; Orazem et al., 2020; Yildiz et al., 2020). A total 12,699 participants were included in this systematic review. Table 1 describes the study characteristics. Telemedicine Intervention Generally, telemedicine can be used either as a single intervention or together with other types of telemedicine (Table 2). In this review, 6 out of 10 articles use single telemedicine (Atreya et al., 2020; Kotsen et al., 2020; Paleri et al., 2020; Rodler et al., 2020; Smrke et al., 2020; Triantafillou et al., 2020) with telephone counseling as the most popular in both groups. The topics during intervention mostly talk about patientsâ&#x20AC;&#x2122; opinions (Kotsen et al., 2020; Orazem et al., 2020) and experiences (Smrke et al., 2020; Triantafillou et al., 2020) when they used telemedicine. The longest intervention was conducted for 21 weeks (Atreya et al, 2020) while the shortest was conducted only for four weeks (Smrke et al., 2020; Triantafillou et al., 2020). The frequency of intervention was only reported in two articles. Patientsâ&#x20AC;&#x2122; Perspectives We classified the responses of patients into three subdomains (negative, moderate, and positive experiences) (Table 3). For the positive experiences, most patients reported they were satisfied with telemedicine services due to the convenience of telemedicine service (Atreya et al., 2020; Orazem et al., 2020; Rodler et al., 2020; Smrke et al., 2020; Triantafillou et al., 2020; Younger et al., 2020). Others also mentioned the reduced cost and time to travel to health-care facilities (Smrke et al., 2020; Triantafillou et al., 2020; Yildiz et al., 2020; Younger et al., 2020). Compared to face-to-face consultation, completion rate was higher in telemedicine service (Klain et al., 2020; Kotsen et al., 2020; Paleri et al., 2020). For the moderate experience, the outcome therapy between telemedicine and faceto-face service was the same (Klain et al., 2020). For the bad experiences, physical contact and physical examination were not performed (Orazem et al., 2020; Triantafillou et al., 2020). Also, some patients felt unmotivated to continue their therapy (Rodler et al., 2020). In the case of bad news, some patients
186
prefer to not hear it with telemedicine (Smrke et al., 2020). Often people with an older age found it is uncomfortable to use telemedicine and prefer face-to-face appointments (Kotsen et al., 2020).
Figure 1. Flow Chart of the Study
187
Table 1. Summary of Findings No. Author (year) Country
Settings
Aim of study
1
Tata medical center
To assess patient's Crossperception about sectional the provision of telehealth service
Atreya et al., 2020
India
Study Design Type of Cancer
Number of Sample
All advance 50 cancer
Summary of Findings
2
3
Klain et al., 2020
Italy
Kotsen et al., USA 2020
University To investigate Hospital Federico telemedicine II impact during COVID-19 pandemic on management of patient
Crosssectional
Thyroid cancer
Memorial Sloan To examine the Kettering Cancer effect of Center telemedicine on patient with tobacco-related cancer engagement
Cohort retrospective
450
188
Tobaccodependent cancer
289
64% of patients and their care-givers scored "comfortable" using telehealth services 54% rated the conversations "satisfying" 82% of the respondents were "satisfied" with regard to the time provided and clarity of advice. 76% of the participants would prefer teleconsultation in future and were ready to pay for teleconsultations Compared to in ward patient in 2019 (n=525), only 15% of outpatients are lost to be followed-up There was not differences between on-site service and telemedicine services outcome
Compared to direct meeting, telehealth visit completion is higher (OR=1.84, CI=1.26-2.71) Older people feels discomfort when they need to navigate an audiovisual feature in their devices
No. Author (year) Country
Settings
Aim of study
Study Design Type of Cancer
Number of Sample
Summary of Findings
4
Institute of Oncology Ljubljana
To assess patients’ perspectives on the potential of remote visits during the COVID-19 situation
Crosssectional
468
Orazem et al., Slovenia 2020
All cancer type
8% avoid face-to-face appointment due to the fear of COVID-19 15% of the patients would prefer video consultations even though it were not existed for a while 92.6% patients experienced "good" or "exceptionally good" during telemedicine service 30.6% patients were interested to use telemedicine more frequently 23.3% patients would try to start using it 27.9% undecided 82.9% felt miss personal contact with their caregivers 89.9% missed the classical clinical examination
5
Paleri V et al., United 2020 Kingdom
Head and neck cancer unit
To demonstrate Crossan sectional implementation of remote triaging system
Head and 10,244 neck cancer
No telemedicine interventions were refused by patients as they understood the reasons behind it
6
Rodler et al., 2020
Ludwig Maximilian University
To address the perceptions and expectations of our patients to forge the future management
Urology cancer
Patients prefer to visit on-site (chemotherapy patients are higher than immunotherapy patients) Generally, telemedicine is appreciated by most patients by rank all measures higher than the other patients. Phone (76.9%), e-mail (56.7%), patient-reported outcome applications (22.0%), and video call are preferred by most patients
Germany
Crosssectional
101
189
No. Author (year) Country
Settings
Aim of study
Study Design Type of Cancer
Number of Sample
Summary of Findings
7
The Royal Marsden Hospital (RMH) Sarcoma Unit
To provide an understanding of patient from adopting telemedicine
Crosssectional
270
Smrke et al., 2020
United Kingdom
Advance stage sarcoma
8
9
Triantafillou et al., 2020
Yildiz et al., 2020
United States
Turkey
Head and Neck Otolaryngology Ambulatory Clinic
To explore head Qualitative and neck patients’ perceptions about telemedicine clinic visits during COVID19.
Head and 56 neck cancer
Oncology Department
To determine the Crossproportion of sectional patients using telemedicine whose demands were met
All type of cancer
421
190
Mean satisfaction for telemedicine was higher than face-to-face (89.9% vs. 83.5%) due to reduced transportation expenses (20%), time (42%), and it is convenience (30%) 86.6% would like to use telemedicine for future appointments Patients who preferred telemedicine were younger than the one who preferred face-to-face. Delivering bad news using telemedicine is declined by most of patient (48%) Accessibility and cost and time savings were the primary advantages with telemedicine service Physical examination still cannot be performed Most patients willingly to participate again in the future remote visits
The demands were met without the need for on-site visit No need to travel across province
No. Author (year) Country
Settings
Aim of study
10
Sarcoma Unit
To assess the Crossimpact of the sectional COVID-19 pandemic on sarcoma patients’ experiences, mental health condition, and their quality of life
Younger et al., 2020
United Kingdom
Study Design Type of Cancer All type of sarcoma
Number of Sample
Summary of Findings
350
191
Patients felt worry about COVID-19 COVID-19 worry and insomnia were felt by most patients who did not know their treatment. Patients who felt COVID-19 worry preferred to have a face-to-face appointment Patients’ satisfaction toward telemedicine service is higher than face-to-face service Patients prefer telemedicine because reduced travel cost and time, and convenience
Table 2. Telemedicine Intervention Author (year) Atreya et al., 2020 Klain et al., 2020
Kotsen et al., 2020 Orazem et al., 2020 Paleri et al., 2020
Type of Telemedicine
Topic
Telephone counseling
Patients’ feeling about telemedicine service N/A
Telephone counseling Fax and email to receive biochemical and imaging data and to send out teleconsultation reports. Telephone counseling
Telephone counseling Contacted by email Telephone counseling
Rodler et al., 2020
Video counseling
Smrke et al., 2020
Telephone counseling
Triantafillou et al., 2020 Yildiz et al., 2020
Video counseling
Video counseling WhatsApp or short messaging service Telephone counseling Younger et Video counseling Telephone counseling al., 2020 *N/A = Not available
Length of intervention (weeks) 21 weeks
Frequency
12 weeks
N/A
Patients’ opinion about telemedicine Patients’ opinion about telemedicine Patients’ acceptance about telemedicinetriage system Patients’ mental health condition and acceptance of telemedicine Patients’ preference between face-to-face or telemedicine consultation and their reason behind it Patients’ experience using telemedicine Can telemedicine fulfill most of patients’ demand?
12 weeks 3 weeks
1 times per month N/A
N/A
N/A
N/A
N/A
4 weeks
N/A
4 weeks
3 times
6 weeks
N/A
Patients’ experiences using telemedicine
8 weeks
N/A
192
N/A
Table 3. Patientsâ&#x20AC;&#x2122; Perspectives about Telemedicine Intervention Negative experiences
Moderate
Positive experiences
Miss physical contact examination No differences in the outcomes (Orazem et al., 2020; Triantafillou et of telemedicine compared to al., 2020) face-to-face consultation (Klain et al., 2020)
High rate of satisfaction (Atreya et al., 2020; Orazem et al., 2020; Rodler et al., 2020; Smrke et al., 2020; Triantafillou et al., 2020; Yildiz et al., 2020; Younger et al., 2020)
Unmotivated to continue the therapy (Rodler et al., 2020)
High rate of visit completion (Klain et al., 2020; Kotsen et al., 2020; Paleri et al., 2020)
Deny any bad news (Smrke et al., 2020)
Low travel cost and travel time (Smrke et al., 2020; Triantafillou et al., 2020; Yildiz et al., 2020; Younger et al., 2020)
Discomfort due to navigating their own device (Kotsen et al. 2020)
Convenience to use (Smrke et al., 2020; Younger et al., 2020)
Discussion COVID-19 greatly affects all people worldwide especially patients with cancer. Currently, there is no antiviral treatment or specific vaccine for this virus. Hence, healthcare needs to protect themselves and prevent people from being infected with this virus. This need for protection makes them experience difficulty in healthcare access and mental health issues. The most commonly reported effects for those in active treatment were for changes to in-person cancer provider appointments (ACS CAN, 2020). In this review, we found that most of the research was conducted in Europe instead of other regions. It is believed the first telemedicine application was in Europe by a Dutch scientist in 1905 (Ryu, 2010). Since the first application, the acceptance of telemedicine is better by people in Europe. Meanwhile, the first usage of telemedicine in hospital settings was in America in 1946. The use was limited only for psychiatric patients in the Nebraska Psychiatric Institute and Norfolk State Hospital (Services & Medicine, 2012). Since then, the implementation of telemedicine has been widely used not only for psychiatric patients, but also other specialties such as ICU, stroke care, and cancer care (Services & Medicine, 2012). Also, socioeconomic status of a nation may not be a burden for the implementation of telemedicine. In this review, we include one study from India which is considered as a developing country with low socioeconomic status (Atreya et al., 2020). Although the application of telemedicine is broadly used, Africa may face difficulties due to the shortage of medical professionals (Mars, 2013). This may explain why there is no study conducted in Africa. Many approaches were mentioned in the studies and the phone was the media that was frequently mentioned. With its flexibility, which does not depend on Internet status, telephone counseling is
193
basically ideal in rural areas with limited Internet connection (Mars, 2013). Moreover, it is more acceptable in patients with an older age since it is convenient and easy to use (Smrke et al., 2020; Younger et al., 2020). Despite its advantage, most patients prefer to have video counseling with their physicians. Orazem et al. reported that most of the physicians in their study believe video calls can help them to follow-up the patients with post-radioiodine therapy (Orazem et al., 2020). Other Internetdependent approaches such as email, instant message, and social media are also mentioned in the studies (Klain et al., 2020; Orazem et al., 2020; Yildiz et al., 2020). Toh et al. in their review believed such approaches can build and strengthen the relationship between patients and care-givers, especially young adults (Toh et al., 2016). In the COVID-19 pandemic, telemedicine in oncology is broadly used to follow-up and control the patient flow to the hospital as they may require a longer period of quarantine if they are exposed to this virus compared with the general population (Alhalabi, et al., 2020). The frequent target population is the post-therapy patients. In regards to telemedicine acceptance in the population, most patients gave more positive feedback on telemedicine services (Atreya et al., 2020; Orazem et al., 2020; Rodler et al., 2020; Smrke et al., 2020; Triantafillou et al., 2020; Younger et al., 2020). Since the use of telemedicine does not need a direct visit, there is no need to travel to healthcare facilities so the cost and time can be reduced (Smrke et al., 2020; Triantafillou et al., 2020; Yildiz et al., 2020; Younger et al., 2020). Stopping travel and direct consultation with local oncologists at a local hospital could avoid unnecessary exposure to COVID-19. Implementing frequent telemedicine visits with very short-term follow-up will likely help avoid miscommunication (Alhalabi et al., 2020). In addition, Atreya and Triantafillou mentioned that most patients were willing to pay for the telemedicine services if it is needed (Atreya et al., 2020; Triantafillou et al., 2020). The effect of telemedicine service is not limited only in travel. The rate of satisfaction in the way care-givers communicate with the patients was higher than face-to-face visits (Atreya et al., 2020). This might encourage patients to complete their therapy (Klain et al., 2020; Kotsen et al., 2020; Paleri et al., 2020). The reason for the phenomenon is unknown, but we speculate that the stress level of care-givers is probably lower in telemedicine services than face-to-face services. A research conducted in 2012 showed high and moderate stress were correlated with care-givers’ word selection, behavior, and offered less psychosocial information which are important for patients’ satisfaction and good quality of care (Ratanawongsa et al., 2012). With a lower stress level, the quality of care, relationship between care-givers and their patients, and patients’ satisfaction can be maintained. The knowledge of patients also played a role in the acceptance of telemedicine. Paleri et al. stated patients who accept telemedicine services already understand the reasons for remote therapy and end up completely finishing their therapy (Paleri et al., 2020). Meanwhile, Klain et al. reported that there were no differences in outcomes of therapy between on-site visits and telemedicine services (Klain et al., 2020). This finding was expected since the implementation of telemedicine is limited to control a patient’s condition, not to treat the cancer itself.
194
Although telemedicine is welcomed in the population, physical contact and physical examination are missed in the services since they are not provided in telemedicine services (Orazem et al., 2020; Triantafillou et al., 2020). Face-to-face services always provide the direct examination and it is more reassuring for some patients (Rodler et al., 2020). Rodler et al. reported that some patients become unmotivated to continue their therapy since their condition is getting worse. Of note, the demand of patients to come and discuss their condition and further plan directly with their care-givers without any mask and physical distancing protocols was considered crucial to incline them to continue their therapy (Rodler et al., 2020). Moreover, some patients feel more worried and anxious about their cancer than being infected with COVID-19 (Rodler et al., 2020; Younger et al., 2020). Some patients stated that they do not want to hear any kind of bad news via telemedicine (Smrke et al., 2020). This is solely reported by Smrke who conducted the research in India. In India, social and cultural norms are some of the many aspects that must be respected. In a recommendation written by Naik, it is noted that delivering bad news by phone or not face-to-face is not accepted in that country (Naik, 2013). Study Strength and Limitations The strength of this study lies in the fact that most studies included in our review used a large number of samples. This review also compares the type of telemedicine used in every article specifically to know its acceptance and effectiveness. However, this review was restricted to journals in English due to language limitations, even though there are several local studies on the use of telemedicine that can be used to review the impact of telemedicine according to the characteristics of a country. Moreover, this review does not include any healthcare professionalsâ&#x20AC;&#x2122; perspectives. Furthermore, this study does not limit the specific type of cancer and study design. Conclusion In order to prevent the exposure of COVID-19 to patients with cancer and care-givers, telemedicine can be used during this pandemic. In this review, the acceptance of telemedicine services, by evidence, is high enough to be implemented during this pandemic. Moreover, telemedicine can help patientsâ&#x20AC;&#x2122; economic situation indirectly by reducing the cost that is needed to access healthcare facilities. However, since telemedicine cannot provide any physical contact, direct physical examination cannot be applied with telemedicine. Hence, it is better suited for consultations for patients with chronic disease. Future Application and Research
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The results of this systematic review can be a basis for oncologists in making decisions regarding the use of telemedicine to reach their patients in the COVID-19 pandemic. Further intervention research is needed to measure the impact of telemedicine during the COVID-19 pandemic. In-depth intervention qualitative research needs to be conducted to explore more deeply the perspectives of patients. The future research should also report the frequency of telemedicine use so that it can become a reference to determine telemedicine applications by clinicians. Acknowledgement We are grateful to our teachers and mentors, Prof. dr. Adi Utarini, M.Sc, MPH, Ph.D. and Martina Sinta Kristanti, S.Kep, Ns., MN, Ph.D. for the support and assistance during the process of creating this review. This review was supported by the Universitas Gadjah Mada. References Alhalabi, O., & Subbiah, V. (2020). Managing cancer care during the COVID-19 pandemic and beyond. Trends in Cancer. doi:10.1016/j.trecan.2020.04.005 Asokan, I., Rabadia, S. V., & Yang, E. H. (2020). The COVID-19 Pandemic and its impact on the cardio-oncology population. Current Oncology Reports, 22(6). Atreya, S., Kumar, G., Samal, J., Bhattacharya, M., Banerjee, S., Mallick, P., Chakraborty, D., Gupta, S., & Sarkar, S. (2020). Patients’/caregivers’ perspectives on telemedicine service for advanced cancer patients during the COVID-19 pandemic: an exploratory survey. Indian Journal of Palliative Care, 26(5), 40. https://doi.org/10.4103/IJPC.IJPC_145_20 Audrey H. Teleconsultation and COVID-19: who can practice remotely and how?. Ministère des Solidarités et de la Santé, (2020). http://solidarites-sante.gouv.fr/soins-et-maladies/maladies/maladiesinfectieuses/coronavirus/professionnels-de-sante/article/teleconsultation-et-covid-19-qui-peutpratiquer-a-distance-et-comment [Google Scholar] Ekeland, A. G., Bowes, A., & Flottorp, S. (2010). Effectiveness of telemedicine: a systematic review of
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Appendix 1. Quality Assessment of Studies For cross-sectional studies Checklist
Smrke et al., 2020
Atreya et al., 2020
Klain et al., 2020
Orazem et al., 2020
Rodler et al., 2020
Yildiz et al., 2020
Younger et al., 2020
Paleri V et al., 2020
1
Criteria for inclusion in the sample were clearly defined
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
2
The study subjects and the setting were described in detail
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
3
The exposure was measured in a valid and reliable way
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
4
Objective, standard criteria were used for measurement of the condition
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
5
Confounding factors were identified
Yes
No
Yes
No
Yes
No
Yes
No
6
Strategies to deal with confounding factors were stated
No
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
N/A*
7
The outcomes were measured in a valid and reliable way
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
8
Appropriate statistical analysis was used
No
No
Yes
Yes
Yes
Yes
Yes
No
No
200
Total Score and Interpretation
5 (moderate)
5 (moderate)
7 (high)
6 (moderate)
6 (moderate)
*N/A: Not applicable For qualitative studies Checklist
Triantafillou et al., 2020
1
Congruity between the stated philosophical perspective and the research methodology
Yes
2
Congruity between the research methodology and the research question or objectives
Yes
3
Congruity between the research methodology and the methods used to collect data
Yes
4
Congruity between the research methodology and the representation and analysis of data
Yes
5
Congruity between the research methodology and the interpretation of results
Yes
6
A statement locating the researcher culturally or theoretically
No
7
The influence of the researcher on the research, and vice- versa, addressed
Yes
8
Participants, and their voices are adequately represented
Yes
9
Evidence of ethical approval
No
No
Conclusions drawn in the research report flow from the analysis, or interpretation, of the data Total score and Interpretation 10
Yes 8 (high)
201
6 (moderate)
7 (high)
4 (moderate)
For cohort studies No
Checklist
Kotsen et al., 2020
1
Two groups were similar and recruited from the same population
Yes
2
The exposures were measured similarly to assign people to both exposed and unexposed groups
Yes
3
The exposure were measured in a valid and reliable way
Yes
4
Confounding factors were identified
Yes
5
Strategies to deal with confounding factors were stated
No
6
The groups/participants were free of the outcome at the start of the study (or at the moment of exposure)
Yes
7
The outcomes were measured in a valid and reliable way
Yes
8
The follow up time was reported and sufficient to be long enough for outcomes to occur
Yes
9
The follow up was complete, and if not, the reasons to loss to follow up were described and explored
Yes
10
Strategies to address incomplete follow up were utilized
Yes
11
Appropriate statistical analysis was used
Yes
Total Score and Interpretation
10 (High)
202
Pre-Conference Competition EAMSC Manila 2021
PATIENT-CENTERED CARE AS FORM OF COMMUNICATION IN INTERPROFESSIONAL COLLABORATION ERA: A SYSTEMATIC REVIEW FROM PATIENT PERSPECTIVE Farida Aisyah1 1 rd
3 Year Of Medical Student, University Of Sebelas Maret, faridaaisyah323@gmail.com Abstract
Introduction Communication becomes main caused of medical error, contributes to 44,000-98,000 patient death. Communication in healthcare delivery handle by health practitioner through IPC yet nowadays, IPC found its challenges like demand for active role of patient, to answer this challenge PCC seems to be the best solution, therefore aim of this review to find the outcome of PCC as form of communication in IPC era. Methodology Using PRISMA criteria with GoogleScholar and PubMed followed by keyword ‘PCC in IPC’ ‘patient satisfaction’ ‘patient and health provider communication’ ‘interprofessional communication and collaboration in healthcare’. For study selection, obtain 8 studies that met inclusion and exclusion and for quality assessment using CASP. Result Studies divided into 3 categories into role of healthcare practitioner, communication and education with patient, and patient need. Role of healthcare practitioner dominate with nurse assistance and patient were subjectively unsatisfied
about role of health provider, for communication and education patient complaint in lack of patient and staff knowledge, lack of communication, and long pause examination, last for patient need dominate on prolonged waiting and lack of understanding among patient in special need. Discussion Effect of lacking these 3 categories is less patient satisfaction where
higher satisfaction and trust were associated with the success of PCC conversely, poor satisfaction from majority studies related to increasing the burden of illness.
203
Conclusion PCC practices from the studies reviewed still show practices that are
not per the IPC leading to patient dissatisfaction and low quality of patient health Keywords: Communication, Interprofessional Collaboration, Patient-Centered Care, Health Practitioner, Patient
204
PATIENT-CENTERED CARE AS FORM OF COMMUNICATION IN INTERPROFESSONAL COLLABORATION ERA: A SYSTEMATIC REVIEW FROM PATIENT PERSPECTIVE
Author: FARIDA AISYAH
(G0018071)
UNIVERSITY OF SEBELAS MARET SURAKARTA 2020
205
Introduction Communication defined as transaction process of message creation, in term of the health system, communication assist the performance of health provider which including accurate, consistent, and easy working environment to establish satisfaction among patient, patient’s family, and health professional (Lambrini et al., 2014). Effective and efficient communication becomes fundamentally and critically in the delivery of healthcare, especially in a country with a general practitioner as an obligatory gatekeeper, such as United Kingdom (Agarwal et al., 2010; Vermeir et al., 2015). Communication in health care is bidirectional in the meaning of the patient have to able to transfer information related to their complaint to the healthcare practitioner, healthcare practitioner requisite adept to understand and interpret patient’s complaint to treat them properly, prevent the recurrent event of disease, and maintain patient’s health (Ratna, 2019). Communication failures among patient, patient’s family, and between health practitioner are the most common primary cause of an adverse event and medical error in health care, study shows inadequate communication on medicine use lead to medication error with the level error was 20% or 50 errors in 250 medication with 27 error were categorized as serious consequences, other studies in American hospital said, poor communication contribute on 44,000-98,000 of patient death annually and the main cause of preventable deaths yet from 2,273 health practitioner who participated in the previous study, 54% physician and 52.3% nurse testify to ever experience medical error due to lack of communication, consist as incorrect drug administration (32.8%), delivery of the drug to the wrong patient (40.7%), followed by a medical error in adult internal medicine by the physician (42.3%) and nurse (39.5%), in financial perspective, communication inefficiencies of healthcare delivery resulting in $12 billion loss annually, increase in length of stay for 53%, and loss of 500 hospital bed equal to $4 million loss annually (Stephanie et al., 2015; Karin et al., 2012; Shaurya, 2010; Ibrahim et al., 2017; Agarwal et al., 2010). Accordingly, inadequate communication remains unscrutinized as communication between physician, between a nurse, between the hospital, and crucially among healthcare professional, one doom fact is interprofessional communication become the vital factor to determine the success of health services yet interprofessional communication shows very poor grades, physician and nurse often develop non-verbal communication where the physician routinely wrote instruction rather than speaking directly, if nurse missed checking the patient’s file and missed the instruction it will affect patient health quality, other hand nurses have fear to question what they might acknowledge as a standard practice
206
of a physician also hierarchy becomes an inevitable obstacle, often happen resident hold themselves from seeking guidance from their physician because the fear to become a nuisance followed by hesitancy among health provider due in case of not to offend attending other physicians (Shaurya, 2010). In this last decade, interprofessional collaboration (IPC) based on interprofessional education (IPE) has become the main candidate in solving interprofessional communication problems among healthcare practitioners as no single profession can meet al.l patient’s needs meanwhile through collaboration, it is hoped that the needs of patients can be met (Vasiliki et al., 2014). Interprofessional collaboration based on interprofessional education defined as the process of working together among two or more professions to improve a patient’s health quality based on their previous experience as a student on learning with other professions related to about, from, and with each other profession (Bart et al., 2015). Lack of interprofessional collaboration will delay healthcare delivery by failures in clinical assessment, clinical reasoning, and shared decision making resulting also in medical error mainly missing indication and misdiagnosis, study shows a lack of IPC which nurses reported they were not informed properly by the department physician (p=0.039) because of skeptical attitude towards nurses (p=0.029) (Timothy et al., 2018). Interprofessional collaboration, although as a form of solution to miscommunication, IPC still met its challenge include improve patient literacy of healthcare, development of pathophysiology of a disease, the rising expectation of chronic illness and cancer patient toward their survival lead to high demands of an active role of the future hospital and in need of designing strategies of effective communication among patient, patient’s family, and healthcare provider as in form of interprofessional collaboration for health practitioner, this challenge supported by report said one-fifth patient complain about their communication with doctor and nurse related to conflicting information and health practitioner not knowing which physician is in charge (Cynthia et al., 2016; Zayyanu et al., 2018; Tess et al., 2017; Seago, 2008). To meet the needs of efficient communication for patients, patient families, and health practitioners in the interprofessional collaboration era, a solution emerged namely patient-centered care communication. Patient-centered care (PCC) communication is considered as a solution that can tackle interprofessional collaboration challenge. Patient-centered care defined as care which is respectful and responsive towards the patient’s need, values, preferences, and assure that patient’s decision guide all clinical decision include respectfully sharing necessary information to encourages and support patients and their families (Stephanie et al., 2015). Definition of PCC should contain eight terms, which is: 1) Respect for patient
207
preferences, values, and expressed needs; 2) Information, education, and communication; 3) Coordination and integration of care and services; 4) Emotional support; 5) Physical comfort; 6) Involvement of family and close others; 7) Continuity and transition from hospital to home; 8) Access to care and service (Cheryl et al., 2012). As a solution to communication in the interprofessional collaboration era, the outcome of patient-centered care can no be determined yet, studies conducted before only discuss the result of PCC separately according to a specific department, additionally study about PCC still limited, therefore, this systematic review has the aim to find out the outcome of patient-centered care as a form of communication in interprofessional collaboration era from a patient perspective and to find out whether PCC is really implemented correctly, not just a back term so that a problem will seem to have been resolved. Materials and Methods This systematic review using Prefered Reporting Items for Systematic Review and Meta-Analysis criteria (PRISMA) (Moher et al., 2009). To find relevant studies, journal searching conduct using an online scientific database such as GoogleScholar and PubMed with the keyword ‘patient-centered care in interprofessional collaboration’ ‘patient satisfaction’
‘patient
and
health
provider
communication’
‘interprofessional
communication and collaboration in healthcare’. Inclusion and exclusion category were determined, inclusion criteria are: 1) Studies published between 2010-2020, in 10 years range; 2) Studies publish only in English; 3) Studies have a good response (more than 50% of participant post their feedback) of interview/survey they were conducted; 4) Studies apply patient-centered care as communication in their interprofessional collaboration. For the type of studies are a qualitative, randomized controlled trial, cohort, descriptive, and observational study with participant have no age range, all gender, races, and in any department, the participant can be patient directly or the caregiver who communicates with a health practitioner or health worker who communicate with another health worker, with eligibility criteria were the role of health practitioner, communication and education with patients, and patient need. Study selection using keyword above followed by removing duplicate, screened on title and abstract, later articles were assessed for eligibility criteria, study selection is shown in Flowchart 1 and for Summary of 8 studies shown in Table 1. For the quality of assessment and risk of bias using a Critical Appraisal Skills Program.
208
Initial Search Result through database searching (n=1005) Study Excluded on title (n=604) Studies after screened on title (n=401)
Study Excluded on abstract (n=193) Studies after screened on abstract (n=203) Study Excluded on repeatition (n=184) Full-text articles assessed for eligibility (n=19) Study Excluded on Full-text assessment Studies Included into Systematic Review (n=8) Flowchart 1. Study Selection Result Table 1. Summary Of Studies Use For Systematic Review Author (Year)
Demographic
Smith
United State,
et al., from (2010)
participants
Study Method Qualitative
consist of 14 person inpatients
feeling insemi-
structured
patient
Some and
in
interaction
participant
of them
a
their physician
the
emergency the
and patient experienced prolonged
a wait,
of feeling
distance education about their impersonal symptoms
209
lack
In department,
A patient complains patient about
range: 20-89) experience, and Emergency
Patient expresses the
health health practitioners
express of
Patient Need
Patient
many questions by between
caregiver (age attitudes, the belief
Education With
because asking too communication
practitioner on
Communication And
frustrated uncertainty
the
palliative care interview and 7 family explore
Practitioners The
21 study Using
Role Of Health
overwhelmed, and
from stretchers
with responsible physician
uncomfortable
Department
(family
(ED)
caretaker
A only
caregiver
described a lack of
approached
coordination of care
when the patient
and
was too ill to be
communication
interview)
between
Interview
effective ED
and
palliative care provider
conducted using single
study
investigator with graduate-level training
in
qualitative research
and
previous experience conducting
a
semi-structured interview Using
a
grounded theory approach to code responses Chen
Taiwan,
Prospective
et al., from a random cohort (2014)
study
59.68%
of
Patients in HCEC
requests for HCEC who
62 participant
with
actively
with different
randomization,
by
nurses/head education
nurses
diagnosis
remaining made by from
conducted
divided
in into intervention
three surgical group to receive intensive care health units
attending
and
from
more both groups do not
requested communication
indication and from 62 patients which
receive
Patient
and complain
about
through time waiting or
the individual consultation any discomfort yet health the intervention of
practitioners showed a individually
physicians, HCEC significant reduction in HCEC does not
care as a communication entire ICU stay and represent
ethics
solution requested hospital
consultation
by health providers achieving the goal of
(HCEC)
because
210
stay
also patientâ&#x20AC;&#x2122;s
of medical care (p< .01)
satisfaction
any
individually (33)
disagreement
and less occurrence of
and usual care between
the medical
uncertainty
(UC) group to healthcare team and regarding value-laden receive
family
family members (37 issues. The percentage
meeting,
disagreements) and of
consultation to a
between
social
healthcare
worker
goal
achieved
internal between a patient with team intervention is
and so on (29),
member
data
analysis
disagreements).
based
on
85%
(16 while usual care 24%, but
the
there
is
no
difference in survival
intention-to-
rate between 2 groups
treat principle Olofss on
Western
Descriptive
et Sweden, from phenomenologic
al.,
14 participants
al method using
(2012)
(9 women, 5 14
Patient state nurse
Nurse
engage
contributor
as
for
the
and make patient perspective
range
feels like â&#x20AC;&#x2DC;center of
years followed qualitative
attentionâ&#x20AC;&#x2122;
by more than 3
attentive
approach
short and quick, carried
with communicates listening patient
request
emergency
patient
out and
all efficiently and
Patient exclaim long
Lack
and
of noneventful delay
A nurse found to communication 12
nurse
nurse skillfully
and respect toward worries
during
patientâ&#x20AC;&#x2122;s
The
visit department
patient
a an understandable way delivery service as
open-ended health practitioner
Inductive
The
become the most patient in dialogue in describes
men) with age interviews 71-90
the
for a doctor to
be truly present and between patients who come and long
months with a
empathetic
with have just arrived and pauses
different
interest and a calm the staff, making them examinations
diagnosis
attitude despite the have puzzle feeling emergency Some declares attitude arrogance
one
of
another
The patient feels a performed by the patient lack
of
information doctor
doctor regarding their status as and doctor visit cause
they feel neglected
The patient feels discomfort because
some
nutritionist
does
not
they
have
211
between
know
diabetes
while nutritionist feed them late Kelley et
Canada,
al. from
(2011)
Using
a
80 senior-friendly
Staff express low staffing
Communication
level among
Environment of
health the
emergency
participants in conceptual
followed by high practitioner described department
the emergency framework with
complexity and lack as troublesome for the express
department
knowledge
focused
aged 75 and ethnography over
in physical environment
geriatric care
with plans was not
includes
Health
physical
practitioner
environment,
knowing well they communicated
social
have
climate,
to
as
overcrowding, chaotic
a, not
always understood by enough space senior
and/or
need
with such as nutrition,
provide patient family
hydration,
hospital policies
comfort
and procedures,
patient-centered
patient and patientâ&#x20AC;&#x2122;s
mobility, sensory,
and wider health
care service
family how lack of
medication,
care system
Communication with toileting, and
Patient feel bad family reassurance and social-emotional
Using interview
and
Patient
an with
because they being problem about moved around
staff need
name tag was often not
is
show
dissatisfaction
senior or their
legible and clothing did from the patient
proxy decision-
not
makers, staff and
between
key community
responsibilities,
informants, on-
making it difficult to
site
patient ask for help
observations,
distinguish roles
The
and complains
patient about
prolonged waiting
a
staff survey, and hospital administrative data Julie et
Australia,
al.
from
(2010)
participants
A descriptive 39 approach using descriptive
consist of 27 statistics caregiver
analysis
roles
and responsibility paramedic was
Communication
are confused about between the
interviews and thematic 12
Patient state they
especially
212
Patient
health expresses
and workers and patients is
prolonged period
of often cut off for a long of staff, time
due
to
a
work (median
waiting waiting
interview
in used to analyze
ambulance
driver, overload
the emergency observation and
with another health worker
department
practitioner
interview data
(average age:
of
health time
61.8
minutes) Patient
Interview
77.1 years old using
is
feel
ED
semi-
was
overcrowding,
and able giving structured face-
workload,
informed
staff shortage
to-face interview
consent)
and
Patient describes that the services they get are equal, there is no caste-related to the penny
Jonger
Netherlands,
den et from
patient
A before-after study, 2 months
family before
and
2
Healthcare
Patients
Family
practitioner attitude communication
al.,
and
(2013)
patient of ICU months after the
“visiting
ward
probabilities” show increase from 65.1 to the ward-like ICU
migration of an intensive
on
the
care a
item
with satisfaction have
of the health practitioner about
their
unit (ICU) to a
statistical role (p<
newly built ICU
.01) and on the item toward staff show a
with all single “emotional
mean
care score from 69.5 in
significant 70.8 (p< .01) Patient
increase
to 74.1 in the
satisfaction single-room ICU
significant number (p<
(p= .02) Mean
patient
room, conducted
support”, “courtesy .05)
satisfaction
with
using 2 surveys
toward
overall
ICU
to
family”,
determine “amount of care”,
family
and
and
experience
“overall
increase from 63.6
patient
experience” show a
in the ward-like
satisfaction
significant number
ICU to 69.6 in the
too (p < .05),
single-room ICU (p= .02)
Parke
Canada,
et al., from 10 older (2013)
adult-family
Qualitative Study Using
dyads, 10 ED interpretive, Registered
Patient feel lack
Patient has difficulty
Patient
of nurse role in an to communicate with complains an
elder patient
descriptive
about
dementia the health practitioner
the prolonged wait
because they may not
in ED room make them feel like an
213
Nurse, and 4 exploratory Nurse
design
Practitioner
interview
participant
The tendency of
using
healthcare provider to assume geriatric
in
patient come to ED
the emergency
with
department
problems
(average age of
be able to explain their
inferior
symptoms
being forgotten or
Communication represents
priority
unimportant,
worse prolonged
wait
non-acute between the healthcare resulting provider and caregiver,
Some
dyads
in
caregiver have to
where caregiver even deal
with
nurse
perceived that staff do not know which difficulty
practitioner
seemed
(27-66
unconcerned, or too for their health
patient’s anxiety,
old), ED NRs
busy
restless behavior,
(24-56
patient needs yet the among health provider
years years
old),
and
unaware, physician responsible including to
address
rest describe one or
Communication and
between
two nurses being provider and patient is
84 yeard old))
attentive such as lacking and sandwich
with feels
about
their
status
and
to
family
member calm also
little caregiver exclaim
contact from staff Patient
effort
health keeping
caregivers (51-
offer hot blanket
and
that
health
lack provider does not health attend
do
not
educate enough about their next step therapy
patient
basic need Patient exclaim about
bedsores,
difficulty going to the bathroom Liu et
Mixed
Observational of
Absent percentage
Absent percentage of
al.,
demography
studies
(2010)
include
caregiver using
caring behavior of 0.385
Kokomo,
survey
healthcare
Absent
of caring behavior is - percentage address
caring behavior is
member’s
-0.321 for show
by questions patiently (p<
concern for family
family
for
of
Detroit,
practitioner
Birmingham,
introducing
and
themselves were - with patient to help
Washington,
0.165% (p< .05), - tune out illness state (p< .05) followed
from
0.321%
emergency
concern
department
caregiver (p< .05) 0.157 for make sure 0.153 for respect
.01), -0.193 for chat member’s
and consideration
show (p< .01) and intensity by
intensity
of
for of caring behavior is caring behavior is
while intensity of patient is aware of
214
needs
patient’s privacy
caring behavior for care-related
detail (p< .05), 0.183 for
positive
facial before exiting (p< .05), asking
expressions
count 0.243
for 0.195 (p< .05)
for
clearly there is anything
communicate
else that is needed
information to patients
before leaving (p<
(p< .01), 0.175 for
.05), and 0.160 for
explaining the purpose actively of visit (p < .05)
respond
to patient’s need (p< .05)
The result from 8 studies conducted in this systematic review categorized into 3 different perspectives, which are the role of health practitioners, communication and education with a patient, and patient need. 1. Role Of Health Practitioner Role of health practitioner defined as responsibility, role, and function of a health practitioner who felt directly by the patient, caregiver, or another health profession, this includes making patient flow goes well with comfort feeling, high knowledge of health practitioner towards patient complaint and understanding of health workers about their function and role in a collaborative team. From studies show, the role of health practitioner as in patient-centered care communication in IPC is still lacking, some patient complains about physician skill with the statement, “they [doctor] were like ants, irrationally running around. No one seemed to do anything meaningful”, in term of practitioner role is dominated by a nurse because of the amount o time they allocate to the patient, a patient testifies difference in treatment form doctors and nurses that he got with the sentence “it was pretty quick, we didn’t wait at all. They [nurse] did the right things from the start…I felt calm with a sense of relief” while doctor got sentence such as “it normally takes an hour to collect and analyze blood samples, but what about all the other hours?”, even with nurse assistance the treatment that a patient gets from a doctor become greater effect on the level of their satisfaction yet it is getting worse in emergency ward as imbalance between the small number of health workers and number service that must be provided. One study shows, the role of health practitioner and patient satisfaction have a statistically significant result and yet 7 other studies
215
whether
show patient were subjectively unsatisfied about the role of health provider (Smith et al., 2010; Chen et al., 2014; Olofsson et al., 2012; Kelly et al., 2011; Julie et al., 2010; Jongerden et al., 2013; Parke et al., 2013; Liu et al., 2010). 2. Communication And Education With A Patient Communication and education with patients are defined as how often there is communication among patients, caregiver, and health worker, how often there is communication between health worker, how well the patient and caregiver understand about patient health status, and the stages of therapy they need to go through during the treatment period. Although, patient-centered care, in some studies patients, states that, “I received no information at all and it made me upset and angry”, the patient state they got no information about what happened to them while health practitioner seems unconcern “the stretcher is not comfortable. They [health practitioner] put you in that room, they close the curtains, and they just leave you in there…you don’t know what is going on. So they say, “Okay, we are going to admit you, you got a room, but you are still waiting”, and you are just wondering, what is going on, what is taking so long”, worse thing a caregiver described lack of collaboration between health provider, “They [health provider] were butting heads. I saw a couple of the nurses and they were just like pissed at her…the nurse said to us [patient and caregiver], that patient can have medication every 2 hours but the palliative care provider had the order is written only for every ½ hour to 1 hour…the nurse just didn’t want to deal with giving him [patient] the pain medications that frequently”. From 8 studies conducted shown communication complaint rotate in lack of patient and staff knowledge about a physician in charge, lack of communication from the patient as the procedure of emergency department, and long pause between examination while communication of a nurse-patient is better than another profession from a patient perspective yet for another profession some hierarchy can still be seen meanwhile one study showing the better outcome of a patient with individual communication and education from the physician (Smith et al., 2010; Chen et al., 2014; Olofsson et al., 2012; Kelly et al., 2011; Julie et al., 2010; Jongerden et al., 2013; Parke et al., 2013; Liu et al., 2010). 3. Patient Need A patient needs defining as a problem related to barrier communication, waiting times especially in the emergency department, physical need includes
216
toilet, nutrition, walking, and symptoms care. The patient needs in patientcentered care have a lot of resistance, especially in the emergency ward, some quoted patient complaint such as “I waited five hours for the doctor, who just pressed me a little on the stomach”, “The staff went to-and-fro in the corridor. I waited for hours but nobody came to me”, ”At 9 o’clock I pressed the alarm. I had not eaten since 12 o’clock. I needed something for my diabetes”, “she [nurse] put me inside the desk to wait, after she said I’m sorry I don’t have room, I’ll have to make room for this one, I think she’s have a heart attack after she moved one man and I go in the room, they had to move someone else from a room to put me into that room off the ambulance trolley because they have the machine in there”, one family member state “we [patient and family] sat there for 3 hours…without anybody ever saying anything to us and now he’s [patient] getting antsy. After about an hour, an hour and a half, ‘when are they [health provider] coming? When are we gonna go? How long we gotta sit here?’ We don’t know. So we sat there and I said. ‘well, we just have to be patient’”. From 8 studies conducted, complaints about PCC in terms of patient need dominate by long hours of waiting time for the doctor to arrive, feeling neglected, and lack of knowledge of staff about patient’s special needs such as diabetes patients (Smith et al., 2010; Chen et al., 2014; Olofsson et al., 2012; Kelly et al., 2011; Julie et al., 2010; Jongerden et al., 2013; Parke et al., 2013; Liu et al., 2010). Discussion This systematic review of patient-centered care as a form of communication in the interprofessional collaboration era conducted using 8 studies from a patient perspective. The main concern to find out the outcome of patient-centered care and to find out whether PCC is really implemented correctly, not just a back term so that a problem will seem to have been resolved. To find out, outcome 3 categorized extracted into the role of health practitioner, communication and education with a patient, and patient needs. First, the role of health practitioner still dominated by nurse which is against the interprofessional collaboration principle where no profession dominates and lack of doctor role felt by patient, is also violates the collaboration team process where doctor should be leader of the team, this process of dominance between professions seen by patients is a manifestation of the lack of health professional and lack of interprofessional education learning in pre-clinic stage, data report there are only 10 doctors per 10.000 population even some country has
217
less than 3 doctors followed by IPE practice has only been implemented in the last decade, so the current IPC implementation sill faces a lot of obstacles (WHO, 2020; West et al., 2017). Second, communication and education with a patient are still testified to be lacking, both from patient to a health provider and health provider to health provider and vice versa, this problem happened because hierarchy still can be seen in junior-senior health provider followed by ego of each profession, as for patient, they fear it will bother to ask too many questions and refrain from expressing how they feel (Shaurya, 2011; Stayko, 2017). The last one is patient need, dominate by prolonging waiting especially in emergency department caused by lack of physician in charge (WHO, 2020). Effect of lacking these 3 categories is less patient satisfaction where higher satisfaction and trust was associated with the success of patient-centered care conversely, poor satisfaction from majority 8 studies related to increasing the burden of illness, low patient quality, bad prognosis, health cost, and raising medical error as state before (Zoffman et al., 2008; WHO, 2018). The limitation of this study is participants dominated by elder patients in the emergency ward and there is no recent study at least for 5 years range that met the eligibility criteria of the study. Conclusion Communication becomes main cause of medical error globally, in this interprofessional collaboration era communication should be orientated in patient-centered care, yet PCC practices from the 8 studies reviewed still show practices that are not in accordance with the IPC leading to patient dissatisfaction and low quality of patient health, therefore the success of PCC as communication solution in IPC are cannot be determined yet because its practice is still not optimal. Recommendation Study-related to IPE learning which later leads to IPC is needed to evaluate collaborative learning. References Agarwal R, Sands D. Z, Schneider J. D. (2010). Quantifying the economic impact of communication inefficiencies in U.S. Hospitals. J Healthc Manag, 55, 81-82. Bart N. Green, Claire D. Johnson. (2015). Interprofessional collaboration in research, education, and clinical practice: working together for a better future. J Chiropr Educ, 29(1), 14-36. DOI 10.7899.
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Liu S. Sandra, Franz David, Allen Monette, Chang En-Chung, Janowiak Dana, Mayne Patricia, White Ruth. (2010). ED Services: The Impact Of Caring Behaviors On Patient Loyalty. Journal Of Emergency Nursing, 36(5), 404-414. Moger D, Liberati A, Tetzlaff J, Altman D. G. (2009). Preferred reporting items for systematic review and meta-analysis: The PRISMA statement. British Medical Journal, 339, b2535. Olofsson R. N. Pia, Carlstrom D. Eric, Siv Back Petterson R. N. (2012). During and beyond the triage encounter: Chronically ill elder patientsâ&#x20AC;&#x2122; experiences throughout their emergency department attendances. International Emergency Nursing, 20, 207-213. Parke Belinda, Hunter F. Kathleen, Strain A. Laurel, March B. Patricia, Waugh H. Earle, McClelland J. Ashley. (2013). Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: A social ecological study. International Journal of Nursing Studies, 50, 1206-1218. Ratna Haran. (2019). The Importance of Effective Communication in Healthcare Practice. Harvard Public Health Review, 23, 1-6. Seaho J. A. (2008). Patient Safet and Quality: An Evidence-Based Handbook for Nurses. Rockville: Agency for Healthcare Research and Quality. Shaurya Taran. (2010). Contributing to Poor Communication Outside the Physician-Patient Sphere. Medical Journal of Malaysia, 13(1), 86-91. Smith K. Alecander, Schonberg A. Mara, Fisher Jonathan, Pallin J. Daniel, Block D. Susan, Forrow Lachlan, McCarthy P. Ellen. (2010). Emergency Department Experiences of Acutely Symptomatic Patients with Terminal Illnes and Their Family Caregivers. J Pain Symptom Manage, 39(6), 972-981. doi:10.1016/j.jpainsymman.2009.10.004. Stayko I. Spiridonov. (2017). Causes For Ineffective Communication Between Medical Specialists.
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The Effectiveness Of The SBAR Method On Factors Related To The Implementation Of Hospital Communication Fatimah1, Alma Mutia Ningrum2 Alkhairaat University
A. Background/Introduction Communication breakdowns are one of the main causes of adverse events in the clinical routine, especially in handover situations. The SBAR communication tool (situation, background, assessment and recommendations) was developed to improve the quality of handovers and is widely assumed to improve patient safety. Effective communication is an important factor in providing safe patient care. Communication failures in health care settings can lead to serious medical errors. B. Brief Research Methodology This research is descriptive in nature analysis with the Cross approach sectional where variable independent and dependent variables researched simultaneously. This research designed to see relationships independent variable knowledge,
attitude,
motivation
with
the
dependent
variable
SBAR
communication. C. Result and Discussion From this research can concluded that there is not a significant relationship knowledge by application SBAR communication at the time of Overan service. There is a significant relationship between attitude and motivation with application of SBAR communication on when overan service in the ward stay. The present systematic review assesses the effect of the implementation of the widely adopted communication strategy SBAR on patientrelated outcomes. Because communication breakdowns have been repeatedly identified as a major source of adverse events and medical error,
223
D. Conclusion Patient safety is the priority in patient care, and communication errors are the most common cause of adverse events during patient care. SBAR communication tool is a structured communication tool which has shown a reduction in adverse events in a hospital setting.
224
The Effectiveness Of The SBAR Method On Factors Related To The Implementation Of Hospital Communication Fatimah1, Alma Mutia Ningrum2 Alkhairaat University
225
A. Introduction Patient safety is crucial for the delivery of effective, high-quality healthcare and is defined by the World Alliance for Patient Safety of WHO as ‘the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum (WHO,2018). To illustrate the impact of patient safety on healthcare quality, the incidence of adverse events is commonly cited. Following the definition of Brennan et al, adverse events are injuries that are caused by medical conduct resulting in prolonged hospitalisation and/or disability at the time of discharge. The Joint Commission reported that poor communication is a contributing factor in more than 60% of all hospital adverse events they reviewed. Poor communication is found in many different healthcare settings and is especially prominent in patient hand-offs and settings where fast and effective management is indispensable. Such settings include the perioperative period, the intensive care unit (ICU) and the emergency department. The components and processes of communications are complex and prone to misunderstanding. To overcome these barriers, communication strategies are desirable, which take little time and effort to complete, deliver comprehensive information efficiently, encourage interprofessional collaboration and limit the probability of error (Müller, 2018). World Health Organization (WHO) recognize SBAR (Situation, Background, Assessment, Recommendation) as an effective communication tool for patients’ handoff. SBAR is a reliable and validated communication tool which has shown a reduction in adverse events in a hospital setting, improvement in communication among health care providers, and promotion of patient safety (Shahid, 2018). Communication breakdown is one of the main causes of adverse events in clinical routine, particularly in handover situations. The communication tool SBAR (situation, background, assessment and recommendation) was developed to increase handover quality and is widely assumed to increase patient safety (Müller, 2018) SBAR is a technique for communicating critical information that requires immediate attention and action concerning a patients condition (O’Daniel M, 2008) SBAR communication is communication using logical tools to organize information so that it can be transferred to others accurately and efficiently. Communication using SBAR (Situation, Background, Assessment, Recomendation) to achieve critical thinking skills, and save time. Weigh acceptance is a technique for conveying and receiving information related to the patient's condition. Weighing and receiving must be done as effectively as possible by explaining briefly, clearly and completely about the nurse's independent actions,
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collaborative actions that have been and have not been done and the patient's development at that time. The information submitted must be accurate so that the continuity of nursing care can run perfectly (Nursalam, 2016 ). B. Material And Method ( Methodology) This research is descriptive in nature analysis with the Cross approach sectional where variable independent and dependent variables researched simultaneously. This research designed to see relationships independent variable knowledge, attitude, motivation with the dependent variable SBAR communication. This research instrument uses knowledge, attitude and questionnaire motivation and SOP observation sheetimplementation of overan SBAR in each service shift. The questionnaire is filled out respondents with the previous ask for approval to be willing be a respondent. Collection data for independent variables done by spreading knowledge, attitude and questionnaire motivation to respondent with guided interview techniques for maximizing the objectivity of the results research. While the variable dependent collected with observing the implementation of Overan SBAR of each team leader which refers to the SOP overan SBAR. C. Results And Discussion 1) Results Based On Research By Fitrianola Rezkiki And Ghita Sri Utami, Entitled Factors Related To Application SBAR Communication In Institution In 2017 Which Has The Following Results : A. Distribution of the Frequency of Knowledge of Respondents in Inpatient Rooms. known that of the 36 respondents, mostly as many as 30 people (83.3%) by category high knowledge. B. Based on the distribution of the Attitude Frequency of the Respondents in the Inpatient Room it is known that out of 36 people respondents, more than part as many as 22 people (61.1%) respondents indicated a response negative attitude. C. Based on the distribution of the Motivation Frequency of Respondents in the Ward Room it is known that of the 36 respondents, it was recorded partly as many as 18 people (50%) of respondents indicated motivation level by category low.
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D. Based on the distribution of the SBAR communication frequency in the inpatient room, it is known that of the 36 respondents, recorded more than part of that is as many as 24 people (66.7%) respondents did not implement good SBAR communication. E. Based on Knowledge Relationship with Application of Communication SBAR at the time the Overan Service in the Inpatient Room was discovered that of the 6 respondents with the lowly, recorded more than half (66.7%) of respondents did not carry out SBAR communication well. Meanwhile from 30 the respondent with high
knowledge,
recorded more of the majority (66.7%) of respondents do not carry out communication SBAR well. Results of the analysis statistics show that it is not there is a relationship between knowledge with the application of SBAR communication with a value of p = 1,000 (p> 0.05). F. Based on attitude relationship with the application of SBAR communication when the Service Overan in the Inpatient Room was discovered that of the 22 respondents who show a negative attitude response, most (86.4%) of respondents do not carry out communication SBAR well. Meanwhile from 14 respondents who show a positive attitude response, less than a portion (35.7%) respondents did not implement Volume 1 No.2 Year 2017 Journal of Human Care Ju SBAR communication well. Results statistical analysis shows that there is a relationship between the attitudes of nurses with the application of SBAR communication at the time of overan service with a value of p 0.003 and OR = 11,400, that is respondents who show attitudes negative has 11.4 times the chance of do not carry out communication SBAR compares favorably respondents who indicated a response negative attitude. G. Based on the Relationship between Motivation and Application of Communication SBAR was at the time Overan Dinas in the inpatient room,18 people respondents with low motivation, recorded mostly (88.9%) respondents did not implement good SBAR communication. Meanwhile, from 18 respondents with high motivation category, noted less than a portion (44.4%) respondents did not implement SBAR communication well. Results statistical analysis shows that there is a relationship between motivation with the application of SBAR communication with p value = 0.013 and OR = 10.00, meaning the respondent with low motivation has 10 times the chance not to carry out SBAR communication when overan service compared to respondents with high motivation mostly as many as 30 people (83.3%) by category high knowledge.
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2) Discussion The present systematic review assesses the effect of the implementation of the widely adopted communication strategy SBAR on patient-related outcomes. Because communication breakdowns have been repeatedly identified as a major source of adverse events and medical error, implementation of a strategy such as SBAR seems a valid remediation approach (MĂźller, 2018). D. Conclusion And Recomendation 1. Conclusion In summary, many authors claim that SBAR improves patient safety. There is some evidence of the effectiveness of SBAR implementation on patient outcome, but this evidence is limited to specific circumstances such as communication over the phone. Especially high-quality studies are lacking. Future studies are needed to further demonstrate the benefit of SBAR in terms of patient safety and keep raising the awareness of communication errors. SBAR might be an adaptive tool that is suitable for many healthcare settings, in particular when clear and effective interpersonal communication is required. Patient safety is the priority in patient care, and communication errors are the most common cause of adverse events during patient care. Health care providers make every effort to avoid communication errors during patient handoff. SBAR communication tool is a structured communication tool which has shown a reduction in adverse events in a hospital setting. Various medical associations and leading health care organizations have been endorsing SBAR communication tool for handoff among health care providers. This communication tool creates a shared mental model around the patientâ&#x20AC;&#x2122;s condition and has been used for transfer of patient care in various clinical settings. SBAR communication tool is easy to use and can be modified based on most of the clinical settings; however, it can be challenging to use for complex clinical cases such as ICU patients. Moreover, the use of SBAR communication tool requires educational training and culture change to sustain its clinical use. 2. Recomendation a. The advantages of SBAR documentation 1) Provide an effective and efficient way to convey information and weigh accept.
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2) Offers a simple way to standardize communication by using the SBAR communication element 3) Avoid mistakes in the weigh communication process thank patient. 4) Creating the same method in the weigh-and-receive process. b. Benefits of SBAR Documentation 1) Can be used again for useful purposes 2) Communicating to nurses and staff other health care about what has been and will be done to the patient. 3) Useful for accurate patient data collection because various patient information has been recorded c. SBAR Documentation advantages: 1) The power of nurses to communicate effectively 2) Doctors believe in a nurse's analysis because it shows the nurse understands the patient's condition. 3) Improving communication is the same as Milgram is doing as follows. by improving patient safety. E. References Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ open, 8(8), e022202. https://doi.org/10.1136/bmjopen-2018-022202 From : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112409/ Nursalam. (2016). Nursing Management Applications in Professional Nursing Practice (5th edition). jakarta: salemba medika. O’Daniel M, Rosenstein AH. Professional Communication and Team Collaboration. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 33. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2637/
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Shahid, S., Thomas, S. Situation, Background, Assessment, Recommendation (SBAR) Communication Tool for Handoff in Health Care â&#x20AC;&#x201C; A Narrative Review. Saf Health 4, 7(2018). https://doi.org/10.1186/s40886-018-0073-1 From: https://link.springer.com/article/10.1186/s40886-018-0073-1#citeas F. Appendix
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Health Literacy Level Among Healthcare Students and Non-Healthcare Students in Indonesia Febrianto Adi Husodo1, Felly Moelyadi2, Liony Ivania Lauwis3, Steffi Audrey Julianto4 Undergraduate Medical Program, Faculty of Medicine, Hang Tuah University Surabaya husodo9@gmail.com ABSTRACT Introduction: Low health literacy (HL) caused several problems i.e. inhibition of health-seeking behaviour, negative attitude, and beliefs towards health issues, bloomed stereotypes, first aid skills deficiency, and effective communication inhibition that could hinder the development of the healthcare system in Indonesia. Those problems result in an escalation of the financial burden in Indonesia. HL is defined as a level where people can access, understand, assess, and communicate information to engage the demands of different health contexts in order to promote and maintain good health in life. Objective: This study aims to determine the levels of HL among healthcare and non-healthcare students. Method: This study used a cross-sectional design with comparative analyses. The samples were 331 students from 53 universities spread in 21 provinces in Indonesia. HL level was measured by using HLSEU-Q16 adapted into Bahasa Indonesia and distributed through an online questionnaire. Result: The result showed that healthcare students have higher HL levels than non-healthcare students (p<0.001). Most of the respondents were female (69.5%), 4th-year students (42.6%), of the healthcare field (55%), and the average age was 20. Discussion: HL is an integral part of healthcare students as prospective medical personnel in supporting their education and future careers as the main actors in dealing with various diseases in society and educating the public to stay healthy. Conclusion: There was a significant difference in HL level between healthcare students and nonhealthcare students. The healthcare students had higher HL levels than non-healthcare students. Keyword: Health Literacy; Healthcare Student; Non-Healthcare Student
232
Health Literacy Level Among Healthcare Students and Non-Healthcare Students in Indonesia
Author: Febrianto Adi Husodo1 Felly Moelyadi2 Liony Ivania Lauwis3 Steffi Audrey Julianto4
Faculty of Medicine Hang Tuah University Surabaya Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia 2020
233
Introduction Health literacy (HL) is defined as a level where people can access, understand, assess and communicate information to engage with the demands of different health contexts to promote and maintain good health in life (Guyanto & Syakurah, 2020). HL is determined by several factors including productive age, high education, and access to technology. A college student is a group of people with all of these factors. This condition supports them to obtain a higher level of HL compared with other groups (Lestari & Handiyani, 2017). Prior research conducted in 219 college students measured HL using a 16-item Health Literacy Scale-European Union-survey Questionnaire-short version (HLS-EU-Q16). The 16 questions used four response categories: tough, fairly difficult, fairly easy and very easy. The total scores were then ranked into inadequate (0–8), problematic (9–12), and sufficient (13–16). The study results showed that healthcare students had a significantly higher mean score of HL (13.2) compared to non-healthcare students (10.2) with a p-value <0.001 (Juvinyà-Canal et al., 2020). Further, levels of HL among university students are found to be limited, especially among nonhealthcare students The main problems experienced by non-healthcare students related to HL are in navigating reliable resources, deciding whether the information is trustworthy or not, and choosing the right healthcare option; while healthcare students are still lacking in point managing time and the ability to consult their condition (Lestari & Handiyani, 2017). Non-healthcare students tend to perceive information from family/friends which they find more reliable and convenient, even though it is not always accurate (Lestari & Handiyani, 2017). They also face many factors that inhibit them from seeking health services such as negative attitudes and beliefs related to seeking professional health (Lumaksono et al., 2020). HL helps to remove stereotypes, improve first aid skills, self-help strategies, encourage helpseeking behaviour and is very important in effective communication (Guyanto & Syakurah, 2020; Kristina et al., 2020). Healthcare system development in Indonesia is determined by the level of HL among the people. Problems will limit growths, increase health costs, and affect the national finances. Based on those problems, this study aimed to determine the levels of HL among healthcare and non-healthcare students, to raise awareness about the importance of HL, and to improve healthcare system development in Indonesia (Ratna, 2016).
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Materials and Methods Study Design and Participants This study used a cross-sectional design. The respondents were healthcare (e.g. Medical Faculties, Midwifery Academy, Nursing Academy, Pharmacist, Physiotherapist, etc.) and non-healthcare (e.g. Law, Social and Politics, Engineering, etc.) college student class of 2017, 2018, 2019, and 2020 from 53 different universities and 21 different provinces in Indonesia. Students were invited to participate in this research through links distributed online in social media. The inclusion criteria for this study were active college students in Indonesia class of 2017-2020 and willing to participate voluntarily in this research. If respondents did not answer completely all of the questions or their answers were not relevant to the questionnaire, then their responses were not included in the analyses. Research Instruments This study used an online questionnaire, consisted of HLS-EU-Q16, demographic and educational backgrounds, such as age, gender, college major, academic year, and province of residence. The level of HL was measured using the HLS-EU-Q16 instrument which was translated into Indonesian and entered into an online questionnaire. This instrument consisted of 16 questions about HL which were later classified into four degrees of difficulty (tough, fairly difficult, fairly easy, very easy) in every situation presented in the survey. There were three themes in the questions: health services (seven questions), disease prevention (five questions), and health promotion (four questions). Responses were scored and grouped into two categories: "tough" and "fairly difficult" were scored "0", whereas "very easy" and "fairly easy" were scored "1". The total scores were calculated to determine the HL index, which consisted of three groups: inadequate (0-8), problematic (9-12), and sufficient (13-16). The reliability of the questionnaire measured using Cronbach's alpha was 0.842, implied a strong reliability. Statistical Analysis The IBM SPSS Statistics ÂŽV23 software package for Windows was used for data analysis. The data were tested for normality distribution and homogeneity of variance, and did not meet the parametric assumption. Therefore, the results were presented in median and minimum-maximum values for univariate analyses. In the bivariate analysis, the comparison between HL (ordinal scale) on the two types of colleges (nominal scale) was analysed using a Chi-square hypothesis test. The level of statistical significance was expected to be p <0.05.
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Results Characteristic of Population Table 1: Sociodemographic Variables of Students Variables Gender Level of Study
Study Field
Category
N
%
Male
101
30.5
Female
230
69.5
1 year (2020)
13
3.9
2nd year (2019)
116
35.0
3rd year (2018)
61
18.4
4th year (2017)
141
42.6
Health
182
55.0
Non-health
149
45.0
st
A total of 331 university students consisted of 182 healthcare students and 149 non-healthcare students from 53 universities and 21 provinces in Indonesia participated in the study. Table 1 showed sociodemographic variables of students. We grouped the respondents' gender into female (69.5%) and male (30.5%) categories. Most of the students (42.6%) were in their 4th year of study, while the rest were in their 3rd year (18.4%), 2nd year (35.0%), and 1st year (3.9%) of studies. More than half of the respondents were from health field students (55%) and the others were from non-health field students (45%). Table 2: Health and Non-healthcare students' Age Value Study Field
Statistic Median (Minimum-Maximum)
Age
Health
20 years old (17-23)
Non-health
20 years old (16-24)
The median, minimum, and maximum of respondent's age among health and non-health field students evaluated by the HLS-EU-Q16 shown in Table 2.
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Health Literacy Results Table 3: Results of HLS-EU-Q16 Scores in The Total Sample Q
Item HLS-EU-Q16
Tough
Fairly
Fairly Easy
Very Easy
Difficult 1
find information on treatments
3 (0.9%)
43 (13 %)
214 (64,7%)
71 (21.5 %)
4 (1,2%)
38 (11,5%)
170 (51,4 %)
119 (36%)
0 (0%)
23 (6,9 %)
235 (71%)
73 (22,1%)
0 (0%)
8 (2,4%)
160 (48,3%)
163 (49,2%)
13 (3,9%)
131 (39,6%)
158 (47,7%)
29 (8,8%)
1(0,3%)
47 (14,2%)
217 (65,6%)
66 (19,9%)
0 (0%)
10 (3%)
165 (49,8%)
156 (47,1%)
20 (6%)
104 (31,4%)
146 (44,1%)
61 (18,4%)
1(0,3%)
7(2,1%)
106(32%)
217(65,6%)
6(1,8%)
62(18,7%)
169(51,1%)
94(28,4%)
13(3,9%)
136 (41,1%)
163 (49.2%)
19 (5,7%)
or illnesses that concern you? 2
find out where to get professional help when you are ill?
3
understand what the doctor says to you?
4
understand your doctorâ&#x20AC;&#x2122;s or pharmacistâ&#x20AC;&#x2122;s instructions on how to take a prescribed medicine?
5
judge when you need to get a second opinion from your doctor?
6
use information the doctor gives you to make decisions about your illness?
7
follow instructions from your doctor or pharmacist?
8
find information on how to manage mental health problems like stress or depression?
9
understand health warnings about behaviour such as smoking, low physical activity and drinking too much?
10
understand why you need health screenings?
11
judge if the information on
237
health risks in the media is reliable? 12
decide how you can protect
3(0.9%)
92 (27,8%)
197 (59,5%)
39 (11,8%)
15 (4,5%)
85 (25,7%)
168 (50,8%)
63 (19%)
7 (2,1%)
43 (13%)
217 (65,6%)
64 (19,3%)
1 (0,3%)
16 (4,8%)
231 (69,8 %)
83 (25,1 %)
1 (0,3%)
48 (14,5%)
198 (59,8%)
84 (25,4%)
yourself from illness based on information in the media? 13
find out what activities are good for your mental well-being?
14
understand advice on health from family members or friends
15
understand information in the media on how to get healthier?
16
judge which everyday behaviour is related to your health?
Table 3 shows the frequencies and percentages for each item on the HLS-EU-Q16 questionnaire with descriptions obtained from the original scores (tough = 0, fairly difficult = 0, fairly easy = 1 and very easy = 1). Table 4: Comparison of HL among Healthcare and Non-Healthcare Students Student’s Health Literacy Level N (%)
Student’s Field Inadequate Health Student
6 (3.3%)
Problematic
Sufficient
Total
45 (24.7%)
131 (72%)
182 (100%)
p <0.001
Non-Health Student
11 (7.4%)
63 (42.3%)
75 (50.3%)
149 (100%)
The association between study fields and HLS-EU-Q16 global score among students are summarized in Table 4. This study found that HL level measured by HLS-EU-Q16 was significantly different between healthcare and non-healthcare students (p <α). From 182 students who enrolled in healthcare studies, 6 students got inadequate score (3.3%), whereas 45 students got problematic score (24.7%) and 131 students got sufficient score (72%). On the contrary, the data from 149 non-healthcare students showed
238
that 11 students got inadequate score (7.4%), 63 students got problematic score (42.3%), and 75 students got sufficient score (50.3%). Discussion This study came from 53 universities with 331 respondents (182 healthcare students and 149 nonhealthcare students) from 21 provinces in Indonesia. The main interest of this paper was to determine the level of health literacy (HL) between healthcare and non-healthcare students. Since this problem has not been studied sufficiently, we used the HLS-EU-Q16 questionnaire to discover more about this issue. The socio-demographic findings of this study showed there were more female (69.5%) than male (30.5%) respondents. The level of study was examined from the first, second, third, and fourth year. Most respondents were from the fourth-year students (42.6%), second year (35%), third year (18.4%), and first year (3.9%). The proportion of healthcare students (55%) was higher than non-healthcare students (45%). The median age of respondents at study was 20 years in both study fields (health: 17-23 years of age; non-health: 16-24 years of age). The Importance of Health Literacy for Student as the Agent of Change of Health Development in Indonesia Based on our research, the level of HL was clearly higher among healthcare students rather than non-healthcare students (p<0.001). Healthcare students, mostly have a ‘sufficient’ level of HL (72%), and only half of the non-healthcare students (50.3 %) has a ‘sufficient’ level of HL. This might be affected by the number of the sample, which was a health student (182;55%) has more participants than the nonhealthcare students (149;45%). The study from Universitas Indonesia by Lestari and Handiyani, 2017 also had a similar result, where healthcare students have a higher level of HL than non-healthcare students. Juvinyà-Canal et al., 2020 also found that nursing students had higher levels of HL compared to the Social Care University Students. HL is an integral part of healthcare students as prospective medical personnel in supporting their education and future careers as the main actors in dealing with various diseases in society and educating the public to stay healthy. One of the targets of health development in Indonesia is health workers as the spearhead of public health services (Ratna, 2016). Research by Nurmandhani et al., 2020 at one of the tuberculosis (TB) treatment centre in Semarang showed a significant correlation between level of HL and reduction of TB stigma in primary health care workers (health and non-health workers) (p <0.001),
239
meaning that the higher the HL level of health workers at the primary health care, the better the reduction of TB stigma. The importance of setting educational standards on student’s health literacy University, as an educational place, has the responsibility of conducting educational interventions to increase the HL level of its students. HL should be integrated in the curriculum of healthcare and nonhealthcare undergraduate programs, so that the graduates have HL competencies. It is hoped that human resources with high level of HL may apply healthy behaviours, have a high understanding on receiving health information and can cooperate in the treatment provided to them, so there will be rapid health development in Indonesia. A study from Bayati, Dehghan, Bonyadi, & Bazrafkan, 2018 found that from 256 health ambassadors who got educational intervention, significantly enhanced their HL mean scores from 79.22 to 95.49 and the study showed a strong correlation (p<0.001) of HL with whole dimensions of health-promoting behaviour pre and post the educational intervention. Limitations of the study The data for this study were collected with an online questionnaire. There were limitations of using online questionnaires such as the possibility to get dishonest answers, limited respondent’s availability, and possible misinterpretation of the questions. There were also limitations in the topic of the studies in the online questionnaire, and data analyses. Conclusion and Recommendation There was a significant difference in health literacy (HL) levels between healthcare students and non-healthcare students. The healthcare students had higher HL levels than non-healthcare students. However, there were some healthcare students with ‘inadequate’ and ‘problematic’ level of HL. Besides, HL is very important for their future career as the agent of change to improve the development of the healthcare system in Indonesia. Therefore, this study suggests the readers to increase their awareness and capacity of HL level for the goodness of their own health. The finding of the study suggests the government to make an educational intervention towards universities in Indonesia by setting an HL curriculum as the first step to improve the development of healthcare in Indonesia. Regardless of the field of study, everyone should have a ‘sufficient’ HL level so they can find reliable health information, understand it, use it to manage their well-being, take an active action for disease prevention, and cooperate well with the healthcare providers.
240
References Bayati, T., Dehghan, A., Bonyadi, F., & Bazrafkan, L. (2018). Investigating the effect of education on health literacy and its relation to health-promoting behaviors in health center. Journal of Education and Health Promotion, 7(1). https://doi.org/10.4103/jehp.jehp_65_18 Guyanto, M., & Syakurah, R. A. (2020). Health Literacy Survey on Medical Students. 11(03), 1692– 1696. Juvinyà-Canal, D., Suñer-Soler, R., Porquet, A. B., Vernay, M., Blanchard, H., & Bertran-Noguer, C. (2020). Health literacy among health and social care university students. International Journal of Environmental Research and Public Health, 17(7), 1–10. https://doi.org/10.3390/ijerph17072273 Kristina, S. A., Mardea, N. A., Ramadhani, F., & Aliyah, H. (2020). Mental Health Literacy among University Students in Yogyakarta. International Medical Journal, 25(04), 2243–2249. Lestari, P., & Handiyani, H. (2017). The Higher Level of Health Literacy Among Healthcare students Compared
with
Non-Healthcare
students.
UI
Proc.
Health
And
Medicine,
1,
1–5.
http://www.proceedings.ui.ac.id/index.php/uiphm/article/view/141 Lumaksono, N. A. P., Lestari, P., & Karimah, A. (2020). Does mental health literacy influence helpseeking behavior in medical students? Biomolecular and Health Science Journal, 3(1), 45. https://doi.org/10.20473/bhsj.v3i1.19093 Nurmandhani, R., Aryani, L., Dewi, F., Anggraini, P., Kesehatan, F., Dian, U., & Puskesmas, P. (2020). HEALTH
LITERACY
DAN
HEALTH
AWARENESS
TERKAIT
DENGAN
STIGMA
TUBERKULOSIS. 8(1), 73–83. Ratna, P. H. dan J. (2016). Literasi Kesehatan Masyarakat Dalam Menopang Pembangunan Kesehatan Di Indonesia.
Prosiding
Seminar
Nasional
Komunikasi,
http://jurnal.fisip.unila.ac.id/index.php/prosidingkom/article/viewFile/249/150
241
1(1),
344–351.
Leading Towards Health Equality for Patients with Speech Disabilities in Health Care using Augmentative and Alternative Communication (AAC): A Systematic Review Authors : Gracella Faustine1, Gammarezka Fitra Fajar1, Rahmah Salsah Hudriyah1, Shofiyah Hasya1 1
AMSA – Pembangunan Nasional Veteran Jakarta University ABSTRACT
Introduction: Health care is demanded to accommodate the needs of each patient, especially patients with speech disabilities. Therefore we recommend the provision of Augmentative and Alternative Communication (AAC). The availability of AAC, both low-tech and high-tech type in health care is expected to enhance patient-provider communication. Aim: This review aims to find out how important and effective the provision of AAC as a facility to help patients with speech disabilities in achieving effective communication with clinicians in health care. Materials and methods: This review is conducted using studies from reliable databases such as PubMed, Science Direct, ProQuest, EBSCO, and Clinical Keys and 8803 studies were identified. Contents then were screened using PRISMA statement guidelines and four final studies were obtained after full-text journal reading. Afterwards, the quality and validity are assessed using JBI critical appraisal indicators. Results: Communication between patients and health care providers is important because of its contribution to quality of care. It was proved that AAC could improve patient-provider communication, expressing patients’ needs, opinions, thoughts, and ability to adapt. Also, both low-tech and high-tech AAC were proved to be useful and could be implemented in health care. Conclusion: There is still lack of awareness from health care providers in using AAC to help patients with speech disabilities, however it has been proven that AAC has a significant role in breaking communication barriers and providing patient-provider effective communication. Keyword:
“Augmentative and Alternative Communication” OR “AAC” AND “Speech
Disabilities” OR “Speech Impairment” AND “Healthcare”.
242
Leading Towards Health Equality for Patients with Speech Disabilities in Health Care using Augmentative and Alternative Communication (AAC): A Systematic Review
Authors Gracella Faustine Gammarezka Fitra Fajar Rahmah Salsah Hudriyah Shofiyah Hasya
FACULTY OF MEDICINE PEMBANGUNAN NASIONAL VETERAN JAKARTA UNIVERSITY 2020
243
INTRODUCTION Communication is a daily process that requires a two-way interaction to achieve an intended goal. In the medical field, communication becomes a fundamental and critical aspect to reach successful therapeutic process and outcomes. Thus, health care is demanded to provide a supportive environment for effective patient-provider communication which leads to improvement of patient satisfaction, therapy continuity, and increased positive outcomes. Patient-provider communication in health care practice often meets several obstacles that decrease the effectiveness of communication. Individuals with speech disabilities often encounter ineffective communication (i.e., individuals who have an acquired or congenital disability that affects the ability to perform spoken language in order to fulfill daily communication needs) (Therrien & Light, 2018). On the other hand, communication disabilities tend to have an adverse impact on health care quality services provided by physicians, health professionals, and other health care providers. Also, patientsâ&#x20AC;&#x2122; safety, outcomes, satisfaction, and health care costs may cause problems for patients with communication disabilities (Blackstone & Pressman, 2015). Speech disabilities or so called speech sound disorders are inability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems. Speech sound disorders classified into organic or functional disorder. Organic speech sound disorders caused by neurological, structural, or sensory impairment. Organic speech disorders can be classified into three main characteristics: 1) Motor or neurological disorder such as childhood apraxia of speech and dysarthria; 2) Structural abnormalities such as cleft lip or palate; and 3) Sensory or perceptual disorders such as hearing impairment. On the other hand, functional speech sound disorders are idiopathic. Functional speech sound disorders are referred to as articulation disorder and phonological disorders. Articulation disorders can be known as disability in production of speech sound and phonological disorders focus on predictable, rule-based errors that affect more than one sound (ASHA, 2017). However, for many people who have speech sound disorder or with complex communication needs, natural speech is an ineffective method of expression or understanding. Therefore, the use of Augmentative and Alternative Communication (AAC) is required to achieve participation in both patients and providers. AAC is defined as a strategy or technique used by the person aimed at maximizing individual communication skills for functional and effective communication about their needs and preferences (ASHA, 2016). It can combine various processes that add, complement, or replace individual speech, thus helping them express their thoughts or ideas. AAC strategies can be broadly classified into unaided and aided AAC (ASHA, 2016). Unaided AAC is considered as the oldest category, given its reliance on the interpretation of facial expressions and voluntary motor movements, such as sign language, to deliver non-verbal messages.
244
Another category is aided AAC that also divides into low and high tech. Low-tech AAC utilizes basic tools, such as books and display boards with extended lexicons of images and phrases to aid the communication process. High-tech AAC encompasses the use of electronic devices to achieve an AAC target. Devices falling under this category, such as smart devices and dedicated AAC devices, integrate hardware and software to support user’s communication needs (Elsahar et al, 2019). Unfortunately, the importance of AAC availability in hospitals remains unnoticed and not considered as a major concern in health care. Lack of evidence-based research about AAC service provision just shows how important it is to focus our attention on this matter. Whereas a survey by Judge et al (2017) in the UK shows highly variable levels of service provision and a mean of 0.0155% also the maximum figure of 0,08% individuals known to be using powered communication aids in service catchment population (Judge et al, 2017). Health care providers also admit the limited time to communicate with patients and limited knowledge about AAC tools in hospitals (Hemsley et al, 2016). Communication barriers remain a concern because in many countries including Indonesia, there is lack of comprehensive studies about provision of AAC in health care settings. This study aimed to find out how important and effective the provision of AAC as a facility to help patients with speech disabilities in achieving effective communication with clinicians in health care. METHOD A systematic review of the published literature was structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors were using independent selection, review, and appraisal of studies to approach the systematic review. In order to find relevant and reliable studies, the authors use several databases such as PubMed, Science Direct, ProQuest,
EBSCO, and
Clinical
Keys,
with keyword
“Augmentative
and
Alternative
Communication” OR “AAC” AND “Speech Disabilities” OR “Speech Impairment” AND “Healthcare”. Studies gained were screened by including the exclusion and inclusion criteria to get sources that match the topic. Inclusion criteria include: studies published between 2015 – 2020, studies published in English, and studies related to Augmentative and Alternative Communication (AAC) for people with speech disabilities, while the exclusion criteria include: systematic review studies, inaccessible and ineligible studies, people with mental illness, people who undergo speech therapy, unaided AAC, and temporary functional speech disorder condition. Afterwards, to obtain reliable data, an assessment of the quality and validity of the literature used was carried out using JBI critical appraisal indicators. The entire process of the systematic review could be seen in Figure 1.
245
Figure 1. Flowchart of the Systematic Review
246
RESULT The search of keywords on various databases and other sources resulted in a total of 8803 articles. 7395 studies were gained after duplicates were removed and resulted in 115 articles after titles and abstract were screened. Another 100 articles were excluded based on exclusion criteria. Lastly, 15 full-text studies were assessed for eligibility and four articles were suitable for our systematic review. Important data such as author(s) name and year of publications, study design, population, country, primary medical conditions, AAC type, study results, and limitation of study were included in Table 1. Studies examined using JBI critical appraisal indicators to check its quality. JBI score of all articles could be seen in Table 2 which located on the appendix, whereas the entire process shown in Figure 1. DISCUSSION The communication between patients and health care providers is widely regarded as important because of its contribution to quality of care (Stans et al, 2018). Unfortunately, interacting with the health care provider presents a challenging set of scenarios for patients with speech disabilities who suffer from acquired brain injury and physical limitations as their primary health conditions. They explained that they could not understand difficult words or that the health care provider did not understand them because of their speech problems. This study highlights that the health care providers are often unaware that using AAC can empower patients to be more involved in conversations. Based on some patient statements, the use of conventional semiotics is a very helpful system, such as writing, for expressing themselves during a conversation. Whereas for health care providers, conversations with photos, a picto-book, or written information by using a computer can also help patients to understand or remember what they said. Therefore, it is important to gain insight into the potential of AAC and how it can help both patients and health care providers to achieve equal participation in dialogue conversations or other communication strategies (Stans et al, 2018). Another study conducted by Naro et al (2019) shows the effectiveness of AAC-training (AAC-T) in patients with early stage of Amyotrophic Lateral Sclerosis (ALS). The use of low-tech AAC proved to be useful in improving communication, expressing patientsâ&#x20AC;&#x2122; needs, preventing loss of motivation, supporting their daily activities, also increasing self-esteem and autonomy. The study also reveals a significant reduction of burden owned by caregivers and an increasing amount on psychological and emotional basis. By providing AAC services to ALS patients, we give patients the opportunity to express their needs, opinions, thoughts, and ability to adapt (Naro et al, 2019).
247
Table 1. Characteristics of Included Studies Author(s)
Study
and Year
Design
Population
Country
of
Primary
AAC
Health
Type
Result
Study Limitation
Condition
Publication Stans et al Qualitative (2018)
Study
with Netherlands
: acquired
Observatio ns
People brain
Brain
Low tech Health care providers are aware of the The limitations of this study
injury and &
injury
and and physical
high importance of preparation, in moderation relate to the potential for bias
physical
tech AAC time, a suitable environment and consider in sampling and socially
limitations
: writing, nonverbal
communication
in acceptable answers during
semi-
limitations
photos, a conversational dialogue. However, both the interview.
structured
and
picto-
interviews
professionals
their
patients
and
service
providers
still
book and struggle with the use of adequate computer
communication strategies, such as verbal communication and AAC due to lack of knowledge.
Moffatt et Qualitative
Clinicians
Germany
Aphasia
al (2015)
Study
with
:Web-
aphasia
AAC
based
patients who
Smart
tech
Devices
ergonomically effective and cheaper also
their
survey and participated Group
in
Observatio
Theraphy
n
Session.
Naro et al Experiment
10
High
- According to the study there is increased The limitation of this study is
Tech
enthusiasm in adapting high-tech AAC low enthusiasm of clinicians
Group
patients Italy
: devices in aphasia patient because high- about the AAC applications. AAC
devices
are
more
carry less stigma than traditional AAC devices. Amyotroph
Low-Tech This study of AAC-training (AAC-T) The main limitation of the
248
(2019)
al design
with
ic Lateral
AAC:
were divided into 2 phases, AAC- study is the small size of the
Amyotrophic
Sclerosis
Communi
intervention (AAC-I) for three months sample and the lack of a
Lateral
(ALS)
cation
followed
tables
(AAC-F) for another three months.
Sclerosis (ALS)
and
Wilcoxon
with test
AAC-familiarization control group. showed
significant
their
improvements in most of the variables
caregivers.
investigated, such as global cognitive functioning, adaptive coping strategies, mood, and QoL.
Holyfield
Experiment
et al (2019)
Three
Down
High-
All three participants showed higher The largest limitation of the
al design : elementary
syndrome,
Tech
engagement with high-technology VSD current study is small number
A
polymicrog
VSD and than
single- school
USA
the
low-tech
isolated
picure of participant (n=3). The
subject,
children
yia and
Low-Tech symbols.
study only using two AAC
alternating
between 6-9
encephalo
Isolated
technology option with their
treatment
years old
macia
Symbol
clinical
design
relevance.
It
is
difficult to tell participantsâ&#x20AC;&#x2122; engangement towards hightech AAC because of the short intervention.
249
On the other hand, according to Holyfield et al (2018) augmentative and alternative communication method using high-tech VSD and low-tech isolated symbols found to be effective for participants with speech disabilities. Participants for this study are three elementary school children between 6-9 years old with speech disabilities and underlying medical conditions. Participants known to have different primary health conditions that are down syndrome, polymicrogyria, and encephalomalacia. Study session for all of the participants was over an 8-week period. Duration per session approximately 5 minutes, and occured in the SLP therapy room. The study was using color photo in AAC app on a 10.2 inch touchscreen tablet for the high-tech VSD and color-printed isolated picture symbols for the low-tech AAC. All three participants showed higher engagement using high-tech color photo VSD than low-tech isolated picture symbols because of the several features that only present on the high-tech VSD. First was the technology itself, high technology may be interesting for the children. Other than that, the high-tech VSD uses voice output in their app as response to selection and can make a higher interest for the children not to mention the use of color photo VSDs itself (Holyfield et al, 2018). In addition, application of AAC in health care is in line with current technological developments. The emergence of new devices has made a positive contribution to the development of high-tech AAC that can be applied in health care. A research was conducted through an online survey for clinicians who are treating aphasia patients and observation on application of various types of AAC in focus groups with aphasia patients. The results show an increased enthusiasm for the use of high-tech AAC devices such as the iPad and iPod Touch (Moffatt et al, 2015). It was found that high-tech AAC devices are the most successful for face-to-face, one-to-one conversations, conversation in supportive locations such as rehabilitation clinics, and with familiar partners such as spouses. It is known that the most frequently used device is DynaVox, which is an assistive device that has been widely used by aphasia patients, although in fact the most recommended device is the iPad which has a more general function. It is known that patients refer to use more familiar device, also it was said that the participants had already invested too much time, effort, and money into DynaVox (Moffatt et al, 2015). Another important thing to notice from the survey is we should consider the advantages and disadvantages of using high-tech AAC. The advantages of using high-tech AAC include less stigma compared to traditional devices, and also they are more ergonomically effective. These devices are also cheaper than traditional options, while the drawbacks are limited software, lower volume, less durable, screen hard to read, and screen hard to use (Moffatt et al, 2015). To overcome the existing disadvantages, it is suggested that in the future the development of high-tech AAC devices must be adjusted based on the user's existing low-tech proficiencies and hopefully could create integrated applications that enhance the
250
learning process, also reduce the customization needed to set up an AAC device. If we can overcome these challenges, affordable low-cost smart mobile devices could significantly aid communication and improve the quality of life for individuals who have aphasia (Moffatt et al, 2015). Limitations In this systematic review, each study has several limitations. The largest limitation of the reviewed studies is the small number of participants, thus the studies unable to represent the whole population. Some of the studies also have a potential bias due to less homogeneous target groups and lack of control groups. Besides that, all of the current studies conducted in developed countries do not cover the whole world population. However, studies regarding AAC provision are still lacking. Lastly, there is limitation in technical, amount, and variety of AAC technology used in the study. CONCLUSION AND RECOMMENDATION Through the process of undergoing assessment in each of the chosen studies, we can conclude that there is still lack of awareness from health care providers in using AAC to improve patientsâ&#x20AC;&#x2122; satisfaction and achieve equal participation for patients with communication disabilities. However, it has been proven that AAC has a significant role in breaking communication barriers and providing patientprovider effective communication. Further studies regarding AAC potential, implementation, and provision in health care settings need to be conducted, especially in developing countries such as Indonesia.
251
REFERENCES 1.
American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology.
2.
American Speech-Language-Hearing Association. (2017). Speech sound disorders: articulation and phonology. Practice Portal. Nd.
3.
Antonino Naro, M. D., Bramanti, P., Simona Portaro, M. D., & Calabrò, R. S. (2019). Augmentative and alternative communication improves quality of life in the early stages of amyotrophic lateral sclerosis. Functional neurology, 34(1), 35-43.
4.
Blackstone, S. W., & Pressman, H. (2016). Patient communication in health care settings: New opportunities for augmentative and alternative communication. Augmentative and Alternative Communication, 32(1), 69-79.
5.
Elsahar, Y., Hu, S., Bouazza-Marouf, K., Kerr, D., & Mansor, A. (2019). Augmentative and alternative communication (AAC) advances: A review of configurations for individuals with a speech disability. Sensors, 19(8), 1911.
6.
Hemsley, B., Georgiou, A., Hill, S., Rollo, M., Steel, J., & Balandin, S. (2016). An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital. Patient education and counseling, 99(4), 501-511.
7.
Holyfield, C., Brooks, S., & Schluterman, A. (2019). Comparative effects of high-tech visual scene displays and low-tech isolated picture symbols on engagement from students with multiple disabilities. Language, speech, and hearing services in schools, 50(4), 693-702.
8.
Judge, S., Enderby, P., Creer, S., & John, A. (2017). Provision of powered communication AIDS in the United Kingdom. Augmentative and Alternative Communication, 33(3), 181-187.
9.
Stans, S. E., Dalemans, R. J., Roentgen, U. R., Smeets, H. W., & Beurskens, A. J. (2018). Who said dialogue conversations are easy? The communication between communication vulnerable people and health‐ care professionals: A qualitative study. Health Expectations, 21(5), 848-857.
10. Moffatt, K., Pourshahid, G., & Baecker, R. M. (2017). Augmentative and alternative communication devices for aphasia: the emerging role of “smart” mobile devices. Universal Access in the Information Society, 16(1), 115-128.
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APPENDIX
Table 2.1 JBI Critical Appraisal Checklist for Qualitative Research Checklist Questions 1.
There is congruity between the stated philosophical perspective
Study 1
Study 2
(Stans et al,
(Moffatt et al,
2018)
2015)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Unclear
Unclear
Yes
and the research methodology 2.
There is congruity between the research methodology and the research question or objectives
3.
There is congruity between the research methodology and the methods used to collect data
4.
There is congruity between the research methodology and the representation and analysis of data
5.
There is congruity between the research methodology and the interpretation of results
6.
There is a statement locating the researcher culturally or theoretically
7.
The influence of the researcher on the research, and viceversa, is addressed
8.
Participants and their voices are adequately represented
Yes
Yes
9.
The research is ethical according to current criteria or, for
Yes
No
Yes
Yes
recent studies, and is there evidence of ethical approval by an appropriate body 10. Conclusions drawn in the research report flow from the
analysis, or interpretation, of the data
253
Table 2.2 JBI Critical Appraisal Checklist for Quasi-Experimental Studies (non-randomized experimental studies) Checklist Questions 1.
There is no ambiguity regarding the independent and dependent variables exploring causal relationships
2.
All the participants included in any comparisons were similar
3.
All the participants included in any comparisons were receiving similar treatment/care, other than the exposure or
Study 3
Study 4
(Naro et al,
(Hoyfield et
2019)
al, 2019)
Yes
Yes
Yes
Yes
Unclear
No
No
No
Yes
No
Yes
Yes
Yes
Yes
intervention of interest 4.
There was a control group
5.
There were multiple measurements of the outcome both pre and post the intervention/exposure
6.
Follow-up was complete and if not, there were differences between groups in terms of their follow up adequately described and analyzed
7.
There were outcomes of participants included in any comparisons measured in the same way
8.
The outcomes were measured in a reliable way
Yes
Yes
9.
The statistical analysis used was appropriate
Yes
Yes
254
The Importance of Communication in Health Can Help Eradicate Hoaxes Holie Frendy1, Gitana Gezatania1, Hiskia1, Shindie Dona Kezia Lethulur1 Undergraduate Program, Faculty of Medicine and Health Sciences, Universitas Kristen Krida Wacana
1
Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia
ABSTRACT
Introduction: There are lots of hoaxes in all parts of the world, people who have not been educated who read hoax news will easily believe hoax news. In this case, education in communication is very much needed to help eradicate the spread of hoaxes which are increasing day by day, and periodically following scientific developments can be done so that they are more educated about new things. In this article, we will explain the truth about Rheumatoid Arthritis (RA) and its relationship with bathing at night. Objective: This systematic review will explain how good communication is to ward off hoax news, namely by providing educational videos. One of the topics we raised was the relationship between rheumatoid arthritis and night baths. Materials and Method: This Systematic Review is based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA). The authors conducted a review search using online search engineering with databases: Science Direct, PubMed, and Google Scholar. In total from initial research, reviewers obtain 3.088 relevant articles which that were retrieved, cloistered, and critically appraised and finally shorten to seven articles established for this systematic review. Conclusion: This systematic review proves that educational videos can be done as a health promotion to the public to ward of hoaxes circulating, especially about rheumatoid arthritis.
Keywords: Healthcare Communication Campaign, Rheumatoid Arthritis.
255
The Importance of Communication in Health Can Help Eradicate Hoaxes
Author: Holie Frendy Gitana Gezatania Hiskia Shindie Dona Kezia Lethulur
Faculty of Medicine and Health Sciences Universitas Kristen Krida Wacana Asian Medical Studentsâ&#x20AC;&#x2122; Association 2020
256
Introduction Sometimes we just need something without speaking, sometimes we want something without speaking, we also want to change something without speaking and that's something that will confuse and disappear. Say it when there's something we want to say and be clear about what it is so yeah it is what it is we say. say what we want, say that if we want to change something. It sounds trivial, but it's very important. because communication is very important in any relationship. The study of communication in the context of health care has an importance that goes beyond other areas of communication inquiry. Most likely, this is because the outcomes of communication in health care settings are viewed as so significant and so relevant to daily life. When the consequences affect the quality of life or even the absence of life, the importance of communication processes is elevated (Schoop, 2019). Although this approach is decidedly linear and does not account for many other factors that will influence health and illness, the connections between these elements provide a starting point for understanding how improved communication can make a difference. Two examples of these possible connections in physician-patient communication are given below (and notice that we could do the same sort of exercise for outcomes of other interpersonal health communication domains, such as social support or self-disclosure): 1. Low patient participation → Poor comprehension of treatment recommendations → Poor adherence → Decreased survival or poor quality of life 2. Provider empathic behavior → Patient satisfaction → Less decisional regret → Continued relationships or fewer malpractice suits Current research provides snapshots of some links in provider-patient communication, and we will review selected research on those associations in this chapter. The key outcomes on which we will focus in this chapter are satisfaction, adherence/compliance/cooperation, health status, malpractice litigation, and quality of life (Bignoli & Simone, 2016) Communication with doctors and patients is very important to fight hoax in Indonesia such as some examples that eucalyptus oil can cure Covid 19, wounds can be healed with toothpaste, soy sauce, colds can be cured with scrapings, eating apples, ulcer medication, rambutan causes a person to become drowsy, if you're on your period, you shouldn't clean your hair, and people say that rheumatism (or in medical language: Rheumatoid Arthritis) is caused by bathing at night. So we will explain in this paper that these are all questions that need to be answered, we will enter some data to show that it is worth considering the last thing that night baths can cause rheumatoid arthritis. Materials and Method This Systematic Review is based on Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA). Authors conducted a review search using online search engineering with database: Science Direct, PubMed, and Google Scholar. Keywords include ‘Healthcare Communication Campaigns’ and
‘Rheumatoid Arthritis. The articles are collected
257
between 22th September and 18th October 2020. The result, we find out 7 articles from the search through database searching. Screening was conducted by four independent reviewers. Search result were assed for duplication, which further assessed. Studies then filtered using inclusion and exclusion criteria. Inclusion criteria are: (a) observational study (b) population-based
Eligibility
Screening
Identification
studied. Exclusion criteria are: publication age >5 years. PubMed (n= 305)
ScienceDirect (n= 223)
Google Scholar (n= 2.560)
Records identified database searching (n= 3.088) Records after duplicates removed (n= 945) 918 article exclude, with reason: - Not relevant (n=305) - No full-text available (n=203) - Publication age >5 years (n=410) Full-text articles assessed for eligibility (n= 27) 8 review articles exclude
Included
Studies included in qualitative synthesis (n= 19) 12 articles exclude, with reason: - Insufficient evidence (n=12) Studies included in qualitative synthesis (n= 7) Figure 1. PRISMA Flow Diagram Result RA is inflammatory arthritis that results from a systemic autoimmune response stimulated by an as yet unidentified antigen. It is commonly believed that the generation of autoantibodies through interactions of the innate immune system (antigen-presenting cells) with the adaptive immune system (CD4+ T cells and B cells) is central to the pathogenesis. The pro-inflammatory cytokines, especially
258
tumor necrosis factor-alpha (TNF-α), and two interleukins (ILs), IL-1B and IL-6 are the key cytokines which drive inflammation and the destructive process. However, it is likely that other cytokines such as IL-23, IL-17A, and interferon-gamma (IFN-γ) also play crucial roles in the pathogenesis of RA. IL4 and IL-10, on the other hand, have been suggested to improve arthritis. Joint damage results from the degradation of connective tissue by tissue-destroying matrix metalloproteinases (MMP) and the stimulation of osteoclastogenesis through the receptor activator of nuclear factor-kB ligand (RANKL). Activated CD4+ T cells also stimulate B cells to produce immunoglobulins, including RF. The prevalence of rheumatoid arthritis (RA) is relatively constant in many populations, at 0.5–1.0%. However, a high prevalence of RA has been reported in the Pima Indians (5.3%) and in the Chippewa Indians (6.8%). In contrast, low occurrences have been reported in populations from China and Japan. These data support a genetic role in disease risk. Studies have so far shown that the familial recurrence risk in RA is small compared with other autoimmune diseases. The main genetic risk factor of RA is the HLA DRB1 alleles, and this has consistently been shown in many populations throughout the world. The strongest susceptibility factor so far has been the HLA DRB1*0404 allele. Tumour necrosis factor alleles have also been linked with RA. However, it is estimated that these genes can explain only 50% of the genetic effect. A number of other non-MHC genes have thus been investigated and linked with RA (e.g. corticotrophin-releasing hormone, estrogen synthase, IFN-γ, and other cytokines) (Worthington, 2015). In Indonesia, the prevalence of RA was investigated as part of a house-to-house survey of musculoskeletal pain in a total population of 4683 rural and 1071 urban subjects 15 years of age and over in Central Java. Those identified as having peripheral joint pant of more than 6 weeks duration (82 men and 129 women) were examined by a rheumatologist and serology test and x-rays arranged. The prevalence of definite RA by ARA criteria was 0,2% in rural and 0,3% in urban subjects (Fauzi, 2017). Rheumatoid Arthritis is also classified based on the symptoms. and we can declare someone has rheumatoid arthritis if we find some of these symptoms. Table 1. Revised American Rheumatism Association Criteria for The Classification of Rheumatoid Arthritis criteria
Definition
1. Morning Stiffness
Joint stiffness in and around joints, lasts for at least 1 hour
2. Arthritis in 3 or more joints
From examination, 3 or more joints simultaneously experiencing swelling or fluid accumulation (not just growth bone). Frequent areas: PIP right / left, MCP,
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wrist, elbow, knee, ankle, and MTP 3. Arthritis of the joints of the hands
At least 1 joint of the hand experienced swelling (wrist, MCP, or PIP)
4. Symmetric arthritis
Involvement of the joints in one area (eg mentioned in criterion 2) on both sides of the body / bilateral.
5. Rheumatoid nodules
Subcutaneous nodules over the bony prominence.
So, there is no research that conclusively states that bathing at night can cause rheumatism. but from some literature think that the influence of temperature also plays an important role when bathing at night. people who take a shower at night will cause the body temperature to change and spread from the floor to the body so that when sleeping and waking up in the morning will feel the same symptoms as rheumatoid arthritis, namely morning stiffness. To be honest, the most common cause of rheumatoid arthritis is from autoimmune disease rather than from bathing at night (Worthington, 2015). Discussion In the end, from some of the readings that have been read, we can know together that rheumatoid arthritis is caused by autoimmune. But what matters from here is how everyone sees disease differently. We can know that rheumatoid arthritis is caused by autoimmune causes but not so many people know. some people still believe that bathing at night can cause rheumatoid arthritis (RA) even though as we know, bathing at night is also recommended for patients who usually undergo surgery the next day.
Picture 1. Data on the spread of hoaxes that take place every day Source: https://tirto.id/
What we need to meet the challenge is education for everyone. Education really helps us all without exception, anyone and anywhere. education can help to raise awareness in terms of
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"communication in Health" to help the improvement of patient's care delivery in Indonesia, to brainstorm for the solution to the problems that hinder effective health communication in clinical care settings in Indonesia, To discover and suggest new scientifically based and innovative methods in health promotion and literacy, to explore topic and issues related to the theme such as health literacy, health promotion, risk communication, social marketing, and ethnic in health communication in Indonesia to raise awareness in the importance of health communication in health care systems. and to demonstrate the current practice of health communication and its role in regard to the development of public health service in Indonesia. always follow the latest developments from scientific journals and read the right articles can also fight the spread of hoaxes (Zhao, 2020). Conclusion The study of communication in the context of health care has an importance that goes beyond other areas of communication inquiry. Most likely, this is because the outcomes of communication in health care settings are viewed as so significant and so relevant to daily life. When the consequences affect the quality of life or even the absence of life, the importance of communication processes is elevated. Communication with doctors and patients is very important to fight hoax in Indonesia such as some examples that eucalyptus oil can cure Covid 19, wounds can be healed with toothpaste, soy sauce, colds can be cured with scrapings, eating apples, ulcer medication, rambutan causes a person to become drowsy, if you're on your period, you shouldn't clean your hair, and people say that rheumatism (or in medical language: Rheumatoid Arthritis) is caused by bathing at night. So I will explain in this paper that these are all questions that need to be answered, I will enter some data to show that it is worth considering the last thing that night baths can cause Rheumatoid Arthritis (RA). but in fact, in the field of research
RA is inflammatory arthritis that results from a systemic
autoimmune response stimulated by an as yet unidentified antigen. and the spread of hoaxes can be overcome with education and following the latest journal developments. References Schoop, M. (2019). “An Empirical Study of Multidisciplinary Communication in Healthcare Using a Language-Action Perspective.” Proceedings of the Fourth International Workshop on the Language Action Perspective on Communication Modelling 59–72. Bignoli, C., & Simone, C. (2016). AI techniques for supporting human to human communication in CHAOS. Bae, Sang Cheol. (2020). “Epidemiology and Etiology of Rheumatoid Arthritis.” Journal of the Korean Medical Association 53(10):843–52.
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Worthington J. (2015). Investigating the genetic basis of susceptibility to rheumatoid arthritis. Journal of autoimmunity, 25 Suppl, 16–20. https://doi.org/10.1016/j.jaut.2005.09.011 Fauzi. (2017). “Rheumatoid Arthritis Rheumatoid Arthritis Overview.” Fakultas Kedokteran Universitas Lampung 3:1–20. Trio.Id. (2018). Hoaks dan Bahaya Rendahnya Kepercayaan terhadap Media. Retrieved October 20, 2020, from https://tirto.id/hoaks-dan-bahaya-rendahnya-kepercayaan-terhadap-media-cKAx Zhao, X. (2020). Health communication campaigns: A brief introduction and call for dialogue. International
Journal
of
Nursing
Sciences,
7,
S11–S15.
https://doi.org/10.1016/j.ijnss.2020.04.009 Aceto, G., Persico, V., & Pescapé, A. (2018). The role of Information and Communication Technologies in healthcare: taxonomies, perspectives, and challenges. Journal of Network and Computer Applications, 107, 125–154. https://doi.org/10.1016/j.jnca.2018.02.008
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Application of Communication Technology for Indonesia Health Workers to Improve Healthcare: A Systematic Review Jane, Tamara Atmogo, Edvano Adam Herbudi, Brigitta Chrysilla AMSA-Universitas Kristen Krida Wacana Background: Technological developments around the world drive evolution in every area of life, including in the world of health. The world is competing to develop technology to be used in the world of health, one of which is Indonesia. Indonesia is a large country with a large population which of course will depend on the world of health. Methods: A search was performed using PubMed, Proquest, ScienceDirect, and Google Scholar for studies reviewing health communication technology from other countries. The keywords used on Pubmed were: (("Communication" OR "Health Communication") AND ("Technology" OR "Wireless Technology") AND ("Delivery of Health Care" OR "Quality Assurance, Health Care" OR "Quality of Health Care" OR "Universal Health Care")) were added to Proquest, ScienceDirect, and Google Scholar. Results: All eight studies that was selected for the review were randomized controlled trials, systematic reviews, and qualitative studies in English. The main inclusion criteria entailed health workers in the use of health communication technology. The quality assessment was done using EBM tools. Discussion: Based on collected studies, Indonesia is certainly able to develop health technology, such as health-based applications. However, this technology still cannot reach all people in all corners of Indonesia. The reasons are signal connections, differences in social and economic conditions, and much more. Conclusion: These findings can be applied in Indonesia to improve healthcare if the issues stated were resolved.
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Application of Communication Technology for Indonesia Health Workers to Improve Healthcare: A Systematic Review Jane, Tamara Atmogo, Edvano Adam Herbudi, Brigitta Chrysilla AMSA-Universitas Kristen Krida Wacana
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Introduction Good and correct communication is crucial in the medical world. The communication that is carried out by the health worker-patient is usually done during the history taking. With anamnesis, all patient complaints can be conveyed both from the patient's previous medical history, which may in the future be related to the main complaint the patient presents, which in essence can increase the diagnostic accuracy of the doctor. However, it should be noted that in order to maintain good communication between health workers-patients, there should be no interruptions, because only patients know their medical history so far. This must be done to maintain the comfort of the patient in conveying all the complaints he feels in his body so that he goes for treatment. In this era of industry 4.0, technological developments have a huge impact on the world, including the world of health. This industrial era 4.0 encourages health professionals or the world of health in particular to think more innovatively and transformative to develop positive things that will have an impact on the satisfaction of health services for patients. With the technology that is rapidly developing in this world, health-patient consultations can be carried out online face-to-face using platforms that are widely available in cyberspace, although it is possible that there are still many patients who prefer to communicate face to face directly with staff. Health. Communication, both short and long distances in this industrial era must be able to run well, in order to increase patient satisfaction in receiving health services, a good explanation of their health, and what treatment these patients can undergo. What's more, in this era of 4.0, medical and medical problems can be found easily in cyberspace, which does not necessarily guarantee its authenticity or fact. Therefore, health workers must be able to properly explain each disease experienced by patients or even answer all questions from patients related to their searches in cyberspace to provide certainty related to clinical problems. Indonesia, as one of the most populous countries, will of course depend very much on the world of health. What's more, in this industrial 4.0 era, Indonesia must be able to improve health services, especially digital platforms. Of course, this platform can be in the form of an application, web, or in any other form in order to increase the ease with which patients can consult with health workers. It cannot be denied, there are already several digital platforms for the medical needs of the community. However, this platform would be better if it could be developed again, especially its communication features, be it face-to-face online or other efforts, in order to increase patient satisfaction in the health services provided which would certainly increase patient compliance and trust in Indonesian health workers. It is undeniable that there are still many Indonesian health workers who have not been able to apply health worker-patient communication properly, which causes patients to be more closed in explaining their health conditions. Therefore, education must be given beforehand to health workers in order to be able to perform anamnesis with patients well. This review will analyse communication technologies that have been applied before in other countries that may or may not can be applied in Indonesia considering its culture, characteristics, and more.
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Method A. Eligibility criteria Types of studies: Qualitative studies, randomized controlled trials and systematic reviews (with meta-analysis included or excluded) about the use of health communication technology from other countries were included. Language is restricted to English only. The publication date or publication status were restricted for the last 10 years. Participants of health workers from other countries were included. Trials or reviews assessing health communication technology from other countries were included. The primary outcome for this review was the increased of quality health care for better public health. B. Information sources Search was conducted using four electronic databases. This search was applied to PubMed, ProQuest, ScienceDirect, and Google Scholar. The last search was run on 23 September 2020. C. Search The keywords used on Pubmed were: ((Communication) OR (health communication) AND ((Technology) OR (wireless technology)) AND ((Delivery of Health Care) OR *quality assurance, health care) OR (quality of health care) OR (universal Health care)) were added to ProQuest, ScienceDirect, and Google Scholar. Additional filters were included to filters the journals from the databases. The additional filters added were: Full text, clinical trial, meta-analysis, randomized controlled trial, systematic review, in the last 10 years, and humans. The search strategies are shown in appendix. D. Study Selection Three separate authors independently assessed eligibility of studies by screening the titles and abstracts identified from the databases. Studies that were considered to be relevant were checked and assessed from the full paper. Disagreements between authors were resolved by a consensus. PRISMA flowchart was completed to summarize this process. E. Data collection process The data was divided to three groups randomly and 3 authors extracted the data groups respectively. Disagreement were resolved by discussion between the two authors. F. Data items Information was extracted from each included studies on: (1) the health communication technology which is used for the intervention; (2) the outcome measure (including effect on the quality of the health care); (3) the limitation of the study (which may influenced the findings or results from the study).
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G. Quality assessment To determine the validity of eligible studies, 3 authors ascertained the risk of bias using EBM tools for assessing the reliability, importance, and applicability of the clinical evidence.(Evidence-Based Medicine Toolbox, n.d.) Result A. Study Selection A total of 9 studies were identified for inclusion in the review. The search of Pubmed, ProQuest, ScienceDirect, Google Scholar databases provided a total of 14,450 citations and 10 additional citations from other sources that met the criteria for inclusion were identified through checking the references of the relevant papers and the studies that have cited these papers. No unpublished relevant studies were used. After the additional filters were added, a total of 1,029 were identified from the databases. 1006 studies were excluded because it did not met the inclusion criteria after reviewing the abstract. The full text of the remaining23 citations were examined in more detail. 14 did not meet the inclusion as described. 6 were discarded because the participants did not match the inclusion criteria while 7 studies were also discarded because the intervention did not match the inclusion criteria. 1 study was not included because it is only a study protocol. After the final screening, 9 studies met the inclusion criteria and were included in the systematic review.
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Identification
Records identified through database searching (n =14,450)
Additional records identified through other sources (n = 11)
Eligibility
Screening
Records after added the additional filters (n = 1,029)
Records screened (n = 23)
Records excluded (n = 1,006)
Full-text articles assessed for eligibility (n = 9)
Full-text articles excluded, with reasons (n = 14) -Participants did not match inclusion criteria (n=6) - The intervention did not match inclusion criteria (n=7)
Included
- Study protocol (n=1) Studies included in qualitative synthesis (n = 9)
Figure 1. PRISMA flowchart of study selection (Liberati et al., 2009)
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B. Study characteristics All nine studies that were selected for the review were randomized controlled trials, qualitative studies, and systematic reviews in english. The studies were published between 2010-2020 and were done in United Kingdom, United States, South Africa, Thailand, Japan, and India. The health communication technologies assessed were: mobile phone devices, alphanumeric pagers, cellular and smart telephones, bar-code technology, personal digital assistant, and programmes which improved the health care personnel in performing duties, which in turn, increased the quality health care and public health. C. Quality assessment Kaewkungwal 2010 Was the assignment of patients to treatment
yes
randomized? Were the groups similar at the start of the
yes
trial? Aside from the allocated treatment, were
yes
groups treated equally? Were all patients who entered the trial
yes
accounted for? And were they analysed in the groups to which they were randomized? Were measures objective or were the patients
no
and clinicians kept â&#x20AC;&#x153;blindâ&#x20AC;? to which treatment was being received? Risk-of-bias-judgement
High risk
Onodera 2018 Was a qualitative approach appropriate?
yes
Was the sampling strategy approriate for the
yes
approach?
269
What were the data collection methods?
The data were collected from mobihealthnews research which is an exclusive database that covers relevant FDA clearances from 1999 to 2016.
How were data analysed and how were these
The data were analysed and classified based
checked?
on the device description summary in the database of the FDA
Is the researcherâ&#x20AC;&#x2122;s position described?
No
Risk-of-bias-judgement
Low risk
Jaroslawki 2014 Was a qualitative approach appropriate?
yes
Was the sampling strategy approriate for the
yes
approach? What were the data collection methods?
The data were collected by interview with 25 to 90 minutes long, 21 by phone and one by email. Complete annonymity and confidentiality were assured.
How were data analysed and how were these
The data were analysed by an inductive
checked?
analytical approach which allowed the study to reflect the rich diversity of experiences of the various mHealth stakeholders.
Is the researcherâ&#x20AC;&#x2122;s position described?
yes
Risk-of-bias-judgement
Low risk
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Henschke 2020 What question (PICO) did the systematic How mobile technologies support healthcare review address?
provider in communication and management of care
Is it unlikely that important, relevant studies yes were missed? Were the criteria used to select articles for yes inclusion appropriate? Were the included studies sufficiently valid yes for the type of question asked? Were the results similar from study to study?
yes
Risk-of-bias-judgement
Low risk
Nguyen 2015 What question (PICO) did the systematic How technology is used for urgent clinician review address?
for clinician communications
Is it unlikely that important, relevant studies yes were missed? Were the criteria used to select articles for yes inclusion appropriate? Were the included studies sufficiently valid yes for the type of question asked? Were the results similar from study to study?
yes
Risk-of-bias-judgement
Low risk
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Odendaal 2020 What question (PICO) did the systematic What is the health workers perceptions and review address?
experiences of using mHealth technologies in delivering primary healthcare services
Is it unlikely that important, relevant studies yes were missed? Were the criteria used to select articles for yes inclusion appropriate? Were the included studies sufficiently valid yes for the type of question asked? Were the results similar from study to study?
no
Risk-of-bias-judgement
Some concern
Poon 2010 Was the assignment of patients to treatment
yes
randomized? Were the groups similar at the start of the
yes
trial? Aside from the allocated treatment, were
yes
groups treated equally? Were all patients who entered the trial
yes
accounted for? And were they analysed in the groups to which they were randomized? Were measures objective or were the patients
yes
and clinicians kept â&#x20AC;&#x153;blindâ&#x20AC;? to which treatment was being received?
272
Risk-of-bias-judgement
Low risk
Free 2013 What question (PICO) did the systematic What is the effectiveness of mobile-health review address?
technologies in improving health care service delivery processes
Is it unlikely that important, relevant studies yes were missed? Were the criteria used to select articles for yes inclusion appropriate? Were the included studies sufficiently valid yes for the type of question asked? Were the results similar from study to study?
No
Risk-of-bias-judgement
Some concern
Discussion A. mHealth Devices A review consisting of several studies about mobile devices summarizes the effect of mobile devices on health workers in several countries such as the USA, Spain, Mongolia, Uganda, Netherlands, Turkey, Norway, Canada, Italy, France, and the Dominican Republic (Free et al., 2013). In the study, mobile technologies affect primary care providers in consulting with hospital specialists by making a little to no difference for primary care providers to follow guidelines for patients with Chronic Kidney Disease, reducing the time between presentation and management of individuals with skin conditions, or patients in need of an ultrasound, or being referred to a specialist attending primary care. The technologies also impacted in reducing referrals and clinic visits among patients with skin conditions, increase the chance of receiving retinopathy screening among diabetes patients, or ultrasound in patients referred with symptoms. The study also reported in making a little to no difference to the patientreported quality of life and health-related quality of life, or clinician-assessed clinical recovery among skin conditions patients. There are also effects of acceptability and satisfaction of healthcare providers or participants when primary care providers consult with dermatologists and the effect of making little
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or no difference for total or expected costs for skin conditions or Chronic Kidney Disease adult participants. The same study also includes the effect of mobile technologies when used by emergency physicians to consult with hospital specialists about people attending the emergency department. The effects included are reduced consultation time between emergency physicians and hospital specialists and reduced participantsâ&#x20AC;&#x2122; length of stay in the emergency department by a few minutes. In addition, the study also includes the effect of mobile technologies when used by community health workers or homecare workers to consult with clinic staff, such as making little or no difference in the number of outpatient clinic and community nurse consultations, or hospitalization for diabetes or older participants treated with home enteral nutrition, making little or no difference for acceptability and satisfaction for diabetes and rheumatoid arthritis participants, and may lead in mortality among HIV-infected people. Although the study provides a wide range of effects that may improve the quality of healthcare because of communication technology, the confidence of the evidence is not high. Therefore, the effects are not statistically significant. Similar effects were found in a study in South Africa (Henschke et al., 2020). The technologies changed how health workers worked with each other, how they delivered care, and how the technologies led to new forms of engagement and relationships with clients and communities. In addition, the study also explored factors that affect health workersâ&#x20AC;&#x2122; use and perceptions of mHealth, such as costs, the technology, the health worker, the health system, society, and poor access to electricity. The technologies improve coordination and quality of care, which is also reported in another study in Japan (JarosĹ&#x201A;awski & Saberwal, 2014). It also let health workers take on new tasks, work flexibly, and reach clients in remote areas. The study also reported that mobile devices improve care and their relationships with clients. The limitations reported regarding mHealth are some still prefer face-to-face contact, some have problems when senior colleagues did not respond or responded in anger, some thought the technologies threatened their clinical skills, some regarded mHealth as creating more work, some think mHealth crossed their privacy when patients contacted them outside working hours. The technologies are appreciated when they improved feedback, speed, and workflow, but it can also be slow or timeconsuming. The use of mHealth by health workers was trusted by some community members, but some are skeptical. Furthermore, the use of mHealth is more positive in health workers who are accustomed to using it than health workers with less expertise because they were sometimes embarrassed about making mistakes in front of clients or worried about job security. The challenges experienced are poor network connections, electricity access, cost of phone credits, damaged devices, also other factors such as language, gender, and poverty issues. Another study in the USA compared phones to pagers (Kaewkungwal et al., 2010). The study reported that using cellular telephones associated with a reduced risk of medical error or injury resulting from communication delay in comparison to anesthesiologists who used pagers. In addition, because of the bidirectional functionality of the phone, less time was needed to pass on important information.
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Similar to previous studies, the positive effects reported are improvements in efficiency and communication, reduced wasted time, and increase the accessibility of information. This study also reported similar limitations such as a reduction of face-to-face interactions which reduce meaningful interactions. However, in contrast to the previous studies, the usefulness of smartphones depended in situational contexts. Also, this study reported the ineffectiveness of IP-based phone systems to reduce interruptions from physiciansâ&#x20AC;&#x2122; mobile phones. While the former study in South Africa showed that health workers understand the importance of confidentiality of patients while using mobile devices, this study reported there are risks of losing confidentiality and data security. Thus, adding more limitations for mHealth. In addition, there are also risks of noise, infection control, and cross-contamination. B. mHealth Technologies A review consisting of studies about mHealth technologies covered the effect of using several technologies on health workers in different countries (Nguyen et al., 2015). The review reported the use of SMS and mobile phone call for appointment reminders impacted in an increase in attendance. Similarly, a study in Thailand about the application of cell phone focusing on mother and child care used a program that sends reminders to mothers for their scheduled visits, which resulted in increased on-time attendance and less delay of antenatal visits and immunizations (Odendaal et al., 2020). One of the key challenges of the study is that health workers still consider it a burden to do. Other than appointment reminders, the review also reported the use of mHealth technologies with test result notification as to the outcome. It reported the use of SMS notification to reduce mean time to the communication of diagnosis, first contact to treatment, and test to treatment. The study also included the use of mobile calls between nurses and surgeon when compared to the usual practice, it resulted in increased call refusal or delay, communication difficulties, intra-operative noise interruptions, and response rate. However, it wasnâ&#x20AC;&#x2122;t significant, except for the response rate. C. Other Technologies One study from the United State of America developed bar-code technology to prevent serious medication errors such as during order transcription or administration of medication as well as potential adverse drug events (Onodera & Sengoku, 2018). The technology prevents such errors by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). The use of bar-code eMAR substantially reduced the rate of errors in order administration of medication and transcription, but the rate of potential adverse drug events associated with timing errors did not change significantly. Although it did not eliminate such errors, the study showed that the barcode eMAR is an important intervention to improve medication safety. Pharmacists and nurses often intercept errors during the medication-ordering stage. Errors made during the administration state during the medication-transcription stage often go undetected. The bar-code technology can act as an additional safety net in medication administration, reducing transcription errors, preventing
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transcription errors that may lead to errors in the administrations. The close integration of the orderentry, pharmacy, and medication-administration systems greatly improved communication between nursing and pharmacy staff within the hospital. The implementation of the bar-code eMAR could substantially improve medication safety and communication between the nurses and pharmacists. Another study from India elaborates the eHealth programs including point-of-care in rural and urban areas, treatment compliance, data collection, and disease surveillance, and distant medical education (Poon et al., 2010). Implementation of eHealth programs may improve the communication between health care and also the quality of care, including follow-up and emergency care, and the number of referrals. It can track the number of beneficiaries in programs and can identify someone who has been lost to follow up, monitor the productivity of rural health workers and educate the social health activist and beneficiaries directly as well. The eHealth programs cannot run solely without government involvement, especially in a rural area, considering the high financial sustainability and the unavailability of suitable health personnel. Nevertheless, programs run solely by the government are unlikely to be the most effective, but collaborations between government and non-profit in particular and for-profit organizations have led to impactful programs. D. Communication technology application in Indonesia Technology in the health sector continues to develop to become more efficient, easier, and more sophisticated. technological advances are also rapid in the medical field so that health services can be better. the presence of today's technology we can use to find information more instantly. but Indonesia is very broad, economic inequality in Indonesia is one of the reasons Indonesia is not ready to face technological developments. Technology in the health sector is considered crucial in facilitating service during a pandemic. As we know, health technology can support the way doctors and patients interact with each other amid COVID-19. Barriers such as poor infrastructure, lack of transportation, and travel distances from home prevent many Indonesians from accessing quality health care services and the support of specialist doctors. Health technology enables rapid improvements in patient-doctor communication, diagnosis, and treatment. Improvements in health are a solution to overcoming many challenges in the health sector. An example of the innovation is to use SMS as a reminder of a meeting between health workers and patients, an application that lists the closest health facilities, or even health emergency services as studied and practiced in India. In addition, another innovative in medical technology comes from the United States of America, where they create barcode technology in hospital administration services to prevent errors in health services between doctors, nurses, pharmacists, and other workers. The question is, is mobile health and health program technologies can be applied in Indonesia? the answer is yes it can. but depends on human resources in Indonesia. The key to success in m-health technologies begins with the availability of mobile phones. The other problem is, not all people in Indonesia understand this mobile-health technology. Indeed, education is needed so that many
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people understand this technology so that health services become easier, Indonesia has lagged in the development of science, technology, and the quality of higher education. Not only at the world level, but also in a smaller scope such as ASEAN. The language factor apparently cannot be underestimated. The language factor is a major obstacle to the low voice of Indonesia in research at the global level, particularly in health and medicine. Indonesia can become a country that is advanced in technology provided that it meets several standards. One of them is by increasing economic growth. The increase in economic growth is expected to increase the purchasing power of the people for domestic industrial products. Universities can work together with industry players to boost domestic industries. The limitations that studied in these journals is the same as the limitations that occur in Indonesia such as reduction of face-to-face interactions which reduce meaningful interactions, the ineffectiveness of IPbased phone system to reduce interruptions from physiciansâ&#x20AC;&#x2122; mobile phones, risks of losing confidentiality and data security, risks of noise, infection control, and cross-contamination, communication difficulties, intra-operative noise interruptions. Afterward, the most important thing is that the environment is conducive to national innovation. Because the technological advances in Indonesia are not comparable with Indonesia's human resources. Conclusion and Recommendation In this era of industry 4.0, technological developments have had a huge impact on the world, including the healthcare system. Indonesia, as one of the most populous countries, will of course depend very much on the healthcare system. Many innovative technologies have affected the system as SMS, barcode technology, and other eHealth programs, has been developed in other countries which substantially results in a positive outcome in the quality of health care and improve the efficacy of health workers or doctor-patients communication. But Indonesia is very broad, economic inequality in Indonesia is one of the reasons Indonesia is not ready to face technological developments. Other factor such as the unavailability of mobile phones, lack of understanding of mobile-health technology, and the language barrier also affect the development rate of technology and science. In conclusion, Indonesia can become a technology-advanced country, especially in health communication technology, provided that it meets several standards which enable innovative technological health communication be implemented with or without the government involvement. However, considering the lack of financial sustainability and the unavailability of suitable health personnel in Indonesia, the health communication technology cannot run solely without government involvement. Nevertheless, programs run solely by the government are unlikely to be the most effective, but collaborations between government and non-profit in particular and for-profit organizations have led to impactful programs.
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References Evidence-Based Medicine Toolbox. (n.d.). Retrieved October 20, 2020, from https://ebmtools.knowledgetranslation.net/ Free, C., Phillips, G., Watson, L., Galli, L., Felix, L., Edwards, P., Patel, V., & Haines, A. (2013). The Effectiveness of Mobile-Health Technologies to Improve Health Care Service Delivery Processes: A Systematic Review and Meta-Analysis. PLoS Medicine, 10(1). https://doi.org/10.1371/journal.pmed.1001363 Henschke, N., Bs, B., Gl, M., Tamrat, T., Shepperd, S., Dc, G., Ar, J. M., Villanueva, G., Ms, F., Glenton, C., Lewin, S., Henschke, N., & Bs, B. (2020). Gonçalves-Bradley DC, J Maria AR, Ricci-Cabello I, Villanueva G, Fønhus MS, Glenton C, Lewin S, Henschke N, Buckley BS, Mehl GL, Tamrat T, Shepperd S. https://doi.org/10.1002/14651858.CD012927.pub2.www.cochranelibrary.com Jarosławski, S., & Saberwal, G. (2014). In eHealth in India today, the nature of work, the challenges and the finances: An interview-based study. BMC Medical Informatics and Decision Making, 14(1), 1–13. https://doi.org/10.1186/1472-6947-14-1 Kaewkungwal, J., Singhasivanon, P., Khamsiriwatchara, A., Sawang, S., Meankaew, P., & Wechsart, A. (2010). Application of smart phone in “better Border Healthcare Program”: A module for mother and child care. BMC Medical Informatics and Decision Making, 10(1), 69. https://doi.org/10.1186/1472-6947-10-69 Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ (Clinical Research Ed.), 339. https://doi.org/10.1136/bmj.b2700 Nguyen, C., McElroy, L. M., Abecassis, M. M., Holl, J. L., & Ladner, D. P. (2015). The use of technology for urgent clinician to clinician communications: A systematic review of the literature. International Journal of Medical Informatics, 84(2), 101–110. https://doi.org/10.1016/j.ijmedinf.2014.11.003 Odendaal, W. A., Anstey Watkins, J., Leon, N., Goudge, J., Griffiths, F., Tomlinson, M., & Daniels, K. (2020). Health workers’ perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis. In Cochrane Database of Systematic Reviews (Vol. 2020, Issue 3). https://doi.org/10.1002/14651858.CD011942.pub2 Onodera, R., & Sengoku, S. (2018). Innovation process of mHealth: An overview of FDA-approved
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mobile medical applications. International Journal of Medical Informatics, 118, 65–71. https://doi.org/10.1016/j.ijmedinf.2018.07.004 Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. Obstetrical and Gynecological Survey, 65(10), 629–630. https://doi.org/10.1097/OGX.0b013e3182021fe9
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Appendices Appendix A - Study Characteristic Author
Year
Country
Intervention
Henschke
2020
United Kingdom
Mobile phone
Nguyen
2014
USA
Alphanumeric pagers, cellular and smart telephones
Odendaal
2020
South Africa
Mobile
devices
(phone or tablet) Eric G. Poon, M.D., 2010
USA
M.P.H. Caroline Free
Bar-Code Technology
2013
England
Personal
digital
assistants (PDA) Kaewkungwal., J.
2010
Thailand
A module combining web-based mobile
and
technology
was developed Jaroslawski., S.
2014
India
eHealth programmes such as point-of-care in rural and urban areas
Onodera., R.
2018
Japan
mHealth,
mobile
medical applications as medical devices, approved by FDA (the US food and drug administration)
Appendix B - Search strategy 1. Search strategy: PubMed Search:(("Communication" [MeSH Terms] OR "Health Communication"[MeSH Terms]) AND ("Technology" [MeSH Terms] OR "Wireless Technology"[MeSH Terms]) AND ("Delivery of Health Care" [MeSH Terms] OR "Quality Assurance, Health Care" [MeSH Terms] OR "Quality of Health Care" [MeSH Terms] OR "Universal Health Care" [MeSH Terms]))
280
2. Search strategy: ProQuest, ScienceDirect, and Google Scholar (("Communication" OR "Health Communication") AND ("Technology" OR "Wireless Technology") AND ("Delivery of Health Care" OR "Quality Assurance, Health Care" OR "Quality of Health Care" OR "Universal Health Care" AND "full text" AND "humans" AND "english")
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Assessment of the Effectiveness of Telepsychiatry as An Emerging Method of Internet-based Intervention Compared to Face-to-face Psychiatric Session as A Comprehensive Alternative to Reach a Mental-health Aware Generation in COVID-19 Pandemic: A Systematic Review Maria G. Vanessa1, Nadia K. Heryadi1, Michele Indrawan1, Michelle Imanuelly1 1
Faculty of Medicine, Pelita Harapan University, Tangerang, Banten, Indonesia
Abstract (Introduction) Mental illness is one of the leading causes of ill-health and disability worldwide but the number of help sought due to that reasoning are still very low. It could be due to stigma, limitation of heathcare accessibility, and discrimination. In this modern era of technologies, several breakthroughs in telepsychiatry have been introduced to the society. Video-conference session as a form of telepsychiatry is one of the closest alternative to face-to-face psychiatric sessions that is limited and not accessible due to the reasons mentioned above. Moreover, in this era of COVID-19 pandemic, social quarantine has been one of the biggest obstacle in reaching for help from mental healthcare providers. In this study, we hope to prove that telepsychiatry is as effective as face-to-face sessions and can act as a comprehensive alternative in this pandemic. (Methodology) A systematic review was conducted through a systematic analysis, such as the PICO method and MeSH terminology. The inclusion criteria: randomized controlled study, telepsychiatry specifically video-conference-based treatment, patients diagnosed with any form of mental illness, and the adult population. The exclusion criteria: Meta-analysis, Systematic review, Literature review, Cross-sectional studies, Case-report, Publication >10 years, Animal studies, and Child population. (Result) Most of the studies accept telepsychiatry through video conferencing service for all mental health is acceptable and effective to approach individuals living in rural areas or people with mental illnesses in COVID-19 era. (Conclusion) Telepsychiatry was proven to be as effective as face-to-face psychiatric sessions. Keyword: randomized controlled study, telepsychiatry, face to face, mental health
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Assessment of the Effectiveness of Telepsychiatry as An Emerging Method of Internet-based Intervention Compared to Face-to-face Psychiatric Session as A Comprehensive Alternative to Reach a Mental-health Aware Generation in COVID-19 Pandemic: A Systematic Review Maria G. Vanessa1, Nadia K. Heryadi1, Michele Indrawan1, Michelle Imanuelly1 1
Faculty of Medicine, Pelita Harapan University, Tangerang, Banten, Indonesia
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INTRODUCTION According to the World Health Report in 2001, mental disorders affect one in four people and around 450 million people currently suffer from these conditions, either from mental or neurological disorders1. To have stumbled upon that one sentence which contains a shocking fact, makes us wonder, who are these people that may have suffered or are currently suffering, could they be one of our friends, family, or perhaps even ourselves? Mental illness is one of the leading causes of ill-health and disability worldwide, yet why does it feel like we never truly understand and comprehend the true meaning of mental illness itself, and with such high numbers, why have they never sought help? It could be due to stigma, discrimination, or even the feeling when one suffers from mental illness it is often viewed as a personal failure, to help understand, first there is somewhat an obligation to fully understand what is mental health, its disorders, and in what ways can people seek help. Mental health, according to WHO, is the absence of mental disease or it can be defined as a state
of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment, but a recent debate by Huber et al2 states that it should be emphasized that health should encompass an individual’s “ability to adapt and to self-manage”. Thus, a new proposed definition is reported as “mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society. Basic cognitive and social skills; ability to recognize, express and modulate one's own emotions, as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium.” 3
With the mental health defined, as important as they are like any other illness or disorder, it needs
treatment which can be given achieved in several ways, either through face-to-face consultations or in these modern times, telemedicine or telepsychiatry emerge as a newer way to interact without predisposing the people suffering from mental illness to further worry about the undying stigma and assumptions from others.
1
https://www.who.int/news/item/28-09-2001-the-world-health-report-2001-mental-disorders-affect-one-infour-people Huber M, Knottnerus JA, Green L et al. . How should we define health? BMJ 2011;343:d1463–6. doi: http://dx.doi.org/10.1136/bmj.d416310.1136/bmj.d4163 [PubMed] [CrossRef] [Google Scholar] 2
3
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471980/
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Telepsychiatry also termed e-mental health or telemental health is defined, broadly, as the use of information and communication technology (ICT) to provide and support psychiatric services all around and across distances, because, despite the high number and prevalence of mental disorders, specialized mental health care or services tend to be inadequate, deficient and it is concentrated in the urban areas, rather than the rural-urban areas which worsen the mental health care of the populations living there. Using newer, many advanced technologies, the health providers or health professionals may use their skills and expertise to patients in far reach areas and provide specialist consultation to primary care providers in rural areas, thus, areas where any of the patients live do not limit their access to services and health care. Modes of communication in telepsychiatry involve the use of telephone, cell phone text messaging, and a two-way closed-circuit television and with the advancement of technology, video conferencing has become an important tool in today’s world and of course in telepsychiatry as it provides live, two-way interactive video, audio, and data communication. These modes of communication will further be used by the patient and health care provider for consultation, crisis management, psychotherapy, and referral4. Hence, in this systematic review we will be assessing the effectiveness of telepsychiatry compared to the usual care of face-to-face treatments in situations and problems such as mental health disorders and to try and observe its benefits and to review whether the outcome can provide greater benefits.
4
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3574452/
285
METHODS For our systematic review, we used the data from several randomized controlled trials published in online journals specifically Pubmed. The RCT studies that we used were published within 2010-2020. The data were accessed on 5th of October 2020 using the following keywords or terms : (("Mental Illness" OR “Mental Health”) AND ("Telepsychiatry" OR “Video”) AND ("Face to Face") AND ("Intervention”) AND ("Comparison") AND ("Adult") AND ("Randomized Controlled Trial" OR "Randomized Controlled Trial Study" OR “RCT” )). We limited our search to studies by only accessing data from NCBI and used English as the primary language for the paper. A systematic analysis, such as the PICO method and MeSH terminology, was also used in this study. For example, for the PICO method, we used “Adult diagnosed with mental illness” for the People or Population (P). For the Intervention (I) we used “Telepsychiatry” or “video-conference based therapy”. For comparison (C) we compared the data from the participant in the “control” group who underwent “usual treatment” or “face-to-face session”. And for the Outcome (O) we used “Decrease in symptoms” or “Decrease in severity”. The inclusion criteria used in this systematic review are a randomized controlled study, telepsychiatry specifically video-conference-based treatment, patients diagnosed with any form of mental illness, and the adult population. For the exclusion criteria, we used Meta-analysis, Systematic review, Literature review, Cross-sectional studies, Case-report, Publication older than 10 years, Animal studies, and Child population. Afterward, the data were reviewed by 2 reviewers using a standardized form. Then each paper was independently checked and assured by 2 other reviewers to reduce the risk of error. The purpose of this study is to assess whether Telepsychiatry is as effective as conventional face-to-face psychiatric sessions in improving symptoms and decreasing severity in several cases of mental illness. Based on our theory in the introduction, our hypothesis for this study is to assess if telepsychiatry can be an emerging solution to the known limited access of psychiatric sessions due to several reasons, especially due to a pandemic. Keyword: randomized controlled study, telepsychiatry, face to face, mental health
286
RESULTS
287
DISCUSSION Chong, J. & Moreno, F. 6 gathered adult
Hispanic patients with major depression (n=167) from a community health center (CHC), Saint Elizabeth’s Health Center (SEHC) in Tucson, AZ to participate in a randomized controlled trial on clinic-based telepsychiatry through a video Webcam (WEB), assessing its feasibility and acceptability compared to treatment as usual (TAU) in a primary care setting. Eligible subjects were randomly assigned to WEB or TAU with both conditions having an equal chance of being selected. The randomization was blinded to both the recruiter and patients until the patient had undergone informed consent and eligibility screening. Patients assigned to WEB (n=80) condition agreed to go through a once-a-month telepsychiatry session for 6 months (1h for intake and six 30-min follow-ups). Patients in the TAU group (n=87) were to receive their usual care from their SEHC providers. Treatment by the psychiatrists followed the measurement-based approach as described in the “Sequenced Treatment Alternatives to Relieve Depression” (STAR*D) study. The medication was based on “Texas Medication Algorithm Project”
strategies
for
the
treatment
of
nonpsychotic major depressive disorder. TAU at SEHC included a one-hour appointment with SEHC mental health specialists. The outcome data were collected at baseline and 3 and 6 months post-baseline to assess outcome at the beginning,
288
middle, and end of patientsâ&#x20AC;&#x2122; participation in this project. Several measurement tools were used for this project, which include The Personal Health Questionnaire 9 (PHQ-9) as a valid tool of depression severity, was administered to WEB patient each time they came for telepsychiatry and administered to TAU patients at baseline and 3 and 6 months post-baseline; The Mini-International Neuropsychiatric Interview (MINI) was used only once for exclusion and inclusion criteria screening; Sheehanâ&#x20AC;&#x2122;s Disability Scale (SDS) as a tool to rate the level of impairment caused by patients psychiatric condition, used at baseline and 3 and 6 months post-baseline(TAU) and the end of monthly telepsychiatry session (WEB); The nine-time Visit Specific Satisfaction Questionnaire (VSQ-9) to reflect patient-doctor communication; Working Alliance Inventory Short Form to measure the relationship between patient and clinician/therapist; demographic information; treatment-related information; health services utilization past 3 months.
289
As shown in table 2, WEB patients were significantly more satisfied with their visits with psychiatrists compared to TAU patients with their primary care provider. WEB patients were also significantly more likely to use antidepressant medication compared to TAU patients. Both WEB and TAU patients showed a significant decrease in depression symptoms from the 6 months follow up (Table 3). However, the significant interaction between assignment (WEB/TAU) and time (baseline, 3 months, and 6 months) indicated that WEB patients improved at a significantly higher rate than TAU patients. Both groups also showed a significant decrease in the number of days of less productiveness due to their symptoms. When patients were asked about how pleased they were with the depression care they received, the mean rating for TAU patients was 8.8±2.4 and for WEB patients was 9.4±1.1 (scale 1 not pleased at all and 10 very pleased). The results of this project suggest that telepsychiatry is acceptable as a method for reaching low-income Hispanic patients with depression and is as acceptable as primary care in TAU. These hypotheses are supported by the data of strong acceptability and feasibility shown by WEB patients.
A randomized clinical trial which was done by Fortney et al.6 , in the matter of
telemedicine-based collaborative care for PTSD has gathered subjects from the outpatients that were
recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics (CBOCs)
290
which serves for veterans living in rural areas, these subjects were recruited and selected due to the stigma and geographic barriers often preventing the rural veterans to engage in psychotherapy and pharmacotherapy treatments for PTSD which was proven in another RCT to be efficacious. Inclusion criteria were patients who meet the diagnostic criteria of PTSD based on the Clinician Administered PTSD Scale (CAPS), while the exclusion criteria include patients with a diagnosis of schizophrenia, bipolar disorder, substance dependence or hearing impairment, having no telephone, having a life-threatening illness and a lacking capacity to consent. Patients were recruited for 22 months, beginning from November 23, 2009 through September 28, 2011. Patients with designated PTSD providers that practiced at the CBOC were recruited through provider-encouraged self-referral and by opt-out letters which were sent to patients with a PTSD diagnosis in their electronic health record. Out of the 186 patients referred to the study, 43 people refused to participate after being contacted, and out of 2273 patients that were sent out opt-letters, 456 opted out before contacted and 606 opted out after being contacted. After a long process of filtering patients by inclusion and exclusion criteria, there were 133 Telemedicine Outreach for PTSD (TOP) intervention patients and out of 133, there were 111 which completed a 12-month follow- up, and 132 usual care (UC) patients out of which 114 manage to complete the 12-month follow up.
291
Baseline characteristics of the patients are described in â&#x20AC;&#x2039;Table 2. â&#x20AC;&#x2039;Symptoms of PTSD were severe, with
mean Clinician-Administered PTSD Scale scores of 75.0. The Mental Component Summary of the 12-Item Short Form Health Survey for Veterans (MCS) and Physical Component Summary of the 12-Item Short Form Health Survey for Veterans (PCS) scores were about 1.5 SDs below the national mean. Most participants reported that they had previously taken a psychotropic medication and/or received counseling for a mental health problem, and 78.1% reported receiving treatment specifically for PTSD.
When controlling for case mix, the TOP group was more likely to be prescribed with any PTSD medications compared to the UC group during the first 6 months s (OR, 2.98 [95% CI, 1.03-8.68]; P = .045), but not the second 6 months (OR, 2.32 [95% CI, 0.82-6.61]; P = .11). There were no significant difference in the number of prescribed PTSD medications between two groups during the first 6 months (risk ratio, 1.18 [95% CI, 0.98-1.43]; P = .08 or the second 6 months (risk ratio, 1.19 [95% CI, 0.99-1.44] ; P = .06).
292
During the 6 month follow up, patients which were randomized to TOP experienced a mean 5.31 decrease in Posttraumatic Diagnostic Scale (PSD) PTSD symptoms severity compared to a 1.07 decrease for patients randomized to UC and during the 12-month follow up, when comparing patients randomized to TOP, they experienced a mean 4.17 decrease in PDS PTSD symptoms severity compared with a mean decrease of 1.32 for patients randomized to UC. Limitation of this study was that the findings, although the face-to-face Clinician-Administered PTSD Scale is the reference standard, but the researchers chose to administer the briefer PDS by telephone to maximize the follow-up rate. Another limitation was there were no rigorous measures of quality of care including cognitive processing therapy (CPT) fidelity. Rural veterans which are present in this sample had considerable illness burden which are vividly reflected by the high levels of severity in PTSD and numerous comorbidities and also poor-health related quality of life. Half of the reported had combat-related trauma and half had service-connected PTSD. IT was also reported that nearly all of the veterans suffering from PTSD have taken psychotropic medications and/or receiving counseling and for the veterans that are randomized to UC experienced virtually no improvement of the symptoms. Compared to the veterans which were randomized to UC, those who are randomized to TOP experienced significantly greater improvements in PTSD and depression severity, despite the effect sizes which ranges from small to medium. To recall, the TOP intervention is done or attempted to improve engagement and access to evidence-based pharmacotherapy and evidence-based psychotherapy. It is shown that this intervention has increased the prescription of prazosin but there was no evidence that was found suggesting an effect on the total number of prescribed PTSD medications or adherence to medication regimens. However, the TOP intervention increased CPT engagement. Veterans randomized to TOP had 18 times higher odds of initiating CPT and 8 times higher odds of completing at least 8 sessions (minimal therapeutic dose).
293
In conclusion, despite several limitations, findings suggest that telemedicine-based collaborative care can successfully help engage the population in evidence-based psychotherapy for PTSD which further improves the clinical outcomes.
According to Engel et al. 7 in a randomized controlled trial to examine the effectiveness of a
nurse assisted online cognitive behavioral self-management intervention of war-related posttraumatic stress disorder (PTSD) and compared it to the optimized usual primary care for PTSD treatment (OUC) to reduce PTSD symptoms, where the participants are gathered from 80 recently deployed military service members and veterans which are referred from their primary care providers, this referral occurs after the screening positive for PTSD and these candidates were screened to meet the inclusion criteria, and these candidates should be war veterans that had seek care at participating Veteran Affairs (VA) or DoD and should report war-related trauma during deployment (including military sexual trauma), they should screen positive on a 4-item PTSD screener and meet the Clinician-Administered PTSD Scale (CAPS) using 1-2 scoring rule. Exclusion criteria were as follow; active engagement in trauma-focused mental health treatment in the previous 2 months, a recent history of failed speciality mental health treatment for PTSD and its associated condition, within the past 2 years has had diagnosis of acute psychosis, psychotic episode or psychotic disorder, active substance dependence in the past year, in the previous 2 months has had active suicidal or homicidal ideation, currently taking antipsychotic or mood-stabilizing medications, unstable administration schedule or dosing of any antidepressant, anxiolytic or sedative-hypnotic during the last month, and acute ot unstable physical illness. Randomization was accurately performed centrally with subsequent notification of the site investigator and of course the site’s delivery of self training and education for stressful situations (DESTRESS) nurse. Participants were randomized to DESTRESS-PC plus OUC or OUC alone. DESTRESS-PC intervention utilizes a variant of CBT-based and stress inoculation training which approaches a nurse-guided online patient self-management paradigm. Participants who are assigned to the DESTRESS-PC were told or asked to log on the secure website three times each week for 6 weeks and complete various homework activities. When logged on to the website, participants were able to access educational information about PTSD, stress, trauma and common comorbid problems and symptoms they might experience. Participants who were receiving OUC, which consisted of usual primary care PTSD treatment augmented with low intensity care management and feedback to the primary-care provider. These participants received three 15 minute telephone check-ins with the DESTRESS nurse, to allow the nurse
294
to monitor their progress, answer questions and assess them for risk at weeks two, four, and six and also in-person consultation in the event of urgent needs or matters impacting participant’s safety. The primary outcome uses the PTSD checklist, civilian version to assess PTSD symptom severity at baseline and at the 6-,12- and 18-week follow ups. It is a 17-item measure that assesses the symptoms of PTSD in accordance with DSM-IV and yields the total score from 17 to 85. Whilst, the secondary outcome was measured using the patient health questionnaire (PHQ) and it was used to assess depression, anxiety and somatic symptom severity at baseline and the three follow-ups.
Sample characteristics can be seen in Figure 1. Of the 252 participants who were screened for
the trial, 119 were ineligible, 40 were excluded, 13 dropped out prior to randomization and remaining 80 participants were randomly assigned to two study arms, 43 DESTRESS-PC and 37 to OUC.
295
There were statistically no significant differences in the individuals assigned to DESTRESS-PC (n=43) and those assigned to Optimized Usual Care (OUC) (n=37) in terms of baseline demographic characteristics or pre-treatment symptomatology, reflecting an achieved baseline comparability across the two study arms.
The DESTRESS-PC group improved at a faster rate than the OUC group and showed larger treatment gains (treatment by time interaction, F(3,186)=372, , p=.012; main effects for time, F(3, 186)=17.21, pb.001, and recruitment site, F(1, 77)=8.32, p=.005), with the largest treatment effect seen at 12 weeks, t(186)=2.44, p=.016 and diminishing by the 18-week follow-up. Six-week effect size was 0.23 (small), 12-week effect was 0.47 (medium) and 18-week effect size was 0.08. Seen in â&#x20AC;&#x2039;Figure 2. Out of the 43 participants who were randomized to the DESTRESS-PC arm, 28 (65%) completed at least 6 logins, 18 (42%) completed at least 12 logins and 15 (35%) completed all 18 logins. The correlation between the number of logins completed and the decrease in PCL scores was r=.36, p=.041 at the 12-week assessment and r=.34, p=.052 at the 18-week assessment. Shown in â&#x20AC;&#x2039;Table 3. Throughout the overall study benefits of the online self-management of primary
296
care patients with PTSD which were measurable and statistically significant, modest and transient there are reasons for guarded optimism. It is found that primary care patients with military related PTSD randomly assigned to 8 weeks of nurse- assisted online CBT self management experienced significantly greater mean improvement in PTSD symptoms than did those patients who were assigned to optimized usual PTSD care alone. Improvement in the online self-management was greatest at the 12-week follow up, but it decreases after discontinuation of online treatment and shows no remaining benefit at 18-week follow up and additional research to increase adherence may improve outcomes, and overall this study shows that DESTRESS-PC may be a promising intervention and provide another option for primary care patients with PTSD.
The study by Hungerbuehler et al.8 was done in a randomized controlled follow-up trial with a total of 107 participants under 2 different treatment
conditions. It was conducted with a 6- and 12-month follow-up including adults (18-55 years of age) who lived in São Paulo and the surrounding areas, had broadband internet access at home, and showed symptoms of mild depression. Fifty four participants underwent monthly face-to-face (F2F) consultations, while the rest performed home-based consultations with their psychiatrists using live interactive videoconferencing. After the first and second follow-up (6 and 12 months), an in-person follow-up consultation was conducted to assess the severity of their depression using the Hamilton Depression Rating Scale (HDRS-17). Clinical
outcomes
(mental
health
status,
medication course, and relapses), satisfaction with
treatment,
therapeutic
relationship,
treatment adherence (appointment compliance and dropouts), and medication adherence were assessed.
297
After the 12-month follow-up, the severity of depression in both groups decreased significantly. However, there was a significant difference between those 2 groups regarding treatment outcomes throughout the follow-up period. The videoconferencing group showed better results. Four relapses had occurred within the F2F group, whilst there was only one in the videoconferencing group. However, no significant differences were found between groups regarding mental health status, satisfaction with treatment, therapeutic relationship, treatment adherence, or medication compliance. At 6 months, the rate of dropouts in the F2F group was higher (n=10) than in the videoconferencing group (n=3) and 12 months, more dropouts were found (n=14 in the F2F group, n=8 in the videoconferencing group). Furthermore, participants in the F2F group tended to miss their appointments than participants in the video-conferencing group. Based on this study, the use of the internet for telepsychiatry in clinically unsupervised settings can be considered feasible and as effective as normal face-to-face consultations for mildly depressed outpatients with respect to clinical outcomes, treatment adherence, medication compliance, satisfaction, and working alliance. This also shows the potentially wide-spread use of telepsychiatry to remote areas and underserved populations.
In a randomized controlled trial by Spence et al. 9 , internet cognitive behavioral therapy (iCBT)
was applied in treatment group as a tool to measure the efficacy of internet-based treatment of
Posttraumatic Stress Disorder in treating symptoms. iCBT treatment protocols provide treatment materials via websites that are typically administered during face to face sessions, including regular communication with a healthcare worker via email, telephone, or other electronic media.
298
Table 1 - iCBT program content for PTSD patients in treatment group. The treatment group was followed through a 3-month follow-up, whereas the control group received treatment following post assessment. Participants were recruited from a website (www.virtualclinic.org.au) and underwent selection for inclusion criteria. Participants that met the initial screening and DSM-IV criteria (n=44) were randomized by a randomization generator into treatment (n=23) and control (n=21) group.
Table 2 - Demographic
characteristics of treatment and control group.
To measure the outcome of iCBT efficacy in this study, several measures were taken; from diagnostic, trauma exposure, then proceed to primary and secondary outcome measure. Mini international neuropsychiatric interview (MINI) was administered before treatment to ensure that participants met the DSM-IV diagnostic criteria. Life events checklist (LEC) provides a list of traumatic events according to DSM-IV. For primary outcome measure, Post Traumatic stress disorder checklist-civilian version (PCL-C) was administered for its brief and valid measure of PTSD symptoms. Three measurement scales were used to assess secondary outcomes, they include: (1) Patient health questionnaire-9 item (PHQ-9) to
299
measure symptoms and severity of depression, (2) Generalized anxiety disorder seven-item scale (GAD-7), and (3) Sheehan disability scales (SDS) to measure impairment in psychosocial functioning due to occurring symptoms.
Table 3 - Means, standard deviations and effect sizes for the two groups for the generic and each of the disorder-specific measures. According to the data, comprehension of the materials was high, with 81% (lessons were easy to understand), 10% (easy/too simplistic), 10% (neutral comprehension), and 0% difficult or very difficult to understand. Post-treatment data were collected from 91% Treatment and 86% Control group participants. Three-month follow-up data were collected from 83% Treatment group participants only. There were no formal withdrawals during the treatment program but failure to complete the program was found in 5/21.
Table 4 - Frequency of each disorder. Outcome measurements showed improvement in the 3-month follow-up of treatment group where 61% participants no longer met diagnostic criteria for PTSD (Table 4), 52% no longer met diagnostic criteria for any of the six disorders, and the mean number of comorbid diagnoses reduced from 1.9
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(SD=1.3) to 0.8 (SD=1.2). The Control group also improved over the treatment period (d=5 0.49); consequently, the between-group ES at posttreatment was small (d=0.47). Despite this, 61% of
participants in the Treatment group met criteria for remission at post treatment compared with 21% in the Control group. This study provides support for iCBT as an efficacious treatment for individuals diagnosed with PTSD. Some limitations of this study are (1) the failure to provide direct comparison of follow-up between Treatment and Control group, (2) the lack of detail on the controlled measures administered to the Control group, and (3) the lack of outcome measurements compared before, during, and after the treatment.
Randomized-controlled trials were conducted by Farabee et al.10 to evaluate the effectiveness of
telepsychiatry among offenders under community supervision in comparison to those receiving in-person care. The allocations of patients were based on the parolees’ identification (ID) number ended in an even or odd digit. Those with even-numbered IDs were assigned to the telepsychiatry condition, while those with odd-numbered IDs received the standard face-to-face sessions. Participants were asked if they would be willing to be randomly assigned to telepsychiatry or face-to-face treatment, be part of a record-based evaluation to monitor rearrest and custody data, and to subsequently complete a baseline and six-month follow-up interview. They were also paid $25 for completing the baseline interview and $25 for completing the follow-up interview. However, only 71 participants completed the baseline questionnaire and out of them, 60 participants completed the six-month follow-up assessment. Satisfaction with treatment, therapeutic alliance, medication adherence, and psychological functioning were measured. Findings showed high satisfaction with telepsychiatry overall and no significant group differences in psychological functioning, therapeutic alliance, and adherence to prescribed psychiatric medications. Nevertheless, telepsychiatry patients reported lower levels of therapeutic alliance at follow-up because patient preference had not been assessed as part of this study. Another reason might be the role of the social worker who accompanied the patient during the session. Even though this study had several methodological strengths (random assignment, high follow-up rate), it also had several limitations related to the sample size, and the recruitment of potential telepsychiatry participants which was affected by temporary technical difficulties. But even in this case,
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telepsychiatry still appeared to be an acceptable and effective approach for providing psychiatric care for parolees.
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CONCLUSION This systematic review aims to assess the effectiveness of treatment either by interactive video or face-to face treatment sessions in the management of mental illness and improve the treatment delivery system, primarily for those who live in rural areas or in conditions such as in COVID-19 pandemic. To conclude, from all of the studies, there are no significant differences in telepsychiatry and face-to-face psychiatric sessions. Most of the studies accept telepsychiatry through video conferencing service for all mental health is acceptable and effective to approach individuals living in rural areas or people with mental illnesses in COVID-19 era. Through this internet based intervention method, psychiatric care can be improved in ways other than directly treating the patients in the same room, face-to-face, and produces a better outcome. We hope that the result of this systematic review may support and improve telemedicine expansion, so more people with any mental illness may be treated properly and effectively.
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APPENDIX Table ... Summary of studies on telepsychiatry compared to face-to-face intervention in mental-health aware generation Authors Chong, et al. 5
Study Randomized
Year of Study 2012
controlled trial
Study Population
Result
167 adult Hispanic patients with
No differences were found
major depression
between WEB and TAU patients
(June 2008 -
in the overall depression score.
October 2009) Fortney, et al. 6
Randomized
2015
265 veterans with PTSD
No significant differences
controlled trial
between a number of PTSD
(November 23,
medications.
2009 - September 28, 2011) Engel, et al.7
Randomized
80 veterans with PTSD
No statistically significant
controlled trial
differences between
(6-, 12-, 18-
DESTRESS-PC and Optimized
weeks follow-up)
Usual Care/
Hungerbuehler,
Randomized
et al.
controlled trial
8
2015
2015
107 individuals with stabilized
No significant differences were
unipolar depression disorder
found between groups regarding
(12 months
mental health status, satisfaction
follow-up)
with treatment, therapeutic relationship, treatment adherence, or medication compliance.
Spence, et al. 9
Randomized
2011
42 individuals with PTSD
No difference between the
controlled trial
Treatment group and the Control
(3 month
group.
follow-up) Farabee, et al. 10
Randomized
2016
104 individuals from psychiatric
No significant differences
controlled trial
care with no group differences in
between telepsychiatry and
(January 20, 2012
terms of gender, age, race-ethnicity,
conventional psychiatry.
- April 25, 2013)
or commitment offense
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mental health. World Psychiatry, 14( 2), 231-233. https://doi.org/10.1002/wps.20231 Malhotra, S., Shah, R., & Chakrabarti, S. (2013). Telepsychiatry: Promise, potential, and challenges.
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Indian Journal Of Psychiatry, 55(1), 3. https://doi.org/10.4103/0019-5545.105499 Chong, J., & Moreno, F. (2012). Feasibility and acceptability of clinic-based telepsychiatry for
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low-income Hispanic primary care patients. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 18(4), 297–304. https://doi.org/10.1089/tmj.2011.0126 Fortney, J. C., Pyne, J. M., Kimbrell, T. A., Hudson, T. J., Robinson, D. E., Schneider, R., Moore, W.
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M., Custer, P. J., Grubbs, K. M., & Schnurr, P. P. (2015). Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial. JAMA psychiatry, 72(1), 58–67. https://doi.org/10.1001/jamapsychiatry.2014.1575 Engel, C. C., Litz, B., Magruder, K. M., Harper, E., Gore, K., Stein, N., Yeager, D., Liu, X., & Coe, T.
[7]
R. (2015). Delivery of self training and education for stressful situations (DESTRESS-PC): a randomized trial of nurse assisted online self-management for PTSD in primary care. General hospital psychiatry, 37(4), 323–328. https://doi.org/10.1016/j.genhosppsych.2015.04.007 Hungerbuehler, Ines, Leite, Rodrigo Fonseca Martins, Bilt, Martinus Theodorus Van de, & Gattaz,
[8]
Wagner Farid. (2015). A randomized clinical trial of home-based telepsychiatric outpatient care via videoconferencing: design, methodology, and implementation. Archives of Clinical Psychiatry (São Paulo), 42(3), 76-78. https://doi.org/10.1590/0101-60830000000052
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Spence, J., Titov, N., Dear, B. F., Johnston, L., Solley, K., Lorian, C., Wootton, B., Zou, J., &
[9]
Schwenke, G. (2011). Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder. Depression and anxiety, 28(7), 541–550. https://doi.org/10.1002/da.20835 Farabee, D., Calhoun, S., & Veliz, R. (2016). An Experimental Comparison of Telepsychiatry and
[10]
Conventional Psychiatry for Parolees | Psychiatric Services. Retrieved 20 October 2020, from https://doi.org/10.1176/appi.ps.201500025
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Overcoming the language barriers in health care as a strategy to make communication more effective between patients and health care professionals : Systematic Review and Meta Analysis Marlin1, Kinanthi Prima Astari2, Nyoman Alit Krisna Wibawa3 Undergraduate Medical Program, School of Medicine and Health Sciences, Jambi University ABSTRACT Introduction: As we know, in this modern era, globalization and migration that happen between countries can increase the possibility of language barriers in the process of health care between patients and clinicians.For the example, using English language, based on evidence show that even bilingual person who can speak English fluently when they are healthy, but on the situation of illness, they exactly feel more comfortable to speak primary language. Some of growing evidence show the fact of language barrier will impact the quality of health care indirectly for patients. Failure of communication such as the problem of language, it will result negative consequence, because the treatment for patients may fail, the patient may not to follow instructions or even choose not to undergo potentially life-saving treatment. Objective : This systematic review and meta analyses will investigate about overcoming the language barriers in health care as a strategy to make communication more effective between patients and health care providers. Materials and Method : This systematic review and meta analysis is reported following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) protocol.This protocol consists of identification, screening, eligibility test, and inclusion of studies which was conducted according to PRISMA statementsâ&#x20AC;&#x2122; flow diagram and checklist to improve the quality of review. Literature search is carried out with multiple electronic databases, such as PubMed, ScienceDirect, and Cochrane.The summarize of outlines the general characteristics of the studies are illustrated in Table 1. The implication of language barriers on the delivery of healthcare in each study in the review will illustrate in Table 2. The quality ofeach study is assessed for their quality by using Quality Assessment of Diagnostic Accuracy Studies â&#x20AC;&#x201C; 2 (QUADAS 2). Key Findings : Eleven studies were included in the meta-analysis. This review investigates the impact of language barriers and the strategy to overcome the language barriers between patients and health care providers in health care. From the results of 11 studies that have investigated, there are so many impacts of language barriers in health care, includes misunderstanding and miscommunication between patients and health care professionals. This factors can decreased in satisfaction of patients and health care professionals. Conclusion Some strategy to overcome the language barriers aim to increase patient satisfaction in health care, so hospital care or non hospital care need to provide professional interpreter or interpreter services (Goggle translate and MediBabble are recommended). Keywords: language barriers, health care, communication,systematic review, meta analyses
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Overcoming the language barriers in health care as a strategy to make communication more effective between patients and health care professionals : Systematic Review and Meta Analyses
Author: Marlin Kinanthi Prima Astari Nyoman Alit KrisnaWibawa
School of Medicine and Health Sciences Jambi University Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia 2020
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principles of human rights and similarity to all their patient (Bischoff et al., 2010)
Introduction Language plays a major role on communication. It can determine whether the communication is effective or not. But, language also relates to the identity of each individuals. As we know, in this modern era, globalization and migration that happen between countries can increase the possibility of language barriers in the process of health care between patients and clinicians. For the example, using English language, based on evidence show that even bilingual person who can speak English fluently when they are healthy, but on the situation of illness, they exactly feel more comfortable to speak primary language. (Roberstsa et al, 2007)
There are some problems that occur and relate to language barriers, for example is health disparities such as unequal treatment. Furthermore it also associate with unequal acces to healthcare and unequal health outcomes (Hilfinger et al., 2009). As an example, a recent research showed that patients in hospital care who don’t speak local language will disadvantage in acccess for health services (Floyd et al., 2017). Likewise, several research also demonstrate that patients who face language barrier will get worse health outcomes and get bad experience rather than patients who speak local language (Divi et al., 2007; Squires A., 2017)
Language barriers can affect health care for ethnic minority groups. Although health professioals are responsible to provide health care to their patients without compare the patient’s culture, ethnic, religion, and so on. But, in health care both of patients and clinicians must communicate, so the differences of language can obstruct the process of it. (Bischoff & Denhaerynck 2010, Hull 2015)
Well, there is a growing evidence that show the fact of language barrier will impact the quality of health care indirectly for patients. Language barrier wil reduce the satisfaction between health provider and patient. A resent research hold at six hospitals in United State about the differences between the patients who speak English fluently and the patients with limited English proficiency, and the result is side effects will occur more often on patients with limited English proficiency (Cohen et al., 2005).
Language barriers are important on the grade and quality for healthcare and of course it has a significant impact and as a challenge to provide effective health care. This problem usually occurs between the health care provider and the patient in hospital care when both of them don’t share an indigenous language (Slade et al., 2018). Irrespectively of language barrier, health care providers are needed to provide high-quality healthcare that take to
Study about diagnosis and treatment, it’s related to deliver accurately the possible risk factors. Risk factors that must be considered is how communication in the diagnosis process. Failure of communication such as the problem of language, it will result negative consequence, because the treatment for
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patients may fail, the patient may not to follow instructions or even choose not to undergo potentially life-saving treatment (Rosse et al., 2015).
This systematic review and meta analysis is reported following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) protocol. This protocol consists of identification, screening, eligibility test, and inclusion of studies which was conducted according to PRISMA statements’ flow diagram and checklist to improve the quality of review (PRISMA, 2015)
The National Health Service in United Kingdom, offers high quality care to diverse patients (Depkes, 2012). And the result from 2011 census, demonstrate that there is minority ethnic communities in UK, some of population have limited english proficiency, it means that they can’t speak English when they interact with clinicians. Language barrier like that which can effect many problems for communication between patients and clinicians, both of them will feel difficult to understand and evaluate what patient’s needs. So that’s why clinicians can’t give the safe and effective healh care (Ali et al., 2017).
Eligibility Criteria The following criteria are considered for studies egibility : type of study, participants, index test, target condition, and reference standars. Type of Studies Randomized- controlled trials, cross sectional, and cohort studies are included. Review, case report, case series, and conference abstracts, book sections, commentaries/ editorials are excluded. Laboratories and non human studies are not included as well. Lastly, articles with unavailable full text, languages other than English, and irrelevant topics are also omitted
An evidence indicates that language barrier relates to negative cosequences of treatment adherence, chronic disease follow up, evaluate diagnosis and treatment for patients, the ability to find consistent health information, and treatment complications. Another evidence also indicates that language barriers can endanger patient safety through increasing the risk of side effects including treatment errors (Ali et al., 2017)
Type of Participants This review involved all professionals limitation for region.
This systematic review and meta analyses will investigate about overcoming the language barriers in health care as a strategy to make communication more effective between patients and health care providers.
includes all studies that patients and health care in hospital care. There is no age, gender, and races and
Index test Studies are evaluating the effectiveness to overcome the language barriers in health care as a strategy to make communication more quality between patients and health care professionals.
Materials and Methods Study Registration and Methodology
311
characteristics of the studies are illustrated in Table 1. The implication of language barriers on the delivery of healthcare in each study in the review will illustrate in Table 2.
Target Condition This studies include all cases of language barriers which related to the implications (Hilal Al Shamsi et al, 2019) and the impacts on quality of care (Daniella de Moissac, 2018), on patients and clinicians that use a second language in hospital care (Renata F I Meuter, 2015).
Quality Assessment Each study are assessed for their quality by using Quality Assessment of Diagnostic Accuracy Studies â&#x20AC;&#x201C; 2 (QUADAS 2). This tool consists of 4 key domain : participants selection, index test, reference standard, flow and timing. Each domain is evaluated for risk of bias, and the first 3 domains are also evaluated for concern regarding applicability to the research question (Whiting et al., 2011). Any discrepancies will be resolved by discussion among the review team.
Reference Standard The reference standard is when between patients and health care professionals donâ&#x20AC;&#x2122;t use native language or use a second language on communication in health care Data Sources and Search Literature search is carried out with multiple electronic databases, such as PubMed, ScienceDirect, and Cochrane. No time and language restriction is applied. The keywords used are presented in Table 1.
Results Search Results Search in electronic database yielded 2679 studies. Screening through titles and abstracts found 360 articles, 42 of which met the inclusion criteria. A total of 11 studies were included in the systemataic review at last (Pino et al., 2014; Kale et al., 2010; Jaeger et al., 2019; Adams et al., 2017; Rosse et al., 2015; Meuter et al., 2015; Moissac et al., 2019; Ali et al., 2017; Al Khatami et al., 2010; Bischoff et al., 2010; Albrecht et al., 2013).
Study Selection Studies were identified using the keywords described above. After removing duplicates using EndNote program, retrieved articles are screened based on their titles and abstracts. Thereafter, potentially eligible full text articles are throughly assessed using the eligibility criteria described above. Any emerging discrepancies will be resolved by consensus among the review team.
Characteristics of Included Studies
Data Extraction
Eleven studies evaluated the impact of language barriers in healthcare and identifies how to overcome the language barriers (Pino et al., 2014; Kale et al., 2010; Jaeger et al., 2019; Adams et al., 2017; Rosse et al., 2015; Meuter et al., 2015; Moissac et al., 2019; Ali et al.,
The following data is extracted from the included studies: first author, publication year, country, study design, number of organization, type of organization, sample size, data collection, and response rate. The summarize of outlines the general
312
2017; Al Khatami et al., 2010; Bischoff et al., 2010; Albrecht et al., 2013).
Communication in health care will be hampered because of language barriers. Study suggest that overcome language barriers is needed (Pino et al., 2014). Language barriers occur because the lack of common language or the variation of language. This problems are significant reasons that participants feel unable to get adequate health care (Adams et al., 2017). Study about diagnosis and treatment, it’s related to deliver accurately the possible risk factors.
Table 1 presents a summary of the general characteristics of the 11 studies arranged by the authors’ names. Seven studies used a cross-sectional design, three used qualitative research, and one was used mixed-methods in cohort study. Two studies collected data from an interview survey, three used questionnaires, one used both an interview survey and questionnaires, one used hospital databases, two used interview and focus grup discussion, one used online questionnaire an telephone interview and one used record review, questionnaire, interview, document analysis, and policy data. Three of the studies were conducted in the Europe, and one each in Canada, Saudi Arabia, England, Dutch, Spain, Australia, Germany and South Africa. The total number of participants in the 11 studies was 3.866, with the number of participants in each study ranging from 23 to 1290. Table 2 presents the most important findings of the 11 studies in this review. Seven of the studies focused on language barriers and patient satisfaction, two on the impact of language barriers between patients and health care providers, two on the cost of health care services. The findings of studies can be divided into three categories: the impact of language barriers on medical providers (such as physicians and nurses) and patients, patients satisfaction and the cost of health care services.
Language barriers has been proven to be a big threat for quality in health care (for the example threat on medication treatment, management of patient’s situation) and interacation between patient and doctor in concerning diagnosis, the risk communicataion in acute situation. Even International studies spotlighted a lack of an adequat health care (Rosse et al., 2015). Language barriers laso have negative implications in health care and patients satisfaction. The study showed that patients who receive treatment from health care professionals who can’t speak local language, 30 % patients are difficult to understand medical intructions, 30 % have problem with the information and reliability, and 50 % said that language barriers have made error treatment (Al Khatami et al., 2010). Therefore understanding the role of language in making barriers to health care is important to evaluate system of healath care that increased in culturally and linguistically diverse population among patients and health care professional (Meuter et al., 2015).
The Impact Of Language Barriers and the Strategy to Overcome the Language Barriers in Health Care
Overcoming language barrier is very important. The sudy in Swiss non-hospital primary care report that language barriers
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can exist asylum-seekers, refugees, and even other migrants (Jaeger et al., 2019). In addition, African patients have been aware of the importance to build communication optimally with healthcare providers, especially for them who can’t speak Spanish, and even health care providers don’t have a cross-cultural mediator interpreter (Pino et al., 2014).
language barrier, to help patients feel satisfaction in health care. And the doctors also affirm the negative consequences due to lack of interpreters and it impacts the quality of care. The fact is the majority of health care providers have faced intercultural difficulties, and it’s related to language, so the strategy is overcoming the language barriers through help of professional interpreters (Jaeger et al., 2019). Meanwhile, 30 % of patients that repoted in the record of patients. Patient’s family often functioned as interpreter in communication proccess low Dutch proficiency, there is no language barrier was documented. But professional interpreters are rarely used (Rosse et al., 2015).
Study has reported that 30 % participants (health care professionals) have reported that they work with language interpreters frequently, because population of immigrant patients are increasing in health care. Even the survey shows that doctors work with interpreters more that nurses. Because doctors are responsible in diagnostic assessment and the plan of treatment, on that process of course doctors will communicate with their patients, especially immigrant patients facilitated by an interpreters. 60 % participants have answered that interpreters are needed to help them on communication with new patients that use a second language. 25,3 % participants have said that they often held initial consultation without know that the patients is from Norwegia or not. And they are difficult in understanding the situation and condition of patients. In Norway especially, health care providers have reported that they had problem in understanding above 36 % until 43 % of patients who don’t speak the local language, and it requires interpreters. Indeed, 37 % of physicians also indicate that the patients hide some information which related to their disease because of language barriers (Kale et al., 2010).
The research also report the patients with limited native language ability will miss the appointment of medical and will face difficulties setting appointments to health care providers because of language barriers (Ali et al., 2017). So that’s why, the patients will feel poor level of satisfaction in health care (Moissac et al., 2019). To increase patient satisfaction in health care, so hospital care or non hospital care need to provide professional interpreter or interpreter service. The study also has pointed out that health care providers needed professional interpreter for 43,2 % of their patients and 21 % until 76 % health care providers had poor access to find interpreter service (Kale et al., 2010). Moreover , 70,7 % of limited English proficiency patients (LEPPs) resulted limited availability of interpreter service (Moissac et al., 2019). And 26,4 % resulted that professional interpreters are not able (Bischoff et al., 2010). But, indirectly LEPPs also need to increase the cost of health care when they ask help to
Doctors work with interpreters are a strategy to communicate in case of
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professional interpreter or interpreter service (Kale et al., 2010). The study has estimated that interpreter service for health care providers about $ 4,7 million for one year. Some of health care organizations also have used online tools, for example google translate or medibabble to overcome the of language barriers in health care. Not only for health care providers, this tools are also free for patients who want to access it. And the study has reported that this tools has contributed to increase and improve the aspect of health care, patient safety can be guaranteed, and decreasing the risk factor for patients or health care providers feel satisfaction in health care (Albrecht et al., 2013).
language, so the patients may accept treatment without clear information, wrong diagnostic or even surgical procedures, of course it will make patients don’t understand about the diagnosis of disease, don’t adherent to treatment, prognosis, and even it will increase the risk of relapse and complication. That’s facts can cause public health problems (Pino et al., 2014). Discussion This review investigates the impact of language barriers and the strategy to overcome the language barriers between patients and health care providers in health care. From the results of 11 studies that have investigated, there are so many impacts of language barriers in health care, includes misunderstanding and miscommunication between patients and health care professionals. This factors can decreased in satisfaction of patients and health care professionals (Pino et al., 2014). Beside of that, it can makes communication in health care is not effective and adequate, and it will impact on the patient safety that made patients don’t understand about the diagnosis of disease, don’t adherent to treatment, prognosis, and even it will increase the risk of relapse and complication (Rosse et al., 2015). The other impact is increasing health care costs if patients or health care provider use professional interpreter or interpreter service (Kale et al., 2010; (Albrecht et al., 2013). And interpreter also doesn’t guarantee for the success in health care, because the interpreter doesn’t necessarily have knowledge of medicine and cases of disease. So, if hospital/ non hospital care want to use interpreter, health care providers must consider it and search the professional interpreter who are
But for interpreter doesn’t guarantee for the success in health care, because the interpreter doesn’t necessarily have knowledge of medicine and cases of disease. As we know medical interpreting requires expert knowledge and skills that are attained through training, while interpreters don’t necessarily master it. So, if health care providers work with interpreters, it only has negative consequences, because it makes medical informations are not accurate, error in translation of diagnosis, and error in treatment. Beside of that, it could make misunderstanding and miscommunication between patients and health care professionals. And if health care professional only work by their self without interpreters, and even the family of patients can’t speak Spanish, so it’s extremely impossible for communication in health care, and make patients lose autonomy about their condition. If the hospital accept the migrant patients, and the health provider only can speak native
315
experts and be sure they have experience as interpreter in the field of medicine or health care (Pino et al., 2014).
Some strategy to overcome the language barrier in this review. The aim of this strategy is to increase patient satisfaction in health care, so hospital care or non hospital care need to provide professional interpreter or interpreter services. The study also has pointed out that health care providers needed interpreters The way is through interpreter services and professional interpreters. (Kale et al., 2010).
Language barriers has been proven to be a big threat for quality in health care and become obstacle in process of interacation between patient and health care professionals. Language barriers are the most important point that cause communication is not effective in health care. Language barriers as obstacle of delivery hiqh-quality in health care. Some studies indicate that language barriers have contributed incomplete of understanding situation and condition of patients, error in diagnosis, treatment will be delayed and incompleted (Rosse et al., 2015).
Some of health care organizations have provide interpreters services or it can call online tools, for example Google translate or MediBabble to overcome the of language barriers in health care. Not only for health care providers, this tools are also free for patients who want to access it. And the study has reported that this tools has contributed to increase and improve the aspect of health care, patient safety can be guaranteed, and decreasing the risk factor for patients or health care providers feel satisfaction in health care. But this services cause critical challenge in the aspects of access and even financial burden. One studies have reported that some healthcare institutions are difficult in accessing interpreter services and even no services at all (Albrecht et al., 2013).
This review also find that patients who donâ&#x20AC;&#x2122;t speak native/ local language/ they use second language, will feel satisfaction in their health care and difficult to access health care services. But if patient can access it, they will feel decreasing of satisfaction, less of understanding about diagnosis, treatment, and even incresing the risk factor of complication (Meuter et al., 2015). This review also find that health care providers who work with interpreters are a strategy to communicate in case of language barrier, to help patients feel satisfaction in health care. And the doctors also affirm the negative consequences due to lack of interpreters and it impacts the quality of care. The fact is the majority of health care providers have faced intercultural difficulties, and itâ&#x20AC;&#x2122;s related to language, so the strategy is overcoming the language barriers through help of professional interpreters or interpreters service (Rosse et al., 2015).
The study also have shown that patients and health care professionals were highly satisfied with interpreters services, especially MediBabble. It because the application was running fastly and can used easily for both of patients and health care professionals (Boujon et al., 2018). In additional, other study in Canada also report that the strategy to improve communication more effective in health care is using MediBabble. This application will help health care professionals to take
316
the refugee’s histories that can help in concerning diagnosis and treatment. Not only that, The main thing is MediBabble has been successed as translator of medical field.
review also focused on various aspects that related to language barriers in health care, so it can helps to evaluate the problem from multiple corner and finally can find the strategy to face it.
The study also has pointed out that health care providers needed professional interpreters (Kale et al., 2010). But for interpreter doesn’t guarantee for the success in health care, because the interpreter doesn’t necessarily have knowledge of medicine and cases of disease. As we know medical interpreting requires expert knowledge and skills that are attained through training, while interpreters don’t necessarily master it. So, if health care providers work with interpreters, it only has negative consequences, because it makes medical informations are not accurate, error in translation of diagnosis, and error in treatment. So, if hospital/ non hospital care want to use interpreter, health care providers must consider it and search the professional interpreter who are experts and be sure they have experience as interpreter in the field of medicine or health care (Pino et al., 2014).
The current study also has several limitations. First, a larger sample size is required for this review to be representative in worldwide population. Second, this review also take some existing studies on the using of online translation tools in healthcare to solve the language barrier. Third, despite showing no concerns in regards of applicability this review also shows unclear risk of bias in aspect of patient selestion. Almost all the included studies don’t specifically addressthe methods of sample recruitment. Conclusions Language barriers has been proven to be a big threat for quality in health care and become obstacle in process of interacation between patient and health care professionals. Language barriers are the most important point that cause communication become not effective in health care. The impacts of language barriers in health care, including misunderstanding and miscommunication between patients and health care professionals, that can decreased in satisfaction of patients and health care professionals. Some strategy to overcome the language barriers aim to increase patient satisfaction in health care, so hospital care or non hospital care need to provide professional interpreter or interpreter services (Goggle translate and MediBabble are recommended).
Strenghts and Limitations The current study has several strenghts. The study included in the reviews were organized in some developed countries in the world, so this study has evaluated the impact of language barriers in some countries, and from that it can finds the strategy to overcome the language barriers through the experiences of hospital or non hospital care, and finally it can find the potential way that can use to solve the problem of language barriers. This review also found some studies including high response rate, even 100 %. And this
Recommendation
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Further comprehensive studies should be done to investigate the impact of language barriers and the strategy to overcome the language barriers in health care. Furthermore, the impact of language barriers must be evaluated in both of public and the private sectors to address the problem of language barriers.
events in hospitalized pediatric patients? (2005) Pediatrics;116(3):575-579. Department of Health (2012) DH Equality Objectives Action Plan: Department of Health Equality Objectives 2012 to 2016., London. Available at: https://www.gov.uk/government/publicatio ns/department-of-health-equalityobjectives-2012- to-2016 (accessed 15 october).
Conflict of Interest The author declares that there are no competing interests in this study.
Albrecht U-V, Behrends M, Schmeer R, Matthies HK, Von Jan U. Usage of Multilingual Mobile Translation Applications in Clinical Settings. (2013).
References Slade S, Sergent SR. Language barrier. In: StatPearls 2018. [Internet]: StatPearls Publishing.
Ali PA, Watson R. Language their impact on provision patients with limited English Nursesâ&#x20AC;&#x2122; perspectives. (2018). ;27(5-6):e1152-e1160.
Bischoff A, Denhaerynck K. What do language barriers cost? An exploratory study among asylum seekers in Switzerland. (2010). BMCHealth Serv Res 10(1):248.
barriers and of care to proficiency: J Clin Nurs
Al-Khathami AM, Kojan SW, Aljumah MA, Alqahtani H, Alrwaili H. The effect of nurse-patient language barrier on patientsâ&#x20AC;&#x2122; satisfaction. (2010). Saudi Med J; 31(12):1355-1358.
Hilfinger Messias DK, McDowell L, Estrada RD. Language interpreting as social justice work: perspectives of formal and informal healthcare interpreters. (2009). ANS Adv Nurs Sci ;32(2):128143.
de Moissac D, Bowen S. Impact of language barriers on quality of care and patient safety for official language minority francophones in Canada. (2018). J Patient; 6(1):24-32.
Floyd A, Sakellariou D. Healthcare access for refugee women with limited literacy: layers of disadvantage. (2017). Int J Equity Health;16(1):195.
Kale E, Syed HR. Language barriers and the use of interpreters in the public health services. (2010). Aquestionnaire-based survey. Patient Educ Couns; 81(2):187191.
Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. (2007). Int J Qual Health Care; 19(2):60-67. Squires A. Evidence-based approaches to breaking down language barriers. (2017);47(9):34-40.
Rahman AA. Rising up to the challenge: strategies to improve health care delivery for resettled Syrian refugees in Canada. (2017). Univ Toronto Med J;94(1):42.
Cohen AL, Rivara F, Marcuse EK, McPhillips H, Davis R. Are language barriers associated with serious medical
Sheik-Ali S, Dowlut N, McConaghie G. Breaking down language barriers with technology. (2016). The Bulletin of the
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Royal College of Surgeons England.;98(3):138- 140.
of
Boujon V, Bouillon P, Spechbach H, Gerlach J, Strasly I. Can speech-enabled phraselators improve healthcare accessibility? (2018). A case study comparing BabelDr with MediBabble for anamnesis in emergency settings. del Pino, Veiga M. Communication with African Patients. The reality in the hospitals of Southern Spain. (2014). Jaeger N, Nicolle P, Benedicte L, Pierre K. The migration-related language barrier and professional interpreter use in primary health care in Switzerland. (2019).
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Table 1 : Summary of general characteristics of studies Author
Country
Pino et Southern al Spain Kale et Frerikstad, al Norway
Year of public ation 2014
Number of Study type organization
Data collection
Samp le size
Hospital
Qualitative
Interview
32
2010
All health centers in three cities Non hospital primary care Hospital
Cross sectional
Questionnair e
1290
Jaeger et al Adams et al
Switzerland
Rosse et al
Dutch
Meuter et al
South East 2015 Queensland, Australia
Moissa c et al
Canada
Ali al
2019
Cape town, 2017 South Africa
et England
2015
Cross sectional Qualitative
Questionnair e Interview and focus grup discussion Hospital care MixedRecord methods review (Quantitativ Questionnair e and e Qualitative) Interview and in cohort document study analysis Policy data 3 Hospitals in Cross Interview and South East sectional Questionnair Queensland e
2018
In 4 canadian Cross provinces sectional
2017
Tertiary care Qualitative hospital in England One medical Cross city Sectional
Resp onse Rate
35.1
599 23
576
100
40
100
Online 297 Questionnair e and telephone interview Interview and 59 focus grup discussion Interview 116
100
100
Al Saudi Khata Arabia mi et al
2010
Bischo ff et al
Switzerland
2010
Five health Cross centers Sectional
Hospital database
795
61.1
Albrec ht et al
Germany
2013
Hospital
Questionnair e
39
90.0
Cross Sectional
320
100
Table 2 : The important findings from 10 studies identified Author Pino et al
Kale et al
Jaeger et al
Focus Assessing communication barriers between healthcare providers and African patients Cross cultural Communication in health care settings and health provider satisfaction The migration-related language barrier and professional interpreter use in primary health care
Adams et al Study of language barriers between South African health care providers and cross border migrants
Rosse et al
Language barriers and patient safety risk in hospital care
Results There were 31 resulting categories which were organized under two main categories : nonprofessional interpreters and no communication/ translation. The response rate was 35,1 %. The largest category of participants (51,1 %) consisted of nurses, followed by the second largest category (26,6 %) of 120 physicians. The results suggested and underutilization of interpreter services in the public health care system. More than 90 % of the 599 participants in this nationwide cross-sectional study face relevant language barriers at least one a year, 30.0 % even once a week. Using family members and friends for translations is reported followed by using gestures (32.0 %) or just accepting the insufficient communication (22.9 %). Minors interpret frequently (frequent use 23.3 %). Two thirds of physicians facing language barriers never have access to a professional interpreter, the majority (87.8 %) though would appreciate their presence and approximately one quarter of these even see a cost-saving potential. Multiple consequences affecting quality of care in the absence of professional interpreters are identified. Zimbabwean participants described how the inability to speak the local South African language (IsiXhosa) gave rise to labelling and stereotyping by healthcare staff. Congolese and Somali participants described medical procedures, including tubal ligation, which were performed without consent. Partners often tried to play the role of interpreter, which resulted in loss of income and non-professional medical interpretation. Participantsâ&#x20AC;&#x2122; highlighted fears over unwanted procedures or being unable to access care. Challenges of communication without a common language (and without professional medical interpretation), rather than outright denial of care by healthcare professionals, mediated these encounters. Situations in hospital care where a language barrier threatened patient safety included daily nursing tasks (i.e. medication administration, pain management, fluid balance management) and patientâ&#x20AC;&#x201C;physician interaction concerning diagnosis, risk communication and acute situations. In 30% of the patients that reported a low Dutch proficiency, no language barrier was documented in the patient record. Relatives of
321
Meuter et al A protocol for investigating safe and effective communication when patients or clinicians use a second language Moissac et Language barriers on al quality of care and patient satisfaction
Ali et al
Impact on the provision of health
Al Khatami Patients satisfaction et al with the health services delivered by non-Arabic speakers (nurses)
Bischoff et Cost of health care al
patients often functioned as interpreter for them and professional interpreters were hardly used. Understanding the role that language plays in creating barriers to healthcare is critical for healthcare systems that are experiencing an increasing range of culturally and linguistically diverse populations both amongst patients and practitioners. The data resulting from this study will inform policy and practical solutions for communication training, provide an agenda for future research, and extend theory in health communication. Patients and interpreters-navigators described experiences where language barriers contributed to poorer patient assessment, misdiagnosis and/or delayed treatment, incomplete understanding of patient condition and prescribed treatment, and impaired confidence in services received. Reliance on Google Translate and ad hoc, untrained interpreters are commonly reported, in spite of evidence highlighting the risks associated with such practice. Limited English proficient patients (LEPPs) reported they had missing appointments and difficulties in arranging appointments because of language barriers. The overall satisfaction of patients about nurseâ&#x20AC;&#x2122;s care was 90%. Whereas, patients reported they had a concern about language barriers while delivering health care. Patients reported the following: 30% of patients have difficulties in understanding the instructions of non-Arabic speaking nurses (NASNs). 30% have a problem with the reliability of the information delivered by NASNs. 50% believed that the language barrier is contributed to more susceptible to error. 50% avoid and 70% end conversation. 40% called for an interpreter. 26.4% of LEPPs reported no interpreter. LEPPs increased the cost of health care indirectly by using an interpreter.
Albrecht et Online interpreter In case of reducing the cost of care (interpreter al service/ tools service), Google translate and MediBabble application used in health organizations. Participants stated: Free and easy to access (92 %), saves time at the visit (92 %), and improves health care delivery and patient safety (92 %),
322
323
Unveiling the Importance of Health Literacy in Improving Clinical and Behavioural Outcomes among Patients with Hypertension: A Systematic Review and Meta-Analysis Muhammad Alifian Remifta Putra1, Raya Makarim Penantian1, Vincent Kharisma Wangsaputra1, Agus Tini Sridevi1 1
Asian Medical Students’ Association-Universitas Indonesia (AMSA-UI) ABSTRACT
Introduction: Health literacy (HL) plays a key role in determining patients’ health outcomes, both clinically and behaviourally. This study aims to comprehensively evaluate the association between HL and clinical and behavioral outcomes among hypertensive patients. Methods: The authors systematically searched through Scopus, CENTRAL, Oxford Academic, ProQuest, PubMed, CINAHL, Science Direct and further analysed the studies based on the PRISMA statement. The NIH Quality Assessment and Cochrane RoB Tools were used to perform critical appraisals of observational and interventional studies, respectively. Result and Discussion: Total of 19 studies were included, with 12 studies in the meta-analysis. Among 7 observational studies, 22% patients were categorized with inadequate or marginal HL, which was associated with a higher systolic blood pressure (SBP) as compared to patients with adequate HL (pooled standardized mean difference [SDM]: 0.26; 95% [CI]: 0.06 to 0.46; p=0.01). Surprisingly, inadequate HL was related to a lower diastolic blood pressure in comparison to adequate HL (SDM: -0.16’ 95% CI: -0.95 to 0.62), however this was proven to be statistically insignificant (p=0.68). Additionally, analysis of 5 interventional studies showed that patients who received HL intervention had lower SBP when compared against control (SDM: 0.80, 95% CI: 0.11 to 1.50, p=0.02) and lower DBP (SDM: 0.39, 95% CI: -0.01 to 0.80, p=0.06). Conclusion: Adequate HL is associated with lower SBP and interventions can effectively improve the outcome. In addition, inadequate HL is also related to worse medication adherence, hypertension knowledge, self-care and patient-physician communication. Keywords: hypertension, health literacy, clinical outcomes, systolic blood pressure, diastolic blood pressure, behavioural outcomes
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Unveiling the Importance of Health Literacy in Improving Clinical and Behavioural Outcomes among Patients with Hypertension: A Systematic Review and Meta-Analysis Muhammad Alifian Remifta Putra1, Raya Makarim Penantian1, Vincent Kharisma Wangsaputra1, Agus Tini Sridevi1 1
Asian Medical Students’ Association-Universitas Indonesia (AMSA-UI)
1. INTRODUCTION Hypertension or elevated blood pressure is a serious medical condition that can significantly increase the risks of heart, kidney, brain, and other diseases. Hypertension persistently remains as the leading risk factor for all-cause mortality worldwide, which in fact can be prevented. Based on data from the World Health Organization (2019), a total of 1.38 billion people or over 1/3 (31.1%) of the global adult population had hypertensive blood pressure. The definition of hypertension can be varied depending on region and guidelines. Based on American Heart Association (AHA) latest guidelines, the diagnosis of hypertension could be confirmed when systolic blood pressure (SBP) reaches ≥ 130 mmHg and/or diastolic blood pressure (DBP) ≥ 80 mmHg according to Rahimi et al. (2015). On another hand, the WHO and 2018 European Society of Cardiology (ESC) guidelines set the threshold of ≥140/90 mmHg for hypertension as stated by WHO (2019) and Camm et al. (2018). In the status quo, hypertension cases increase considerably due to various factors including the rise of the aging population and accumulation of different exposure to lifestyle risk factors such as lack of physical activity and unhealthy diets (for instance low potassium, and high sodium intake) as mentioned by Mills et al. (2020). Moreover, the changes in the prevalence of hypertension are not uniform globally. Low and middle-income countries (LMICs) had experienced significant increases in hypertension and cardiovascular diseases (CVD) as the most common type of complication, while in contrast, the high-income countries (HICs) were able to decrease the hypertension prevalence moderately. In the aspect of mortality, hypertension-related deaths still become the most common cause of global death such as ischemic heart disease, and stroke (hemorrhagic and ischaemic types) which these three diseases only account for over 4.9, 2.0, and 1.5 million global deaths, respectively. Not only that, another problem that arises is beyond its impact on mortality, an increase of SBP has become the largest contributor toward global disability, that accounts for 218 million disability-adjusted life years (DALYs) worldwide for both sexes. Therefore, urgent measures are needed to suppress the increasing rate of hypertension cases worldwide. One of the most important factors that affect the health condition and outcomes in a patient is health literacy. Health literacy can be defined as the ability or capacity of individuals in obtaining, processing,
325
and understanding fundamental health information and services which are crucial in making the appropriate health decisions. Past research suggests that low health literacy might be correlated with poor health conditions and outcomes such as an increase in mortality, and hospitalizations. However, to the best of the writer’s knowledge, there is no existing meta-analysis that estimates the effects of health literacy toward hypertension and its outcomes along with possible effective intervention in increasing health literacy among patients with hypertension. Therefore, the writers create this metaanalysis to shed new light on this problem. 2. MATERIALS & METHODS 2.1 Search Strategy The authors conducted the search to find the literatures using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement as described by Moher et al. (2009). The search was done by utilizing seven different online databases which includes Scopus, CENTRAL, Oxford Academic, ProQuest, PubMed, CINAHL, and Science Direct using these keywords as filters: “health literacy” AND “hypertension” OR “high blood pressure” OR “elevated blood pressure”. The studies were limited to the last fifteen years and language restriction of only English and Bahasa Indonesia was applied. The illustration of the literature search is depicted in Figure 1. 2.2 Inclusion and Exclusion Criteria For the purposes of this review, the following inclusion criteria were applied: (1) studies published in the last fifteen years; (2) study design, cross-sectional studies, cohort studies, clinical trials; (3) study outcomes, hypertension clinical profiles, health behavioural outcomes; (4) studies published in English or Bahasa Indonesia. While the criteria for exclusion are: (1) studies older than fifteen years; (2) types of articles: letters, conference abstracts, comments; (3) publications in languages other than English or Bahasa Indonesia; (4) studies with unextractable or unobtainable data despite having contacted the author. 2.3 Data Extraction and Risk of Bias Assessment Three independent reviewers performed the data extraction, with discrepancies adjudicated by the consensus with a fourth investigator. The following details of information were extracted from the included articles: (1) authors and year of publication; (2) study characteristics, including the study design, recruitment period, country of origin, and category of health literacy; (3) subject characteristics, including the sample size, mean or median age of sample, gender proportion, and comorbidities; (4) health literacy evaluation tool, (5) outcomes, including the clinical outcomes and behavioural outcomes. The main clinical outcomes observed in this review were the level of systolic and diastolic
326
blood pressure (measured in mmHg) with other supplementary parameters such as mean arterial pressure and blood pressure control. In addition, the authors also included behavioural outcomes, such as hypertension knowledge, self-reported monitoring, medication adherence, et cetera whenever the data were available in the studies. The assessment of methodological quality in terms of risk of bias (RoB) was performed using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and CrossSectional Studies (2020), which subsequently judged to be showing good, fair, or poor risk of bias. The tool consists of 14 criteria, each addressing specific parameters or domains to identify potential bias in the studies. As for controlled trials, Cochrane Risk of Bias Tool was utilized to carry out the assessment, yielding high, unclear, or low risk of bias for the overall risk of bias as described by Higgins et al. (2011). Each of the 7 domains was evaluated in the same manner with the overall bias, i.e. judged to be high, unclear, or low. The certainty of evidence was then evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, in which the quality of evidence was classified as high, moderate, low, or very low as stated by Guyatt et al. (2008). 2.4 Data Synthesis and Statistical Analysis Quantitative synthesis was conducted with Review Manager software (RevMan 5.4). Heterogeneity of the included studies was assessed using Cochrane chi-square and I2. An I2 value of more than 50% indicates a significant heterogeneity, and vice versa. Random-effect model was applied, considering the heterogeneity of the data due to differences in populations. The inverse variance method was used to accumulate effect sizes from multiple studies. For cross-sectional and cohort studies, the authors evaluate association between the health literacy (inadequate against adequate health literacy) and the clinical outcomes such as systolic and diastolic blood pressures. Whereas for interventional studies, we evaluate the association between specific interventions to improve health literacy (control against intervention) and the clinical outcomes. As different instruments were used by different studies, we used the standardized mean difference in calculating the pooled effect size with a Confidence Interval (CI) of 95%. We conducted subgroup analysis based on the study location and overall risk of bias. Findings were said to be statistically significant when the p value < 0.05. In general, potential publication bias was assessed using funnel plot, from which we observed whether there is an asymmetry or not. If publication bias assessment using funnel plot showed an asymmetry result, the Egger test would be conducted.
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3. RESULTS 3.1 Study Selection The process to select the included studies is depicted in Figure 1. The primary search from the seven online databases of Scopus, CENTRAL, Oxford Academic, ProQuest, PubMed, CINAHL, and ScienceDirect results in a total of 2845 search hits after filters were applied and from these 37 duplicates were removed. Screening of titles and abstract yields 102 full-text articles which were then assessed for eligibility and it was found that 16 have no extractable data, 51 have irrelevant outcomes, 4 have irretrievable full-text, and 7 have inappropriate study design, leaving with 24 eligible studies of 3 cohort studies, 16 cross-sectional studies, and 5 randomized controlled trials. 12 out of the 24 studies were included in meta-analysis. The quality and risk of bias assessment of the included studies are shown in Appendix Table 1 & 2. Overall, most of the observational studies yielded good results for the risk of bias with only one fair and two poor studies. However, the risk of bias for controlled trials demonstrated the opposite with mostly high risk and one study with intermediate risk.
Figure 1: Flowchart of Study Selection in Accordance to PRISMA Statement
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3.2 Study Characteristics In total, we reviewed 24 included studies, of which the detailed characteristics are shown in Table 1. These studies were published between 2008 â&#x20AC;&#x201C; 2020 and the study designs include case-control, cohort and randomized controlled trials (RCTs). There were 16 case-control studies, 3 cohorts and 5 RCTs. The studies were done in various countries, predominantly in the United States, followed by other countries including Iran, China and Japan. Among the 19 observational studies, we included 7 studies in the meta-analysis with a total number of 71,910 patients, 22% of which have inadequate or marginal health literacy. Moreover, the authors further analysed 5 interventional studies in the meta-analysis. Among 3,076 patients that were included, 1820 patients were in the intervention group while 1256 patients act as controls. The subjects were mostly adults and elderly, with the majority of them being female. Different researchers used different cut-off values to define hypertension, the majority of which used the guideline by Joint National Committee-7 (systolic blood pressure > 140 mmHg, diastolic blood pressure > 90). Many patients also have other comorbidities, with diabetes and obesity among common ones. Various instruments were used to measure HL including Rapid Estimate of Adult Literacy in Medicine (REALM), Newest Vital sign (NVS) and Short Test of Functional Health Literacy in Adults (S-TOFHLA), as well as the translations of those instruments into the respective languages.
329
Table 1: Study Characteristics
JNC-7
330
331
332
Abbreviations - AHA: American Heart Association; CAD: Coronary Artery Disease; CVD: Cerebrovascular Disease; DBP: Diastolic Blood Pressure; ESC: European Society of Cardiology; IQR: Interquartile Range; JNC: Joint National Committee; RAMP: Risk Assessment and Management Program; SBP: Systolic Blood Pressure; SD: Standard Deviation
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3.3 Study Outcomes Table 2 & 3 (on the following page) shows a summary of study outcomes that were extracted from the 24 studies. Two main outcomes that were extracted from these studies are clinical and behavioral outcomes. In clinical aspects, the data that were extracted are mean and SD values of systolic blood pressure (SBP) , mean and SD values of diastolic blood pressure (DBP), mean and SD values of Mean Arterial Pressure (MAP), and Blood Pressure Control (% of people with BP <140/90). Meanwhile, for the behavioral outcomes that are being analyzed are hypertension knowledge, self-care/ self-reported monitoring, medication adherence, and patient-physician communication. The quality of evidence for the outcomes following the GRADE framework is depicted in Table 4. In general, the quality of these outcomes was very low-to-moderate, due to their study design nature, bias limitations, inconsistency and indirectness. Table 4: Quality of Evidence based on GRADE Framework Outcomes
Number
Numbe
Relative
Limitati
Impre
Incon
Indirectness
Publica
Quality
of
r of
effect
ons
cision
sisten
of patients,
tion
of
Studies
partici
(95% CI)
(RoB)
cy
intervention
bias/Ot
Evidenc
(Study
pants
, and
her
e
comparator
conside
Design)
rations Systolic
7 (cross-
Blood
sectional
(0.06 to
◯
Pressure
and
0.46)
MODE
71,910
SMD: 0.26
V
V
V
XX
V
cohort) 5
RATE 3,076
SMD: 0.8
(controll
(0.11 to
ed trial)
1.5)
Diastolic
7 (cross-
Blood
sectional
(-0.95 to
Pressure
and
0.62)
71,910
SMD: -0.16
XX
V
V
V
V
3,076
SMD: 0.39
(controll
(-0.01 to
ed trial)
0.80)
⊕⊕◯ ◯ LOW
V
V
X
XX
V
⊕⊕◯ ◯ LOW
cohort) 5
⊕⊕⊕
XX
V
X X
V
⊕◯◯ ◯ VERY LOW
For GRADE factors: V = no serious limitations; X = serious limitations; XX = very serious limitation
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Table 2: Study Outcomes - Observational Studies
335
336
337
Abbreviations - BHLS: Brief Health Literacy Scale; BP: Blood Pressure; CHL: Critical Health Literacy; DBP: Diastolic Blood Pressure; HL: Health Literacy; NVS: Newest Vital Sign; OR: Odds Ratio; S-TOFHLA: Short Test of Functional Health Literacy in Adults; SBP: Systolic Blood Pressure; SD: Standard Deviation; STARx: Self- management and Transition to Adulthood with Rx
338
Table 3: Study Outcomes â&#x20AC;&#x201C; Interventional Studies
339
Abbreviations - BHLS: Brief Health Literacy Scale; BP: Blood Pressure; CHL: Critical Health Literacy; DBP: Diastolic Blood Pressure; HL: Health Literacy; NVS: Newest Vital Sign; OR: Odds Ratio; S-TOFHLA: Short Test of Functional Health Literacy in Adults; SBP: Systolic Blood Pressure; SD: Standard Deviation; STARx: Self- management and Transition to Adulthood with Rx
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3.3.1 Association between Health Literacy and Clinical Outcomes in Hypertensive Patients in Observational Studies In analyzing the association between health literacy and their clinical outcomes in hypertensive patients in observational studies, the main data that are being used are the mean and SD values of SBP and also DBP. This meta-analysis consists of 7 observational studies with a total of 71910 patients (15512 inadequate health literacy and 56398 with adequate health literacy). The pooled effect size for SBP was 0.26 (95% CI: 0.06 - 0.46). This meta-analysis also shows a significant heterogeneity among the studies (p<0.00001, I2 = 98%). Test for overall effect shows Z score of 2.5 which is also statistically significant (p = 0.01). (Figure 2)
Figure 2: Forest Plot of SMD between Adequate and Inadequate HL for SBP However, the pooled effect size for DBP was -0.16 (95% CI: -0.95, 0.62). It still shows a good and significant heterogeneity with a score of I2 = 100% (p<0.00001). In testing the overall effect, we measured it based on the Z score, and it was acquired the Z score value was 0.41 but it was regarded as statistically insignificant (p=0.68). (Figure 3)
Figure 3: Forest Plot of SMD between Adequate and Inadequate HL for DBP 3.3.2 Association between Health Literacy in Hypertensive Patients and Clinical Outcomes in Observational Studies based on Study Location Subgroup Analysis In an attempt to compensate for the variety of health literacy and blood pressure which is possibly influenced by ethnicity, we try to implement subgroup analysis according to the study location (USA, China, and Japan). Firstly, the subgroup analysis in correlation between the HL and SBP based on the country shows the pooled effect size for studies that were conducted in the USA was 0.16 (95% CI: -
341
0.06 - 0.39). Meanwhile for the other countries which are China and Japan, the pooled effect size and heterogeneity tests cannot be conducted due to the limited studies that are available (only one study for each subgroup). However, this meta-analysis still shows a significant heterogeneity among the subgroup differences (p<0.00001, I2 = 95.6%). (Figure 4)
Figure 4: Subgroup Analysis for Study Location (Adequate and Inadequate HL for SBP) Secondly, the subgroup analysis in correlation between the HL and DBP based on the country shows the pooled effect size for the USA subgroup was -0.26 (95% CI: -0.06 - 0.39). The pooled effect size along with heterogeneity tests for the other subgroup countries such as China and Japan canâ&#x20AC;&#x2122;t be acquired due to the limited studies that are existing (only one study for each subgroup). The subgroup differences were also deemed as insignificant and poor due to the heterogeneity test with p-value of 0.80, and I2 score of 0%. (Figure 5)
Figure 5: Subgroup Analysis for Study Location (Adequate and Inadequate HL for DBP)
342
3.3.3 Association between Health Literacy and Clinical Outcomes in Hypertensive Patients in Interventional Studies based on Risk of Bias (RoB) Subgroup Analysis The premise that higher adequacy in health literacy has an association with lower level of systolic blood pressure (SBP) has been strongly demonstrated, especially in the study by Shi et al. (2017) in China. The two studies which do not find an association between adequate health literacy and lower SBP are the study in Japan by Shibuya et al. (2011) and one study in the USA by Willens et al. (2013). Another attempt to analyze the correlation can be based on the overall methodology quality of studies. This was assessed based on the NIH RoB tool which evaluates the quality of studies. By conducting subgroup analysis based on RoB, we are able to selectively observe studies that have good overall quality in giving impact to pooled effect size for the outcomes, due to sometimes poor qualities studies can masked the overall result. First and foremost, in the subgroup analysis of SBP based on RoB, we have three subgroups which are studies with good quality (which also imply that the respective studies had minimum risk of bias), fair quality (moderate RoB), and poor quality (High RoB). For the first subgroup, the good quality studies have pooled effect size of 0.40 (95% CI: 0.14, 0.66) with a good and significant heterogeneity level (I2=92%, p<0.00001), and also significant overall effect score based on Z score of 3.01 (p=0.003). Another two subgroups, which are fair and poor quality studies cannot be assessed due to only one study that belong to both two categories. However, the subgroup differences test shows a good and significant value with I2 of 84.4% and p-value of 0.002. (Figure 6)
Figure 6: Subgroup Analysis for Risk of Bias (Adequate and Inadequate HL for SBP) In the subgroup analysis of DBP based on RoB, we still have the same three subgroups which are studies with good quality, fair quality, and poor quality (High RoB). The good quality studies have pooled effect size of -0.02 (95% CI: -0.13, 0.10) with a good but insignificant heterogeneity level
343
(I2=57%, p=0.06), and also insignificant overall effect score based on Z score of 0.29 (p=0.77). On the other hand, the fair and poor quality subgroup cannot be assessed due to only one study that belong to both two categories. However, the subgroup differences test shows a good and significant value with I2 of 99.8% and p-value of <0.00001. (Figure 7)
Figure 7: Subgroup Analysis for Risk of Bias (Adequate and Inadequate HL for DBP) 3.3.4 Association between Health Literacy and Clinical Outcomes in Hypertensive Patients in Interventional Studies In investigating the association between health literacy and clinical outcomes in hypertensive patients in interventional studies, data that are being used are still the mean and SD values of SBP and also DBP. This meta-analysis includes 5 interventional studies with a total of 3076 patients (1256 control patients and other 1820 patients received interventions). The pooled effect size for SBP was 0.80 (95%CI: 0.11 - 1.50). It also has a good and significant heterogeneity among the included studies (p<0.00001, I2 = 98%). This meta-analysis also has a statistically significant overall effect with Z score of 2.26 (p = 0.02). (Figure 8)
Figure 8: Forest Plot of SMD between Experimental and Control for SBP
344
Secondly, in terms of DBP the pooled effect size for DBP was 0.39 (95% CI: -0.01, 0.80). In the aspects of heterogeneity, the I2 score was 96% (p<0.00001), while the overall Z-score was 1.91 but it was regarded statistically insignificant (p=0.06). (Figure 9)
Figure 9: Forest Plot of SMD between Experimental and Control for DBP 3.3.5 Association between Health Literacy in Hypertensive Patients and Clinical Outcomes in Interventional Studies based on Study Location Subgroup Analysis Considering the heterogeneity of the data on interventional studies, we performed a subgroup analysis among these studies based on the geographical location (1 study in the US, 1 in China, 1 in Hongkong and 2 in Iran). From Figure 10, we could observe that the subgroup effect is statistically significant (p < 0.00001), which shows that study location can influence the effect of intervention on lowering the systolic blood pressure as compared to the controls. Majority of the subgroup shows that intervention gives favorable results over the control population with the exception of the subgroup USA. Therefore, the subgroup effect is considered as qualitative. In addition, the test for subgroup differences have also shown a substantial unexplained heterogeneity (I2 = 98.2%)
Figure 10: Subgroup Analysis for Study Location (Experimental and Control for SBP)
345
The Figure 11 below illustrates the test for subgroup differences for the outcome diastolic blood pressure. It shows that there is a statistically significant subgroup effect (p < 0.00001), meaning that interventions to improve HL have a favorable outcome in decreasing the DBP in comparison to control. Looking at the results between subgroups, we can observe a qualitative subgroup effect as intervention is favoured over control in 2 subgroups (Hong Kong and Iran) whereas the opposite is seen in the other subgroups (USA and China). Also, there is a substantial unexplained heterogeneity indicated by an I2 of 93.5%.
Figure 11: Subgroup Analysis for Study Location (Experimental and Control for DBP) 3.3.6 Association between Health Literacy and Clinical Outcomes in Hypertensive patients in Interventional Studies based on Risk of Bias (ROB) Subgroup Analysis The next subgroup analysis was based on Risk of Bias performed in Cochrane (Appendix Table 1), where we found 2 categories: High and Unclear. Figure 12 depicts the test for subgroup differences which indicates that there is a statistically significant subgroup effect (p < 0.0002) and that the risk of bias could modify the effect that intervention has on SBP. However, there is also a high heterogeneity (I2 = 93.0%) for this subgroup analysis.
Figure 12: Subgroup Analysis for Risk of Bias (Experimental and Control for SBP)
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For the other clinical outcome, DBP, the result of subgroup analysis is demonstrated in Figure 13. The test for subgroup differences shows that the subgroup effect is statistically insignificant (p = 0.08). This implies that there is no subgroup effect, in other words, a low likelihood that the risk of bias could alter the effect of intervention on DBP as compared to control. Furthermore, there is a moderate unexplained heterogeneity with a I2 value of 66.6%.
Figure 13: Subgroup Analysis for Risk of Bias (Experimental and Control for DBP) 3.4 Health Literacy and Behavioral Outcome in hypertensive patients Five out of six studies results regarding hypertension knowledge have shown that with increasing health literacy, there is an increase in hypertension knowledge. In study by Miranda et al. (2019), it was shown that the highest HL was among Dutch, followed by African Surinamese and South-asian Surinamese, and the odds of having better information regarding hypertension followed the same trends. Self-care for hypertension was also reported to be higher amongst more health literate groups. Studies also showed that groups with adequate HL tend to have a higher proportion of patients who adhere to their medications. Interventions by Delavar et al. (2020) and Sany et al.(2020) have also yielded higher adherence scores. Meanwhile, the outcomes of the other studies seemed to yield different results in terms of medication adherence and health literacy. Overall, it can be inferred qualitatively that better adequacy in health literacy provides more favorable behavioural outcomes among hypertensive patients.
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4. DISCUSSION Our systematic review and meta-analysis showed that the degree of health literacy does demonstrate significant influence towards patientsâ&#x20AC;&#x2122; outcomes. In addition to the clinical parameters that we observed, our study had also attempted to summarize the behavioural outcomes and elaborate the implications in daily practice as evidenced and recommended by global guidelines. 4.1 Clinical Outcomes and their Implications in Daily Practice 4.1.2 Systolic Blood Pressure in Observational Studies Seven studies have observed the clinical parameters on SBP. The pooled estimates of standard mean difference favoured an adequate level of health literacy which has been associated with lower mean SBP. This indicated that blood pressure control or monitoring was better achieved in populations with better understanding regarding hypertension. Office SBP measurement has become one of the important parameters in diagnosing and monitoring hypertension in both essential and optimal settings based on the recent 2020 International Society of Hypertension Guidelines by Unger et al. (2020). This globally accepted guideline also highlighted lifestyle modifications as initial management, emphasizing the need of well-established patient-physician communication to achieve the well-controlled target BP. Understanding these facts, we strongly encourage physicians to enhance patientsâ&#x20AC;&#x2122; health literacy by sending the right health message, leading to improvement of this essential clinical parameter. 4.1.2 Diastolic Blood Pressure in Observational Studies On the other hand, mean diastolic blood pressure showed opposing pooled estimates of standard mean difference, revealing lower DBP in lower health literacy. The underlying reason remains unknown. It is to be noted that in our review, the test for overall effect however resembles no significant difference suggesting possible interindividual variability that requires larger sample size. 4.1.3 Systolic Blood Pressure and Diastolic Blood Pressure in Interventional Studies From all of five studies, it implements various interventions to improve health literacy. First, a study that was conducted by Katzmarzyk et al. (2018) found that by implementing intervention for 24 months that has a high-intensity, health literacy- and culturally-appropriate lifestyle to the population will generate a greater reduction in body weight and bring other positive outcomes in the population such as better blood pressure control. Secondly, Delavar et al. (2020) applied self-management education tailored to health literacy among the patients in his study. It showed significant improvement in medication adherence, but not in blood pressure control.
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Thirdly, Zhang et al. (2019) used innovative community-based hypertension self-management involving general practitioners to provide feedback and program on learning the skills related to daily management, communication, et cetera leading to significant improvement of the general health condition of the patients. It improves blood pressure control but not significantly. Fourth, study by Fu SN et al. (2020) implements Risk Assessment and Management Program (RAMP) intervention for home BP monitoring in an older population that has insufficient health literacy. RAMP was able to successfully demonstrate a significant reduction in BP along with CVD risk of hypertensive patients. Furthermore, a significantly higher BP control is able to be achieved by applying RAMPgroup intervention compared to RAMP-individual. Not only that, in RAMP-individual intervention, patients had a significant increase in BW and BMI, while in RAMP-group patients both BW and BMI do not have any significant changes. This intervention also has no adverse effect that was reported. Fifth, Sany et al (2020) applied an intervention on 35 physicians through 2 sessions of focus group discussions (FGDs) and 2 workshops and observed the outcomes on both the physicians and the patients. Through this intervention, there is an improvement in health outcomes such as a decrease in SBP and DBP as well as better scores of health literacy, medication adherence and self-efficacy. All in all, based on our meta-analysis of all of these interventional studies, it shows that intervention in improving health literacy was able to lower SBP & DBP. 4.2 Behavioural Outcomes and their Implications in Daily Practice As described previously, better medication adherence, self-care and other behavioural parameters were predominantly associated with higher HL. The possible explanation was that better understanding would also lead to better cooperation between physician-patient relationships. Given that hypertension requires lifelong management, the knowledge regarding possible adverse effects during medications and compliance to follow the prescription importantly serve as the key to better behavioural outcomes. In line with Shi et al. (2019), specific pertinent strategies to promote better health literacy need to be developed to facilitate better adherence, self-care, and blood pressure control. 4.3 Study Limitations and Strengths We acknowledge that there are several limitations to this study. Due to the limited number of studies in our meta-analysis, we were unable to perform a publication bias evaluation through funnel plot. However, we searched through nontraditional sources to alleviate this concern. Secondly, the majority of the studies we included were cross-sectional which could limit the conclusion for a long-term impact of an improved health literacy on health outcomes. Furthermore, different studies used different tools to assess health literacy, increasing the heterogeneity of the data and affecting the comparability of the
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results. Finally, variations among the subjects such as age, comorbidities and other health status may still contribute as confounding factors despite being adjusted. Despite the aforementioned limitations, this review has several important strengths. To the best of the authorsâ&#x20AC;&#x2122; knowledge, this is the first systematic review and meta-analysis to comprehensively examine the association of different levels of health literacy and outcomes such as blood pressure and medication adherence. Moreover, we contacted the authors of the studies when we could not retrieve the data that we needed. Another key strength is the extensive study search that was applied to generate the final results along with subgroup analyses to compensate for heterogeneity. 5. CONCLUSION In summary, hypertensive patients who have higher health literacy are more likely to have better outcomes in terms of blood pressure and behavioral outcomes such as hypertensive knowledge and medication adherence. Our findings have important implications for public health in the aspect of knowledge, attitude and practice. 5.1 Future Recommendations We recommend that future studies examine the clinical parameter of mean arterial pressure since it resembles more closely the average of arterial pressure in one cardiac cycle, which is better in predicting the perfusion of vital organs. This also correlates with the urgency of confirming the suspicion of hypertension-mediated organ damage among the hypertensive patients. In addition, a more globally uniform tool for health literacy can be developed to carry out future studies to minimize possible differences.
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APPENDIX Appendix Table 1: Cochrane Risk of Bias (RoB)
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Appendix Table 2: NIH Quality Assessment Tool for Observational Cohort and Cross-sectional Studies
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Effectiveness of the Suami SIAGA Campaign as a Form of Health Communication on Maternal Healthcare: A Systematic Review Muhammad Mikail Athif Zhafir Asyura1, Shuffa Chilla Mayhana1, Ilma Ranjani Wijaya1, Muhammad Afif Naufal1 1
Faculty of Medicine, Universitas Indonesia
BACKGROUND: Maternal health is one of the most persistent public health problems. Antenatal care has been conducted globally in order to tackle this issue, but the participation of pregnant women in the program still varies. A contributing factor that is commonly overlooked is these women’s partner involvement. Suami SIAGA is a campaign that has previously been enforced nationwide to promote husband involvement, but as of now, no available study has been conducted to review the impact of this campaign on maternal health and husband’s involvement. OBJECTIVES: This systematic review was conducted to assess the effectiveness of the Suami SIAGA campaign in Indonesia as a campaign aiming to increase husband involvement and improve overall maternal health. METHODOLOGY: Searches were conducted through 3 categories of databases, which are international (MEDLINE, Cochrane, and ProQuest), national (Google Scholar, Garuda Dikti, and Media Neliti), and university repositories (Universitas Indonesia e-Library, Airlangga University Repository, and Gajah Mada University Repository). After collecting the studies, we further assessed the risk of bias using the National Institute of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies. RESULTS: The articles showed a positive association between the SIAGA status and improved participation in maternal health especially in antenatal care visits, routine pregnancy checks and overall involvement in wife’s routines. Certain factors such as education may also influence the SIAGA status of the husbands. CONCLUSION: The suami SIAGA campaign has been proven to be effective in promoting antenatal care and should be re-implemented with the support of modern media keywords: antenatal care, suami siaga, maternal health, paternal involvement
357
Effectiveness of the Suami SIAGA Campaign as a Form of Health Communication on Maternal Healthcare: A Systematic Review Muhammad Mikail Athif Zhafir Asyura1, Shuffa Chilla Mayhana1, Ilma Ranjani Wijaya1, Muhammad Afif Naufal1 1
Faculty of Medicine, Universitas Indonesia
BACKGROUND: Maternal health is one of the most persistent public health problems. Antenatal care has been conducted globally in order to tackle this issue, but the participation of pregnant women in the program still varies. A contributing factor that is commonly ove.looked i
he e
omen
a ne
involvement. Suami SIAGA is a campaign that has previously been enforced nationwide to promote husband involvement, but as of now, no available study has been conducted to review the impact of this campaign on maternal health and h band involvement. OBJECTIVES: This systematic review was conducted to assess the effectiveness of the Suami SIAGA campaign in Indonesia as a campaign aiming to increase husband involvement and improve overall maternal health. METHODOLOGY: Searches were conducted through 3 categories of databases, which are international (MEDLINE, Cochrane, and ProQuest), national (Google Scholar, Garuda Dikti, and Media Neliti), and university repositories (Universitas Indonesia e-Library, Airlangga University Repository, and Gajah Mada University Repository). After collecting the studies, we further assessed the risk of bias using the National Institute of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies. RESULTS: The articles showed a positive association between the SIAGA status and improved participation in maternal health especially in antenatal care visits, routine pregnancy checks and overall in ol emen in ife
o ine . Ce ain fac o
ch a ed ca ion ma al o influence the SIAGA status
of the husbands. CONCLUSION: The suami SIAGA campaign has been proven to be effective in promoting antenatal care and should be re-implemented with the support of modern media keywords: antenatal care, suami siaga, maternal health, paternal involvement
358
1. Introduction Maternal health remains as one of the biggest and most persistent public health problems in the world. Every day, 810 pregnant females die from preventable causes and in 2017, more than 295,000 deaths occurred in such fashion. Almost all deaths are contributed from low and lower-income countries. Although a significant improvement has been observed during the last 2 decades, the death count remains intolerable (WHO, 2019). Indonesia, though declared as an upper-middle income country, still faces this problem today. With 117 per 100.000 live births, Indonesia.s Maternal Mortality Rate (MMR) is still relatively high compared to other upper-middle income countries around Southeast Asia (The World Bank, 2017). Studies have shown these unnecessary deaths can be effectively prevented with adequate antenatal care (ANC) (Wondemagegn, Alebel, Tesema, & Abie, 2018). ANC is a specialized healthcare system for pregnant women. It consists of 6 different aspects, namely health system interventions, nutrition interventions, maternal and fetal assessments, preventive measures, and common pregnancy symptom interventions. All these aspects are divided into eight visits throughout pregnancy trimesters (WHO, 2018). Despite its noble mission, the parity of this program s utilization is clear. Maternal deaths in Indonesia predominantly comprises deaths in rural areas and coincidentally, the frequency of antenatal visits in rural areas in Indonesia compared to those who live in urban areas is lower by 10% (UNICEF, 2016). Factors that contribute to this parity include maternal age, education, socioeconomic status, history of pregnancy-related complications, spouse or partner support, quality of care, and distance to the nearest ANC centre (Ali, Dero, Ali, & Ali, 2018). One of the most important factors in increasing the frequency of ANC visits is the involvement of the partner. Studies have shown that male company in ANC improves overall maternal outcome in ANC (Suandi, Williams, & Bhattacharya, 2019). Therefore, it is possible the aforementioned shortage of antenatal visits is caused not only because of infrastructure inequality but also because of a deficiency in husband knowledge and attention. Hence, in an attempt to increase the knowledge and involvement of husbands during pregnancy, the Ministry of Health of Indonesia put campaigns in motion. These efforts started back in 1996 with the Mother-Friendly Movement or Gerakan Sayang Ibu. (Sood, Chandra, Palmer, & Molyneux, 2004). This campaign evolved into Suami SIAGA (abbreviation for Siap, Jaga, Antar or Ready, Watch, Drive) or directly translated to Alert Husband (Karlina, 2018). This campaign, along with its missions, suggest that the government acknowledge the impact of conditioning the social environment surrounding the mothers, hence a commitment to not only improve communication between healthcare workers, but their interaction with patients' relatives. However, until now, there is no review that assesses the effect of said campaign toward husband knowledge and overall maternal health. For that very reason, this systematic review was conducted in hopes of being the very first to assess the overall effectiveness of this campaign and its impact on overall maternal health.
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2. Methodology 2.1. Search Strategy The systematic review is conducted based on the PRISMA statement. Initially, we conducted searches on various international databases such as MEDLINE, Cochrane, and ProQuest for relevant journal articles. However, due to very limited results we decided to extend our research on established local databases such as Garuda Dikti, Media Neliti, and Google Scholar. Furthermore, a more extensive search was done on multiple local universities' databases; namely the University of Indonesia e-Library, Airlangga University repository, and the repository of Gajah Mada university. Articles mentioning the Suami SIAGA Campaign and its effectiveness towards the husband s role in maternal health were included. Both subject heading and text word searches were utilised and different search terms were implemented for each database. No language restrictions were applied, however the studies included in the review were restricted to Bahasa Indonesia and English; which were the only languages readable by the authors. The search yielded a total of four studies that were selected based on relevancy and eligibility. Table 1 summarizes the search term used and Figure 1 shows the overview of the study selection process using the PRISMA flowchart. The studies were then further assessed by the National Institute of Health (NIH) quality assessment tool by four reviewers collaboratively. The risk of bias assessment result is shown in Figure 2 with further justifications explained in Appendix 1 of the Appendix section at the end of this review. Table 1. Search term used
Database
Search terms
Pubmed
("suami siaga" AND "maternal health" OR "Kesehatan Maternal " OR "effectiveness" OR "effect" OR "efektivitas")
NCBI
("suami siaga" AND "maternal health" OR "Kesehatan Maternal " OR "effectiveness" OR "effect" OR "efektivitas")
Cochrane
("suami siaga" AND "maternal health" OR "Kesehatan Maternal " OR "effectiveness" OR "effect" OR "efektivitas")
ProQuest
("suami siaga" AND "maternal health" OR "Kesehatan Maternal " OR "effectiveness" OR "effect" OR "efektivitas")
Garuda Dikti
Suami Siaga
Media Neliti
Suami Siaga
Google Scholar
("suami siaga" OR ("Involving Husbands" AND "Indonesia") OR "Alert Husband") AND ("Kehamilan" OR "Antenatal care" OR "Efek" OR
360
"Efektivitas" OR "Effectiveness" OR "Kesehatan Maternal" OR "Maternal Health") University of
("suami siaga" AND "maternal health" OR "Kesehatan Maternal " OR
Indonesia e-Library
"effectiveness" OR "effect" OR "efektivitas")
Airlangga
("suami siaga" AND "maternal health" OR "kesehatan maternitas")
University Repository Gajah Mada
Suami Siaga
University Repository
2.2. Study Selection The inclusion and exclusion criteria were developed in accordance with our initial searches. Only observational studies conducted between 2010 until 2020 among husbands and/or wives alone were included. The impact of the Suami SIAGA Campaign on increased awareness and better maternal health had to be offered in the study s outcome. Elaborations on the impact of the Suami SIAGA Campaign on maternal health can be represented by the number of antenatal care visits, birth preparedness, and behaviour towards pregnancy. Confounding variables were considered but not limited to education level, husband s occupation, as well as work hours. We omitted non-observational studies to ensure uniformity. Other than the year of publication no further restrictions were put on language, location, and the publication status of the studies. 2.3. Data Extraction From each journal article, we extracted the study design, the characteristics and confounding factors of the sample population, the impact of the Suami SIAGA Campaign, as well as comparing the results with other articles to identify a trend. 2.4. Quality & Bias Assessment The risk of bias assessment was conducted based on the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies, as shown in Figure 2. Each study is evaluated based on a number of criteria that measures the eligibility of the sample population, exposure to the participants, outcome of the study, and confounding variables. Each journal article
361
would receive a score for the respective criteria which classifies each study into Poor, Fair, and Good, which is then tabulated to determine the risk of bias of the article. 3. Results and Discussion 3.1. Search Results After exploring international, national, and university databases as well as conducting individual searches we acquired a total of 600 studies using the search terms used in respective databases. 567 studies were excluded based on its title relevance, and 16 studies were excluded based on duplicate titles. Furthermore, 8 studies are assessed for eligibility. However, 4 studies cannot be included due to the fact that the inappropriate study design. After analysing the studies based on its relevancy and eligibility, a total of 4 studies are included in this systematic review. Figure 1 shows the overview of the study selection process using a PRISMA flowchart.
Figure 1. PRISMA flow chart of search strategies 3.2. Study Characteristics and Findings In order to maintain uniformity, four cross-sectional studies were reviewed. The studies included were all conducted in Indonesia, published between 2010 until 2020. This review involves a sum of 55,139 study participants, primarily relying on primary data obtained from a questionnaire that classifies the husband's alertness into SIAGA and non-SIAGA husbands. The summary of the characteristics and results of the studies is provided in Table 2. In terms of outcomes, all of the studies included in this review show a positive association between the husband s alertness towards maternal health.
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Table 2. Summary of cross-sectional studies Author
Study
and Year
Design
Fazdria et al,
Cross-
Langsa
2014
sectional
Village,
Location
Sample
Subject
Method of
Size
Characteristics
Measurement
43
Eligible male
Univariate and
subjects
bivariate analysis
- SIAGA status have a significant association with
using cross-
knowledge (p= 0.036), behavior (p<0.000, OR= 15.5), and
tabulation and
education status of the husbands (p=0.04, OR= 6.5), but not
chi-square of
with husband's working hours (p= 0.16, OR= 2.875)
questionnaire
- Furthermore, there is a positive correlation between
Indonesia
Outcome - There are more non-suami SIAGA
knowledge about antenatal care and education status with husbandâ&#x20AC;&#x2122;s involvement in routine pregnancy checks and motivation in helping their wifeâ&#x20AC;&#x2122;s with their daily routines Kurniati et al,
Cross-
2017
sectional
Indonesia
54,913
Eligible husband
Bivariate and
and wife couples
multiple logistic regression analysis of the
- Suami SIAGA is a significant predictor in improving maternal health - 92% SIAGA husbands would accompany their wives for ANC (OR = 2.3)
Indonesia
- 73% SIAGA husbands brought their wives to receive a
Demographic and
professional assistance at delivery in a hospital/ health
Health Survey
facility compared to Non-SIAGA husbands (65%) (OR =
(IDHIS) 2012
1.1)
363
Table 2. (continued) - Couples living in urban areas have a higher probability to deliver at a health facility by 2.7 times than in rural areas - Likelihood of women to have SIAGA husband is increased with the level of education by 1.8 times with secondary level and 2.7 times in women with a higher level of education Puspita et al,
Cross-
Ambaraw
2015
sectional
37
Eligible pregnant
Univariate and
- Most of the husbands in Ambarawa village are non-
a Village,
women in third
bivariate analysis
SIAGA husbands (51,4%)
Indonesia
trimester
using chi square
- There is a positive correlation between the role of SIAGA
of questionnaire
husbands with the increasing frequency of ANC visits (p=0.029). 63,2% wives with non-SIAGA husbands receive inadequate ANC, while 77,8% wives with SIAGA husbands receive adequate ANC - 36,8% wives who receive inadequate ANC is influenced by the husbandâ&#x20AC;&#x2122;s knowledge and occupation - 43,2% of pregnant wives have inadequate number of visits - The quality of non-SIAGA husbands in Ambarawa shows that they did not accompany their wives to conduct USG examination (18,9%), did not listen to their wivesâ&#x20AC;&#x2122; complaints during pregnancy (16,2%), and did not help their wives with household-related work (24,3%)
364
Table 2. (continued) \Rakhmawati
Cross-
and Indawati,
sectional
Indonesia
146
Eligible husband
Univariate and
- 43.8% SIAGA husbands play a bigger role in
and wife couples
bivariate analysis
accompanying their pregnant wives compared to mid-
using cross
SIAGA husbands (28.8%) and non SIAGA husbands
tabulation
(27.4%)
2013
- There is a correlation between the majority of non-SIAGA husbands with aging between 26-35 years (31.1%), previously educated until primary school (62.5%), and having a lower income (â&#x2030;¤ Rp1.700.000,00) (36.7%)
365
3.2. Risk of Bias Assessment The studies included were assessed by the National Institute of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies by four reviewers collaboratively. The risk of bias assessment results are shown in Figure 2, along with the justification in Appendix 1. After tabulating individual impressions and reaching a collaborative consensus, all four studies have a low risk of bias, based on the criteria used in the assessment. Studies conducted by Puspita, Widodo, & Mulyasari (2013) and Fazdria, Emilda, & Sukamdewi (2015) are classified as Fair as it fulfills a minimum of 8 out of 14 criteria, meanwhile the studies conducted by Kurniati, Chen, Efendi, Ku, & Berliana (2017) and Rakhmawati & Indawati (2013) are classified as Good as it fulfills a minimum of 10 out of 14 criteria. With that in mind, the reviewers feel confident to draw conclusions from the studies, considering its reliability. 3.3. Summary of Interpretation of Evidence Fundamentals of the SIAGA Campaign The SIAGA campaign, which was part of the Maternal and Neonatal Health (MNH) program, was the first campaign aimed towards increasing awareness on maternal and newborn care via the promotion of birth preparedness and complication readiness (BP/CR) The initial phase of the campaign dubbed Suami SIAGA was aimed towards husbands to improve their participation in maternal health via multiple mediums. These communication mediums namely: television, radio, and mass media events have been proven to be effective in communicating health information on the target population. An effectively conveyed SIAGA campaign has been proven to improve one s knowledge towards specific danger signs during pregnancy, childbirth, and postpartum period. A study involving 3,364 subjects demonstrated that around 53% of all of the study participants affirmed that they were aware of Suami SIAGA at the end of the study. The effectiveness of the SIAGA campaigns is also supported by the statement, present in the study stating that women and husbands who were exposed to the SIAGA campaign were more likely to conduct four or more ANC visits than those not exposed. This shows that effective health communication plays a role in influencing the community s awareness, particularly in increasing overall maternal health (Sood et al., 2004). Thus, to further cement these claims, a systematic study from multiple articles was conducted. Association between SIAGA husbands and maternal health From the four articles that were in line with our inclusion criteria, some trends were identified regarding the impact of the SIAGA status on husbands towards different aspects of maternal health. All four articles showed a positive association between the SIAGA status and improved participation in maternal health. The most notable is the improvement in husband's awareness about ANC visits and routine pregnancy checks among SIAGA husbands (Fazdria et al., 2015; Kurniati et al., 2017; Puspita
366
et al., 2015; Rakhmawati & Indawati, 2013). In Kurniati et al. (2017), men in the SIAGA group were more likely to be present during wives ANC by a whopping 2.3 OR, and similar probabilities can be found in Rakhmawati & Indawati (2013), which states that 43% of SIAGA husbands accompany their pregnant wives, more than 1.5 times more likely than mid-SIAGA husbands (28.8%) and non SIAGA husbands (27.4%). Meanwhile, Puspita et al. (2015) suggests a positive correlation between the SIAGA status and increased frequency of ANC visits (p = 0.029). Furthermore, three of four studies show that the SIAGA campaign improves husbands' involvement in the daily routines of their wives (Fazdria et al., 2015; Kurniati et al., 2017; Rakhmawati & Indawati, 2013). In Fazdria et al. (2015) 77,7% of husbands that are considered SIAGA have decentto-good knowledge about pregnancy, which includes awareness of the huge amount of risks associated with pregnancy. Also, good attitudes towards pregnancy are relatively present within all SIAGA husbands. From Kurniati et al. (2017), a high proportion of men (86%) in this study is classified as Suami SIAGA reflecting their willingness to involve in the birth preparedness including planning place of delivery, skilled birth attendant, delivery fund, transportation to the birth-place, and blood donation. In addition to that, men in the SIAGA group were more likely to be present during wives ANC (OR 2.3; 95% CI: 1.4 3.7). SIAGA husbands also tend to take their spouses to give birth at a health facility, although this result was not significant (OR 1.1; 95% CI: 0.8 1.6). Furthermore, Puspita et al. (2015) claims that 92.2% husbands play a pivotal role in maternal health. This is directly represented by the positive correlation between SIAGA husbands and the frequency of involvement in ANC. Finally, in Rakhmawati & Indawati (2013), the SIAGA status of husbands were further separated into three categories: SIAGA, mid-SIAGA, and non-SIAGA husbands. The survey conducted showed that 43.8% husbands which are considered SIAGA husbands played a bigger role in accompanying their pregnant wives compared to mid-SIAGA husbands (28.8%) and non-SIAGA husbands (27.4%). The importance of paternal involvement in maternal health The husband s knowledge and awareness are a factor to be reckoned in maternal health and outcome. In the study conducted by Kurniati, et al. (2017) it was shown that the SIAGA status of the husbands was a significant predictor of ANC visits. Such result happens to be present in the study conducted by Puspita, et al. (2015) further signify these findings. Paternal involvement is said to be associated with maternal psychosocial stress, prenatal care behaviors, and substance use (Bond, 2010). All of the factors related to the associations were found in all four studies gathered, further validating the importance of paternal involvement in Indonesia. Also, the effect of paternal involvement is found at the community level. Based on a review that assess the effectiveness of health campaign interventions and its direct correlation towards ANC visits, two studies conducted in Nepal involving primary health programs in the form of facility-based couples education as well as community-based education in Pakistan have shown that there is no change in ANC visits after the respective interventions. In contrast, six out of the
367
eight studies compared in the review demonstrated a substantial increase of ANC visits when multicomponent interventions with male involvement were conducted. Thus, it could be inferred that a direct involvement of husbands plays a huge role in the quality of ANC. The review also stated the fact that there is no further change in the frequency of ANC visits if the intervention stopped; further proving that a multi-component intervention, directly involving the family member, such as Suami SIAGA, is effective (Tokhi et al., 2018).
Factors influencing SIAGA husbands Moreover, certain factors were also identified which were associated with the SIAGA status of husbands. In all the studies, education status remained a prevalent factor which was correlated with the SIAGA status of husbands (Fazdria et al., 2015; Kurniati et al., 2017; Puspita et al., 2015; Rakhmawati & Indawati, 2013). Educational status was further elaborated; touching on previous formal education and general knowledge about pregnancy (Fazdria et al., 2015). A positive correlation was shown between well-educated husbands with their SIAGA status (Fazdria et al., 2015; Kurniati et al., 2017; Puspita et al., 2015; Rakhmawati & Indawati, 2013). This claim is further supported by a separate study conducted by Jungari & Paswan (2019) which analysed the association between husband s knowledge of general pregnancy and maternal health. Within this cross-sectional study, husband s education levels were significantly associated with an increase in wife s utilization of ANC care services (OR: 2.64; 95% CI: 0.847 8.24) (Jungari & Paswan, 2013). Other than education, Rakhmawati & Indawati (2013) showed that the majority of non SIAGA husbands were associated with being in the age range of 26-35 and a relatively lower income (<Rp1.700.000,00). Furthermore, Kurniati et al. (2017) stated multiple other variables that may influence the SIAGA status. Several variables that may affect a husband in becoming SIAGA include: husband factors (age, place of residence, education, wealth index), wife factors (age, education), women empowerment factors (involvement of women in decision-making about their own health care), childwish factors (whether husbands wish to have another child within two years or after more than two years or are undecided) and parity (number of children ever born). Interestingly, only variables that involve wife participation were significant in this study compared to the other confounding variables (Kurniati et al., 2017).
Revitalization of the Suami SIAGA Campaign After comparing with similar health campaigns in other middle-to-lower income countries and assessing the apparent benefits of paternal involvement in maternal health, we could raise the urgency to revitalize the Suami SIAGA campaign as a multi-component community education that particularly targets the husband. The needs to revitalize the campaign is clear as the high number of non-SIAGA
368
husbands, shown in all four studies, is prominent. All the studies recommended revitalization of the campaign to increase the number of SIAGA husbands. Moreover, recent efforts done to revitalize the Suami SIAGA campaign showed promising results. A study conducted by Santoso et al. (2017) to evaluate ANC in the form of birth preparedness and complication readiness (BP/CR), showed that the integration of the Suami SIAGA campaign with an android-based application was favourable. The study was conducted on two different groups in which one acts as a control with no intervention being initiated. Both groups received ANC counselling, but one group also received the mobile app intervention called Suami SIAGA PLUS Study results presents that the application boosted the husband s BP/CR score by 20% (60.4 % to 72.9%) (p=0.000), in comparison to a 2% increase (61.5% to 62.6%) when sole counselling was conducted. Along with the increase of advances and accessibility of communication technology, it is highly recommended to revitalize the campaign from previously directly consulting couples and socialization to a more modernized approach.
3.4. Strengths and limitation of selected studies The strengths and weaknesses of the studies included in this systematic review have been taken to consideration. The strength of the selected studies lies in the fact that All of the studies included demonstrated clarity in sampling, with appropriate data and sample size representation. Moreover, almost all of the studies conducted the chi square test to analyze the data obtained. One study qualitatively analyzed the data using cross tabulation, instead using chi square test to conduct the bivariate analysis (Rakhmawati & Indawati, 2013). A solid and clear recommendation is offered at the end of each study. Finally, all four studies have shown low risk of bias based on the NIH quality assessment. Nevertheless, there are several limitations in these studies, one study, conducted by Rakhmawati & Indawati (2013) pointed out survivorship bias without further validation. Some of the studies might include authors own interpretations and assumptions in discussions. Although the sample sizes are variable, there are more small sample sized studies than the relatively big one. One study also is sourced from secondary data that might limit the variables studied (Kurniati et al., 2017). 3.5. Strengths and limitations of the review The strength of this review lies on the uniformity of the study design across the four studies.This homogeneity made it possible for easy comparison between the dependent and confounding variables. Thus, helping in the analysing process and resulting in a justified and accountable conclusion being drawn from the four studies. Moreover, the qualitative outcomes of similar variables and its correlation with the main independent variable (SIAGA status) across the four studies are intersecting with one
369
another, hence making the outcomes more easily comparable. Looking into the sample characteristic of the studies, the majority are centralized in the rural regions of Indonesia. This could be a strength of this review if the analysis is used for future interventions that target the similar demographic. Most importantly, from our prior research across multiple databases, there has not been an identical or similar review analysing the association between the SIAGA campaign and its impact on maternal health. However, a difference in result presentation of the studies may limit the qualitative analysis of the review. Only two studies expressed p values and OR while one only mentioned p values and the other solely compared percentages using a tabulation table. Nonetheless, this setback can be compensated by the high OR and significant results obtained individually from the results. Another limitation would be that only one study bridged the confounding variables with the SIAGA campaign and how it was related to maternal health. However, the relation between the confounding variables and maternal health can still be justified by referencing a previous study which has proven a significant positive correlation with an OR of >1. 4. Conclusion and Recommendations 4.1. Conclusion The Suami SIAGA campaign initiative is positively beneficial to maternal health. It is a prime example of communication media with consequential impact on healthcare and sets a precedent for all following health promotion campaigns. However, the enforcement of this campaign is still narrow in scope, as reflected by the low prevalence of SIAGA status among husbands and the disparity of this status among different regions. This is especially significant in Indonesia, where the Maternal Mortality Rate is still relatively high, parity of antenatal care is prevailing, and husband involvement in maternal care is lacking. Therefore, the urgency for a widespread campaign is clearly needed to alleviate the national burden. Suami SIAGA effectively increases awareness and involvement of males in maternal healthcare, as most evident in the rise of antenatal care sessions when husbands participate, better encouragement and attitude of their wives, and improved facilities during the pregnancy, childbirth, and postpartum period. It has great potential to transform the attitude and contributions of males in healthcare as well as promote the implementation of communication on a nationwide basis. 4.2. Recommendations It is recommended that the Suami SIAGA campaign is implemented again in the future, but on a larger scale, and involving populations with less access such as lower income areas. Furthermore, the campaign could be widely disseminated through more varying forms of media. With the rapid advancement of health technology, digital mediums could be incorporated beyond television, radio, and mass media events. Even so, currently popular methods used to spread health information must be
370
maintained or revitalized, and health workers who work closely with the community should also actively promote the campaign message. It is also important to recognize that a concerted effort from different parties is required for the sustainability of an impactful campaign. The party with the highest level of responsibility is the government, which has the most access to implementation of this campaign in institutions around the country. It is highly recommended for their interventions to emphasize further the importance of maternal and paternal contributions in antenatal care, and on a broader scale, educate husbands regarding their roles and responsibilities as the head of the household in Indonesia s patriarchal community. Further research would be beneficial in better and wider utilization of Suami SIAGA. More variables affected by and affecting the SIAGA status may be explored, such as the use of postpartum family planning, the impact of domestic behavior regarding respect and abuse during pregnancy, and the cost-efficiency of the campaign. Additionally, more interventional or experimental research should be conducted in regions that are still lacking in maternal health education. Conflict of Interest The authors declare no conflict of interest Funding The authors did not receive any grant from any funding agency in public, commercial, or not-for-profit sectors.
371
References Ali, S. A., Dero, A. A., Ali, S. A., & Ali, G. B. (2018). Factors affecting the utilization of antenatal care among pregnant women: A literature review. Journal of Pregnancy and Neonatal Medicine, 2(2), 41-45. https://doi.org/10.35841/neonatal-medicine.2.2.41-45 Bond, M. J. (2010). The missing link in MCH: paternal involvement in pregnancy outcomes. American Journal of Men s Health, 4(4), 285-286. https://doi.org/10.1177/1557988310384842 Fazdria, Emilda, A. S., & Sukamdewi, M. (2015). Karakteristik suami SIAGA terhadap masa kehamilan sampai persalinan di ruang rawat kebidanan BLUD RSUD Kota Langsa tahun 2014. Jurnal Kesehatan
Ilmiah
Nasuwakes,
8(1),
39-50.
http://r2kn.litbang.kemkes.go.id:8080/handle/123456789/66297 Jungari, S. & Paswan, B. (2019). What he knows about her and how it affects her? Husband s knowledge of pregnancy complications and maternal health care utilization among tribal populations
in
Maharashtra,
India.
BMC
Pregnancy
and
Childbirth,
19(70),
https://doi.org/10.1186/s12884-019-2214-x Karlina, L. (2018). Gambaran pengetahuan suami tentang suami SIAGA dalam masa kehamilan di puskesmas matakali kecamatan matakali kabupaten polewali mandar. Jurnal Kesehatan Bina Generasi, 8(1), 107-1. https://doi.org/10.35907/bgjk.v8i1.56 Kurniati, A., Chen, C., Efendi, F., Ku, L. E., & Berliana, S. M. (2017). Suami SIAGA: male engagement in
maternal
health
in
Indonesia.
Health
Policy
Plan,
32(8),
1203-1211.
https://doi.org/10.1093/heapol/czx073 Puspita, M. A., Widodo, G. G., & Mulyasari, I. (2015). Hubungan antara peran suami SIAGA dengan frekuensi kunjungan antenatal care (ANC) pada ibu hamil trimester III di Kelurahan Pojoksari Kecamatan Ambarawa Kabupaten Semarang. Rakhmawati, M. & Indawati, R. (2013). Kondisi sosio demografi pasangan usia subur (PUS) dan peran suami SIAGA terhadap kesehatan maternal. Jurnal Biometrika dan Kependudukan, 2(1), 6674. http://repository.unair.ac.id/id/eprint/22570 Santoso, H. Y. D., Supriyana, S., Bahiyatun, B., Widyawati, M. N., Fatmasari, D., Sudiyono, S., Sinaga, D. M. (2017) Android application model of Suami SIAGA PLUS as an innovation
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in birth preparedness and complication readiness (BP/CR) intervention. Journal of Family and Reproductive Health, 11(1), 30-36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5664987/ Sood, S., Chandra, U., Palmer, A., & Molyneux, I. (2004) Measuring the effects of the SIAGA behaviour change campaign in Indonesia with population-based survey results. Retrieved: http://resources.jhpiego.org/system/files/resources/bci_indonesia.pdf Suandi, D., Williams, P., & Bhattacharya, S. (2019). Does involving male partners in antenatal care improve healthcare utilisation? Systematic review and meta-analysis of the published literature from
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https://doi.org/10.1093/inthealth/ihz073 The World Bank. (2017). Maternal mortality ratio (modeled estimate, per 100,00 live births). Retrieved from: https://data.worldbank.org/indicator/SH.STA.MMRT Tokhi, M., Comrie-Thomson, L., Davis, J., Portela, A., Chersich, M., & Luchters, S. (2018). Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. Plos One, https://doi.org/10.1371/journal.pone.0191620 United Nations Children's Fund. (2016). Maternal and Newborn Health Disparities. Retrieved from: https://data.unicef.org/wpcontent/uploads/country_profiles/Indonesia/country%20profile_IDN.pdf Wondemagegn, A. T., Alebel, A., Tesema C., & Abie, W. (2018). The effect of antenatal care followup on neonatal health outcomes: a systematic review and meta-analysis. Public Health Reviews, 39, 33. https://doi.org/10.1186/s40985-018-0110-y World Health Organisation. (2018). WHO recommendations on antenatal care for a positive pregnancy
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Appendix 1. Risk of bias assessment based on National Institute of Health (NIH) quality assessment
Item
Fazdria, et al
Study
Kurniati, et al
Puspita, et al
No
Rakhmawati and Indawati
Criteria 1
Was the research question or objective in this paper clearly stated?
Yes
No
Yes
Yes
2
Was the study population clearly specified and defined?
Yes
Yes
Yes
Yes
3
Was the participation rate of eligible persons at least 50%?
Yes
Yes
Yes
Yes
4
Were all the subjects selected or recruited from the same or similar
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
Yes
No
No
No
No
populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? 5
Was a sample size justification, power description, or variance and effect estimates provided?
6
For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
7
Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?
374
Appendix 1. (continued) 8
For exposures that can vary in amount or level, did the study
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)? 9
Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
10
Was the exposure(s) assessed more than once over time?
No
No
No
No
11
Were the outcome measures (dependent variables) clearly defined,
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
valid, reliable, and implemented consistently across all study participants? 12
Were the outcome assessors blinded to the exposure status of participants?
13
Was loss to follow-up after baseline 20% or less?
No
No
No
No
14
Were key potential confounding variables measured and adjusted
Yes
Yes
Yes
Yes
statistically for their impact on the relationship between exposure(s) and outcome(s)?
375
Benefits and Challenges of Synchronous Teleconsultations among Physicians to Improve Healthcare Services: A Systematic Review Rexel Kuatama1a, Anindita Agung Pradnya Savitri1, Helen Susanto1, Ghea Mangkuliguna1 1
Undergraduate Medical Program, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta 14440, Indonesia a
To whom correspondence should be addressed. Email: rexelkuatama@gmail.com
ABSTRACT Introduction: Healthcare workers have to face several challenges due to maldistribution, inadequacy of physician and COVID-19 pandemic. To tackle these issues, telemedicine (specifically teleconsultation) has been continuously researched as a potent solution. Teleconsultations have demonstrated advantages in clinical decision, education between physicians and cost-effectiveness. Objective: This review aims to illustrate the benefits and challenges of synchronous teleconsultations among physicians. Materials and Method: This systematic review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Literature search is carried out in electronic databases, such as PubMed, ScienceDirect, EBSCO and ProQuest. The outcomes of interest were the benefits and challenges on the use of synchronous teleconsultations. The quality of each study was assessed using Newcastle-Ottawa Scale (NOS). Key Findings: Fifteen studies were included in this review. Observed benefits of video conferences among physicians include change in diagnosis and treatment plan, avoidance of unnecessary referral and test, increased self perception of expertise and confidence, and possible cost savings. Most of the included studies reported technical problems such as audio problems, visuals problems, connection problems, and human errors. Conclusion: Synchronous teleconsultation can aid challenges faced by physicians and plays a role in improving health care services. Keywords: doctors; physicians; synchronous; systematic review; teleconsultation; videoconferencing
376
Benefits and Challenges of Synchronous Teleconsultations among Physicians to Improve Healthcare Services: A Systematic Review
Author: Rexel Kuatama Anindita Agung Pradnya Savitri Helen Susanto Ghea Mangkuliguna
School of Medicine and Health Sciences Atma Jaya Catholic University of Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia 2020
377
Introduction In recent years, healthcare workers in Indonesia have faced various problems. Disproportionate physicians distribution remains an issue, where the ratio of specialists per 100,000 people in Jakarta Province was 52.2:100,000, while Papua only has 3 specialists per 100,000 people. This leads to inadequacy of specialistic care and ineffective clinical decision making by general practitioners, notably in rural areas (Ministry of Health Republic of Indonesia, 2017). In addition, Coronavirus Disease 2019 (COVID-19) pandemic complicates direct meetings between physicians, specialists and patients. All of these combined proved that immediate solutions for these problems were crucial. Telemedicine is proposed as an effective strategy to aid the maldistribution and lack of physicians in remote areas and, while doing so, improve access between physician and patient. It started in the 1950s and has transformed significantly with overwhelming speed. Telemedicine can be accessed with numerous appliances and have various methods of interaction, including asynchronous teleconsultation (the practice does not involve face-to-face contact, such as messages, e-mails, etc) and synchronous teleconsultation (face-to-face contact using videoconferencing devices) (Bowman et al, 2003). Several studies consider synchronous teleconsultation as a potential solution to the disparity in healthcare, allowing the patients to get professional opinions from a distance and simplify access to healthcare (Bertani et al, 2012). The technology was also proved as a reliable, safe, and efficient way to diagnose and manage a patient (Chilelli et al, 2014). Furthermore, teleconsultation accommodates physicians in remote areas to seek expertâ&#x20AC;&#x2122;s view from specialists miles away, improving clinical decision making, facilitate education among physicians, and as a cost-effective answer to the pressing demands (Buvik et al, 2019; Paul et al, 2016; Potter et al, 2014) This review focuses on teleconsultation, specifically synchronous teleconsultation among physicians. The main purpose of this review was to gain insight into the advantages of synchronous teleconsultation among physicians, such as improving clinical decision, education, and saving cost. This review will also elaborate on the challenges in the video conference application. Materials and Method Study Registration and Methodology This systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria (Moher et al, 2009). Eligibility Criteria The following criteria was considered for studiesâ&#x20AC;&#x2122; eligibility: type of studies, population, intervention, comparison and outcome.
378
Type of Studies: Randomized-controlled trials, cohort, case-control and cross-sectional studies were included. Review, case report, case series, conference abstracts, book sections, commentaries/editorials were excluded. Articles with unavailable full-text, languages other than English and irrelevant topics were also omitted. Population: All general practitioners and specialists were included for this study. There was no limitation for age, gender, races and years of experience. Intervention: Studies evaluating the role of synchronous teleconsultations in any medical fields were included. Synchronous referred to the use of real-time videoconferencing between general practitioners and specialists. Included studies had to report teleconsultations intended either for diagnosis or treatment of patients. Telementoring that provides lectures or training and does not provide real life patient cases were excluded. Comparison: Comparators included the use of face-to-face consultations. Outcome: Outcomes of interest were the benefits and challenges on the use of synchronous (videoconferencing) teleconsultations. Benefits included improvement in clinical decision making, education and reduction of expenditures. Challenges included the limitations and/or difficulties in conducting synchronous teleconsultations. Data Sources and Search Literature search is carried out with multiple electronic databases, such as PubMed, ScienceDirect, EBSCO and ProQuest for articles published within the last 20 years. No language restriction is applied. The keywords used are presented in Table 1. Study Selection Articles are identified using the keywords described above. After removing duplicates using EndNote program, retrieved articles are screened based on their titles and abstracts. Thereafter, potentially eligible full-text articles are thoroughly assessed using the eligibility criteria described above. Any emerging discrepancies will be resolved by consensus among the review team. The planned procedure is illustrated in Figure 1. Data Extraction The following data is extracted from the included studies: (1) first author and publication year; (2) study design; (3) total teleconsultations; (4) stakeholders involved; (5) medical fields; (6) geographical aspect; and (7) video conferencing equipments
379
Quality Assessment Newcastle-Ottawa Scale (NOS) was used to assess the quality of included studies (Wells et al, 2000). The tool consisted of 3 domains: selection, comparability, and outcome. The study was rated either as “good” (3 or 4 stars in selection, 1 or 2 stars in comparability, and 2 or 3 stars in outcomes), “fair” (2 stars in selection, 1 or 2 stars in comparability, and 2 or 3 stars in outcomes) or “poor” (0 or 1 star(s) in selection, or 0 stars in comparability, or 0 or 1 star(s) in outcomes). Four researchers (RK, AAPS, HS, GM) independently evaluate the quality of each study with any discrepancies resolved through discussion. Data Synthesis If the majority of included studies had overlapping outcome measures, we planned to pool these data together in a meta-analysis. Odds Ratio (OR) or Risk Ratio (RR) with a confidence interval (CI) of 95% will be used in the determination of the benefits and challenges in the implementation of synchronous teleconsultations. OR or RR is considered significant if the value is not equal to 1 with p<0.05. Whether OR or RR will be used as a pooled effect is determined with sensitivity analysis which shows higher P value. Either Fixed Effect Model (FEM) or Random Effects Model (REM) will be chosen in light of the similarity of methodology between included studies. The combined effect size are plotted using a forest plot. Heterogeneity of included studies are assessed using χ² Test (Q Cochran Test) of homogeneity and I² measure. Publication bias is assessed using funnel plot. All statistical tests are done using Review Manager (RevMan) 5.3. Given the novelty of the topic and the heterogeneous nature of the outcome, it was not possible to calculate the pooled effect across studies. A narrative synthesis evaluating the benefits and challenges in the implementation of synchronous teleconsultations was performed instead. Findings of included studies are presented in a table, which includes the main characteristics of each study and the results in natural units. Results & Discussion Search Results Search in the electronic database yielded 2572 studies. Screening through titles and abstracts found 1629 articles, 31 of which met the inclusion criteria. A total of 15 studies were included in the systematic review at last. Search flowchart and selection methods used this systematic review was summarized in Figure 1. Characteristics of Included Studies Of the 15 studies included, 6 are prospective while 9 are retrospective studies. Twelve studies reported videoconferencing between general practitioners (GP) and specialists. Five studies not only provided videoconferencing among GP but also between GP and patients. The rest of the studies
380
reported discussion among specialists. Most videoconferencing were related to one specific field (dermatology (1), surgery (1), pediatric (2), stroke (3), neurology (1), pediatric orthopedic (1), physiotherapy (1), cardiology (1), HIV (1)) with the exception of 5 studies that include multiple fields. Two studies were done in multiple countries, while the rest was conducted within a country. Almost all studies derived data from surveys or questionnaires of participating physicians. The videoconferencing equipment varied across studies. Gathered data from 4,071 subjects were analyzed together in this study. The majority of included studies have shown good quality in selection, comparability and outcome domains. Two studies were considered to be fair in quality because they neither represented the actual population nor used a non-exposed cohort as control. Five studies were judged to be poor in quality because they did not report the duration or adequacy of participants’ follow-up. Findings in this section is summarized in Table 2. Benefits of Synchronous (Videoconferencing) Teleconsultations among Physicians Teleconsultation allows remote physicians to connect with specialists to seek medical expertise. Most teleconsultation networks are a ‘hub and spoke’ model, where tertiary health facilities act as a hub for multiple rural health facilities (spokes). The teleconsultation protocol varies, yet the common concept is illustrated as follows: when a patient with unclear clinical problems present, remote physicians could request a second opinion. Requesting physicians will then provide information regarding initial assessment to specialists or clinical advice. This can be done in two types of interactions: ‘store and forward’ (asynchronous) and ‘videoconferencing’ (synchronous). In store and forward, patients data are collected and sent to secondary health facilities for diagnosis or clinical advice. Such a method allows more flexibility in schedule and possible lower implementation cost. On the other hand, video conferencing’s real time interaction allows for immediate clinical decisions and more thorough discussions. Videoconferencing also allows the patient to be present in case more data is needed. Despite its common use in teleconsultation and after extensive research, there is no systematic review that analyzes video conferencing use in teleconsultation among physicians. Based on surveys of participating physicians, telemedicine was well perceived in all studies. The benefits reported from the included studies can be further categorized into clinical decision, education, and cost saving (Table 3). In clinical decisions, one of the most important benefits reported are changes in diagnosis or treatment plan for patients. Since hubs are mostly specialists or secondary health facilities with higher expertise, these changes might translate to reduction of misdiagnosis and inaccurate treatment plans. A study conducted by Smith et al reported change of diagnosis in 23% (7 % complete change and 16% partial change) patients as well as change of treatment plan in 78% (11% complete change and 67% partial change) of patients (Smith et al, 2005). A study by Bynum et al, consultant dermatologists established diagnosis in 71% patients and changed diagnosis in 16% patients. The study also reported change of treatment plans in 89% patients (Bynum et al, 2011). In Norway,
381
telemedicine has also changed 71% of patients’ treatment plans. (Donnem et al, 2012) Similar results were seen in studies with larger sample sizes. A 2001 teleconsultation analysis in Taiwan reported change of diagnosis 15.78% (80/507) patients (Lin et al, 2001). In Italy, teleconsultation among specialists also resulted in modification of treatment plans in 77% (37/48) pediatric orthopedic patients (Bertani et al, 2012). Several other subjective outcomes also supported the benefit videoconference has on aiding clinical decisions especially for GP. In a study by Lin et al, a survey on 507 rural GP participating in the telemedicine program revealed that 95.3% (483/507) agree on the need for specialist advice for diagnosis (Lin et al, 2001). In a study by Sergeant et al, 48% (32/66) participants agree that videoconferences are “useful clinical supports” (Sergeant et al, 2004). Another study by Paiva et al also reported that 58% (52/90) general practitioners agree that video conferences provide support for diagnosis (Paiva et al, 2001). In one study by Aarnio et al, videoconference was reported to be more informative than conventional referral letters (Aarnio et al, 2000). This is to be expected as videoconferences allow live interaction compared to store and forward (letters). Real time teleconsultation is especially beneficial for management of acute stroke. In this case, initial assessments of possible stroke patients were done by a remote emergency physician. Patient cases were then consulted to neurologists along with supporting data such as imaging and lab results to determine treatment plan. Studies conducted by Amorim et al and Schwamm et al have shown increased use of recombinant tissue plasminogen activators (rtPAs) by emergency physicians after the establishment of telemedicine in remote hospitals (Amorim et al, 2013; Schwamm et al, 2004). One possible reason would be that clinical judgements from specialists in hub help remove hesitations. A clinical trial conducted by Meyer et al compared the impact of videoconference and telephone consultation (asynchronous) towards correct use of rtPA. Video conference led to more correct treatment of rtPA compared to telephone based consult (98% for telemedicine compared to 82% telephone). Secondary outcomes such as 90 days outcome, 90 days mRS, and mortality rates were not significant between the two groups (Meyer et al, 2008). This findings was also supported by a survey done from Swhamm et al studies that show most neurologists and emergency physicians think that telephone consult is “not equivalent” (Schwamm et al, 2004). Unlike telephone consultation, videoconferencing allows for imaging and laboratory tests to be discussed directly. In videoconference, patients were also able to be indirectly assessed by neurologists as seen in study by Meyer et al where unclear NIHSS were reevaluated via videoconference (Meyer et al, 2008). Neither of these 3 studies has shown significant reduction of door to rtPA time in telemedicine compared to telephone or usual practice. Therefore, video conferencing proved to be an excellent system to improve stroke care management. Aside from stroke, one study by Veasey et al also reported earlier intervention in cardiology patients. Telemedicine among cardiologist and cardiac surgeon was found to reduce waiting times for coronary artery bypass graft procedure (non-video conferencing (140.9±71.8 days), video conferencing (99.4±56.6 days) (Veasey et al, 2011).
382
Another reported benefit was the reduction of referral. Unnecessary referral puts huge burden on patients time and cost as some are required to travel long distances. Furthermore, the increased effectiveness of the healthcare system might save cost in the long run. Avoiding referral promotes financial viability of local health facilities and prevents unnecessary expenditure of national healthcare coverage. In a study by Albritton et al, a neonatal telehealth system on eight hospitals resulted in significant reduction of referral rates (0.70 per facility-month) and a total of 67.2 less referral in one year (Albritton et al, 2018). In another study by Paiva et al, avoidance of referral to a specialist were seen in 46% (41/90) patients (Paiva et al, 2001). In a study by Donnem et al, the usage of video conference consultation among the cancer patients will likely keep 82% (116/141) of them stay at the same place. Transfer to tertiary level hospital was estimated to be reduced from 13% to 6 % by the use of video conferences (Donnem et al, 2012). Teleconsultation also provides a learning platform for physicians due to continuous medical discussion with specialists. In the end, increased medical expertise and confidence is expected from requesting physicians. In order to maximise learning experience, specialists need to explain motives and workflow behind clinical decisions. (Paul et al, 2016) This is why video conferences might excel as it allows two ways discussion compared to store and forward. In a study by Aarnio et al, gp reported increased expertise in 72% (36/50) teleconsultation. In a study by Donnem et al, teleconsultation provides some kind of increase in confidence for adequate patient care in 96% of the session. (Donnem et al, 2012). Another study by Lin et al reported 97% of participating physicians benefit from medical advice. Outcomes measured in our studies were based on self perception measured by surveys. Though this might serve as evidence, objective measures are more favorable. Such measures would be achieved by comparing the level of participating physiciansâ&#x20AC;&#x2122; knowledge or expertise by the end of teleconsultation with baseline knowledge as reported in various telementoring projects. (Teixeira et al, 2018; Wood et al, 2018) Numerous studies have shown cost effectiveness of teleconsultation between physicians and patients. Teleconsultation among physicians might also save cost directly (avoiding unnecessary outpatient consultation and test) and indirectly (more accurate treatment plan). However, cost benefit analysis for teleconsultation among physicians are yet to be elucidated. Only two studies reported cost savings analysis. A pediatric teleconsultation service reported a total saving of $1,220,352 in one year when accounting air travel fees to referral sites (Albritton et al, 2018). Other indirect saving costs would be avoidance of unnecessary tests which is seen in 11 and 44% of cases (Paiva et al, 2001; Smith et al, 2001). Despite possible benefits of videoconferencing compared to store and forward methods, videoconference requires additional equipment, maintenance, and training. Therefore, a cost benefit analysis would be of great interest. Unfortunately, our review found no such studies. It is worth noting that each medical field might benefit from a different method. In stroke, teleconsultation using videoconferencing is preferred as it results in better clinical decision. However, recent studies have
383
shown that medical fields such as pathology and dermatology might achieve the same level of diagnostic accuracy through store and forward method (Brinker et al, 2018). Challenges of Synchronous (Videoconferencing) Teleconsultations among Physicians Teleconferencing could be a potential solution to deliver healthcare to patients in remote and rural areas across the world, although medical providers have expressed some concerns on its application. Most of the included studies reported technical problems such as audio problems, visuals problems, connection problems, and human errors (Table 4). In teleconsultations audio and visual quality are key factors to perform clinical assessment in order to conduct precise diagnosis and health management. Medical decisions cannot be made accurately if physicians have problems communicating either with their patient or fellow physicians. One of the causes of audio problems is temporary disconnection of phone calls due to power supply problems (Smith et al, 2004). Study conducted by Lin showed that most of the physicians in dermatology and psychiatry fields were complaining about satisfaction of the camera quality, low quality of the camera can reduce the quality of the delivered pictures and affecting clinical assessment results (Lin et al, 2001). Study by Donnem showed that “Extensive” technical problems happened in 2% (3) cases, because the camera was only working at the tertiary hospital; this means only the local providers at the communities saw the healthcare providers in tertiary health care but not vice versa. “Quite a bit” technical problems also found in 7% (10) of cases, because providers partly used telephone instead of videoconferencing sound (Donnem, 2012). In terms of human error, a study by Paiva revealed that some General Practitioners find it difficult to use the computer, only less than 10% were familiar with using it (Paiva et al, 2001). Furthermore, human error as one of the crucial factors affecting the effectiveness of applying equipment, study by Bynum reported that problems with equipment give moderate effects (7%) to the consultation session (Bynum et al, 2011). The success of teleconsultations was facilitated by establishing a definite protocol for collaboration among physicians and other important health professionals. Collaborative care model has become a necessity to build credibility and confidence for both patients and healthcare providers. Excellent relationships among personnel in a healthcare system could influence public perspective on the services they provided. This structure was very important to overcome the barriers of stigma, distance, and technology that might hinder patients’ receiving appropriate treatment (Springer et al, 2020). Technological barriers could be addressed through familiarization of videoconferencing equipment. Clinicians reported that they had already gotten used to utilizing videoconferences after using it for practices several times. In addition, establishing a protocol on what patients and/or providers should prepare as well as how to use the equipment could help ensuring teleconsultations went on smoothly (Donaghy et al, 2019). A study by Springer et al also stated that frustrations with technical challenges could be moderated by recognizing the benefits of teleconsultation services being offered to
384
the community. Medical practitioners were able to justify the limitations of the equipment because they felt that they had given appropriate services to those in remote areas who were unable to do so in normal situations (Springer et al, 2020). Strengths and Limitations The current study has several strengths. This is the first systematic review investigating the benefits and challenges of synchronous teleconsultations among physicians to deliver effective and efficient healthcare services. We specifically discussed the role of teleconsultations from physiciansâ&#x20AC;&#x2122; perspectives. Moreover, the majority of included studies had shown good quality in regards to selection, comparability and outcome. However, the current study has several limitations. First, a more generalized population is required for this systematic review to be representative of the worldwide population. Included studies mostly originate in America or Europe. Second, the majority of studies did not have a control group as a comparison. Third, the limited evidence available implies that this systematic review must be interpreted with caution. Conclusion and Recommendation Teleconferencing could be a potential solution to deliver healthcare to patients in remote and rural areas across the world. The implementation of synchronous teleconsultation among physicians have proven to bring medical expertise in remote areas, allow immediate response, reducing cost, allowing continuous learning among physicians, and improving the quality of primary health care. For future references, we recommend conducting an analytical study which compares videoconference and store-and-forward (in terms of effectiveness, efficacy, time savings, and cost benefit analysis) in various medical fields. Author Contributions RK: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing - original draft; Writing - review & editing; AAPS: Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing - original draft; HS: Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing - original draft; GM: Data Curation, Formal Analysis, Investigation, Methodology, Writing - original draft; Writing - review & editing. Declaration of Interest The authors declare that there are no competing interests in this study. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
385
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Appendices Table 1. Search Keywords Databases PubMed
Keywords ("remote
consultation"[MeSH
Terms]
OR
"teleconsultation"[Title/Abstract])
AND
"videoconferences"[Title/Abstract]
OR
"remote
Articles consultation"[Title/Abstract]
("videoconference"[Title/Abstract] "videoconferencing"[Title/Abstract])
OR
103
OR AND
("physician"[Title/Abstract] OR "physicians"[Title/Abstract] OR "doctor"[Title/Abstract] OR "doctors"[Title/Abstract]) ScienceDirect
("remote consultation" OR "teleconsultation") AND ("videoconference" OR "videoconferences"
319
OR "videoconferencing") AND ("physician" OR "physicians" OR "doctor" OR "doctors") ProQuest
("remote consultation" OR "teleconsultation") AND ("videoconference" OR "videoconferences"
1481
OR "videoconferencing") AND ("physician" OR "physicians" OR "doctor" OR "doctors") EBSCO
("remote consultation" OR "teleconsultation") AND ("videoconference" OR "videoconferences" OR "videoconferencing") AND ("physician" OR "physicians" OR "doctor" OR "doctors")
389
669
Table 2. Characteristics of Included Studies
First Author, Year
Study Design
Total Teleconsultations
Stakeholders Involved
Medical Fields
Geographical Aspect
Videoconferencing Equipment
Quality Assessment (NewCastle-Ottawa Scale) Selection
Comparability
Outcome
Total
Aarnio et al, 2000
Prospective
50
GP-Specialist GP-Patient
Surgery
Intracountry (Finland)
Videoconferencing system (Concorde 4500, PictureTel; Venue 2000, Picture Tel) using three ISDN lines (giving a bandwidth of 384 kbit/s); document camera (EV 450 AF, Elmo)
★★☆☆
★☆
★☆☆
4/9
Albritton et al, 2018
Retrospective
ND
GP-Specialist
Pediatric (neonatology)
Intracountry (USA)
ND
★★★☆
★★
★★★
8/9
Amorim et al, 2013
Retrospective
1669
GP-Specialist
Stroke
Intracountry (USA)
ND
★★★★
★☆
★★★
8/9
Bertani et al, 2012
Prospective
48
Specialist-Specialist
Pediatric orthopedics
Intercountry (France Djibouti)
ND
★★☆☆
★☆
★★★
6/9
Bynum, 2011
Prospective
454
GP-Specialist
Dermatology
Intracountry (USA)
Polycom View Stations (Polycom, Inc., Milpitas, CA, USA), Tandberg interactive video units (Tandberg, Lysaker, Norway), and ELMO-400 Document Cameras (ELMO, Plainview, NY, USA) Interactive compressed
★★★☆
★☆
★★★
7/9
390
video technology transmitted over T1 lines at 768 kbit/s bandwidth Demartines et al, 2000
Retrospective
40
Specialist-ResidentsTrainee
Surgery
Intercountry (Brussels, Belgium, France, Germany, Switzerland)
Using ISDN phone line at a rate of 384kb/s using the videoconferencing system Picturetel Venue 2000 (Picturetel Corp, Danvers, MA) in standard configuration.
★★★☆
★☆
★☆☆
5/9
Donnem et al, 2012
Prospective
106
GP-Specialist GP-Patient
Oncology
Intracountry (Norway)
ND
★★★☆
★☆
★★☆
6/9
Lin et al, 2001
Retrospective
1107
GP-Specialist Specialist-Patient
Radiology, internal medicine, surgery, dermatology, family medicine, gynecology and psychiatry
Intracountry (Taiwan)
Unified multimedia database developed by National Taiwan University Hospital, used two kinds of network (ATM and ISDN), data transfer (REFRESH and PREFETCH)
★★★☆
★☆
★★★
7/9
Meyer et al, 2008
Prospective
111
GP-Specialist Specialist-Patient
Stroke
Intracountry (USA)
ND
★★★★
★★
★★★
9/9
391
Oliveira et al, 2014
Retrospective
100
GP-Specialist Specialist-Patient
Diabetes, traumatology, orthopedics, general and pediatric surgery, respiratory medicine, urology,gastroenterology, clinical oncology, cardiology, dermatology, physical medicine and rehabilitation, pain, neurology, thyroid, and obesity
Intracountry (Portugal Alentejo)
Health Information Network (Rede Informa ´tica de Sau´ de), managed by the Ministry for Health
★★★★
★☆
★☆☆
6/9
Paiva et al, 2001
Prospective
90
GP-Specialist
Neurology
Intracountry (Portugal Lisbon)
NetMeeting (Microsoft) was used as the communication tool Access to the European Neurological Network was via PCs equipped with an ISDN card and connected by a single ISDN line (128 kbit/s)
★★★☆
★☆
★★☆
6/9
Sergeant et al, 2004
Retrospective
66
GP-Specialist
Radiology, Dermatology, Pediatric Psychiatry
Intracountry (Canada)
ND
★★☆☆
★☆
★☆☆
4/9
Schwamm et al, 2004
Retrospective
24
GP-Specialist
Stroke
Intracountry (USA)
ViewStation 512; PolyCom, Inc., Austin, TX) connected to 13’’– 21’’ televisions on each end. Data were transmitted at 256–384 kbps (full CIF) at 30 frames/s.
★★☆☆
★☆
★★★
6/9
Smith et al, 2005
Retrospective
86
GP-Specialist
Pediatric, Physiotherapy
Intracountry (Australia)
Robot contained a videoconference codec (PCS-11, Sony), a 51cm liquid crystal display (LCD) television (TV)
★★☆☆
★☆
★☆☆
4/9
392
monitor (TX-20LA1Q, Panasonic) and two battery packs (1 kVA, Powerware). The Ethernet output of the videoconferencing codec was connected to a wireless bridge (Aironet, Cisco) Veasey et al, 2011
Retrospective
120
Specialist-Specialist
Cardiology
Intracountry (UK)
LifestreamTM video conferencing system , over a secure standard hospital broadband (100 mb) internet link.
★★★★
Abbreviations: ATM: Asynchronous Transfer Mode; GP: General Practitioner; ISDN: Integrated Services Digital Network; ND: No Data
393
★★
★★★
9/9
Table 3. Benefits of Synchronous Teleconsultations Author, Year Aarnio et al, 2000
Clinical Decision Making
Reduction in referral
Perception on video conferencing compared to usual practice 52% (26/50) of the surgeon and 84% (n=42/50) of the GP agreed that their interaction from video conference gave more information than the usual referral letter
Albritton et al, 2018
Education
Cost Analysis
Others
Increased expertise In 72% (36/50) session, GPs agree that there is an increase in ability to treat the same kind of patients Reduction in referral Telehealth consultation was associated with a significant reduction in transfers (0.70 per facility-moth)
Estimation based on average travel fees, the program was associated with a savings of $1,220,352 per year
Telehealth consultation was associated with 67.2 fewer transfers per year Amorim et al, 2013
More accurate treatment for patient Telestroke implementation was associated with the increased rate of thrombolytic use in remote hospitals (113 patients post-telemedicine, p=.70)
Bertani et al, 2012
Change in diagnosis Advice from expert modified the management in 37 (77%) (n=37/48) teleconsultations
Bynum, 2011 (VC)
Change in diagnosis
Specialist perception
394
Dermatologist significantly more likely to establish a diagnosis (p < 0.01) (71%)
93% specialist agree that use the telemedicine system improve patients access to care
Dermatologist significantly more likely to change the diagnosis (p = 0.005) (16%) Change in treatment Plan Dermatologist specialist significantly more likely to establish a treatment plan (p = o.03) (89%)
Demartines, 2000
Categorization of clinical advice from specialist Expert opinions were defined as constructive in 40% of cases (n=16/40), negative in 7.5% (n=3/40), and neutral in 45% (n=18/40). Opinions were not offered in the remaining 7.5% of cases (n=3/40).
Donnem et al, 2012
Change in treatment: ● None 17 (13%) ● Change in medication 51 (38%) ● Chemotherapy 27 (20%) ● Surgery 7 (5%) ● Radiotherapy 10 (8%) ● Other (none of the above-mentioned alternatives) 46 (34%) Improve patient care: ● Quite a bit 53 (38%) ● Very much 65 (47%)
Reduction in referral After teleconsultation, the number of patients who: ● stayed at the same place 116 (82%) ● transferred to a local nursing home 1 (1%) ● transferred to a primary hospital 4 (3%) ● transferred to the Department of Oncology/tertiary hospital 9 (6%) ● others 9 (6%) Without teleconsultation, the number
395
Lin et al, 2001
Confidence in giving adequate care for patients: ● Quite a bit 44 (31%) ● Very much 92 (65%)
of patients who: ● stayed at the same place 99 (70%) ● transferred to a local nursing home 6 (4%) ● transferred to a primary hospital 4 (3%) ● transferred to the Department of Oncology/tertiary hospital 18 (13%) ● others 1 (1%)
Change in diagnosis: 15.78% (n = 80/507) of patients’ cases were altered in accordance with advice from the medical center.
Reduction in referral The number of patients transferred to the medical center was reduced from 24 to 8 cases.
Perception of GP In survey, most rural-site GP 95.3% (483/507) agree that they need specialists’ advice to help with the diagnosis.
Learning experience In a survey, most of the rural site GP (97%) (488/503) thought that they did benefit from advanced medical experience and knowledge from specialists available through the telemedicine system.
GP satisfaction 98.4% (501/507) gp were satisfied with the judgements concerning patients Specialist satisfaction In survey, most (91.6%, n=644/705) specialists were satisfied with the results of telemedicine Number of miscommunication during video conference The error rate caused by misunderstandings during videoconference was only 0.9% (6/705).
Meyer et al, 2008
Increased accuracy compared to telephone consult Correct treatment decisions were made much more often using telemedicine than telephone
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consult (98% telemedicine, 82% telephone; OR 10.9, 95%CI 2.7-44.6; p=0.0009). Oliviera et al, 2014
Reduction in referral In interview from 12 physician, reduction of unnecessary were mentioned as perceived benefits
Paiva et al, 2001
Perception of GP In a survey, 58% GP agree that the system provide support in reaching a diagnosis (52/90)
Sergeant et al, 2004
Perception of GP Primary care providers (32/66) agree that teleconsultations (radiology, dermatology, pediatric psychiatry) are very useful clinical supports (Likert scale, mean±SD = 4.00±0.8)
Schwamm et al, 2004
More accurate intervention for patient Increase use of rtPA for ischemic stroke patient after telemedicine support was established ( o → 6)
Reduction in referral Avoidance of referral to a specialist 46% (41/90)
Learning experience In interview from 12 gp, continued medical education were mentioned as perceived benefits
Participants perception 11/12 participant would recommend use of telemedicine to colleagues 20/30 and 7/30 participant were ‘very satisfied’ and ‘somewhat satisfied with telemedicine service Avoidance of unnecessary test Avoidance of unnecessary laboratory test was reported in 44% (40/90) patients
Participants’ perception In every consultation survey,, all emergency physicians agreed that the telemedicine interaction improved patient care. In the survey, both neurologists and emergency physicians frequently
397
believed that telephone consultation alone would not have been equivalent to managing patients. Smith et al, 2004
Change in diagnosis completely 7% (3/45), partially 16% (7/45), and remained unchanged 77% (35/45)
Change in local physician’s way of thinking: ● History taking: completely 0% (0/45), partially 11% (5/45), remained unchanged 89% (40/45) ● Examination: completely 0% (0/45), partially 16% (7/45), remained unchanged 84% (38/45) ● New protocols: completely 2% (1/45), partially 22% (10/45), remained unchanged 76% (34/45)
Change in clinical management: completely 11% (5/45), partially 67% (30/45), remained unchanged 22% (10/45).
Veasey et al, 2011
Avoidance of unnecessary test Cancellation of planned tests or investigation 11% (5/45)
Participants’ perception In survey, all staff agree that telepediatric service improved access and delivery of specialist services to rural and remote areas, facilitated communication between regional and metropolitan health professionals (9/9)
Earlier treatment for patient ● Significant difference in waiting times for CABG procedure between nonvideoconferencing (140.9±71.8 days) and videoconferencing (99.4±56.6 days) groups.
Abbreviations: CABG: Coronary Artery Bypass Grafting; GP: General Practitioner; PrEP: Pre-exposure Prophylaxis; rtPA: recombinant tissue plasminogen activator
398
Table 4. Challenges in Synchronous Teleconsultations First Author, Year
Technical
Self Perception
Aarnio et al, 2000
Problems with ISDN connections
Bynum et al, 2011
Problems with audio (2%), video (4%), peripheral equipment (1%), software (0.20%), human errors (0.60%), others (2%)
Donnem et al, 2012
Technical problems were categorized as: “Extensive” in 3 (2%) cases because camera was only working at the tertiary hospital (local providers at the communities saw the healthcare providers at the tertiary hospital but not vice versa) “Quite a bit” in 10 (7%) cases because providers partly used telephone instead of videoconferencing sound.
Lin et al, 2001
Dissatisfaction with camera quality
Meyer et al, 2008
Technical problem were seen in 12 teleconsultations (technical failure (1,) radiology interface problems (6), audio difficulties (3). camera control failure (1) and delay in obtaining faxed consent (1))
Oliveria et al, 2014 Paiva et al, 2001
Face-to-face consultations more preferred (1/12), unable to physically touch the patients (6/12) Difficulty in using computers. Less than 10% GP use it, but those that participate use it regularly
Sargeant et al, 2004
● Face-to-face consultations more preferred ● Inadequate promotion of telemedicine ● Reduced funding for more basic health services
Schwamm et al, 2004
Failure to transmit CT-scan images (4.2%)
Smith et al, 2004
Temporary disconnection of the call related to power supply problem
399
Figure 1. PRISMA Flow Diagram
400
Repurposing Virtual reality as a Visual Communication Tool Compared to Conventional Physical Therapy in Improving the Balance of Parkinsonâ&#x20AC;&#x2122;s Disease Patients: A Systematic Review Robby Soetedjo, Rivaldi Ruby, Erlangga Saputra Arifin, Teresa Averina B. Tiono AMSA-UAJ
Abstract Introduction: Parkinson's Disease (PD) has a globally high prevalence. Each year, 45% to 68% of PD patients will experience falls, leading to severe complications. Conventional physical therapy modalities have been used as interventions, but there is a growing interest in utilizing virtual reality (VR). VR enables communication and delivery of continuous rehabilitation therapy despite travel and physical restrictions in this pandemic era. Objectives: To summarize evidence comparing the use of VR as visual communication tools and conventional physical therapy in improving the balance of PD patients. Method: Systematic review was conducted with the PRISMA statement guideline to identify VR effectiveness compared with conventional physical therapy. A literature search was done using PubMed, ProQuest, ScienceDirect, and EBSCO with "Virtual Reality," "Physical Therapy," and "Parkinson's" as the main keywords. Cochrane RoB tool 2.0 was utilized in the quality assessment of the studies. Result and Discussion: Search strategy identified 546 studies. Five relevant full-text articles met our inclusion criteria. Overall, studies had a low risk of bias. Non-immersive VR than conventional physical therapy yielded statistically significant results across studies (p<0.005). Immersive VR also showed promising results in each study with an overall significant p<0.04. Conclusion: Quantitatively, each study concluded significant results in VR physical therapy. However, in the authors' qualitative assessment, the difference between VR and conventional physical therapy is minor. Both interventions can be utilized accordingly, and visual communication through VR can serve as an alternative rehabilitation method for PD. Keywords: Virtual Reality, Physical Therapy, Parkinsonâ&#x20AC;&#x2122;s Disease, Visual Communication, Systematic Review
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Repurposing Virtual reality as a Visual Communication Tool Compared to Conventional Physical Therapy in Improving the Balance of Parkinsonâ&#x20AC;&#x2122;s Disease Patients: A Systematic Review
AUTHORS:
Robby Soetedjo Rivaldi Ruby Erlangga Saputra Arifin Teresa Averina B. Tiono
School of Medicine and Health Science Atma Jaya Catholic University of Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia 2020
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Introduction Parkinson's Disease (PD) is a neurodegenerative disorder that impairs certain dopaminergic neurons in the substantia nigra, which results in the disturbance of motor functions ("What is Parkinson's," 2020). It is ranked as the second most common neurodegenerative disorder after Alzheimerâ&#x20AC;&#x2122;s disease (Centers for Disease Control and Prevention [CDC], 2011). According to the Global Burden of Disease Study in 2016, PD prevalence was around 6.062.893, with the number of deaths reaching 211.296 (as cited in Dorsey et al., 2018). Balance is one of the most common issues when dealing with patients with PD. Studies showed that 45% to 68% of PD patients would fall each year (Pelicioni et al., 2019). Falls may cause fractures and may further lead to disabilities or even death (Kalilani et al., 2016). Physical problems in patients are still inevitable despite the various pharmacological and surgical interventions for PD (Tomlinson et al., 2013). Therefore, physiotherapy and physical therapy, such as exercise therapy, general physiotherapy, treadmill training, cueing, dance, and martial arts (National Institute for Health and Care Excellence UK, 2017), need to be implemented in the strategic management of PD. The therapies are utilized in the hope of maintaining the patient's best function in various aspects of motor ability (Tomlinson et al., 2013). However, one of its downsides is the need for inpatient therapy since it can be challenging in effectively managing the complex medical and rehabilitation needs of PD patients (Ellis et al., 2008). Along the way, new therapies have emerged to meet the diverse demands of PD patients. There is currently a growing interest in telerehabilitation, which is assessment, monitoring, intervention, supervision, education, consultation, and counseling of rehabilitation services utilizing communication technologies ("Telerehabilitation," 2019). Virtual reality (VR) is amongst the popular examples of telerehabilitation (August et al., 2005). As a part of telemedicine, VR offers similar advantages such as convenience, better assessments in outpatient settings ("Benefits of Telemedicine," 2020), and effectiveness in the distance, time, and cost (Boxer & Ellimoottil, 2019). The technologies can also provide more ease in integrating the therapy into daily life (Ekker et al., 2016). Furthermore, in this pandemic era, the use of VR can prevent the risk of transmitting and acquiring COVID-19 ("Benefits of Telemedicine," 2020), enabling communication and delivery of continuous rehabilitation therapy despite travel and physical restrictions. For this reason, the systematic review aims to summarize the evidence of using virtual reality physical therapy compared to conventional physical therapy for improving balance in PD patients.
Methodology The systematic review was conducted with Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement guideline (Moher et al., 2009) to identify VR's effectiveness compared with conventional physical therapy. The literature search was done using four databases:
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PubMed, ProQuest, ScienceDirect, and EBSCO with "Virtual Reality," "Physical Therapy," and "Parkinson's" as the main keywords. The last search date was 28 September 2020. No language and time restrictions were applied. The complete keywords are listed in Table 1 in the appendix. The result of the search was then imported to EndNote X9, and the duplicates were removed. All authors participated through each phase of the review independently by screening the titles and abstracts, assessing the full text for eligibility criteria, then including the relevant studies. The eligibility criteria used for this study include the study design, participants, and relevant interventions as well as outcomes according to PICO questions. Eligible studies met the following criteria: (1) The study design had to be a Randomized Control Trial (RCT); (2) The participants are diagnosed with Parkinson's Disease; (3) The interventions must be included VR (immersive or nonimmersive) and conventional physical therapy with a 12-week maximum duration; (4) Main outcomes assessment in dynamic balance and gait. Cochrane risk of bias tool 2.0 was utilized in the studies' quality assessment, which covers the following seven domains of risk. Included study quality will be classified as low, unclear, or high risk of bias (Sterne et al., 2019). Disagreements arising in the process of the evaluation were all resolved by discussion among the review team.
Result Search Results A literature search from electronic databases yielded 546 studies. After removing the duplicates, 498 studies remained. Screening through titles and abstracts excluded 488 studies with ten other studies that met the inclusion criteria. The result showed five studies that matched the criteria of inclusion. The search flowchart and selection method were summarized in Figure 1. Study Characteristics All studies were conducted with RCT as a study design with two comparable interventions, VR and conventional physical therapy. Overall studies had common inclusion criteria that consisted of patients diagnosed with Parkinson's Disease (PD) between 50-85 years of age. All patients have MMSE > 23 with no other systemic comorbid and Hoehn-Yahr stages between I-III. Detailed study characteristics were summarized in Table 2. Quality Assessment Quality assessment results based on the Cochrane risk of bias tool 2.0 (Sterne et al., 2019) showed an overall low risk of bias. Most studies have unclear risks in the allocation concealment domain because there were no further explanations about the allocation mechanism that the studies used. The unclear risk was also stated at Gandolfi et al. (2017) and Pazzaglia et al. (2019) studies in reporting
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bias; both studies did not use any reporting guidelines such as CONSORT, which is used in other included studies. The risk of bias summary and graph were summarized in Figure 2. Immersive VR Rehabilitation Improves Balance, Gait, and Motor Function Studies were done by Pazzaglia et al. (2019) using an immersive VR therapy enrolling 51 patients, in which it is randomized to 26 patients who underwent conventional rehabilitation and 25 patients underwent VR rehabilitation. Interventions will be undergone for six weeks with a 40-minute session three times per week. Patients diagnosed with the Gelb criteria as having PD were enrolled in the study accounting for other inclusion and exclusion criteria. The primary outcome measure was the changes in the standing balance using the Berg Balance Scale (BBS). Other outcomes, or as it is stated, secondary outcomes such as Dynamic Gait Index (DGI), Disabilities of the Arm, Shoulder, and Hand (DASH), and Physical and Mental composite score (SF-36) were also measured in the study. Results showed a significant increase in the BBS score for participants undergoing VR rehabilitation with a mean difference of 3.6 (95% CI 1.3 to 5.9; P = 0.003). In participants undergoing conventional rehabilitation, there is an insignificant increase in the BBS score with a mean difference of 0.8 (95% CI −1.3 to 2.9; P = 0.441). DGI scoring, which correlates with mobility and walking, also showed a significant increase in participants undergoing VR rehabilitation with a mean difference of 1.6 (95% CI 0.6 to 2.5; P = 0.003). However, there is still an insignificant result for participants undergoing conventional rehabilitation with a mean difference of −0.2 (95% CI −1.3 to 0.9; P = 0.776). Betweengroup differences in VR and conventional therapy were also measured and showed a significant result (P = 0.011). Feng et al. (2019) used similar kinds of intervention, which studies 24 patients distributed into two groups of intervention, experimental and conventional groups. After treatment, both groups showed significantly improved (P<0.05) BBS, Timed Up and Go Test (TUGT), and Functional Gait Assessment (FGA) scores. The experimental group also performed significantly better (P<0.05) after the treatment; however, the conventional group did not (P<0.05). Between the experimental group and control group, the experimental group yielded significantly better (P<0.05) BBS, TUGT, the third part of the Unified Parkinson's Disease Rating Scale test (UPRS3), and FGA scores than the control group. With these scores, we can conclude that the experimental group's balance, gait, and motor function improved relatively better than the control group. Non-immersive VR Rehabilitation Leads to Better Balance, Gait, and Mobility A different study conducted by Pompeu et al. (2012) using a non-immersive VR with 14 patients in two groups were assessed before and after training with 60 days follow-up. Dynamic balance was assessed using BBS, indicating the risk of falls if a score below 46. Repeated Measures-Analysis of Variance (RM-ANOVA) showed a significant effect of assessment on the BBS. Mean scores and
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standard errors for the BBS before training and at follow-up in the experimental and control groups showed a significant result in Post-hoc Tukey with p<0.005. A similar study using non-immersive VR done by Yang et al. (2016) involved 23 patients who were enrolled and randomized in the control and experimental group. Interventions were done in 6 weeks, with two weeks of follow up. Pretest, posttest, and follow-up result was assessed with the primary outcome, the BBS, resulting in a significant time main effect (p < 0.001) despite the group main effect (p = 0.893) and group time interaction (p = 0.786) yielded insignificant results. Respectively, In the secondary outcomes of walking function (DGI), a significant time main effect (DGI, p < 0.001) was found despite the group's main effect (DGI, p = 0.970) and group time interaction (DGI, p = 0.614) not being significant. Pairwise comparisons between pretest, posttest, and follow-up showed that BBS and DGI at posttest and follow- up were significantly higher than at pretest in the VR and control groups (BBS posttest > BBS pretest, p = 0.001; BBS follow-up > BBS pretest, p = 0.003; DGI posttest > DGI pretest, p < 0.001; and DGI follow-up > DGI pretest, p < 0.001). A more recent and updated study done by Gandolfi et al. (2017) which did a randomized controlled trial involving 76 outpatients diagnosed with PD divided into two groups of different interventions of in-home VR-based balance training using Nintendo Wii Fit system (TeleWii) and inclinic sensory integration balance training (SIBT). Both groups consisted of 38 patients that have been through computer-generated randomization and matched with inclusion and exclusion criteria, and both were given 21 individualized 50-minute treatment sessions, three days per week, for as long as seven weeks. Data on the patients' gait and balance measurements were taken before treatment (T0), after treatment (T1), and at a one-month follow-up (T2). The outcomes were assessed by an examiner to whom the treatment assignments were blinded and showed a significant between-group improvement in BBS scores (p=0.04). Other than that, no more between-group significance was found. There was a significant "Time*Group" interaction in the DGI scores (p = 0.004). The SIBT group reached the minimal clinically important difference (MCID) at T1, but at T2, there was only a 1.71 mean score difference in the DGI score. In comparison, the TeleWii group improvements were 0.85 and 0.93 at T1 and T2. Besides that, both groups showed overall significantly improved results in BBS, ABC (Activities Balance Confidence scale), 10-MWT (10-Meter Walking Test), DGI, and PDQ-8 scores (Parkinson's Disease Questionnaire).
Discussion Based on the evidence so far, this systematic review shows a promising result of VR as a feasible and valid alternative in PD patients' therapy. Various instruments were used to measure different outcomes. Two of the crucial instruments are BBS and DGI scoring, which measure balance and walking ability, respectively. Furthermore, one of the vital outcome data is the difference at the
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start and end of the study, called the within-group differences. Of all five studies, three showed a significant increase in both BBS and DGI for either VR or conventional therapy groups. One study by Feng et al. (2019) has the same result only for BBS scoring since they did not measure the DGI. A study done by Pazzaglia et al. (2019) summarized a significant increase in BBS and DGI for VR groups but not for conventional therapy groups. Another essential outcome data is the difference in the VR and conventional therapy groups called the between-group differences. Three out of five articles measured this outcome data and showed a significant difference between the VR and conventional therapy groups. Yang et al. (2016) study summarized a non-significant difference, while Pompeu et al. (2012) did not measure this outcome data. All five studies summarized somewhat similar results regardless of each study's strengths and limitations. Small sample sizes are one of the limitations, such as the one found in Feng et al. (2019) and Yang et al. (2016) studies. Moreover, the limitation of Yang et al. (2016) study is the short followup time. A study done by Gandolfi et al. (2017) has a large patient sample as its strength. However, the study struggles with its lack of instrumental evaluation to assess balance, postural, and the like. Pazzaglia et al. (2019) study did not collect follow-up data, which is essential to evaluate the improvement duration. The VR exercises proposed in this study were also not representative of daily activities. The absence of a control group became the limitation in Pompeu et al. (2012) study. The risk of bias in each study can also be regarded as one of the limitations. All studies were not double-blinded; therefore, poses a great risk. However, these problems do not influence the results based on the authors' judgment. The rationale of VR groups having better motor performance than conventional training groups in most studies is because the usage of VR technology provides better advantages in several ways. First, conventional training usually utilizes medical physiotherapists. Therefore, it is highly likely that the treatment requires one-on-one sessions. On the other hand, VR utilization, especially when home-based, makes it possible for one physiotherapist to supervise more than one patient simultaneously. Treatment using VR also facilitates more engagement because of its interactive features, compelling the patients to proactively participate, thus increasing motivation and leading to a better quality of life (Yang et al., 2016). Second, the process of sensory input involvement and information integration in the brain that leads to the patient's movement during a given task in VR programs is more applicable in real life than in conventional training. The close resemblance of the VR environment and task to real-world situations supports the hypothesis that VR treatment can produce better outcomes. Previous studies have proven that immersive VR treatment is better than non-immersive ones in improving the patient's memory tasks (Cousa et al., 2019; Ventura et al., 2019). However, no study has yet to summarize which treatment is better at improving PD patients' motor function. The authors hypothesize that the immersive VR treatment will bring a much greater outcome. The reason behind this hypothesis is based on the advantage of VR treatment in sensory stimulation, hence increasing motor learning better than the conventional group (Cano et al., 2018). This is connected to the
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characteristic of immersive VR treatment, which brings immersion of the environment to the user, thus better enhancing the balance, gait, and mobility of PD patients (Pazzaglia et al., 2020; Feng et al., 2019). We also consider that training duration and intensity might play an important part in the outcome results. Each study showed various rehabilitation programs with a somewhat similar duration ranging from 6 to 7 weeks, with each exercise lasting around 30 to 50 minutes per day. One study by Feng et al. (2019) conducted a rehabilitation program that lasted for around 12 weeks. The mean difference between the start and end of the study showed a much higher increase of 6.07 in Feng et al. (2019) study. The studies in which programs range from 6 to 7 weeks resulted in a mean difference ranging from the lowest 0.85 to the highest 4.09 for either BBS or DGI scoring. This concludes that the duration of the intervention can influence the outcomes of the patients. The authors also acknowledge that there are some limitations in this systematic review. The first and most important is that the inclusion and exclusion criteria used was still too broad. This resulted in data heterogeneity regarding the populations involved, specific VR programs used, and the like. Usage of immersive and non-immersive VR also poses a challenge, since it carries the risk of influencing the study outcomes. The application of the VR method in rehabilitation is currently extensively studied not only in PD but also in stroke and cerebral palsy (Laver et al., 2017; Ravi et al., 2017). Promising results can be clearly drawn from these few articles. However, larger sample size and a longer follow-up time can be considered for future studies. Regardless of all that, the VR method can be helpful as a long-range treatment that requires no physical interaction, and that is as effective as conventional training or even has the potential to yield a better outcome.
Conclusion This systematic review revealed that each study concluded significant results in using VR physical therapy in quantitative settings. However, in the authors' qualitative assessment, both VR and conventional or home-based physical therapy only showed slightly different effects. Both interventions can be utilized in various ways depending on the situation and the needs. Visual communication through VR can serve as an alternative rehabilitation method for the therapy of Parkinson's Disease.
Recommendation Future development in visual communication technology for both treatment and rehabilitation will be beneficial for advances and comprehensive management. Moreover, we recommend extensive VR implementation research to be done in idiopathic or secondary PD.
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Conflict of Interest The authors declare that there are no competing interests in this study.
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Multicenter, Single-Blind, Randomized, Controlled Trial [Research Article]. BioMed Research International; Hindawi. https://doi.org/10.1155/2017/7962826 Genetics, coffee consumption, and Parkinson’s disease | CDC. (2011). Retrieved October 20, 2020, from https://www.cdc.gov/genomics/hugenet/casestudy/parkinson/parkcoffee_view.htm Kalilani, L., Asgharnejad, M., Palokangas, T., & Durgin, T. (2016). Comparing the Incidence of Falls/Fractures in Parkinson’s Disease Patients in the US Population. PLoS ONE, 11(9). https://doi.org/10.1371/journal.pone.0161689 Laver, K. E., Lange, B., George, S., Deutsch, J. E., Saposnik, G., & Crotty, M. (2017). Virtual reality for stroke rehabilitation. The Cochrane Database of Systematic Reviews, 11, CD008349. https://doi.org/10.1002/14651858.CD008349.pub4 Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, T. P. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097 Negro Cousa, E., Brivio, E., Serino, S., Heboyan, V., Riva, G., & de Leo, G. (2019). New Frontiers for Cognitive Assessment: An Exploratory Study of the Potentiality of 360° Technologies for Memory Evaluation. Cyberpsychology, Behavior, and Social Networking, 22(1), 76–81. https://doi.org/10.1089/cyber.2017.0720 Non-pharmacological management of motor and non-motor symptoms. (2017). In Parkinson’s disease in adults: Diagnosis and management. National Institute for Health and Care Excellence (UK). https://www.ncbi.nlm.nih.gov/books/NBK535845/ Pazzaglia, C., Imbimbo, I., Tranchita, E., Minganti, C., Ricciardi, D., Monaco, R. L., Parisi, A., & Padua, L. (2020). Comparison of virtual reality rehabilitation and conventional rehabilitation in Parkinson’s disease: A randomised controlled trial. Physiotherapy, 106, 36–42. https://doi.org/10.1016/j.physio.2019.12.007 Pelicioni, P. H. S., Menant, J. C., Latt, M. D., & Lord, S. R. (2019). Falls in Parkinson’s Disease Subtypes: Risk Factors, Locations and Circumstances. International Journal of Environmental Research and Public Health, 16(12). https://doi.org/10.3390/ijerph16122216 Pompeu, J. E., Mendes, F. A. dos S., Silva, K. G. da, Lobo, A. M., Oliveira, T. de P., Zomignani, A. P., & Piemonte, M. E. P. (2012). Effect of Nintendo WiiTM-based motor and cognitive training on activities of daily living in patients with Parkinson’s disease: A randomised clinical trial. Physiotherapy, 98(3), 196–204. https://doi.org/10.1016/j.physio.2012.06.004 Ravi, D. K., Kumar, N., & Singhi, P. (2017). Effectiveness of virtual reality rehabilitation for children and adolescents with cerebral palsy: An updated evidence-based systematic review. Physiotherapy, 103(3), 245–258. https://doi.org/10.1016/j.physio.2016.08.004 Sterne, J. A. C., Savović, J., Page, M. J., Elbers, R. G., Blencowe, N. S., Boutron, I., Cates, C. J., Cheng, H.-Y., Corbett, M. S., Eldridge, S. M., Emberson, J. R., Hernán, M. A., Hopewell, S., Hróbjartsson, A., Junqueira, D. R., Jüni, P., Kirkham, J. J., Lasserson, T., Li, T., … Higgins, J.
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P. T. (2019). RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ, 366. https://doi.org/10.1136/bmj.l4898 Telerehabilitation—Department of Communication Sciences and Disorders. (2019, October). https://csd.wp.uncg.edu/shc-test/telerehabilitation/ Tomlinson, C., Patel, S., Meek, C., Herd, C., Clarke, C., Stowe, R., Shah, L., Sackley, C. M., Deane, K. H. O., Wheatley, K., & Ives, N. (2013). Physiotherapy for treatment of Parkinson’s disease. https://doi.org/10.1002/14651858.CD002817.pub4 Ventura, S., Brivio, E., Riva, G., & Baños, R. M. (2019). Immersive Versus Non-immersive Experience: Exploring the Feasibility of Memory Assessment Through 360° Technology. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.02509 What Is Parkinson’s? (2020). Parkinson’s Foundation. Retrieved October 20, 2020, from https://www.parkinson.org/understanding-parkinsons/what-is-parkinsons Yang, W. C., Wang, H. K., Wu, R. M., Lo, C. S., & Lin, K. H. (2016). Home-based virtual reality balance training and conventional balance training in Parkinson’s disease: A randomized controlled trial. Journal of the Formosan Medical Association, 115(9), 734–743. https://doi.org/10.1016/j.jfma.2015.07.012
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APPENDIX Table 1. Search Keywords Databases
Keywords
Articles
PubMed
((((((((Virtual reality[MeSH Terms]) OR (virtual reality[Title/Abstract])) OR (reality, virtual[Title/Abstract])) OR (virtual reality, instructional[Title/Abstract])) OR (instructional virtual reality[Title/Abstract])) OR (instructional virtual realities[Title/Abstract])) OR (virtual realities, instructional[Title/Abstract])) AND (((((((((Physiotherapy[MeSH Terms]) OR (physiotherapy[Title/Abstract])) OR (physiotherapies[Title/Abstract])) OR (Physical Therapy Modalities[Title/Abstract])) OR (Modalities, Physical Therapy[Title/Abstract])) OR (Modality, Physical Therapy[Title/Abstract])) OR (Physical Therapy Modality[Title/Abstract])) OR (Neurological Physiotherapy[Title/Abstract])) OR (Neurophysiotherapy[Title/Abstract]))) AND (((((((((Parkinson's disease[MeSH Terms]) OR (Parkinson's disease[Title/Abstract])) OR (Parkinson disease[Title/Abstract])) OR (Idiopathic Parkinson's disease[Title/Abstract])) OR (Lewy Body Parkinson's disease[Title/Abstract])) OR (Parkinson's disease, idiopathic[Title/Abstract])) OR (Parkinson's disease, lewy body[Title/Abstract])) OR (Idiopathic Parkinson disease[Title/Abstract])) OR (Lewy Body Parkinson disease[Title/Abstract]))
46
ProQuest
(ti(virtual reality OR virtual reality, instructional OR instructional virtual reality OR instructional virtual realities OR virtual realities, instructional) OR ab(virtual reality OR virtual reality, instructional OR instructional virtual reality OR instructional virtual realities OR virtual realities, instructional)) AND (ti(physiotherapy OR physiotherapies OR Physical Therapy Modalities OR Modalities, Physical Therapy OR Modality, Physical Therapy OR Physical Therapy Modality OR Neurological Physiotherapy OR Neurophysiotherapy) OR ab(physiotherapy OR physiotherapies OR Physical Therapy Modalities OR Modalities, Physical Therapy OR Modality, Physical Therapy OR Physical Therapy Modality OR Neurological Physiotherapy OR Neurophysiotherapy)) AND (ti(Parkinson's disease OR Parkinson disease OR Idiopathic
7
413
Parkinson's disease OR Lewy Body Parkinson's disease OR Parkinson's disease, idiopathic OR Parkinson's disease, lewy body OR Idiopathic Parkinson disease OR Lewy Body Parkinson disease)OR ab(Parkinson's disease OR Parkinson disease OR Idiopathic Parkinson's disease OR Lewy Body Parkinson's disease OR Parkinson's disease, idiopathic OR Parkinson's disease, lewy body OR Idiopathic Parkinson disease OR Lewy Body Parkinson disease))
ScienceDirect
(virtual reality OR instructional virtual reality) AND (physiotherapy OR physiotherapies OR Physical Therapy Modality OR Neurophysiotherapy) AND (Parkinson's disease OR Idiopathic Parkinson's disease OR Lewy Body Parkinson's disease)
EBSCO
( AB ( virtual reality OR virtual reality, instructional OR 15 instructional virtual reality OR instructional virtual realities OR virtual realities, instructional ) OR TI ( virtual reality OR virtual reality, instructional OR instructional virtual reality OR instructional virtual realities OR virtual realities, instructional ) ) AND ( AB ( Parkinson's disease OR Parkinson disease OR Idiopathic Parkinson's disease OR Lewy Body Parkinson's disease OR Parkinson's disease, idiopathic OR Parkinson's disease, lewy body OR Idiopathic Parkinson disease OR Lewy Body Parkinson disease ) OR TI ( Parkinson's disease OR Parkinson disease OR Idiopathic Parkinson's disease OR Lewy Body Parkinson's disease OR Parkinson's disease, idiopathic OR Parkinson's disease, lewy body OR Idiopathic Parkinson disease OR Lewy Body Parkinson disease ) ) AND ( TI ( physiotherapy OR physiotherapies OR Physical Therapy Modalities OR Modalities, Physical Therapy OR Modality, Physical Therapy OR Physical Therapy Modality OR Neurological Physiotherapy OR Neurophysiotherapy ) OR AB ( physiotherapy OR physiotherapies OR Physical Therapy Modalities OR Modalities, Physical Therapy OR Modality, Physical Therapy OR Physical Therapy Modality OR Neurological Physiotherapy OR Neurophysiotherapy ) )
414
478
Fig 1. PRISMA flow diagram of the identification and selection of studies included in the analysis
415
Fig 2. Risk of bias summary: review authorsâ&#x20AC;&#x2122; judgements about each risk of bias item for each included study
416
Table 2. Characteristics of the Included Studies Author
Feng 2019
Study Design
Randomized Controlled Trial
Inclusion Criteria
-Improved Hoehn-Yahr classification grade 2.5-4, in which there is balance dysfunction but independent walking -age 50 to 70 years old
Gandol fi 2017
Randomized Controlled Trial
Age >18 years Modified Hoehn and Yahr 2,5 - 3 Stable medication usage in the previous month, ability to perform postural transfer and maintain upright standing posture for at least 10 minutes. Presence of a caregiver.
Exclusion Criteria
Sample Intervention s
-Other causes of tremor, such as hereditary ataxia and cerebellar or vestibular lesions; -bone and joint diseases or serious diseases affecting organ function; -visual or hearing disorders -unable to cooperate with the study.
N=28
Cardiovascular , orthopedic, and otovestibular disorders, visual or other neurological conditions that could interfere with balance. Severe dyskinesias or on-off fluctuations. MMSE score <24 / 30. Severe depression as measured on the GDS.
N=70
Conventi onal
VR
N=14
N=14
-Warm-up 5 minutes -Balance 10 minutes -Physical condition 10 minutes Coordinati on 10 minutes -Cooldown 10 minutes
-Warm-up 5 minutes -Hands and feet touch the ball 10 minutes -Hard boating 10 minutes -Take the maze 10 minutes -Cooldown 10 minutes
N= 36
N= 34
Warm up
Warm up
Static and dynamic balance exercises under different sensory conditions (free vision, blindfolded , wearing a visualconflict dome, firm/compl iant surfaces, neck extensions) : 4 selfstabilizatio n, 4 external destabilizat ion, 2 combined selfdestabilizat ion and
10 games selected according to the patientâ&#x20AC;&#x2122;s clinical condition and improveme nt
417
Duration
Outcome s and measure ment tools
Result
12 weeks
BBS, TUGT, UPDRS3, and FGA
Significantly improved BBS , TUGT, and FGA scores in both groups after treatment. The experimental groupâ&#x20AC;&#x2122;s UPDRS3 significantly increased after treatment. Experimental group yield significantly better BBS, TUGT, UPDRS3, and FGA score than conventional group
7 weeks
BBS, DGI, ABC, 10MWT, PDQ-8
BBS improved significantly between the two groups (p = 0.04). There is a significant Time*Group interaction in the DGI scores (p = 0.04). The SIBT group reached the MCID at T1 (after treatment), but at T2 (1-month follow-up) there was only a 1.71 mean score difference. Meanwhile the TeleWii group showed improvements above MCID at both T1 and T2. ABC, 10-MWT, DGI and PDQ-8 were significantly improved in both groups, but there were no significant group differences.
external destabilizat ion exercises. Each exercise was repeated 510 times for 5 minutes, depending on the patient’s capabilities .
Pazzagl Randomized ia 2019 Controlled Trial
-
-
Pompe u 2012
Randomized Controlled Trial
Ability to perform rehabilitation program withlow risk of falling Ability to perform motor rehabilitation independently MMSE >25 No changes in drug therapy for PD during rehabilitation
- Diagnosis of idiopathic Parkinson’s disease treated with levodopa - Age 60-85 years - Hoehn-Yahr stages I-II
Severe hearing loss and/or visual defect Comorbidities resulting in impossible to perform rehabilitation (postural hypertension, heart disease, stroke)
N/A
N=51
N=14
N=26
N=25
Convention al rehabilitati on was arranged according to KNGF guidelines for physiothera py in PD patients. There are three sessions as follows: 1. Warm up phase: passive mobilizati on 2. Active phase: exercise, balance and walking training 3. Cooldown phase: seated exercise (mobilizat ion and respirator y)
Exercises using VR consisted of several sessions with different tasks. Patients are firstly placed in the center of the room and were asked to perform the tasks given. Each task/exerci se was performed for 4 minutes followed by 1 minute of rest.
Global exercises: 10 minutes of warming, stretching, and active exercises, 10 minutes
Wii fit training for the experiment al group playing 10 games. It composed 14
418
6 weeks
Primary outcome: BBS
2 main outcomes are balance (BBS) and walking (DGI) between pre and post intervention.
Secondary outcome: DGI, BBS score: DASH, SF- VR mean 36 difference of 3.6 (Physical (95% CI 1.3 to and Mental 5.9; P = 0.003) composite Conventional score) mean difference of 0.8 (95% CI −1.3 to 2.9; P = 0.441) -
-
DGI score: VR mean difference of 1.6 (95% CI 0.6 to 2.5; P = 0.003) Conventional mean difference of −0.2 (95% CI −1.3 to 0.9; P = 0.776) A between-group differences also showed significant results (P = 0.011).
7 weeks
Outcomes to measures:A DL, balance and gait BBS: DGI, TUG,
Mean scores and standard errors for the BBS before training and at follow-up in the experimental and control groups
- Good visual and auditory acuity - 5-15 years of education - no other neurological or orthopedic diseases - MMSE >23 - GDS >6
Yang 2016
Randomized Controlled Trial
- age 55-85 years - MMSE score >24 - Hoehn-Yahr Stages II-III - Not engaged in balance or gait training in the past 6 months - No untreated medical conditions that might affect balance and walking function
- Untreated depression or underlying significant visual/auditory impairments
N=24 Lost to follow up =3
of resistance exercises for limbs, 10 minutes of exercises in diagonal patterns for trunk, neck, and limbs
sessions, each lasting 30 minutes.
Practice the static posture maintainin g (10minute block) and dynamic weight shifting (2 x 10minute blocks)
Practice the static posture maintainin g (10minute block) and dynamic weight shifting (2 x 10minute blocks). Indoor and outdoor tasks in VR simulation.
6 weeks
Abbreviation: 10 - MWT
: 10-Meter Walking Test
ABC
: Activities Balance Confidence scale
ADL
: Activity of Daily Living
BBS
: Berg Balance Scale
CI
: Confidence interval
DGI
: Dynamic Gait Index
DASH
: Disabilities of the Arm, Shoulder and Hand Questionnaire
FGA
: Functional Gait Assessment
GDS
: Geriatric Depression Scale
KNGF
: Koninklijk Nederlands Genootschap Fysiotherapie
MCID
: Minimal Clinically Important Difference
MMSE
: Mini-Mental State Examination
N
: number of participants
419
UPDRS-II
showed a significant result in Post-hoc Tukey with p<0.005
Outcomes to measures: Balance, gait
BBS-time main effect (p < 0.001), the group main effect (p = 0.893) and group time interaction (p = 0.786). DGI-time main effect (DGI, p < 0.001), the group main effect (DGI, p = 0.970) and group time interaction (DGI, p = 0.614) Pairwise comparison: (BBS posttest > BBS pretest, p = 0.001; BBS follow-up > BBS pretest, p = 0.003; DGI posttest > DGI pretest, p < 0.001; and DGI follow-up > DGI pretest, p < 0.001).
BBS: 14item performanc e-based balance measure with scores 0-56 DGI, TUG test, PDQ39, UPDRS
N/A
: not available
p
: p value
PD
: Parkinson’s Disease
PDQ-8
: Parkinson’s Disease Quality of Life Questionnaire
PDQ-39
: the 39-item PDQ
SF-36
: Short Form 36 Health Survey Questionnaire
SIBT
: Sensory Integration Balance Training
TUG
: Timed Up and Go
TUGT
: TUG Test
UPDRS-3
: the third part of the Unified Parkinson’s Disease Rating Scale test
UPDRS-II
: the second part of the UPDRS
VR
: Virtual Reality
420
KNOWLEDGE, ATTITUDE, AND PRACTICES TOWARD COVID-19 : HOAX AMONG HIGH SCHOOL STUDENTS IN INDONESIA Author : Teguh Islamy Putra Aminah Karima Aridya, Stevens Wijaya ABSTRACT
COVID-19 is a disease caused by infection of SARS-COV2 virus which was first discovered in Wuhan, China at the end of December 2019, Declared a pandemic by WHO on Wednesday, 11 March 2020 until now. From then on, the government adopted a response that used elements of what other countries had successfully tried (including a sensible socio- economic relief package), but rejected a coherent, strictly enforced stay-at- home regime advocated by medical professionals. The result is that there are still many people who do not comply with health protocols such as not using masks when leaving the house, not using hand sanitizers and still gathering in crowded places which can actually increase the risk of rapidly spreading Covid-19. This raises questions about knowledge, attitudes, and practices (KAP) towards Covid19 in social media users, especially high school teenagers who like to use social media. This KAP crosssectional study aims to provide basic information about Covid-19 in order to avoid misunderstandings in the face of the Covid-19 Virus outbreak. A quantitative approach was used to achieve the objective of this descriptive study. The study instrument used in this study is an adaptation of the measures developed in a study of Chinese residentsâ&#x20AC;&#x2122; Knowledge, Attitude, and Practice (KAP) towards COVID-19 in China. The study results in good practice yet poor knowledge and attitudes. Keywords : COVID-19, Knowledge, Attitudes, and Practices, Senior High Schoolers of Indonesia
421
Knowledge, Attitude, and Practices Toward COVID-19: Hoax Among High School Students in Indonesia
Scientific Paper
Teguh Islamy Putra Aminah Karima Aridya Stevens Wijaya
Faculty of Medicine Universitas Hasanuddin
422
Introduction Covid - 19 is a disease caused by infection with the Sars - CoV - 2 virus which was first discovered in Wuhan, China at the end of December 2019. Declared a pandemic by WHO on Wednesday, 11 March 2020 Until now (October 2020), 39,801 have been obtained, 612 Confirmed cases included 1,110,908 patients who died worldwide ( WHO, 2020 ). The first case in Indonesia itself was reported on 2 March 2020 at the RS. Sulianti Saroso, involving 2 positive confirmation patients for Covid - 19. The number of cases continues to increase to date (19 October 2020) in Indonesia 365,240 confirmed cases have been recorded with 12,617 patients dying. One of the efforts made by the Indonesian Government to prevent the transmission of the Corona virus is Semi-Lockdown. In principle, the implementation of the Semi-Lockdown limits nonessential activities outside the home and is implemented in various regions throughout Indonesia. Residents are only allowed to leave the house for very important things, such as shopping for basic necessities or health needs, factories and industries are also asked to close or lay off their employees. In addition, the Indonesian government also enforces the application of Health Protocols when outside the home, such as wearing a mask, using a hand sanitizer, maintaining distance and not gathering in crowded places. From then on, the government adopted a response that used elements of what other countries had successfully tried (including a sensible socio- economic relief package), but rejected a coherent, strictly enforced stay- at- home regime advocated by medical professionals ( Meitzner et al, 2020 ). Without recourse to expert advice and recommendations, Indonesia and their government downplayed the emergence of COVID-19 in their territory there by hesitating the adoption of initial preventive measures which would have saved costs while protecting the citizenry from undue exposure to the virus ( Reuben et al, 2020 ). Especially for people who do not understand the medical world, especially about Covid-19 . The result is that there are still many people who do not comply with health protocols such as not using masks when leaving the house, not using hand sanitizers and still gathering in crowded places which can actually increase the risk of rapidly spreading Covid-19, coupled with the spread of misinformation (Hoax) regarding Covid - 19 which was distributed to social media became a communication breakdown between the health system and the public. This raises questions about knowledge, attitudes, and practices (KAP) towards Covid-19 in social media users, especially high school teenagers who like to use social media. This KAP study aims to provide basic information about Covid-19 in order to avoid misunderstandings in the face of the Covid-19 Virus outbreak ( Azlan et al, 2020 ). Assessing KAP related to COVID-19 among social media users will help provide better insights to overcome poor knowledge about the Covid-19 disease and increase efforts to prevent disease transmission and overcome
423
the spread of Hoax on social media as a form of Communication Breakdown between Systems Health and Society.
Methods Study Design A quantitative approach was used to achieve the objective of this study, and the type of study used was a descriptive study. In this study, a cross-sectional survey was utilised to gather the information regarding COVID-19 as it can be easily utilized in a large population (Jones et al, 2013). Data collection was performed using the Google Form platform, comprising a serial of questionnaires about the hoax and facts regarding the COVID-19.
Recruitment Procedure The cross-sectional survey was conducted between 17th to 19th October 2020, with the target sample size 100 respondents. Senior High School Students in Indonesia were eligible to participate in the survey. The social media platforms used in disseminating this survey are Whatsapp and Line.
Study Instrument The study instrument used in this study is an adaptation of the measures developed in a study of Chinese residents’ Knowledge, Attitude, and Practice (KAP) towards COVID-19 in China (Zhong et al, 2020). The questionnaire consisted of 4 main themes : 1) demographics, which surveyed participant’s socio-demographic information, 2) Knowledge about COVID-19, 3) Attitudes toward COVID-19, and 4) Practices relevant to COVID-19, with a total of 21 items. To measure knowledge about COVID-19, 8 items included the participant trivial knowledge regarding the COVID-19 disease. Participants were given “True” or “False” response options to each of these items. To measure attitudes toward COVID-19, 4 items included the participants’ certainty or uncertainty that the pandemic would be successfully controlled. To measure practices, 5 items included whether the participants comply to the COVID-19 safety protocol or not (Azlan et al, 2020). Each of participants’
424
result reaching 80% of the proper answers would be considered Good, whereas each of participantsâ&#x20AC;&#x2122; result not reaching 80% of the proper answers would be considered Poor.
Result A total of 111 respondents completed this online survey. Majority of the study population were female (69.37%) and all of them were high school student. Among the respondents 77 (69.37%) chose social media, 30 (27.03%) chose television, 1 (0.9%) chose school, 1 (0.9%) chose medical journal, and 2 (1.8%) chose health authority as source of information regarding COVID-19. These students chose Twitter 27.02% (30), Facebook 29.73% (33), WhatsApp 72.07% (80), Line 16.22% (18), Instagram 76.58% (85), YouTube 49.55% (55), and TikTok 1.8% (2) as the social media platforms they use the most. Gender Male Female Source of Information Social media Television Radio School Medical journal Newspaper Health authority
Most Used Social Media Twitter Facebook WhatsApp Line Instagram YouTube TikTok
34 77 n
total 77 30 0 1 1 0 2
30 33 80 18 85 55 2
111 30,63063 111 69,36937 % 111 69,36937 111 27,02703 111 0 111 0,900901 111 0,900901 111 0 111 1,801802
111 111 111 111 111 111 111
27,02703 29,72973 72,07207 16,21622 76,57658 49,54955 1,801802
425
Aspect
Question
TRUE
FALSE
Total
%
COVID-19 was first identified in Wuhan, China, in December 2019, and is now a pandemic affecting many countries globally, including Indonesia. Knowledge
Attitude
Practice
Inhaling steam prevents COVID-19. Neem leaves cure COVID-19. COVID-19 does not infect patients with mental disorder. Thermo gun damages brain cells. Ginger and black pepper cure COVID-19. Wearing mask causes pleurisy. Wearing mask decreases inhaled oxygen level up to 60%. I often forward social media messages/posts without reading through the whole article. I often try to find references to the social media messages/posts. I tend to trust every messages/posts from the social media. Are you confident that Indonesia will be able to overcome COVID-19? Do you wear mask everytime you leave house? Do you avoid crowded places? Do you open your windows or keep a healthy air circulation in your house frequently? Do you wash your hands with soap and water or with hand sanitizer regularly? Do you often clean surfaces you regularly touch (such as phone, door handles, etc)?
Good Poor Knowledge 50 Attitude 47 Practice 99
107 71 93 96 88 78 95 68 14 77 94 99 106 87 96 92 64
61 64 12
The current foundings showed that majority of the respondents stated social media as their source of knowledge (69,37%), followed by television (27.03%). Although 96.4% (107) agreed on COVID-19 status as a pandemic, 3.64% (4) did not have the correct knowledge. 13.51% (15) believed COVID-19 does not infect a person with mental disorder. Majority of respondents showed knowledge of samples of false information regarding of herbal remedies as cure and/or prevention against COVID-19, 16.22% for neem leaves and 29.73% for ginger and black pepper. 85.59% agreed wearing mask does not cause pleurisy. However, only 61.26% agreed on mask causing a decrease in inhaled oxygen level. This concludes 50 respondents have good knowledge regarding COVID-19 and 61 poor. 87.39% respondents showed a tendency to forward messages/posts before reading throughly, 69.36% finds references of them, and 84.68% trusts every of them. Over all, 89.19% believes that Indonesia can overcome the pandemic. This concludes 47 respondents have good attitude regarding COVID-19 and 64 poor. The survey also shows respondents willingness to wear mask 95.5%, avoid crowded places 78.38%, keep healthy air circulation 86.49%, keep hands hygiene 82.88%, and clean surfaces regularly touched 57.66%. This concludes 99 respondents had applied good practice regarding COVID-19 and 12 poor.
Discussion
426
4 40 18 15 23 33 16 43 97 34 17 12 5 24 15 19 47
111 111 111 111 111 111 111 111 111 111 111 111 111 111 111 111 111
96,3964 63,96396 83,78378 86,48649 79,27928 70,27027 85,58559 61,26126 12,61261 69,36937 84,68468 89,18919 95,4955 78,37838 86,48649 82,88288 57,65766
This study is the first epidemiological survey aimed at assessing the KAP (Knowledge, Attitude, and Practice) of individuals within Indonesia towards the COVID-19 Pandemic. With the novelty of COVID-19 with its pathological and epidemiological uncertainties, the study of the population levels of KAP becomes critical for efficient health planning, implementation and management of the public. (Reuben et al, 2020) This survey was dominated by female (69,37%) respondents, Social medias (69,36%) and Televisions (27,02%) constitute the major sources of informations about COVID-19, and the most frequently used social medias were Instagram (76,57&) and Whatsapp (72,07%). In the Knowledge aspect, most of the participants (96,39%) answered correctly on statement “COVID-19 was first identified in Wuhan, China in December 2019, and is now a pandemic affecting many countries globally, including Indonesia.”, while 61,2% of the participants answered wrong on statement “Wearing masks decreases inhaled Oxygen level up to 60%.”. In the Attitude aspect, most of the participants (89,19%) answered the question “Are you confident that Indonesia will be able to overcome COVID-19?” with the correct attitudes, while 30,63% of the participants answered the statement “I often try to find references to the social media messages/posts.” With the poor attitude. In the Practice aspect, most of the participants (95,49%) answered the question “Do you wear mask everytime you leave the house?” with good practices, whereas 42,34% of participants answered the question “Do you often clean surfaces you regularly touch (such as phone, door handles, etc)?” with poor practices. While 57,65% of the participants display poor attitudes towards COVID-19 and 54,95% display poor knowledge about COVID-19, 89,18% of the survey participants display good practices relevant to COVID-19. Despite the poor knowledge and attitudes towards COVID-19, most of Senior High Schoolers of Indonesia seem to display high compliance to their school rules regarding the correct practices relevant to COVID-19.
Conclusion This study provides assessment of the KAP of high school student in Indonesia towards COVID19. The findings concludes a situation of concerning susceptibility of high school students in Indonesia of false information spreading through the social media, as well as their attitude regrading COVID-19. Although the number of students who had good practice regarding COVID-19 were relatively high (89.19%), the number of student who had poor practice might be an alarming sign of false information effect on public health.
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References : WHO. (2020, October 20). WHO Coronavirus Disease (COVID-19) Dashboard. Retrieved October 20, 2020, from https://covid19.who.int/ Azlan, A. A., Hamzah, M. R., Sern, T. J., Ayub, S. H., & Mohamad, E. (2020). Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia. PloS one, 15(5), e0233668. https://doi.org/10.1371/journal.pone.0233668 Reuben, R. C., Danladi, M., Saleh, D. A., & Ejembi, P. E. (2020). Knowledge, Attitudes and Practices Towards COVID-19: An Epidemiological Survey in North-Central Nigeria. Journal of community health, 1–14. Advance online publication. https://doi.org/10.1007/s10900-020-00881-1 Mietzner, M. (2020). Populist Anti-Scientism, Religious Polarisation, and Institutionalised Corruption: How Indonesia’s Democratic Decline Shaped Its COVID-19 Response. Journal of Current Southeast Asian Affairs, 39(2), 227–249. https://doi.org/10.1177/1868103420935561 Jones, T. L., Baxter, M. A., & Khanduja, V. (2013). A quick guide to survey research. Annals of the
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https://doi.org/10.1308/003588413X13511609956372 Zhong, B. L., Luo, W., Li, H. M., Zhang, Q. Q., Liu, X. G., Li, W. T., & Li, Y. (2020). Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. International journal of biological sciences, 16(10), 1745–1752. https://doi.org/10.7150/ijbs.45221
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Telehealth as a Solution for the Management of Obese and Hypertension Patient during the COVID-19 Pandemic Tirsa Adella1a, Lamria Agnes Meilani1, Sharon Levita1 Undergraduate Medical Program, School of Medicine and Health Sciences, Christian University of
1
Indonesia Asian Medical Students' Association Indonesia tirsadella@gmail.com
a
ABSTRACT Introduction: Communication between health care providers and the patient is crucial for giving the right health service, especially for patients with comorbidity that need to be monitored routinely, for example, in obese and hypertension patients. The ongoing COVID-19 pandemic restricts direct meetings for health communication and therapy between clinicians and their patients in fear of COVID-19 transmission. Telehealth is a promising medical technology development that can be used in this pandemic, so health care providers can still communicate and give health intervention to their patients. Methods: This systematic review aimed to assess compilation evidence of telehealth effectiveness in monitored BP in hypertensive patients and BMI of obese patients. Pubmed, Google Scholar, and Science Direct were searched from the earliest date (of each database) up to June 2020. Interventions were screened for five technical key components: self-monitoring, counselor feedback and communication, group support, use of a structured program, and outcome. Results and Discussion: Most interventions showed significant decreases in weight or BMI and blood pressure by self-monitoring through telehealth provided by health care providers compared to controls. During the COVID-19 pandemic, telehealth might prove an efficient health communicator tool, considering how social distancing needs to be implemented to prevent COVID-19 transmission. Moreover, it is advantageous to implement telehealth in the present given situation. One of those benefits is being able to monitor a patient's BMI and blood pressure remotely. It is also proven to be costeffective, bring significant results, and capably facilitate time-saving online health consultations from clinicians. Conclusion: Technology-based interventions like telehealth shows to be a useful tool for weight loss and blood pressure reduction in the succeeding future and particularly during the persistent COVID-19 pandemic outbreak.
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Keywords: telehealth, blood pressure, hypertension, BMI, COVID-19, systematic review
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Telehealth as a Solution for the Management of Obese and Hypertension Patients during the COVID-19 Pandemic: A Systematic Review
Authors: Tirsa Adella Lamria Agnes Meilani Sharon Levita Faculty of Medicine Christian University of Indonesia 2020/2021
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I.
INTRODUCTION Telehealth is the "delivery of health care services, where patients and providers are separated by
distance." (WHO, 2016). This term is often used to encompass a broader application of technologies to distance education, consumer outreach, and other applications wherein electronic communications and information technologies support healthcare services. (WHO, 2006). Telehealth services can be provided through devices such as computers, smartphones, and tablets that have the potential to reduce existing healthcare inequities by supporting primary care professionals in remote areas (Almim et al., 2007; Jennett et al., 2003; Kirigia et al., 2005). The modes of delivery in which Telehealth uses to deliver its services include patient monitoring via phone calls, SMS text messages, online health counseling and intervention, mobile phone applications to support behaviour goals, and videos (Foley et al., 2016). The COVID-19 outbreak prevents patients and health care practitioners from having direct health consultations and management, especially in patients with comorbidities that need to be monitored from time to time. The use of telehealth has the potential to maintain control of the severity of the disease and constant supervision of a patient's urgent clinical situation (Monaghesh & Hajizadeh, 2020). In this case, we specifically focus on obese patients with a risk of hypertension. Healthcare practitioners could use telehealth to constantly monitor the conditions of those patients, such as obtaining their BMI and blood pressure measurements, observing the consistency and quality of their diets, and keep track of their physical activity. Several kinds of research that had been done on this topic found that most patients treated and consulted online by the health professionals using telehealth showed improvements in their diet, activity level, weight, and blood pressure. (Shaikh et al., 2008). II.
METHOD Literature searching was conducted with databases in PubMed, Science Direct, and Google
Scholar. For the article published between 2006-2020. We use the following keyword in the search field (â&#x20AC;&#x153;telehealth, telecommunication, teleconsultation, obesity, hypertension, weight management, COVID19). The search results were downloaded to a personal database. The inclusion criteria used in this literature searching were the following: 1. The study was published between 2006-2020, 2. Was written in English, 3. Was fully accessible, and 4. Was correlated to the aim of this paper. The articles which did not meet the criteria were excluded.
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III.
RESULTS According to the literature searching we conducted, there are various ways telehealth could be
conducted in health management. Trials of remote-patient monitoring is done through a variety of platforms, such as telephone-based intervention, Internet-based intervention, online interactive services, virtual small groups, mobile phone messages, emails, online motivational interviewing, coaching calls, synchronous chat groups, and apps for smartphones. Each literature has its own interventions, characteristics, advantages, and disadvantages. From a meta-analysis conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, (Huang et al., 2019, p.2). adult subjects of age 19 years and over are to be performed one of the interventions that involved any for of telemedicine (e.g. Internet-based system, mobile phone, text messaging, video-conferencing, or telephone); one of the control groups received usual care or standard treatment; the effect of intervention was evaluated by a change in BMI. The analysis revealed that there was a significant difference in the change in BMI between the telemedicine and control groups (Huang et al., 2019, p.7). Since the included studies had different features, which contributed to a certain degree of heterogeneity, subgroup analysis was performed.
Subgroups were differentiated by type of intervention ('Internet' and 'Telephone'),
participants ('With diabetes or hypertension' and 'Without diabetes or hypertension'), main purpose of intervention ('For diabetes control', 'For hypertension control', 'For weight loss', and 'For increasing physical activity.'), and length of intervention ( 18 ≤ month, 12 ≤ month < 18, 6 ≤ month < 12, 3 ≤ month < 6, month < 3). Regarding the type of intervention, both Internet-based and telephone-based interventions significantly decreased BMI at the end of the intervention. Regardless of whether the participants had diabetes or hypertension, the intervention was effective. Among the 25 included studies, the interventions were designed for different goals according to their participants. All of the interventions significantly decreased BMI. Regarding the different lengths of intervention, subgroup analysis revealed that only a length longer than six months could significantly decrease BMI (Huang et al., 2019, p.8). An original research article had run a trial on a simple telehealth intervention utilised in a project which required patients to use a home, electronic sphygmomanometer and text via a mobile phone. Patients obtained their BP readings and texted the results to a secure server, ‘Florence’. Florence is an interactive service, which reminds patients to text their BP readings each day, and sends reminders if a reading is not received within 2 h. It also sends automatic responses to patients regarding any further required actions based upon the BP readings obtained, from sending a repeat reading if the programme
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detects that an error may have occurred, through advising patients to contact their doctor or practice nurse. This allows for ‘closed loop’ monitoring with weekly, or more frequent, review by the patient’s own general practitioner (GP)/nurse who can log into the secure server and access their results. Messages can be sent back to the patient from their primary healthcare team with advice on continuing management. (Cottrell et al., 2012, p.2). Average SBP and diastolic BP readings for all intervention patients fell within the normotensive range from month 1 of the programme. From subgroup analysis, intervention patients included with uncontrolled hypertension without CKD stages 3–5 became normotensive (≤140/90 mm Hg) by month 2. Despite intervention patients having significantly elevated SBP compared with control patients at baseline and 1 year prior to this, intervention patients had no significant difference in their average SBP from control patients from month 1 of the programme (Cottrell et al., 2012, p.3). Average BP readings from patients with CKD stages 3–4 only fell into the normotensive range (≤130/85 mm Hg) in month 3. Changes in BP from baseline at each month among intervention patients were greatest and most significant among patients without CKD stages 3–5 who had systolic hypertension at baseline, see table 4 and figure 2. These patients had significant reductions in SBP ranging from −15 to −16 mm Hg during the 3 months of the programme, a significant difference of at least −10 mm Hg continued to be observed up to 6 months post recruitment ; controls who were hypertensive at baseline did not have an equivalent reduction in BP identified until month 3. (Cottrell et al., 2012, p.3). Significantly more changes, 0.31 vs 0.08 (p<0.05; CI for difference 0.16 to 0.32) were made to the medications of intervention patients, compared with control patients over the 3-month programme, respectively. (Cottrell et al., 2012, p. 5). The data that we have found in one of the studies showed BP control rates among patients receiving the telehealth intervention were 51% and 25–30% respectively. In our study, 52.2% of patients achieved BP control, and the SBP decreased by an average of 22.1 mm Hg over one year. (CDC, 2012) Another journal had also done a research to evaluate the efficiency eHealth has in weight loss and blood pressure. It's participants were men between the ages of 21–60 years old at the time of enrollment with a body mass index (BMI) between 30 and 40 kg/m2 were invited to participate. (Azar et al., 2015, p.38). Men were to be involved in an intervention which consisted of two main components: (1) 12 weekly classes, delivered through web-based, virtual small groups, and (2) wireless and internetconnected (Wi-Fi) “smart” scales for weekly weighing. The intervention consisted of the Diabetes Prevention Program-based Group Lifestyle Balance (GLB) core curriculum for 12 weeks through virtual small groups using Blue Jeans™, a real-time, encrypted, web and cloud-based VC software. (Azar et al., 2015, p.38). Participants who completed the intervention lost significantly more weight than those in the control group. Modest weight loss (5–10 % reduction in total body weight) for individuals who are
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overweight or obese has been shown to produce health benefits such as improvement in blood pressure, cholesterol, and glucose. (Azar et al., 2015, p.41). In another study, mobile phone messages and emails served as a platform for telehealth intervention. In this study, participants with ≥3 risk factors (family history of cardiometabolic disease, overweight/obesity, high blood pressure, impaired fasting glucose, hypertriglyceridemia, high LDL cholesterol and low HDL cholesterol) were included. (Limaye et al., 2017, p.564). They were sent information on lifestyle modification through mobile phone messages and e-mails for 1 year. After a survey of participants’ preferences, three mobile phone messages and two emails were sent per week between 1000–1300 h; no message was repeated. Emails contained info-graphics. Participants in the intervention group had additional support through a website and a Facebook page (closed group) (Limaye et al., 2017, p.564). At 6 months, the intervention group had significantly greater reductions in weight, waist circumference, systolic blood pressure, and diastolic blood pressure compared with the control group. At 1 year, participants in the intervention group achieved a greater number of lifestyle goals compared with those in the control group. Those who achieved a greater number of lifestyle goals had a greater reduction in weight. (Limaye et al., 2017, p. 566-567). One of the systematic reviews elaborates on how motivational interviewing (MI) delivered via technology can be used as a form of behavioral intervention for weight loss. This intervention is done for about ≥12 weeks with a comparison condition that does not include motivational interviewing. Weight loss outcomes (in kg, lb., or % body weight lost) at baseline and at least 1 follow-up visit (Patel et al., 2019, p.2). Ten trials reported the percentage of participants who achieved at least 5% weight loss from baseline, which is considered a clinically significant amount of weight loss (Jensen et al., 2014). Among this subset, a mean of 32% (range: 17–44%) of participants in the arms with both remote and in-person MI achieved this thresho(Anderson et al., 2014; Anderson et al., 2018; Appel et al., 2011; Barnes et al., 2014; Bennett et al., 2012; Rock et al., 2015; Svetkey et al., 2015), compared to 32% (range: 19–38%) in the remote-only MI arms (Appel et al., 2011; Fischer et al., 2016; West et al., 2016; Young et al., 2017), 23% (range: 17–30%) in active comparator arms (Barnes et al., 2014; Svetkey et al., 2015; West et al., 2016; Young et al., 2017), and 15% (range 0–25%) in no-treatment control arms (Anderson et al., 2014; Anderson et al., 2018; Appel et al., 2011; Barnes et al., 2014; Bennett et al., 2012; Fischer et al., 2016; Svetkey et al., 2015; Young et al., 2017). Another systematic review is done and this time the inclusion criteria involves the usage of Internet-based weight management tools, social media, smartphone apps, telephone and/or smartphone/mobile phone use in general or active video games. Studies were eligible and considered to be of acceptable quality if 1) study participants were 18 years or older; 2) study participants were
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overweight, obese or morbidly obese, defined respectively as having a Body Mass Index (BMI) of >25 kg/m2, â&#x2030;Ľ 30 kg/m2 and â&#x2030;Ľ 40 kg/m2 (WHO, 2015); 3) interventions had a technology aspect; 4) interventions aimed at reducing weight or maintaining weight loss; 5) data on weight change were provided (Raaijmakers et al., 2015, p.139). This review contributes to the assumption that technology can add or replace essential components of weight loss interventions. Different studies demonstrate that selfmonitoring dietary intake; physical activity and body weight is the centrepiece of weight loss intervention programs (Burke,Wang, & Sevick, 2011; Shay, Seibert, Watts, Sbrocco, & Pagliara, 2009; Tate, Jackvony, & Wing, 2006; Wadden et al., 2005). Self-monitoring is associated with greater weight loss (Tate et al., 2006; Tate, Wing, & Winett, 2001; Womble et al., 2004). Using the Internet or digital scales could for example, replace the paper-monitoring diary. In the study of Wharton, Johnston, Cunningham, and Sterner (2014) participants using an app for self-monitoring in weight management more consistently entered complete days of dietary data compared with the paper-and-pencil group. This is important for both increased commitment to behaviour change interventions as well as for health outcomes and weight management. Counsellor feedback and motivation has a positive impact on weight loss as well. Research shows that the more counselling is provided, the more weight is lost (Perri et al., 2014). However, intensive counselling results in higher costs. By providing counselling by email, these costs can be drastically decreased (van Wier et al., 2012). Furthermore, technology-based interventions can be easily implemented in daily practice and also in the daily life of patients (Franc et al., 2011). Another effective component in weight loss interventions is social support (Greaves et al., 2011; Jeffery et al., 1984). Support from another person in a weight loss intervention not only helps to improve weight loss, it also reduces time spent on weight counselling. Technology can help by developing, for example, online forums or chat rooms or the usage of social media (Turner-McGrievy & Tate, 2013). IV.
DISCUSSION Telehealth is an effective, efficient way to triage and deliver timely, quality medical care (Lee et
al., 2020). Public health agencies, governments, stakeholders, and policymakers must introduce this technology into existing health systems globally, especially during this COVID-19, characterized as a pandemic by WHO (2020). The number of these cases is increasing rapidly, and critical care facilities are limited. (Phua et al., 2020; Bhutta et al., 2020; Ali & Khoja, 2020). Furthermore, telehealth services are also an efficient way to provide people with remote access to quality healthcare services without increasing the risk of transmitting infection (Ali & Koja, 2020). Telehealth services can be provided through devices such as computers, smartphones, and tablets (Zhoa et al, 2020). Doctor-patient interaction can still occur despite social distancing and stay-at-home
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orders (CDC, 2020) and telehealth services eliminate the exposure risk inherent in an in-person clinic visit. Telehealth also provides a way to reach populations that have low or no access to care. (Ali & Koja, 2020). Telehealth can also improve patient health outcomes (Oâ&#x20AC;&#x2122;Connor et al., 2016) with developing an established pathway for contact and evaluation for urgent patients and also ensuring that patients know there is a clear line of communication to minimize emergency department overuse for noncritical issues (Lee et al., 2020). It was demonstrated that patients with greater frequency and intensity of home SMBP monitoring behaviour tended to achieve the appropriate BP level more easily. Furthermore, an immediate BP warning reminder, generated by the home telehealth equipment may help to motivate the patientsâ&#x20AC;&#x2122; towards better BP control. These results were similar to those reported in other studies (Stoddart et al., 2013; Bray et al., 2015; Margolis et al., 2013). One of the studies found that telemedicine significantly decreased greater BMI than usual care, regardless of the type of telemedicine (Internet-based or telephone-based), participants (with or without diabetes or hypertension), or purpose of telemedicine (for diabetes control, for hypertension control, for weight loss, or for increasing physical activity). We also observed that only interventions with a length longer than six months could significantly improve BMI. As seen in the study, the intervention on weight loss and blood pressure using telehealth proves to be quite a success. This combined health management of body weight and blood pressure could prove to be a huge advantage among patients with diabetes and hypertension who in need of controlled care, especially during the COVID-19 pandemic where patients are too paranoid to undergo routine clinical visits to the hospital at the risk of contracting COVID-19. Clinical guidelines for diabetes and hypertension by the American Diabetes Association and American College of Cardiology/American Heart Association Task Force on Clinical Practice both have strongly recommended that to achieve and maintain an ideal body weight is a fundamental aspect of treatment (Huang et al., 2019). This is similar to another study discussed in the results, which was a study done by Limaye, et al. (2017). The intervention was well received; 98% of participants opted for a continuation of the virtual assistance, while 96% would recommend it to family and friends. The findings of the present study show a high burden of risk factors for Type 2 diabetes and cardiovascular disease in young Indian employees in the IT industry. Virtual assistance-based lifestyle intervention in these high-risk employees reduced the prevalence of overweight/obesity significantly, and led to improvements in waist circumference, and total and LDL cholesterol levels at 1 year. Those who achieved a greater number of lifestyle goals experienced a greater risk reduction. Hence, telehealth would prove useful to patients with underlying comorbidities to
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obesity or hypertension, both in which constant and efficient interventions are needed (Limaye et al., 2017). In a research done by Azar, et al. (2015) which was discussed in results, elaborates on the fact that remote monitoring of body weight is an innovative aspect. In the study, it was found that a majority of participants were compliant and participated in the intervention of weighing themselves at least once per week during the course of the 12-week intervention. They lose approximately 0,6 kg of additional body weight. These findings are consistent with the extensive literature in support of self-monitoring as a crucial component of long-term weight management strategies. A recent study examining the efficacy of daily self-weighing with smart scales with tailored feedback produced clinically significant weight loss among participants compared to a control group. This further demonstrates the potential benefits and feasibility of integrating remote monitoring of body weight into future technology enhanced behavioral weight loss interventions. Based on the observations and feedback from intervention participants, cost savings to the participants included reduction in travel time, mileage, and other associated costs; increased productivity; and reduction in lost wages and childcare costs. This further concludes other than using remote monitoring of body weight as a means of weight loss, it was also fairly accepted as a successful telehealth intervention by its participants. (Azar et al., 2015). Other than using technology or eHealth as a means of health monitoring, findings suggest that motivational interventions (MI) via technology are as effective as non-MI approaches for weight loss (Patel et al., 2019). Interventions that lasted at least 6 months tended to have better engagement and weight loss outcomes than shorter interventions, which is consistent with a recent meta-analysis of
text-messaging interventions
(Armanasco et al., 2017), suggesting that longer duration may be relevantâ&#x20AC;&#x201D;or perhaps is a signal for higher methodological quality (Patel et al., 2019). The use of MI reminds us about the importance of interventions used, which are based on essential theories and therapies, such as cognitive behavioural therapy. Intervention Mapping states that theory-informed methods and practical strategies have to be used when developing an intervention to effect changes in health behaviour. An intervention method is a defined process by which theory postulates and empirical research provides evidence for how change may occur in behaviour of individuals (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011). Implementing a telemedicine as a weight management programme was more cost-effective than implementing the same face-to face services delivered weekly by dietitians, a physical therapist, a psychologist and a wellness nurse (Chung et al., 2015).
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This study done on various literatures about the impact telehealth has on obese and hypertensive patients certainly comes with advantages and limitations. Because works this topic are still limited, we apologize if the outcomes are still too few to prove a definite statement, and more research needs to be breached on this particular topic in the future.
V.
CONCLUSION & RECOMMENDATION Telehealth can enable remote triaging of care, provide additional mental health services, and
rapidly accessible information through technology during infectious disease outbreaks, that already proved in several countries (Australian Government Department of Health, 2020; Priya, 2020) . Restricting physical contact and social distancing in the COVID-19 pandemic makes it difficult for clinicians to directly meet patients, especially patients who need to be monitored periodically like obese and or hypertension patients. Several studies that apply telehealth to monitoring obese and or hypertension patients showed reductions in blood pressure, which is meant diastolic, weight, and body mass index achieved in self-management (McKoy, 2015; Park, 2009; Salisbury, 2016; Senesael, 2013). Also, both patients with chronic disease and overweight/obese people could benefit from telemedicine interventions (Huang, 2019). Therefore, telehealth could be a potential solution to prevent any direct physical contact, provide continuous care to the community, and finally reduce morbidity and mortality in the COVID-19 outbreak (Monaghesh & Hajizadeh, 2020) Telehealth manages the patients condition while at the same time remain at a certain safe distance. This is especially useful in hindering the infectious condition of the pandemic in public clinical settings, but still allowing a certain degree of patient-to-healthcare practioner communication. REFERENCES Ali, N. A., & Khoja, A. (2020). Telehealth: An Important Player During the COVID-19 Pandemic. The Ochsner journal, 20(2), 113â&#x20AC;&#x201C;114. https://doi.org/10.31486/toj.20.0039. Alkmim, M. B., Ribeiro, A. L., Carvalho, G. G., Pena, M., Figueira, R. M., & Carvalho, M. B. (2007). Success factors and difficulties for implementation of a telehealth system for remote villages: Minas Telecardio Project Case in Brazil. J eHealth Technol Appl, 5(2), 197-202. American Diabetes Association. (1999). The Diabetes Prevention Program. Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes care, 22(4), 623-634.
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