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ACCEPTANCE AND UTILIZATION OF TELEPRIMARY CARE IN SARAWAK

HoAi Chia

Doctor of Public Health 2013

Pusat Kbidmat Maklunaat Akademik UNJVEltSm MALAYSIA SARAWAK

ACCEPTANCE AND UTILIZATION OF TELEPRIMARY CARE IN

SARAWAK PKHIDMAT MAKLUMAT AKADEMIK

1111 1lIlIlll~ii 111111111 1000246994

HOAI CHIA

A dissertation submitted in partial fulfilment of the requirements for the degree

ofDoctor ofPublic Health

Faculty of Medicine and Health Sciences

UNIVERSITI MALA YSIA SARA W AK

2013

ABSTRACT

Teleprimary Care (TPC) is an electronic system used in healthcare to facilitate the

workflow in healthcare organization and improve quality of patient care The system which

was introduced in year 2004 has been implemented in 31 health facilities throughout Sarawak

including two hospitals and six divisional health offices To date no proper evaluation has

been done on TPC especially on the acceptance of users towards the system The objective of

this study was to analyze the characteristics of TPC users in Sarawak their acceptances and

perceptions towards the system challenges and barriers faced and comments in improving the

system This was a cross-sectional study using quantitative research method supplemented

with qualitative data to better understand the actual feelings of system users in the field A

total of 516 TPC users throughout Sarawak were surveyed using self-administered

questionnaire and 44 system users as well as system coordinators were interviewed The

overall acceptance of users towards TPC was good Analysis revealed that job relevance

perceived usefulness result demonstrability and subjective norms appeared to be significant

influencing factors for acceptance of TPC However perceived ease of use motivation and

voluntariness were not strong predictors for intentions to use the system Two-fifth of users

preferred TPC system while 28 preferred the conventional paper-based system for

documentation Users who preferred TPC system were those working in the hospital

registration officers and users who had been using the system for more than 3 years The

commonest barriers faced by users were related to technical issues followed by database

problems disruption of face-to-face contact with patients and lack of training Improving the

server for TPC and providing training for all users were among the priorities to improve the

utilization of TPC from the users perspectives Clinic and Divisional coordinators played

important role in TPC implementation but were limited by time constraint and financial

control In conclusion result from the study highlighted the need for future strategies to focus

on improving functionality of TPC in enhancing the workflow of users in their daily works

Supervisors and middotDivisional Health Officers need to be TPC-minded and to encourage the

usage ofTPC among users in the Division There is also an overwhelming need for tackling

the technical issues of TPC and providing training for all users in order to improve the

implementation ofTPC

11

~------------------------------------ ----shy

ABSTRAK

Penerimaan dan Penggunaan Teleprimary Care di Sarawak

Teleprimary Care ([PC) merupakan satu sistem elektronik yang digunakan dalam

bidang kesihatan untuk memudahkan kelancaran kerja dalam organisasi kesihatan serta

meningkatkan kualiti perawatan pesakit Sistem terse but telah diperkenalkan pada tahun

2004 dan kini dilaksanakan di 31 buah fasiliti kesihatan di seluruh Sarawak termasuk dua

buah hospital dan enam buah pejabat kesihatan bahagian Setakat ini tiada penilaian

menyeluruh dilakukan pada sistem TPC terutamanya dari segi peninjauan penerimaan

pengguna terhadap sistem berkenaan Objektif kajian ini adalah untuk menganalisa ciri-ciri

demografi pengguna TPC di Sarawak penerimaan dan pandangan mereka terhadap sistem

berkenaan cabaran dan halangan yang dihadapi serta komen pengguna dalam

penambahbaikan sistem TPC Kajian ini merupakan kajian rentas silang yang melibatkan

teknik pengumpulan data secara kuantitatif ditambahkan dengan data kualitatif bagi

meningkatkan pemahaman perasaan sebenar para pengguna system di lapangan Seramai

516 orang pengguna TPC dari seluruh Sarawak telah disoalselidik menggunakan borang

soalselidik isian sendiri dan 44 orang pengguna beserta penyelaras TPC telah ditemubual

Secara keseluruhannya penerimaan pengguna terhadap sistem TPC adalah baik Analisa

menunjukkan bahawa relevansi kerja tanggapan faedah keupayaan demonstrasi hasil serta

norma subjektif merupakan faktor-faktor yang mempengaruhi penerimaan pengguna

terhadap sistem TPC Walaubagaimanapun tanggapan kesenangan penggunaan motivasi

serta kesukarelaan bukan faktor-faktor yang utama dalam meramal niat kepenggunaan TPC

di kalangan pengguna Dua per lima pengguna lebih menggemari sistem TPC manakala

28 lebih cenderung kepada sistem kertas yang konvensional bagi tujuan dokumentasi

iii

Pengguna yang cenderung kepada TPC merupakan mereka daripada kalangan yang bekerja

di hospital bekerja sebagai pegawai pendaftaran serta pengguna yang telah menggunakan

sistem TPC melebihi tiga tahun Rintangan yang paling kerap dihadapi oleh pengguna TPC

adalah masalah berkaitan teknikal diikuti dengan masalah pangkalan data gangguan dalam

pelaksanaan kerja yang berkualiti serta kekurangan latihan dalam bidang ini Berdasarkan

kepada perspeksi pengguna penambahbaikan rangkaian server TPC serta penyediaan

latihan bagi semua pengguna TPC adalah antara strategi yang patut diberi keutamaan dalam

meningkatkan penggunaan TPC Penyelaras TPC peringkat klinik serta Bahagian turut

memainkan peranan yang penting dalam implementasi TPC Namun usaha mereka dalam

hal ini kerap terse kat dari segi desakan masa dan kuasa pengawalan kewangan TPC

Kesimpulannya keputusan yang diperolehi melalui kajian ini menegaskan keperluan bagi

perancangan strategi masa hadapan untuk berfokus kepada meningkatkan fungsi-fungsi TPC

dalam melancarkan aliran kerja para pengguna Penyelaras dan Pegawai Kesihatan

Bahagian sepatutnya mempunyai minda yang positij terhadap TPC dan menggalakkan para

pengguna TPC di bawah penguasaannya supaya meningkatkan penggunaan TPC Masalah

teknikal berkenaan TPC juga patut ditanggani dengan segera dan latihan penggunaan TPC

wajar diberikan kepada semua pengguna TPC supaya implementasi TPC dapat ditingkatkan

lV

DECLARATION

No portion of the work referred to in this dissertation has been submitted in support of an

application for another degree of qualification of this or any other university or institution of

higher learning

Signature

Name HOAICHIA

Date 27 MAY 2013

v

ACKNOWLEDGEMENTS

It is my prestigious privilege to express my deepest gratitude and appreciation to both

my research supervisors Professor Dr Mohamad Raili bin Suhaili and Dato Dr Andrew Kiyu

Dawie Usop for their enthusiasm constant guidance and valuable suggestions from the

beginning to the end of my research I am truly grateful for their sincere effort and greatest

patience in giving clear guidance and intellectual direction to my dissertation Their

continuous supports have been the greatest cue for me to embark on this research I can never

thank Prof Raili enough for his assistance and effort in making my data collection process for

this research a smooth sail

This dissertation would not have completed in time without the dedication and

enthusiasm given by my lecturer in Biostatistics Associate Professor Dr Md Mizanur

Rahman His continuous inspiration constructive criticism and valuable directions all through

the course had guided me throughout the dissertation preparation period

I would also like to express my deepest thanks to the Dean of Faculty of Medicine and

Health Sciences UNIMAS Professor Dr Ahmad Hata Rasit and the Deputy Dean

(postgraduate and Research) Professor Dr Lela Suut for their kindest supports in this

programme and our research study My special thanks also goes to my lecturer and fonner

Dean Tan Sri Datu Prof Dr Hj Mohd Taha bin Arif for his continuous support and guidance

throughout my study

I can go no further without expressing my appreciation and gratitude to Dr Flora Ong

whom had provided valuable guidance and advice on this research based on her enriching

experience in Teleprimary Care of Sarawak

VI

I would like to acknowledge the State Health Director of Sarawak Dato Dr Zulkifli

bin Jantan for his kind consideration and approval on my proposal in order for me to proceed

with my research study This study would not have gone this far without the support from all

the Divisional Health Officers involved in the research Dr Kamarudin bin Lajim Dr Julaidah

bt Sharip Dr Muhamad Rais Abdullah Dr Osman Bin Rafaie Dr Hasrina Hassan and Dr

Ngian Hie Ung and former Directors of Sibu Hospital Dr Chin Zin Hing and Dr Audrey

Gapoh to agree to this research in their respective health premises and offer of assistance in

transportation and accommodation

I would like to give special acknowledgement to all the staff of Telehealth Unit of

Sarawak State Health Department and Sibu Hospital especially Dr Eunice Melissa Joseph Dr

Diana Jawa SAMO Mr Bobby Hudson Didet and AMO Mr Alexander Ringga for their time

and effort in extracting the relevant data from the database and sharing of invaluable

comments and suggestions for this research Without their kind assistance and cooperation

this study could not be accomplished

A word of appreciation also goes to Mdm Chin Siew Kiaw Dr Lai Boon Foo and Dr

Nolan Teo who have given my all the support and help during the data collection I would

also like to extent my deepest appreciation to all nursing sisters matrons and assistant

medical officers whom were hold in-charge of TPC in every divisions and clinics for their

contributions and support at various stages of the study None ever hesitate to assist whenever

required to do so

My very special thanks to the Head of Department of Community Medicine and

Public Health Department UNIMAS Associate Professor Dr Kamaluddin Bakar Associate

Professor Dr Ong Puay Hoon and all my academic advisors and lecturers for their

continuous efforts of assistance valuable advice and encouragement throughout my study

vii

process and dissertation writing I will never forget the enthusiasm and kindness they have

given to me

My sincere gratitude also goes to my dearest course-mates Dr Sharifah Norashikin

binti Wan Ahmad and Dr Shahnur Begum and all other DrPH candidates of UNIMAS for

their valuable supports and helpfulness throughout the course All your opinions and

suggestions had contributed to the success of this dissertation I would like to specially

mention my appreciation for Dr Sharifah Norashikin for being such a wonderful companion

of mine when travelling throughout Sarawak for data collection

I am particularly indebted to my loving parents and family members for their love

support inspiration encouragement and good understanding of me throughout this study

period which enabled me to reach the study goal

I would like to acknowledge all of the other people who have knowingly or

unknowingly contributed towards whatever merits this research and dissertation possess I

am regretful if am not able to recall everyone as I am certainly indebted to them

Last but by no means least lowe a great debt of gratitude to all the TPC users in

Sarawak who have agreed to spare their precious time off from their working hours to

participate in this study This study will never come to a success without their willingness to

share their thoughts on TPC

Thank you very much to all

HoAiChia

viii

Pusat Khidmat Maklumat Akademik UNlVERSm MALAYSIA SARAWAK

TABLE OF CONTENTS

page

ABSTRACT i

LIST OF ABBREVIATIONS xviii

ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi

TABLE OF CONTENTS ix

LIST OF TABLES xiv

LIST OF FIGURES xvi

CHAPTER 1 INTRODUCTION LITERATURE REVIEW

11 Introduction 1

111 Teleprimary Care in Malaysia 3

12 Problem Statement 5

13 Research Questions 7

14 Research Objectives 8

141 General Objective 8

142 Specific Objectives 8

15 Research Hypotheses 9

16 Significance of the Study 10

17 Literature Review 12

171 Health Delivery System in Sarawak 12

172 The Future of Health Delivery System in Malaysia 13

ix

173 Primary Healthcare Infonnatics in Malaysia 16

174 Teleprimary Care in Sarawak 17

175 Computer Literacy among Health Staff 28

176 Implementation oflnfonnation Technology Application in Healthcare 29

177 Theories explaining Acceptance of Technology 32

178 Summary44

18 Research Framework 47

CHAPTER 2 METHODOLOGY

21 Research Design 50

22 Study Population and Setting 50

221 Population and Setting 50

222 Inclusion and Exclusion Criteria 51

23 Sample Size Calculation 54

231 Sample Size for Quantitative Study 54

232 Sample Size for Qualitative Study 55

24 Sampling Procedure 56

241 Sampling Procedure for Quantitative Study 56

242 Sampling Procedure for Qualitative Study 58

25 Instrument Development 60

251 Study Instrument 61

252 Variables 63

253 Operational Definitions 64

26 Data Collection Procedure 67

x

261 Document Analysis 67

262 Data Collection Procedure for Quantitative Phase 67

263 Data Collection Procedure for Qualitative Phase 68

27 Validity and Reliability Testing 69

271 Validation ofQuestiOlUlaire 70

272 Pilot Study for Quantitative Study 70

273 Pretesting for Qualitative Study 72

28 Data Analysis 73

281 Document Analysis on TPC Utilization 73

282 Quantitative Data Analysis 74

283 Qualitative Data Analysis 74

29 Ethical Consideration 75

210 Duration of Study 77

211 Limitations of Study 78

CHAPTER 3 RESULTS

31 Introduction80


321 Utilization of Teleprimary Care according to Divisions and Centres 81

322 Utilization according to Category of Post (Jan-Jun 2012) 82

323 Summary from Document Analysis 84

33 Quantitative Analysis 85

331 Socio-Demographic Characteristics 85

332 Information related to TPC usage 89

Xl

333 Factors affecting Computer Literacy 95

334 User Acceptance ofTPC 102

335 Perceptions of Users on TPC usage 120

336 Challenges and Barriers Faced by TPC Users 129

337 Comments and Recommendations by TPC Users 131

338 Summary from Quantitative Analysis 132

34 Qualitative Analysis 133

341 Acceptance ofTPC Usage 134


343 Challenges and Barriers Faced by Users 155

344 Comments and Recommendations Users Perspectives 161

345 Supervisors Perceptions of Teleprimary Care 164

346 Summary from Qualitative Analysis 171

CHAPTER 4 DISCUSSION

41 Discussion 172

42 Management Implications 189

CHAPTER 5 SUMMARY AND CONCLUSIONS

51 Summary and Conclusion 191

52 Recommendations 194

521 Recommendations for Future Study 194

522 Recommendations for Future TPC Implementation Strategies 194

xii

BIBLIOGRAPHy 199

APPENDICES

APPENDIX A - List of Teleprimary Care centres in Sarawak 216

APPENDIX B1 - Questionnaire (Quantitative Study) English Version

APPENDIX Gl - Percentage ofTPC usage based on Visit Records from TPC Database and

217

APPENDIX B2 - Questionnaire (Quantitative Study) Malay Version 223

APPENDIX C1 - Informed Consent Form (English Version) 230

APPENDIX C2 - Informed Consent Form (Malay Version) 233

APPENDIX D1 - Researchers Information Form (English Version) 237

APPENDIX D2 - Researchers Information Form (Malay Version) 239

APPENDIX E1 - Interview Guide For Clinic TPC Users 242

APPENDIX E2 - Interview Guide For Clinic Supervisors 245

APPENDIX E3 - Interview Guide For Divisional Supervisors 247

APPENDIX Fl - Approval Letter from MREC 249

APPENDIX F2 - Approval Letter from CRC 250

APPENDIX F3 - Approval Letter from Ethics Committee UNIMAS 251

Workload from HMIS January to June 2012 in Sarawak 252

APPENDIX G2 - Original Research Model Unstandardized Parameter Estimates 254

APPENDIX G3 - Original Model Standardized Parameter Estimates 255

APPENDIX G4 - Modified Model Unstandardized Parameter Estimation 256

APPENDIX G5 - Modified Model Standardized Parameter Estimates 257

APPENDIXH - Research Schedule (Gantt Chart) 258

XIII

LIST OF TABLES

page

Table 1 Internal Consistency for each Factor in Questionnaire prior to Modification 71

Table 2 Modules in Teleprimary Care selected for Different Categories of Users

Table 3 Utilization of Teleprimary Care System by Users according to Different Category

74

ofPost from January to June 2012 84

Table 4 Distribution of the Respondents by Socio-demographic Characteristics (n = 516) 88

91

Table 5 Distribution of the Respondents by Information related to Teleprimary Care usage

Table 6 Distribution of the Respondents by Computer Literacy (n=516) 92

Table 7 Percentage Distribution ofTechnical Supervisory Visits by Teleprimary Care Team

(n=516) 94

Table 8 Percentage Distribution of Administrative Supervisory Visits (n=516) 94

Table 9 Factors affecting Computer Literacy Bivariate Analysis (n=516) 98

Table 10 Faotors influencing Computer Literacy among TPC users Multinomial Logistic

Regression Analysis 101

106

Table II Distribution of Respondents by Factors affecting Acceptance to use TPC (n=516)

Table 12 Distribution of Respondents by Intention to use TPC (n=516) 108

Table 13 Pearson Correlations between Predictor and Dependent Variables (n=516) 110

Table 14 Means and Standard Deviations for Predictor Variables and Dependent Variable

for Model Testing (n=516) 112

Table 15 Factors affecting Intention to Use TPC Standard Multiple Linear Regression

Analysis (n=442) 112

xiv

Analysis of Overall Model Goodness-of-Fit for Original Research Model 114

Analysis of Overall Model Goodness-of-Fit for Modified ModeL 117

Distribution of the Respondents by Perception on TPC Usage 122

Factors affecting Preferred Method of Documentation Bivariate Analysis (n=350)

125

Factors affecting Preference between Teleprimary Care and Current Paper-based

System Binary Logistic Regression 128

Challenges and Barriers faced by TPC Users (n=516) 130

Comments to improve TPC Usage (n=516) l32

xv

LIST OF FIGURES

page

Figure 1 Network Architecture of Teleprimary Care prior to Migration ofNetwork (Adopted

from the presentation slide by Fauziah 2010) 22

Figure 2 Database Architecture of Teleprimary Care (Adopted from the presentation slide by

Figure 11 Research Framework on Acceptance of Teleprimary Care and Factors affecting it49

Figure 16 Percentage ofTPC usage based on Visit Records from TPC Database and

Rebi amp Pairan 2012) 22

Figure 3 Distributed Multi-Tier Architecture used in Teleprimary Care (Raili et al 2006) 24

Figure 4 Theory of Reasoned Action (Fishbein and Ajzen 1975) 34

Figure 5 Reciprocal Determinism in Social Cognitive Theory (Compeau amp Higgins 1995) 35

Figure 6 Theory of Planned Behaviour (Ajzen 1991 ) 36

Figure 7 Technology Acceptance Model (Davis 1989) 38

Figure 8 Extended Technology Acceptance Model (Venkatesh and Davis 2000) 39

Figure 9 The Model of PC Utilization (Thompson et al 1991) 41

Figure 10 Unified Theory of Acceptance and Use of Technology (Venkatesh et al 2003) 45

Figure 12 Sampling Frame for Quantitative Data Collection 52

Figure 13 Sampling Method for Quantitative Phase of Study 57

Figure 14 Sampling Method for Qualitative Phase of Study 60

Figure 15 Data Collection Procedure for 9uantitative Phase of Study 69


Figure 17 Computer Literacy of Respondents (n=516) 92

Figure 18 Framework on Utilization of Teleprimary Care (Original Model) 116

xvi

19 Framework on Utilization of Teleprimary Care (Original Model) (Standardized

estimates) 116

igure 20 Framework on Utilization of Teleprimary Care (Modified Model) (Unstandardized

Figure 21 Framework on Utilization of Teleprimary Care (Modified Model) (Standardized

estimates) 119

estimates) 119

Figure 22 Any Challenges or Barriers faced(n=516) 130

xvii

LIST OF ABBREVIATIONS

ACG = Adjusted Clinical Group

AMO = Assistant Medical Officer

BPKK = Bahagian Pembangunan Kesihatan Keluarga (FHDD)

CI = Confidence Interval

df = Degree of Freedom

DHO = Divisional Health Office

FHDD = Family Health Development Division

ICT = Information and Communication Technology

lOT = Innovation Diffusion Theory

IT = Information Technology

JM = Jururawat Masyarakat (Community Nurse)

JPL = Jabatan Pesaldt Luar (Out-patient Department)

Lab = Laboratory

LAN = Local Area Network

KK = Klinik Kesihatan (Health Clinic)

KKIA = Klinik Kesihatan Ibu dan Anak (Maternal and Child Health Clinic)

KKM = Kementerian Kesihatan Malaysia (Malaysian Ministry ofHealth)

MA = Medical Assistant (now known as Assistant Medical Officer)

MCH = Maternal and Child Health Clinic

MO = Medical Officer

xviii

------------ --

= Ministry of Health

= Model of Personal Computer Utilization

= Personal Computer

= Pejabat Kesihatan Bahagian (Divisional Health Office)

= Person Management System

= Senior Assistant Medical Officer

= Social Cognitive Theory

= Standard Deviation

= Structural Equation Modeling

= Sasaran Kerja Tahunan

= Technology Acceptance Model

= Extended Technology Acceptance Model

= Theory of Planned Behaviour

1PC = Teleprimary Care

TRA = Theory of Reasoned Action

DNlMAS = Universiti Malaysia Sarawak

UTAUT = Unified Theory of Acceptance and Use ofTechnology

= Very Small Aperture Terminal

WHO = World Health Organization

XIX

CHAPTERl

INTRODUCTION LITERATURE REVIEW

The use of Internet for e-health or medical infonnatics and related technologies to

deliver or improve health services and infonnation has been an emerging field in healthcare

DIII18gement worldwide (Eysenbach 2001) Within this field the World Health Organisation

(WHO) has identified Telemedicine as a possible application to strengthen health systems and

improve the quality of health care delivery in rural areas (WHO 2010) In Malaysia health

management infonnation system such as Teleprimary Care (TPC) were also expected to

show great potential in providing substantial benefits to healthcare providers healthcare

organizations and patients These electronic systems were believed to be able to facilitate the

workflow in healthcare organization improve quality of patient care and enhance patient

safety in management (Brinfo nd)

Teleprimary Care was launched in Malaysia in the year 2004 Till date there are 88

clinics and seven hospitals equipped with TPC system throughout Malaysia (BPKK 2012

BomeoPost Online 2013) TPC system has been designed to provide many functions to help

bealth managers in delivering more efficient health services and having easier monitoring of

the health status of the community However until now TPC has functioned mainly as an

electronic medical record system for storage and retrieving of patients medical data The use

ofTPC for other functions has been limited

Before the introduction of TPC system patients clinical records were documented in

writing and were subjected to errors The conventional system involved tedious paperwork

which required great amount of resources in tenns of time money and manpower both in

ilCOlrdiIll2 and data extraction Many of these surveillance data collected were left aside and

used to its fullest due to the lengthy procedures required to extract information from piles

files and documents Teleprimary Care system was then created with the hope to improve

health information system by providing more timely and accurate information to help

iWMlnvp health status monitoring With TPC system the communication between healthcare

IIImJrittft in rural areas with specialists in hospitals will also be improved as sharing of

PfOlma1tion can be done more effectively

Introduction of TPC in the healthcare system would also mean a major change from

current paper-based documentation system to a fully computerized management system

to this major change should be well expected and anticipated during its

The greatest challenge remains having all the eligible TPC users to

iftMmiddotIVrAt TPC into their routine daily work Despite the great potential in improving the

_Iitv of health care service delivery the positive impact from TPC will only be discerned if

users access and utilize the functions of TPC regularly Therefore understanding of the

1acceDtanCe of TPC among the users and factors affecting their acceptance are crucial for the

~Jaonirlg of a more efficient implementation of TPC in the country Unfortunately the

I tnl[)wlledle and empirical research on the adoption ofTPC currently is still limited in general

The purpose of this study was to gather data regarding usage of TPC system among

the users The data would then be used to explore the socio-demographic characteristics of the

1I8etS their acceptances as well as the factors which may predict their utilization of the TPC

system The acceptance of users towards TPC was assessed through their intentions to use the

system The study also intended to set a platform for the TPC users to voice their perceptions

barriers faced when using the system and to gather the users opinions and priorities in

the current TPC implementation All these information are important in healthcare

2

lIiIDagemelnt for future plaruting to improve TPC implementation in Sarawak as well as other

Teleprimary Care in Malaysia

Teleprimary Care system is a method of delivering a wide range of healthcare services

community by integrating primary and secondary care via Information and

~DDlunication Technologies (lCT) It covers a wide range of functions including disease

epidemic management and technical support services such as laboratory

_OIOjn and pharmacy (Brinfo nd)

The Malaysian Ministry of Health developed TPC as an electronic clinic management

to link clinics to hospitals in an area It was implemented in 2004 as a pilot project in

rlUaWlltlc and Jobor at an initial cost of RM245 million (Sarawak State Health Department

By the end of 2009 the system has expanded to Pedis Selangor Kuala Lumpur

and Pahang (Utusan Online 2009)

In addition to centralized electronic medical records TPC also has many other

Jeabm~ including tele-referral tele-consultation auto-notification of infectious disease and

1iItItraquo-2cmelaii()n of reports It also facilitates collection and analysis of health data and allows

~lISUIltation and joint management between facilities such as between clinics and hospitals

is indeed a tool to help improve the quality of care in clinics especially in remote and

iIICCClSiblle localities of Sarawak by bringing specialist care closer to patients and reducing

__cgtnal isolation of health staff working there (Sarawak State Health Department 2009)

The TPC application integrates various services available in health clinics and links

to related specialist clinics in larger hospitals Presently TPC only involves disciplines

are available in primary healthcare clinics such as internal medicine paediatrics

3

Pusat Kbidmat Maklunaat Akademik UNJVEltSm MALAYSIA SARAWAK

ACCEPTANCE AND UTILIZATION OF TELEPRIMARY CARE IN

SARAWAK PKHIDMAT MAKLUMAT AKADEMIK

1111 1lIlIlll~ii 111111111 1000246994

HOAI CHIA

A dissertation submitted in partial fulfilment of the requirements for the degree

ofDoctor ofPublic Health

Faculty of Medicine and Health Sciences

UNIVERSITI MALA YSIA SARA W AK

2013

ABSTRACT






























11

~------------------------------------ ----shy

ABSTRAK























iii


















lV

DECLARATION



higher learning

Signature

Name HOAICHIA

Date 27 MAY 2013

v

ACKNOWLEDGEMENTS


















throughout my study




VI




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

ABSTRACT






























11

~------------------------------------ ----shy

ABSTRAK























iii


















lV

DECLARATION



higher learning

Signature

Name HOAICHIA

Date 27 MAY 2013

v

ACKNOWLEDGEMENTS


















throughout my study




VI




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3







11

~------------------------------------ ----shy

ABSTRAK























iii


















lV

DECLARATION



higher learning

Signature

Name HOAICHIA

Date 27 MAY 2013

v

ACKNOWLEDGEMENTS


















throughout my study




VI




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

ABSTRAK























iii


















lV

DECLARATION



higher learning

Signature

Name HOAICHIA

Date 27 MAY 2013

v

ACKNOWLEDGEMENTS


















throughout my study




VI




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3


















lV

DECLARATION



higher learning

Signature

Name HOAICHIA

Date 27 MAY 2013

v

ACKNOWLEDGEMENTS


















throughout my study




VI




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

DECLARATION



higher learning

Signature

Name HOAICHIA

Date 27 MAY 2013

v

ACKNOWLEDGEMENTS


















throughout my study




VI




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

ACKNOWLEDGEMENTS


















throughout my study




VI




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3




















required to do so





vii


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3


given to me


















HoAiChia

viii


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3


TABLE OF CONTENTS

page

ABSTRACT i


ABSTRAK iii

DECLARATION v

ACKNOWLEDGEMENTS vi


LIST OF TABLES xiv

LIST OF FIGURES xvi


11 Introduction 1












ix






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3






178 Summary44















252 Variables 63



x








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3








28 Data Analysis 73







CHAPTER 3 RESULTS

31 Introduction80








Xl















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3















41 Discussion 172







xii

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

BIBLIOGRAPHy 199

APPENDICES




217


















XIII

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

LIST OF TABLES

page




74



91




(n=516) 94





106








xiv





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3





125





xv

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

LIST OF FIGURES

page






















xvi


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3


estimates) 116



estimates) 119

estimates) 119


xvii














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3














Lab = Laboratory








xviii

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

------------ --



= Personal Computer

















XIX

CHAPTERl














































2























3

CHAPTERl














































2























3

























2























3























3

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ACCEPTANCE AND UTILIZATION OF TELEPRIMARY CARE IN … and utilization of... · ACCEPTANCE AND UTILIZATION OF TELEPRIMARY CARE IN SARAWAK . HoAi Chia . Doctor of Public Health . 2013