PERENCANAAN BEKERJADALAM KEMITRAAN DENGAN PEREMPUAN

DAN TIM MULTIDISIPLIN

TUGASMata Kuliah Manajemen Pelayanan Kebidanan

Dosen Pembimbing :

Dr. Emi Nurjasmi, M.Kes

Oleh :Kelompok IV

Rulfia Desi Elmispendriya Gusna

Indri Putri SariDian Febrida Sari

Laila RahmiEtika Mulia Sari

Irma Seriana

PROGRAM STUDI S2 KEBIDANANPASCASARJANA UNIVERSITAS ANDALAS PADANG

T.A 2012/ 2013

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KATA PENGANTAR

Puji syukur penulis ucapkan kehadirat Allah SWT yang selalu melimpahkan rahmat

dan karunia-Nya serta nikmat kesehatan kepada penulis sehingga penulis dapat

menyelesaikan Tugas dengan judul “Perencanaan Bekerja dalam Kemitraan

dengan Perempuan dan Tim Multidisiplin” pada mata kuliah Manajemen Asuhan

Kebidanan Program Studi S2 Kebidanan Pascasarjana Universitas Andalas Padang

T.A 2013/ 2014 ini dapat diselesaikan. Shalawat beserta salam senantiasa tercurah

untuk Baginda Rasulullah SAW, sebagai simpul mata rantai agung seluruh

kebenaran, penyejuk dan penerang bagi umat manusia.

Penulis menyadari masih banyak kekurangan dalam penyusunan penugasan

ini, namun penulis berharap dengan kekurangan tersebut tidak mengurangi makna

dan tujuan dari penugasan ini.

Akhir kata hanya kepada-Nya lah kita semua kembali, semoga kita semua

mendapatkan karunia dan ridho dari-Nya sehingga menjadi cendikiawan yang

berguna, Amin.

Padang, Mai 2013

Penulis

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DAFTAR ISI

KATA PENGANTAR............................................................................................ i

DAFTAR ISI ........................................................................................................ ii

BAB I PENDAHULUAN

BAB II PEMBAHASAN

A. Strategi Making Pregnancy Safer .................................................... 4

B. Bidan Sebagai Ujung TombakPelayanan Kesehatan Ibu dan Anak................................................. 6

C. Langkah Membangun Kemitraan .................................................... 12

BAB III PENUTUP

DAFTAR PUSTAKA

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BAB IPENDAHULUAN

Istilah bidan mencerminkan filsafat peduli; satu yang lebih khusus diarahkan

pada individu wanita dan kebutuhan reproduksi. Seorang bidan biasanya

menawarkan berbagai pilihan dan berusaha untuk menghilangkan atau

meminimalkan intervensi yang tidak perlu. Pelayanan/ praktik kebidanan didasarkan

pada philosophy kebidanan. Pada intinya, filsafat kebidanan menganggap bahwa

kelahiran yang aman, indah dan proses normal. Praktik kebidanan didasarkan pada

pemahaman bahwa kehamilan, persalinan dan kelahiran adalah pengalaman

mendalam yang membawa arti penting bagi seorang wanita, keluarga dan masyarakat

Praktik kebidanan menggabungkan seni dengan teoritis dan pengetahuan

berbasis penelitian untuk memungkinkan wanita dan bayi mencapai kesehatan yang

optimal. Pengetahuan berbasis penelitian untuk memungkinkan wanita dan bayi

mencapai kesehatan optimal dari prasangka, melalui kehamilan, persalinan, kelahiran

dan periode neonatal. Bidan menggunakan pengetahuan ilmiah ketika

mempromosikan, melindungi dan mendukung menyusui untuk memberikan yang

optimal kepada mereka dengan informasi dan bantuan yang diperlukan. Praktik

kebidanan menyediakan kesinambungan layanan antara bidan dan perempuan dari

prasangka, melalui kehamilan, persalinan, kelahiran, dan postpartum. Perawatan

kebidanan terjadi dalam kemitraan dengan perempuan dan keluarganya yang

didasarkan pada saling menghormati dan disediakan dalam cara yang holistik,

fleksibel, kreatif, memberdayakan dan mendukung. Perawatan kebidanan harus

tersedia sebagai pilihan untuk semua wanita, baik itu wanita tanpa komplikasi atau

dengan komplikasi kehamilan, terlepas dari lokasi geografis, status sosial ekonomi,

usia, latar belakang kebudayaan, orientasi gender dan agama. Mempromosikan

praktik kebidanan sebagai pengambilan keputusan bersama, tanggung jawab antara

wanita, keluarganya, dan penyedia layanan. Bidan menyediakan informasi yang

lengkap, akurat dan obyektif serta membantu wanita untuk mengambil keputusan.

Perawatan kebidanan dapat diatur, tetapi yang paling penting adalah memberdayakan

perempuan untuk menentukan pilihan dan mengambil keputusan.

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BAB IIPEMBAHASAN

Istilah bidan mencerminkan filsafat peduli; satu yang lebih khusus diarahkan

pada individu wanita dan kebutuhan reproduksi. Seorang bidan biasanya

menawarkan berbagai pilihan dan berusaha untuk menghilangkan atau

meminimalkan intervensi yang tidak perlu. Pelayanan/ praktik kebidanan didasarkan

pada philosophy kebidanan. Pada intinya, filsafat kebidanan menganggap bahwa

kelahiran yang aman, indah dan proses normal. Praktik kebidanan didasarkan pada

pemahaman bahwa kehamilan, persalinan dan kelahiran adalah pengalaman

mendalam yang membawa arti penting bagi seorang wanita, keluarga dan

masyarakat. Kebidanan didasarkan pada keyakinan bahwa memiliki bayi adalah

proses kehidupan alam dan kesempatan bagi pertumbuhan yang cukup besar. Tujuan

dari perawatan kebidanan adalah untuk meningkatkan pengalaman hidup ini. Praktik

kebidanan didasarkan pada konsep kesehatan dan kesejahteraan. Melahirkan anak

dipandang sebagai proses fisiologis yang normal untuk sebagian besar perempuan,

dan pengalaman hidup utama bagi semua perempuan dan keluarga mereka.

Kebidanan didasarkan pada penghormatan terhadap perempuan dan keyakinan yang

kuat dalam nilai pekerjaan perempuan melahirkan dan membesarkan setiap generasi.

Bidan bekerja secara otonom dan bekerjasama dengan perawatan lain untuk

meningkatkan kesehatan dan kesejahteraan pada perempuan, bayi dan keluarga.

Praktik kebidanan menggabungkan seni dengan teoritis dan pengetahuan

berbasis penelitian untuk memungkinkan wanita dan bayi mencapai kesehatan yang

optimal. Pengetahuan berbasis penelitian untuk memungkinkan wanita dan bayi

mencapai kesehatan optimal dari prasangka, melalui kehamilan, persalinan, kelahiran

dan periode neonatal. Bidan menggunakan pengetahuan ilmiah ketika

mempromosikan, melindungi dan mendukung menyusui untuk memberikan yang

optimal kepada mereka dengan informasi dan bantuan yang diperlukan. Praktik

kebidanan menyediakan kesinambungan layanan antara bidan dan perempuan dari

prasangka, melalui kehamilan, persalinan, kelahiran, dan postpartum. Perawatan

kebidanan terjadi dalam kemitraan dengan perempuan dan keluarganya yang

didasarkan pada saling menghormati dan disediakan dalam cara yang holistik,

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fleksibel, kreatif, memberdayakan dan mendukung. Perawatan kebidanan harus

tersedia sebagai pilihan untuk semua wanita, baik itu wanita tanpa komplikasi atau

dengan komplikasi kehamilan, terlepas dari lokasi geografis, status sosial ekonomi,

usia, latar belakang kebudayaan, orientasi gender dan agama. Mempromosikan

praktik kebidanan sebagai pengambilan keputusan bersama, tanggung jawab antara

wanita, keluarganya, dan penyedia layanan. Bidan menyediakan informasi yang

lengkap, akurat dan obyektif serta membantu wanita untuk mengambil keputusan.

Perawatan kebidanan dapat diatur, tetapi yang paling penting adalah memberdayakan

perempuan untuk menentukan pilihan dan mengambil keputusan. Bidan

menghormati hubungan mereka dengan wanita dan keluarganya, menjaga

kerahasiaan informasi yang diperoleh, dan hanya berbagi informasi terkait dengan

izin wanita atau berkaitan dengan hukum.

Pada prinsipnya asuhan yang diberikan oleh bidan kepada pasien harus

berdasarkan filosofi kebidanan. Beberapa keyakinan sebagai arahan bidan dalam

memberikan asuhan:

1. Kehamilan dan persalinan:

a. Merupakan proses alamiah/ fisiologis

b. Merupakan pengalaman yang sangat bermakna bagi perempuan, keluarga dan

masyarakat.

c. Akan membawa risiko bagi kehidupan ibu dan bayi bila terjadi kesalahan

dalam proses

2. Perempuan:

a. Pribadi yang memiliki hak, kebutuhan dan harapan.

b. Harus berpartisipasi aktif dalam pelayanan selama kehamilan, persalinan, dan

nifas.

c. Membuat pilihan dan keputusan tentang pelayanan.

d. Diperhatikan dan dihargai selama kehamilam, persalinan, dan nifas

e. Ibu dan keluarga adalah pusat asuhan kebidanan.

3. Fungsi profesi dan manfaatnya:

a. Mengupayakan kesehatan ibu dan bayinya.

b. Bidan mempunyai “power” untuk mempengaruhi/ memberikan asuhan

kebidanan.

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c. Proses yang fisiologis harus dihargai, didukung dan dipertahankan, tapi bila

ada penyulit gunakan teknologi yang referal dan aktif agar bayi dan ibu sehat

4. Pemberdayaan dan pengambilan keputusan:

a. Perempuan harus diberdayakan dalam pengambilan keputusan melalui KIE

dan Konseling

b. Keputusan merupakan kesepakatan bersama antara bidan dengan ibu sebagai

penentu utama dalam proses pengambilan keputusan

5. Tentang asuhan :

a. Difokuskan pada aspek prevensi, promosi kesehatan dan kealamiahannya.

b. Menyediakan informasi yang obyektif, relevan guna memfasilitasi penentu

pilihannya.

c. Dilaksanakan secara kreatif, fleksible, mendukung, melayani, membimbing,

memonitoring, dan mendidik.

d. Dilakukan secara kontinyu, individual, dan tidak otoriter

e. Harus aman, memuaskan, menghormati, dan memberdayakan perempuan dan

keluarganya.

A. Strategi Making Pregnancy Safer

1. Peningkatan akses dan kualitas pelayanan kesehatan Ibu, Bayi Baru Lahir di

tingkat pelayanan dasar dan rujukan.

2. Membangun kemitraan yang efektif.

3. Mendorong pemberdayaan perempuan, keluarga, dan masyarakat.

4. Penguatan manajemen program KIA: sistem survailans, monitoring, dan

informasi KIA dan pembiayaan.

Ibu meninggal disebabkan karena tidak mempunyai akses ke pelayanan kesehatan

ibu berkualitas, terutama pelayanan kegawatdaruratan tepat waktu yang

dilatarbelakangi kejadian:

1. Terlambat mengenal tanda bahaya dan mengambil keputusan

2. Terlambat mencapai fasilitas kesehatan

3. Terlambat mendapatkan pelayanan di fasilitas kesehatan

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Peningkatan Akses dan Kualitas Pelayanan Kesehatan Ibu, Bayi Baru Lahir

1. Keluarga Berencana

a. Penyediaan pelayanan KB gratis bagi Gakin

b. Penyediaan Alokon

c. Menurunkan kejadian Unmet Need dan 4 terlalu

2. Pelayanan Antenatal

a. Peningkatan kualitas: pemeriksaan laboratorium, konseling, imunisasi dan

gizi.

b. Integrasi dengan program terkait: IMS, HIV, Malaria, TB dan kecacingan.

c. Program perencanaan persalinan dan pencegahan komplikasi (P4K)

3. Pertolongan persalinan

a. Kemiteraan bidan – dukun

b. Persalinan dengan MAK III

c. Pertolongan persalinan di fasilitas kesehatan

4. Pelayanan masa nifas

a. Ibu

b. Neonatus

c. Dilakukan sedini mungkin

5. Penanganan Komplikasi

Penyediaan Puskesmas mampu PONED dan RS mampu PONEK yang berfungsi

menurunkan CFR

Pemberdayaan Perempuan, Keluarga dan Masyarakat

1. Pendidikan kesehatan reproduksi remaja di sekolah (formal dan non formal) dan

non sekolah.

2. Promosi tentang kesehatan reproduksi pada masyarakat termasuk pemerintah.

3. Peningkatan pengetahuan dan kesiapan tentang bahaya kehamilan, persalinan dan

nifas: Desa Siaga, GSI, pemanfaatan Buku KIA dan P4K

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B. Bidan Sebagai Ujung Tombak Pelayanan Kesehatan Ibu dan Anak

Peningkatan Akses dan Kualitas Pelayanan Maternal dan Neonatal

1. Di masyarakat (Pelayanan esensial, deteksi kasus risti + PPGDON di Polindes/

Poskesdes).

2. Puskesmas (Pelayanan esensial, deteksi kasus risti + PONED (Tim PONED).

3. RS. Kabupaten/ Kota

4. (Pelayanan esensial, deteksi kasus risti + PONEK (Tim PONEK)

5. Pemantapan jaringan pelayanan obstetri dan neonatal di wilayah kabupaten/ kota.

6. Peningkatan Kemitraan (Lintas sektor dan program).

7. Jamkesmas

Prinsip Pelayanan Kebidanan di Desa

1. Pelayanan di komunitas desa sifatnya multi disiplin meliputi ilmu kesehatan

masyarakat, kedokteran, sosial, psikologi, komunikasi, ilmu kebidanan, dan lain-

lain yang mendukung peran bidan di komunitas.

2. Dalam memberikan pelayanan di desa bidan tetap berpedoman pada standar dan

etika profesi yang menjunjung tinggi harkat dan martabat manusia.

3. Dalam memberikan pelayanan bidan senantiasa memperhatikan dan memberi

penghargaan terhadap nilai-nilai yang berlaku di masyarakat, sepanjang tidak

merugikan dan tidak bertentangan dengan prinsip kesehatan.

Ukuran keberhasilan bidan dalam pelayanan di komunitas/ desa tidak hanya

penurunan AKI dan AKB, tapi juga bangkitnya gerakan masyarakat untuk mengatasi

masalah dan memenuhi kebutuhan kesehatan serta kualitas hidupnya.

Dapat disimpulkan bahwa:

1. Pada hakekatnya masyarakat mempunyai hak memperoleh pelayanan yang

berkualitas, sehingga Ibu Sehat Bayi sehat, selanjutnya juga Bangsa yang sehat.

2. Bidan sebagai pemberi jasa harus menjaga mutu pelayanan dan melayani sesuai

kebutuhan (mitra perempuan).

3. Bidan harus tetap meningkatkan kemampuan.

4. Bidan sebagai tenaga kesehatan pada lini terdepan (ujung tombak).

5. Bidan punya kebutuhan dan harapan (kesejahteraan, masa depan dan keamanan).

6. Pemerintah bertanggungjawab menyediakan yankes (Sarana prasana, SDM dll

(Sustainability dan Jamkesmas)

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7. Pemerintah dan OP melakukan pengawasan dan pembinaan

Kesenjangan Kebijakan dan Implementasi Kebijakan Kesehatan Reproduksi

Penurunan Kematian Ibu di Indonesia Gerakan Sayang Ibu:

1. Indonesia ikut mendukung WSC (1990), yakni bersepakat untuk menurunkan

AKI menjadi separuh pada tahun 2000 (225 per 100.000 kelahiran) dan

meningkatkan layanan keluarga berencana bagi yang membutuhkan.

2. BKKBN melancarkan Kampanye Ibu Sehat Sejahtera (KISS), kemudian

diperbaharui menjadi Gerakan Keluarga Sehat Sejahtera (GKSS).

3. Perbaikan kualitas layanan antenatal untuk mengenali secara dini kehamilan

risiko tinggi – program bidan di desa.

4. Pada tahun 1996 dicanangkan Gerakan Sayang Ibu

Pokok Permasalahan

1. Rendahnya akses penduduk miskin pada layanan kesehatan yang berkualitas

sehingga status kesehatan mereka tertinggal dibandingkan dengan kelompok

masyarakat yang lebih mampu.

2. Motivasi rendah khususnya untuk penempatan di daerah terpencil dan miskin.

3. Kebijakan insentif yang lemah.

4. Dwi-fungsi memberikan insentif yang lebih kuat bagi petugas kesehatan untuk

bekerja di pusat-pusat pertumbuhan.

5. Program PTT dan berbagai insentif yang dikembangkan belum berhasil

mengatasi kesenjangan geografis.

6. Decentralisasi secara nyata semakin memperburuk skema insentif dan semakin

melemahkan sistem informasi kesehatan

Quality of Care

Bidan setelah mengenali kondisi gawatdarurat kebidanan perlu segera merujuk

ibu bersalin ke sistem rujukan yang handal. Namun, tidak jarang sistem rujukan yang

tersedia belum didukung kompetensi klinis dan kelengkapan peralatan medis yang

tersedia masih sub-standar. Peran bidan adalah mengenali kasus gawat darurat,

merujuk dan memfasilitasi proses rujukan.

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Tantangan AKI di Indonesia

Masih rendahnya cakupan perawatan antenatal dan persalinan oleh nakes terlatih –

rendahnya posisi tawar perempuan. Penyebab utama AKI di Indonesia adalah

perdarahan dan infeksi, di balik angka ini tersembunyi abortus:

1. Ditaksir 2,3 juta abortus (tidak aman) terjadi setiap tahun di Indonesia.

2. 1 juta keguguran spontan.

3. 700.000 karena tidak menggunakan alkon – kehamilan tidak diinginkan.

4. 600.000 karena kegagalan KB.

15% aborsi dilakukan oleh kelompok usia <20 tahun (remaja) – tidak ada akses

pada alat kontrasepsi

Beberapa kajian tentang Bidan di desa menunjukkan bdi daerah terpencil Bidan di

Desa dituntut juga untuk melakukan asuhan perawatan anak, dan fungsi kuratif di

samping asuhan rawatan kehamilan/ persalinan. Selain itu utilisasi layanan kesehatan

masih rendah di desa, fungsi rujukan masih jauh dari optimal. Apakah masalahnya

terletak pada suplai atau demand? Sekalipun masyarakat miskin sudah dijamin

(askeskin, jamkesmas) untuk layanan kuratif, bagaimana dengan transportasi?

Catatan atas Kebijakan Kesehatan

1. Sektor swasta belum lagi diperhitungkan dalam perencanaan kesehatan, padahal

kontribusinya pada kespro sangat bermakna khususnya di perkotaan.

2. Merupakan kenyataan bahwa kebijakan publik masih belum menyentuh

persoalan publik yang semakin hari semakin merupakan ancaman: pengendalian

tembakau (Indonesia belum bersedia meratifikasi FCTC), pergeseran pola diit

yang semakin memburuk – junk food menjadi makanan trendy?, kebijakan

kesehatan masih fokus pada layanan kuratif (UKP?)

Indikator Sistem Informasi Manajemen Kesehatan Ibu dan Anak

Target global penurunan Angka Kematian Ibu (AKI) MDGs (Millenium

Development Goals sebesar tiga-perempatnya pada tahun 2015. Sementara target

penurunan Angka Kematian Bayi (AKB) dan Angka Kematian Balita (AKABA)

sebesar dua-pertiga. Berdasarkan kesepakat global tersebut Indonesia mempunyai

komitmen untuk menurunkan Angka Kematian Ibu menjadi 102/100.000 Kelahiran

Hidup (KH), Angka Kematian Bayi dari 68 menjadi 23/1.000 KH, dan Angka

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Kematian Balita 97 menjadi 32/1.000 KH pada tahun 2015. Jika dilihat dari potensi

untuk menurunkan Angka kematian Ibu (AKI) masih on track walaupun diperlukan

sumber daya yang kompeten (Pedoman Pengawasan Wilayah Setempat Kesehatan

Ibu dan Anak, Depkes RI. 2009).

Terkait dengan tujuan dan target diatas, kemudian diterapkan berbagai

strategi untuk menurunkan AKI-AKABA, maupun AKB, sehingga tetap on the track

menuju target MDGs. Dan salah satu strategi ini, diantaranya dengan penerapan

system informasi manajemen kesehatan ibu dan anak, dengaan penerapan

pemantauan wilayan setempat (PWS) KIA.

Menurut Davis (1992), pada dasarnya, Sistem Informasi Manajemen

merupakan sistem manusia atau mesin yang terpadu guna menyajikan informasi

untuk mendukung fungsi operasional, manajemen dan pengambilan keputusan di

dalam suatu organisasi. Sementara menurut Jogiyanto (2009), sistem informasi

manajemen dapat digunakan untuk mendukung kegiatan-kegiatan yang ada di fungsi-

fungsi bisnis. Sistem informasi di fungsi-fungsi organisasi yang memanfaatkan basis

data (data base) ini untuk pelaporan-pelaporan manajemen ini disebut dengan sistem

informasi bisnis (business information systems).

Alur Pencatatan, Pengolahan, dan Pemanfaatan Data PWS KIA

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Menurut Jogiyanto (2009), manajemen dengan menggunakan pendekatan

sistem informasi merupakan langkah yang mengarah pada peningkatan efisiensi dan

efektifitas kerja. Untuk menjadi suatu sistem informasi maka hasil dari sistem itu

harus berupa informasi yang berguna dan didukung oleh tiga pilar sebagai berikut:

tepat kepada orangnya atau relevan (relevance), tepat waktu (timeliness) dan tepat

nilainya atau akurat (accurate). Sistem informasi mempunyai enam komponen yaitu

input, model, output, teknologi, basis data dan control.

Terkait dengan sistem informasi tersebut, khusunya pada pelaksanaan proram

KIA, sejak tahun 1985, di Indonesia telah diaplikasikan alat pemantauan program

dengan Pemantauan Wilayah Setempat (PWS). Pemantauan Wilayah Setempat dapat

digunakan sebagai alat manajemen untuk melakukan pemantauan program di suatu

wilayah kerja secara terus menerus, agar dapat dilakukan tindak lanjut yang cepat

dan tepat. Program PWS KIA dapat memantau program KIA yang meliputi

pelayanan ibu hamil, ibu bersalin, ibu nifas, ibu dengan komplikasi kebidanan,

keluarga berencana, bayi baru lahir, bayi baru lahir dengan komplikasi, bayi, dan

balita. Adapun kegiatan PWS KIA terdiri dari pengumpulan, pengolahan, analisis

dan interpretasi data serta penyebarluasan informasi ke penyelenggara program dan

pihak/ instansi terkait dan tindak lanjut.

Beberapa indikator pemantauan program KIA yang dipakai untuk PWS KIA

meliputi indikator yang dapat menggambarkan keadaan dalam program pokok KIA

sebagai, antara lain :

1. Akses pelayanan antenatal (K1)

Adalah cakupan ibu hamil yang pertama kali mendapat pelayanan antenatal oleh

tenaga kesehatan di suatu wilayah kerja pada kurun waktu tertentu. Indikator

akses ini digunakan untuk mengetahui jangkauan pelayanan antenatal serta

kemampuan program dalam menggerakkan masyarakat.

2. Cakupan pelayanan ibu hamil (K4)

Adalah cakupan ibu hamil yang telah memperoleh pelayanan antenatal sesuai

dengan standar, paling sedikit empat kali dengan distribusi waktu 1 kali pada

trimester satu, 1 kali pada trimester dua, dan 2 kali pada trimester tiga di suatu

wilayah kerja pada kurun waktu tertentu. Dengan indikator ini dapat diketahui

cakupan pelayanan antenatal secara lengkap (memenuhi standar pelayanan dan

menepati waktu yang ditetapkan), yang menggambarkan tingkat perlindungan ibu

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hamil di suatu wilayah, di samping menggambarkan kemampuan manajemen

ataupun kelangsungan program KIA.

Alur Pencatatan Manual Pelayanan KIA oleh Bidan

3. Cakupan persalinan oleh tenaga kesehatan (PN)

Adalah cakupan ibu bersalin yang mendapat pertolongan persalinan oleh tenaga

kesehatan yang memiliki kompetensi kebidanan, di suatu wilayah kerja dalam

kurun waktu tertentu. Dengan indikator ini dapat diperkirakan proporsi

persalinan yang ditangani oleh tenaga kesehatan dan ini menggambarkan

kemampuan manajemen program KIA dalam pertolongan persalinan sesuai

standar.

4. Cakupan pelayanan nifas oleh tenaga kesehatan (KFIII)

Adalah cakupan pelayanan kepada ibu pada masa 6 jam sampai dengan 42 hari

pasca bersalin sesuai standar paling sedikit 3 kali dengan distribusi waktu 6 jam

sampai dengan 3 hari, 8 sampai dengan 14 hari dan 36 sampai dengan 42 hari

setelah bersalin di suatu wilayah kerja pada kurun waktu tertentu. Dengan

menggunakan indikator tersebut, dapat diketahui cakupan pelayanan nifas secara

lengkap (memenuhi standar pelayanan dan menepati waktu yang ditetapkan),

yang menggambarkan jangkauan dan kualitas pelayanan kesehatan ibu nifas,

11

disamping menggambarkan kemampuan manajemen ataupun kelangsungan

program KIA.

5. Cakupan pelayanan neonatus pertama (KN I)

Adalah cakupan neonatus yang mendapatkan pelayanan sesuai standar pada 6 –

48 jam setelah lahir di suatu wilayah kerja pada kurun waktu tertentu. Dengan

indikator ini dapat diketahui akses/jangkauan pelayanan kesehatan neonatal.

6. Cakupan pelayanan neonatus Lengkap (KN Lengkap).

Adalah cakupan neonatus yang mendapatkan pelayanan sesuai standar sedikitnya

tiga kali yaitu 1 kali pada 6 – 48 jam, 1 kali pada hari ke-3 sampai hari ke-7, dan

1 kali pada hari ke-8 sampai hari ke-28 setelah lahir disuatu wilayah kerja pada

kurun waktu tertentu. Dengan indikator ini dapat diketahui efektifitas dan

kualitas pelayanan kesehatan neonatal.

7. Deteksi faktor risiko dan komplikasi oleh Masyarakat

Adalah cakupan ibu hamil dengan faktor risiko atau komplikasi yang ditemukan

oleh kader atau dukun bayi atau masyarakat serta dirujuk ke tenaga kesehatan di

suatu wilayah kerja pada kurun waktu tertentu. Indikator ini menggambarkan

peran serta dan keterlibatan masyarakat dalam mendukung upaya peningkatan

kesehatan ibu hamil, bersalin dan nifas.

8. Cakupan Penanganan komplikasi Obstetri (PK)

Adalah cakupan Ibu dengan komplikasi kebidanan di suatu wilayah kerja pada

kurun waktu tertentu yang ditangani secara definitif sesuai dengan standar oleh

tenaga kesehatan kompeten pada tingkat pelayanan dasar dan rujukan.

Penanganan definitif adalah penanganan/pemberian tindakan terakhir untuk

menyelesaikan permasalahan setiap kasus komplikasi kebidanan. Indikator ini

mengukur kemampuan manajemen program KIA dalam menyelenggarakan

pelayanan kesehatan secara professional kepada ibu hamil bersalin dan nifas

dengan komplikasi.

C. Langkah Membangun Kemitraan

3 (tiga) Prinsip kemitraan, 7 (tujuh) Landasan dan 6 (enam) Langkah.

12

Langkah 1 adalah Penjajakan

Langkah ini untuk menjajaki para calon mitra yang akan diajak kerjasama untuk

suatu Tujuan Kemitraan Kesehatan.

Beberapa hal yang harus dilakukan adalah :

1. Mencari tahu organisasi apa saja yang akan kita ajak.

2. Mengetahui apa yang menjadi Tugas pokok dan fungsi (Tupoksi) dari masing-

masing organisasi tersebut, misal untuk kemitraan Posyandu :

a. Camat mempunyai Tupoksi sebagai koordinator dan penanggung jawab

pembangunan di Kecamatan (cocok kita ajak bermitra),

b. UPT Dinas Pendidikan tupoksinya sebagai penyelenggara pendidikan baik di

sekolah maupun luar sekolah (cocok kita ajak bermitra),

3. Setelah tahu tupoksinya dari masing-masing calon mitra maka kita kaji manfaat

apa yang akan kita tawarkan bagi calon mitra, agar yang bersangkutan mau

diajak bermitra.

Langkah ke-1 ini adalah untuk memenuhi Landasan 1 (Stucture) dan 2 (Capacity).

Langkah 2 adalah Penyamaan Persepsi

Disini kita mengundang para calon mitra untuk menawarkan kemitraan, dengan

menjelaskan secara rinci tentang :

1. Tujuan yang akan dicapai

2. Manfaat kemitraan (keuntungan bagi masyarakat dan masing- masing mitra)

3. Resiko yang mungkin akan dihadapi bersama.

Pada langkah ini dituntut kemampuan kita untuk berkomunikasi, lobi, dan menarik

perhatian calon mitra.

13

Langkah 3 adalah Pengaturan Peran

Pengaturan peran hanya di konsep kesehatan saja, secara tertulis (formal) adalah

tertulis. Peran/ Tugas masing- masing anggota mitra.

Ada 7 Peran untuk anggota mitra, yaitu :

1. Inisiator : memprakarsai kemitraan dalam rangka sosialisasi dan operasionalisasi

Indonesia Sehat.

2. Motor/dinamisator : sebagai penggerak kemitraan, melalui pertemuan, kegiatan

bersama dan sebagainya.

3. Fasilitator : memfasilitasi, memberi kemudahan sehingga kegiatan kemitraan

dapat berjalan lancer.

4. Anggota aktif :  berperan sebagai anggota kemitraan aktif.

5. Peserta kreatif : Sebagai peserta kegiatan kemitraan yang kreatif.

6. Pemasok sumber daya : memberi masukan tehnis (Program kesehatan).

7. Dukungan sumber daya :  memberi dukungan sumber daya sesuai keadaan,

masalah, dan potensi yang ada.

Langkah 4 adalah Komunikasi Intensif

Hal ini dilakukan untuk menjaga kesepakatan yang telah dicapai, dan untuk

mengetahui apa ada masalah yang dihadapi oleh masing- masing anggota mitra,

sehingga bisa pecahkan bersama.

Langkah 5 adalah Melaksanakan Kegiatan

Setelah Kesepakatan Kemitraan sudah disetujui oleh anggota Mitra, maka kita

menyusun rencana kerja kemitraan dan pelaksanaan kegiatan bersama dengan 

14

anggota Mitra. Prinsip dari pelaksanaan kemitraan adalah seluruh anggota Mitra

yang telah diberi peran harus ikut serta dalam pelaksanaan.

Langkah 6 adalah Pemantauan dan Penilaian

Pemantauan dan penilaian sudah harus masuk dalam rencana kerja kemitraan,

sehingga dalam pelaksanaannya sudah ada kesepakatan tentang : Indikator

penilaian

15

Health Promotion Services For Lifestyle Development Within A UK Hospital – Patients' Experiences And Views

Charlotte L Haynes Correspondence: Charlotte L Haynes charlotte.haynes@stockport.nhs.ukAuthor AffiliationsClinical Effectiveness Unit, Stockport NHS Foundation Trust, Cheshire, UK BMC Public Health 2008, 8:284 doi:10.1186/1471-2458-8-284© 2008 Haynes; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

BackgroundUK public health policy requires hospitals to have in place health promotion services which enable patients to improve their health through adopting healthy behaviours, i.e. health education. This study investigated hospitalised patients' experiences of health education for smoking, alcohol use, diet, physical activity, and weight, and their views concerning the appropriateness of hospitals as a setting for the delivery of health education services.

MethodsRecently discharged adult hospital patients (n = 322) were sent a questionnaire asking about their smoking, alcohol use, diet, physical activity, and weight. For each of these risk factors, participants were asked whether they agreed with screening for the risk factor, whether they received health education, whether it was "helpful", and if they wanted to change their behaviour. Participants were also asked a set of general questions concerning health education within hospitals.

Results190 patients responded (59%). Over 80% agreed with screening for all risk factors. 80% of smokers, 52% consuming alcohol above recommended limits, 86% of obese, 66% consuming less than five fruit and vegetables a day, and 61% of physically inactive participants wanted to change their respective behaviour. However only a third reported receiving health education. While over 60% of patients wanted health education around discharge, the majority of those receiving health education did so at admission. The majority agreed that "hospital is a good place for patients to receive" health education (87%) and that "the hospital should provide patients with details of community organisations that provide" health education (83%). Only a minority (31%) reported a preference for health education from their GP instead of hospital.

16

ConclusionWhile the delivery of health education to patients within hospital was poor, hospitals are viewed by patients as an appropriate, and in some cases preferred setting for the screening of risk factors and delivery of health education.

Background

There is increasing pressure on hospitals to deliver health promotion services for

healthy lifestyles to patients [1-4]. The Ottawa charter for health promotion, 1986

provides a broad definition of health promotion as "the process of enabling people to

increase control over, and to improve, their health" [5]. This can only be achieved

through coordinated action from governmental and nongovernmental organisations,

the health, social and economic sectors, voluntary organization, local authorities,

industry, the media and communities to achieve "healthy public policy" [5] which

creates environments supportive of health, (such as safe walking and cycling routes),

supporting people in developing personal skills (by providing information on healthy

lifestyles and disease management, enhancing health literacy and life skills),

reorienting health services so that they focus on preventing disease/encouraging

health in addition to curing existing conditions [5] and strengthening community

action by involving communities in socio-political activities that impact on their own

health [5,6]. The principles and practice of health promotion specifically within

hospitals has been further developed in The Budapest Declaration on Health

promoting Hospitals, 1991 [7] and The Vienna Recommendations on Health

Promoting Hospitals, 1999 [8]. These recommendations are embodied in the

guidelines developed by the World Health Organisation Health Promoting Hospitals

(WHO HPH) project/network [3,4]. One of the core aims of the WHO HPH network

is to facilitate change within the quality management of hospitals, with health

promotion a core quality dimension [9]. To this end the WHO HPH network has

recently developed a strategic and quality framework for health promoting hospitals

[4]. This highlights areas which all health promoting hospitals should have as part of

their quality development strategy that would benefit key stakeholders: patients, staff

and communities (see table 1 for the development strategy aimed at patients). The

first three strategies (PAT 1 to PAT 3) should be delivered by all health promoting

hospitals as they aim to further develop the health promoting quality of the hospital

services and setting, whereas strategies PAT 4 through to PAT 6 are viewed as

additional health promotion strategies which hospitals can offer.

17

Key to the concept of health promotion is "empowerment" of individuals,

social groups and communities: "a process through which people gain greater

control over decisions and actions affecting their health" [10]. Health promotion

interventions within healthcare can empower people through "self-reproduction":

supporting patients to take responsibility for self-care physically, mentally and

socially; through "co-production": collaboration of the patient in their therapy;

empowering health promotion services for illness management (usually part of

integrated care and beyond the hospital boundaries); and empowering health

promotion services for lifestyle development: people are empowered to live healthy

lives by preventing risk (e.g. not smoking or excessive alcohol intake) or enhancing

lifestyles (e.g. becoming more physically active). This latter aspect of empowerment

relates to the concept of "health education" which can be defined as "an activity that

seeks to inform the individual on the nature and causes of health/illness and that

individual's personal level of risk associated with their lifestyle-related behaviour....

[it] seeks to motivate the individual to accept a process of behavioural-change

through directly influencing their value, belief and attitude systems, where it is

deemed that the individual is particularly at risk or has already been affected by

illness/disease or disability" (p. 313 [6]).

It is the provision of health promotion services for lifestyle development

(health education) to patients within hospitals which is of interest in this study (Table

1, strategy PAT 5). Specifically, the strategy for health promoting lifestyle

development aims at "improving the outcome of hospital interventions by

empowering patients to build up specific health literacy (knowledge, skills and

preferences) for developing and maintaining health promoting life styles" ([4] p.30).

The strategies should be viewed as a coherent programme of development as they are

inextricably linked with one another. For example, for the health education strategy

(PAT 5) to work optimally, patients who are empowered to self care and co-produce

will be more able to take responsibility for developing and maintaining healthy

lifestyles post-discharge (PAT 1 and 2). The hospital also has to be an appropriate

environment for providing health education (e.g. suitable rooms; PAT 3); and

empowerment to self manage diseases/impairments will often be associated with

particular lifestyles (PAT 4).

18

In addition to the WHO HPH network strategies, public health policy in the

UK now highlights the importance of providing personalised support (understanding

patients' cultural and social background, etc) to patients to enable them to lead a

"healthy" life (not smoking, sensible alcohol use, etc) [1]. While UK hospitals have

always had elements of health promotion within routine care, the explicit demand

that hospitals provide health promotion services to patients for lifestyle development,

in particular focusing on smoking, alcohol misuse, obesity, diet, and exercise, is

relatively new [11].

An audit of health promotion activities within 9 English hospitals revealed

that while the majority of hospitalised patients were screened for smoking (94.1%)

and alcohol use (83.1%), few were screened for diet (23.0%), physical activity

(2.6%) or obesity (11.7%). The provision of health education was poor: an average

of 22.5% of patients received health education for smoking cessation, 36.0% for

alcohol misuse and very few for diet, physical activity or weight management

(numbers of patients identified as requiring health education for the latter three risk

factors was so low that reporting the average figures would be misleading) [12].

While the above findings present a bleak picture of health education services

within hospitals, there is evidence that medical records show low levels of accuracy

for the recording of such activities [13,14]. Direct observation is viewed as the "gold

standard" for measuring practice; however it is not practical for exploring the

provision of health education provision to hospitalised patients as these services may

be delivered at any/many points during an admission. Previous research within

primary care settings indicates that patients' recall of health education is more

accurate than medical records [14]. It therefore appears that relying on patient recall

may be the most pragmatic approach to measuring health education delivered on

potentially multiple occasions and by multiple healthcare professionals.

There is evidence that approximately 50% of the English public support the

NHS "taking a lead role in preventing illness and improving health" [15], and that the

majority of adult hospitalised patients think hospitals should take a role in health

education [16]. However, with the exception of a study by McBride, 2004, views

regarding the appropriateness of hospitals as a setting for the delivery of health

promotion services, including health education, have received little investigation

[16].

19

This study aimed to provide an insight into the provision of health education

for smoking, alcohol misuse, obesity, diet, and exercise within a UK hospital

following UK public health policy changes highlighted above and the WHO HPH

strategy for health promoting lifestyle development for patients; and to address the

paucity of research on patients' views of the appropriateness/acceptability of the

hospital as a setting for the delivery of health promotion services for lifestyle

development.

Methods

Rationale

A search of the literature at the time of developing this study indicated that there was

no one survey tool that adequately met the study research questions: What lifestyle

development (health education) services do patients want from a hospital setting? Is

the hospital a suitable setting for the delivery of health education services? And how

are patients' views related to their lifestyles? A self-administered questionnaire was

deemed the most appropriate tool for investigating the research questions as it could

be distributed to a relatively large number of patients and allowed for anonymity,

hence increasing the likelihood of honest opinions about views and experiences of

health education within the hospital [17].

Questionnaire

The following tools were adapted to assess the prevalence of smoking, alcohol

misuse, obesity, physical inactivity and unhealthy diet (risk factors): Stockport

Health and Lifestyle Survey [18], the "Five Shot Screening Tool": a validated test for

detecting hazardous and harmful alcohol use [19], and a validated two-item dietary

questionnaire [20]. As no questionnaires existed which addressed patients' attitudes

to health education in hospitals a semi-structured interview was developed, based on

face validity, by the researcher and steering group (patient representatives, hospital

management, nursing, clinician and academic representatives). This was undertaken

to the point of data saturation: 10 hospital patients differing in age, gender and

ethnicity.

20

Following content analysis of the interviews and adaptation of the aforementioned

existing tools, the questionnaire was designed. The steering group and hospital

patients provided comments on the coherence and legibility of the questionnaire to

ensure that it adhered to the principles of good survey design [17]. The questionnaire

was finalised following a pilot phase in which 19 recently discharged patients

completed the questionnaire.

For the purposes of the study, the term health promotion rather than "health

education" was used throughout the questionnaire as the former term was deemed

more familiar to the public and there were concerns that "education" would be

interpreted as reflecting a "teacher-pupil" relationship rather than a collaborative

relationship where the patient plays an active role in their lifestyle development.

"Health promotion" was defined as any action taken by a member of staff at the

hospital to enable the patient to take control over aspects of their lifestyle that may

have a negative effect on their health. Actions included verbal and written advice,

medications and referral to specialists/services that aim to change unhealthy

behaviours into healthy behaviours (e.g. quitting smoking). While patients were

being asked their views on "health promotion", given that the definition provided

more accurately reflects "health education", the latter term will be used throughout

the paper.

The questionnaire followed the same format for each risk factor (smoking,

alcohol, diet, exercise, and weight). Patients were asked whether they agreed that "all

adult patients should be asked about their risk factor" (screening agreement).

Responses were on a five point likert scale ranging from "strongly agree" to

"strongly disagree". Patients were then asked whether anyone at the hospital asked

them about the risk factor (screening). For example "During your hospital admission

were you asked about the amount of alcohol you drink?" Participants could answer

"yes" or "no". Measurements of height and weight were not asked about as this does

not necessarily indicate that body mass index (BMI) was calculated. Information was

then gathered on whether the patient has a risk factor (risk factor prevalence). They

were then asked whether they wanted to change their "risky" behaviour (change).

The options were "yes" or "no".

21

Information on the type of health education delivered within the hospital was

gathered. This could range from leaflets, verbal advice, referral to a

specialist/service. Participants were asked to circle the correct option(s) and there

was a free text option for describing any additional health education delivered.

Patients were asked who delivered the health education and to rate the "helpfulness"

of the health education on a likert scale from 1 ("not at all helpful") to 5 ("very

helpful"). Patients were also asked a set of general questions relating to the

appropriateness of health education within hospitals.

Participants

Participants for this study were selected on the basis that they were from the adult (≥

17 years old) hospitalised and day-case patient populations of one Acute Trust. A

routine was established in which all patients discharged alive between January and

March 2006 were identified within one week of their discharge from twelve wards

representing surgery and medicine. Patients who were terminally ill were excluded

from this study as it was deemed inappropriate to deliver health education to these

patients.

A total of 322 people were identified and sent a questionnaire within a

maximum of one month of their discharge. To optimise return-rate patients were sent

a pre-letter, pre-paid return addressed envelopes along with the questionnaire, and

two reminders sent 1 week and 2 weeks following the questionnaire.

Analyses

An Excel workbook was developed for recording all data. Analyses were performed

using StatsDirect Version 2.4.5 and SPSS 15.0. Patients who returned the

questionnaire are described as "responders" and those who did not return the

questionnaire "non-responders". Differences in age between responders and non-

responders were assessed by one-way ANOVA with gender as a factor. Mann-

Whitney U tests were employed to assess differences in length of stay (LoS) and

Index of Multiple Deprivation (IMD) scores [21] as data were distributed non-

parametrically. IMD scores provide an indicator of deprivation based on income,

employment status, self-reported health and disability, educational level, housing,

living environment and crime based on geographical area (the small area level).

22

The higher the score, the greater the level of deprivation. Proportion

differences for screening of smoking and alcohol use, smoking behaviour and

alcohol misuse were calculated for responders versus non-responders based on

findings in patients' case notes.All reported significance values are two-tailed. In

order to describe the responses to all questions, these were subject to descriptive

statistics: proportions, proportions ± 95% confidence interval (CI) and tests for

proportion differences where appropriate. SCREENING AGREEMENT questions

were also subject to the Friedman test to examine whether responses were similar

across the four risk factors (smoking, diet, alcohol and exercise).

This study received Local Research Ethics approval.

Results

Demographics

One hundred and three females and eighty-seven males returned the questionnaire

(59% response rate). The mean age and median length of stay for responders and

non-responders are reported in table 2. There was a trend towards male non-

responders being younger than female non-responders and all responders. There were

no significant differences in the median length of stay or socio-economic status

(IMD score) between the groups, nor in the proportion of responders and non-

responders who were (according to their medical case notes) screened for smoking

and alcohol, or identified as misusing alcohol (see table 3). There were however

significantly more smokers (according to case note information) amongst non-

responders compared to responders.

Questionnaire findings

Screening

The majority of responders reported that they were asked by a member of the

hospital staff whether they smoked (156/183; 95% CI = 0.79 to 0.90) and they were

asked about their alcohol use (115/188; 95% CI = 0.54 to 0.68). However only about

a quarter were asked about their usual diet (46/184; 95% CI = 0.19 to 0.32) and

physical activity (42/175; 95% CI = 0.18 to 0.31).

23

Risk factor prevalence and health education delivered

Additional file 1 reports the proportion of responders identified by the questionnaire

as having a risk factor, and of those with a risk factor, the proportion receiving any

type of health education, plus details of the form health education took for each risk

factor. Of the 20.5% respondents identified as smokers, 44.4% reported receiving

some type of health education. The proportion of patients identified as misusing

alcohol according to self-reported weekly consumption compared to the Five shot

tool is not significant (proportion difference = -0.019, 95% CI = -0.11 to 0.08 P =

0.70). Between 21% and 29% of these patients received health education for alcohol

misuse. While the majority of respondents consumed less than five portions of fruit

and vegetables a day and were physical inactive, only 11.9% and 15.4% received

health education for diet and physical activity respectively.

Nearly half of respondents were either obese or overweight, but very few

received any form of health education concerning weight loss. In total sixty-three

patients reported receiving health education for at least one risk factor during their

hospital episode (i.e. 33.2% of respondents). Forty-four received health education for

one risk factor only, eleven for two risk factors, six for three risk factors and two

received health education for four risk factors.

Figure 1 reports the "helpfulness" ratings for the health education delivered.

51.7% of patients reported that the health education they received was helpful (score

of 4 or 5), 27.6% appear undecided (score of 3) and 20.7% viewed the health

education services as unhelpful (score of 1 or 2).

Ratings of "helpfulness" for health promotion delivered. A score of 1 indicated

that the health promotion was "not at all helpful" and a score of 5: "very helpful".

White fill: Exercise, Horizontal lines fill: Diet, Diagonal lines fill: Alcohol, Grey

dots fill: Smoking.

Change

Figure 2 shows the percentage of participants who reported that they would like

advice concerning how to change a risk factor (only for those with evidence of the

risk factor). The majority of smokers wanted to quit smoking. Based on self-reported

alcohol consumed in the past week, 16/31 identified as harmful/hazardous drinkers

reported that they wanted to reduce their alcohol intake.

24

On the basis of the Five shot tool 25/48 participants categorised as potentially

misusing alcohol said they wanted to reduce their alcohol intake.Of those who

consumed alcohol within recommended weekly limits (100) only 9 wanted to reduce

their alcohol intake; and only 2/140 participants categorised as having no alcohol

problem according to the Five shot tool wanted to reduce their alcohol intake.

Figure 2. Percentage of responders who wanted to change a risk factor. Figures

are based on identified need. Grey fill: Yes, White fill: No.

While approximately half of all respondents wanted to reduce their weight,

when desire to lose weight was related to BMI, 86% of obese individuals (BMI >30

Kg/m2; see figure 2), 78% of overweight individuals (BMI 26–30 Kg/m2), 28% of

those with a normal BMI (18.5–25 Kg/m2) and none of the underweight participants

(BMI <18.5 Kg/m2) wanted to lose weight.

Significantly more people who consumed less than five portions of fruit and

vegetables a day wanted dietary advice during their hospital admission compared to

those who consumed five portions a day (67% and 36% respectively, chi-square test

using continuity correction, P = 0.0012).

There was no difference in the proportion of patients who wanted to increase

exercise when assessed according to whether patients engaged in the recommended

30 minutes of moderate physical activity five times a week or not (55.1% and 61.3%

respectively, chi-square test using continuity correction, P = 0.397).

Appropriateness of health education within hospitals

Screening agreement

Inspection of figure 3 reveals that the majority of participants "strongly

agreed"/"agreed" with all adult hospital patients being asked about their smoking,

alcohol use, diet and exercise. The overall Friedman test statistic was significant (F =

31.94, P < 0.0001). Patients agreed significantly more with screening for smoking

compared to screening for all other risk factors (P < 0.0001 for smoking compared to

each remaining risk factor) and with screening for alcohol compared to exercise (P <

0.02).

25

Timing of health education

Of those participants who received health education, 52/63 reported when it

was delivered. The majority reported that health education was delivered at only one

time-point, with only three patients reporting health education at two time points.

While the majority of patients who received health education within the hospital

reported that it was delivered on admission (22/52), most reported that they would

like health education delivered just prior to discharge or at discharge (see figure 4).

Admission was the third most popular time for receiving health education, and just

after admission the least popular. A number of patients (10.9%) also reported that

they did not want any form of health education during their hospital admission.

When patients want health promotion and when they were delivered

health promotion within the hospital. White fill: When patients wanted to receive

health education, Grey fill: When patients received health education.

Hospital setting

The majority of participants agreed that hospital was a "good place" to

receive health education and that "the hospital should provide patients with details of

community organisations that provide" health education (see Table 4). The largest

proportion of respondents were undecided about whether they would prefer to get

health education from their GP rather than hospital staff.

Just over half of the responders would like the hospital to let their GP know

about their risk factors and the health education they received while in hospital.

While 23.8% did not want their GP to know about their risk factors, only 15.7% did

not want the hospital to inform their GP of the health education they had received.

Out of the 31 disagreeing with letting their GP know about their risk factors, 2 were

smokers, 2 reported consuming alcohol above recommended limits (and 7 had

positive five shot scores). Of the 10 strongly disagreeing, 3 were smokers and 2

misused alcohol (self-reported units and five shot tool). Exactly the same people who

misused alcohol "disagreed"/"strongly disagreed" with their GP being told about the

health education they received, but only 1 smoker (strongly) disagreed with their GP

being told about the health education received.

26

Discussion

The results of this survey indicate that hospital patients view hospitals as an

appropriate place for the delivery of health education for all risk factors. While there

was clear support for screening all adult hospital patients for risk factors, reported

screening was not ideal for any of the risk factors, in particular for diet and physical

activity. There was also considerable demand for health education, but little

provision.

While it appears that the hospital may not be meeting UK public health

requirements or international standards for health education within hospitals [1-4],

some may question whether patients' recall was accurate. Patients' memory may be

affected by the emotional state they were in when information was imparted,

potentially resulting in attentional narrowing or state-dependent learning [22,23].

Memory may also be affected by the perceived importance of information (diagnosis

is viewed as very important and treatment less so), and age-related cognitive

impairments [23]. The communication style of healthcare professionals delivering

health promotion services also affects recall, with patients more likely to remember

medical information if healthcare professionals provide simple to follow, specific

written instructions (rather than general/verbal instructions) [23]. Medical

information is least likely to be recalled, and therefore acted upon, if it is delivered

verbally compared to written/pictorial presentation or a combination of written and

verbal presentation, yet the most frequent form health education took was verbal

advice.

The questionnaire showed good criterion validity as risk factor prevalence in

this sample was similar to national and local profiles for the age group: 22% of the

local population are smokers and 22% are estimated to be obese [24]. In England,

87% of the population does not consume five portions of fruit and vegetables a day,

63% of men and 76% of women are physically inactive [25]; and approximately 20%

of adult in-patients are expected to be hazardous or harmful drinkers [26]. The

percentage of smokers wanting to quit is also similar to previous reports that more

than 70% of smokers wish to quit [27]. There is however little data on the proportion

of people with other risk factors who want to change their behaviour. The

information on the percentage of patients wishing to reduce the amount of alcohol

they drink, reduce their weight, and improve their diet and level of physical activity

27

can be used by hospitals as the basis for developing realistic standards for the

number of patients delivered health education once a risk factor has been identified.

The findings indicate that hospitals should initially aim to deliver health education to

a minimum of 70% of smokers and obese individuals and 50% of people misusing

alcohol, consuming an unhealthy diet and physically inactive.

The timing of health education is also important to patients. While the

majority felt that the time around discharge was the most appropriate period for

health education, those receiving health education reported that it was usually

delivered on admission. This may be because admission is the usual time for

screening of risk factors. However, it is likely that this is not necessarily the optimum

time for health education as patients may be in an unreceptive state due to their

condition and their primary concern may be the immediate improvement in health

(Haynes, 2004 unpublished).

As the purpose of health promotion is to enable people to change a behaviour,

it is important to assess whether the different potential forms of health education

have achieved this. This was evaluated by asking patients how "helpful" the health

education services they received were. While more patients viewed the services as

"helpful" than "unhelpful", given that so few patients received any form of health

education, it is not possible to draw definitive conclusions concerning the

"helpfulness" of the different services. It is recommended that this question remains

as it could provide valuable information about health education services when they

are delivered to a larger number of patients.

Given that primary care is the traditional setting for the delivery of health

education it was surprising that approximately a quarter of respondents expressed

disagreement with the statement "I would prefer health promotion [education] from

my GP rather than hospital staff". While this infers that they would prefer health

education from a hospital, further research is required to verify this finding (e.g.

changing the statement to "I would prefer to get health education from hospital staff

instead of my GP"); and to explore the reasons for this preference. For example, are

hospital staff viewed as more approachable than GPs? Is there a perception of greater

anonymity within a hospital, circumventing embarrassment? Although 1 in 10

respondents expressed that they never wanted health education while hospitalised, it

28

is encouraging that only 3% disagreed with the statement that "hospital is a good

place for patients to receive health promotion [education]".

Disagreement with the statements "I would like the hospital to let my GP

know about my smoking, diet, exercise, and alcohol intake/the health promotion

[education] I received from hospital staff" indicates that there is an objection to the

sharing of information between hospitals and GPs. However, the use of the word

"like" may be the reason, and further research is required to clarify whether there is

an actual objection. If there is a true objection to communication between hospitals

and GPs, it may be difficult to justify automatically informing a patient's GP of their

patient's risk factors and health education delivered, and hospitals may need to ensure

that they have patient consent for sharing this type of information. However an

argument can be made for the transfer of information as being in the public interest

and part of continuing care, and therefore not subject to the need for informed patient

consent [28]. With the drive towards greater collaboration/communication between

services, and the creation of electronic patient records available to all health care

providers, these findings are of concern. Reasons for such an objection also require

clarification. There was no evidence that disagreement with the sharing of

information was related to the presence of risk factors.

Study Limitations

There were some limitations to this study. The sample included patients from

only one hospital and results may therefore not be generalisable to other hospital

populations. The trend towards fewer young men responding to the questionnaire

indicates that the views of this group were not expressed. Young men are less likely

than other populations to respond to questionnaires [29]; and it may be that other

methods such as focus groups are more appropriate for investigating this group's

preferences for health promotion services for lifestyle development. The views of

this population need to be explored as young men consume more alcohol and less

fruit and vegetables than older adults, and are more likely to be smokers [25]; hence

they are at risk of developing chronic diseases. The finding that smokers were less

likely to respond to the questionnaire may have repercussions on the findings

concerning the receptivity of patients to health education. Previous research has

indicated that smokers are less likely to believe that "the way people live affects their

29

health" [16], suggesting they may be less responsive to health education, and that

hospitals may face additional challenges in successfully delivering health education

to smokers.

While there was a reasonable response rate to the questionnaire, the poor

provision of health education meant that statistical analysis of some questionnaire

items was limited by small sample sizes. Improvements in the provision of health

education within hospitals and/or larger sample sizes would improve the situation.

Some questionnaire items require minor changes in wording to allow for definitive

conclusions concerning patients' views on sharing information between healthcare

sectors and preferences for hospitals over GPs for health education delivery.

Conclusion

The findings of this study should encourage hospitals to improve their health

promotion services. Hospital healthcare professionals should be made aware that

approximately a quarter of patients may in fact prefer health education from a

hospital setting rather than their GP, that there is a demand for health education, and

agreement with screening of all risk factors. This information may allay concerns

that some risk factors are too sensitive to address, and challenge the view that lack of

receptivity from patients is an obstacle to delivering health education [30,31]. Health

education is however not for everyone, with approximately 1 in 10 patients choosing

not to receive health education for risk factors while hospitalised, and staff need to

ensure that they respect this desire. The (apparently substantial) challenge now

facing UK hospitals, is how will they meet their patients' demand for health

education? Guidance on how to embed health promotion services within hospitals

has been provided by the WHO HPH [3,4]. While there is some controversy

concerning the "success" of this project/network [32-35], there are examples of

successful health promotion projects within hospitals and some reports of hospitals

becoming health promotion settings [36-38], lessons from which, UK hospitals

would be wise to learn from.

Competing interests

The author declares that they have no competing interests.

30

Authors' contributions

CH was involved in the conception and design of the project. CH collected, analysed

and interpreted the data. CH wrote the entire article.

Acknowledgements

Thanks to the "Health Promotion in Hospitals Steering Group" and Dr Gary Cook,

Stockport NHS Foundation Trust for their contribution to this project. This project

was funded by Stockport NHS Foundation Trust Research & Development Funds.

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BAB IIIKESIMPULAN

Ukuran keberhasilan bidan dalam pelayanan di komunitas/ desa tidak hanya

penurunan AKI dan AKB, tapi juga bangkitnya gerakan masyarakat untuk mengatasi

masalah dan memenuhi kebutuhan kesehatan serta kualitas hidupnya.

1. Pada hakekatnya masyarakat mempunyai hak memperoleh pelayanan yang

berkualitas, sehingga Ibu Sehat Bayi sehat, selanjutnya juga Bangsa yang sehat.

2. Bidan sebagai pemberi jasa harus menjaga mutu pelayanan dan melayani sesuai

kebutuhan (mitra perempuan).

3. Bidan harus tetap meningkatkan kemampuan.

4. Bidan sebagai tenaga kesehatan pada lini terdepan (ujung tombak).

5. Bidan punya kebutuhan dan harapan (kesejahteraan, masa depan dan keamanan).

6. Pemerintah bertanggungjawab menyediakan yankes (Sarana prasana, SDM dll

(Sustainability dan Jamkesmas).

7. Pemerintah dan OP melakukan pengawasan dan pembinaan.

Target global penurunan Angka Kematian Ibu (AKI) MDGs (Millenium

Development Goals sebesar tiga-perempatnya pada tahun 2015. Sementara target

penurunan Angka Kematian Bayi (AKB) dan Angka Kematian Balita (AKABA)

sebesar dua-pertiga. Berdasarkan kesepakat global tersebut Indonesia mempunyai

komitmen untuk menurunkan Angka Kematian Ibu menjadi 102/100.000 Kelahiran

Hidup (KH), Angka Kematian Bayi dari 68 menjadi 23/1.000 KH, dan Angka

Kematian Balita 97 menjadi 32/1.000 KH pada tahun 2015. Jika dilihat dari potensi

untuk menurunkan Angka kematian Ibu (AKI) masih on track walaupun diperlukan

sumber daya yang kompeten (Pedoman Pengawasan Wilayah Setempat Kesehatan

Ibu dan Anak, Depkes RI. 2009).

34

DAFTAR PUSTAKA

Kemenkes RI, 2010, Pedoman Bidan Koordinator. Jakarta: Bina Husada, Kemenkes RI

Kementrian Pendidikan Nasional, 2010, Membangun Jejaring Kerja Kemitraan, Jakarta: Direktorat Jenderal Pendidikan Nonformal dan Informal.

UNFPA. 2006, Kebijakan dan Strategi Nasional Kesehatan Reproduski di Indonesia, Jakarta: UNFPA.

Kemenkes RI. 2011, Pedoman Pemantauan Wilayah Setempat Kesehatan Ibu dan Anak, Jakarta: Bina Husada.

Haynes, Charlotte L, 2008, Health promotion services for lifestyle development within a UK hospital – Patients' experiences and views. United Kingdom: BMC Public Health.

35