APPENDIX 1

Pilot Project of Quit Smoking Programme in Health Clinics

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SLIDE Health Clinic Batu Pahat 1 Population in Batu Pahat District

Immensity: 1872.56 km2 (10 % of Johor), PopulationL 419,800 people (2010)

SLIDE Health Clinic Batu Pahat Operational Area 2 Total of Health Clinics: 15 Total of Community Clinics: 47

The operational area is managed by Batu Pahat District Office. There are 3 Community Clinics which is under Batu Pahat Health Clinic supervision.

Health clinic (KK) / Community Clinic (KD) Total Population

KK Batu Pahat 100,000

KD Sungai Ayam 8,500

KD Minyak Beku 6,000

KD Patah Pedang 2,100

SLIDE Batu Pahat Health Clinic Profile 3 • Type 2 under RMK 9 project • Built on the old Batu Pahat Hospital area • Under Batu Pahat District Office management • Operational service started on 26th July 2010 • Officially given on 3rd September 2010 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Services 4 1. Specialist Treatment 5. Diagnostic (Xray and Laboratory) 2. Mother and child clinic 6. Rehabilitation Unit 3. Dental clinic 7. Pharmacy 4. Outpatient Department

SLIDE Workload in year 2011 – 2012 ( Health clinic, dental, Mother and Child health clinic) 5

OPD Attendance 14661 15660 14040 17612 15524 16831 96027

KKIA Attendance 2422 2948 2885 2928 3565 3782 18530

Dental Attendance 2519 2563 2755 2646 3005 2478 15962

Total 17180 18223 16795 20258 18529 23091 130519

Brief Intervention In Smoking Cessation SLIDE Objective 6 Help the smoker to quit smoking in the right and effective way beside to maintain the client’s status clean from smoke. Target group is smoker who : 1. Determine to quit smoking 3. Tried to quit but failed 2. No intention to quit smoking Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Implementation 7 Strengthening Primary Health Care Systems For Treating Tobacco Independence Oriental Workshop at Crystal Hotel, Kajang, on 23rd, 24th and 25th October 2011. Taklimat Brief intervention about (3A) conscept among the clinic staff at Dewan Banang District Office Batu Pahat on 29th November 2011 Briefing at Batu Pahat Health Clinic level is held on 6th, 12th and13th December 2011 Evaluation meeting for work process program related to 3A intervention and school free from smoking 2012 is on 18th-19th January 2012 Evaluation / audit programme in March 2012 3As intervention performance meeting for quit smoking on 6th June 2012 at Health Clinic Batu Pahat meeting room Problem inquired brief the members about the intervention 3As on 29th June 2012 Performance presentation of brief intervension on 2nd July 2012 Quit smoking services operating hour is every Thursday is afternoon.

SLIDE Promotion 8 3A Intervention Form (Cop and Form)

Saringan Intervensi Ringkas Tarikh :

Nama : Bangsa:

No KP : Umur :

i. Adakah anda Ya merokok Tidak

ii. Nasihat diberi Ya

Tidak

iii. Tindakan Rujuk

Tidak dirujuk

Unit yang merujuk b. Poster Tarikh temujanji

a. 3As intervention in a form of Stamp or screening form Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Integrated Registration 9 Counter Counter to treatment room

Counter to KKIA Counter to Laboratory

Counter to Emergency department

Counter to TB unit Counter to Xray Department Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Flow Chart 10 Pelanggan di kaunter Tidak Kekalkan status tidak Tanya status merokok merokok Ya Tidak Nasihat supaya Terangkan lagi berhenti bahaya merokok Ya merokok

Beri temujanji Perkhidmatan berhenti merokok

Daftar pelanggan di PBM

Sejarah pelanggan dan pemeriksaan fizikal

Ujian Fagerstorm

Rawatan berhenti merokok

Rawatan Berhenti Susulan merokok

Meneruskan rawatan/penilaian/ pengukuhan Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Perfomance result 11 Jan Feb Mac April May June Total OPD attendancy 14661 15660 14040 17612 15524 16831 96027

KKIA attendancy 2422 2948 2885 2928 3565 3782 18530

(GG) attendancy 2519 2563 2755 2646 3005 2478 15962

Total amount 17180 18223 16795 20258 18529 23091 130519

3A Intervention NA 307 472 787 743 1581 3890 4.05% (KKBP) 3A Dental 9 10 13 9 6 10 57 0.36% Intervention Total amount 9 317 485 796 749 1591 3947 3.02%

PBM Registered 7 7 6 9 14 19 62 1.60% (OPD) 62 1.57% Quit Smoking 1 1 0 1 4 1 8 12.9%

SLIDE Challenge 12 • Not all the health clinic staff is do the brief intervention. • Most of the client just want to take the medication only. • At the begining, there is no medication supply and it is only available in April Medication start to have in the health clinic. • Difficult to come to clinic on the appointment date given.

SLIDE Management commitment 13 • Health Office Management is very commited with quit smoking programme. • District Office – Chairman and Facilitator from JBAR state • Produced the Quit Smoking Service module at the school level – 1st edition (2009), 2nd Edition (2010) and 3rd Edition (2012 - 3As component is included in the screening tool) 1. Quit rate at average of 60% – 62% 2. Extended to all district in Johor 3. As a facilitator for District and State

4. Expanded to the Ministry of Health level Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Presentations 14 QA Convention 2011- (Poster ) Increasing the success rate of quit smoking clinic among adolescents. 1. Primer level: (between the district) – won the 1st place 2. State level – won the 1st place 3. National level – 2nd place • 15th FMS Scientific Conference 2011 – (Poster). School based quit smoking clinic won 1st place • 8th Johor Scientific Meeting 2011 – Oral Presentation

SLIDE Presentations 15 Conclusion • About 4.05 % (3890) of client came to the Health Clinic Batu Pahat for their brief intervention screening for quit smoking since January till June 2012 • 1.6 % (62 clients) came and registered under the quit smoking service. • Health care officer’s commitment is very important and need to enhance. • Technique and skill to attract the client should be studied and improve. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Health Clinic Jasin Melaka 1 “ FREE FROM CIGARETTE SMOKE” 1. Rearrangement of the Quit Smoking Srvice in Melaka at the end of 2010. 2. Quit Smoking Service has been expanded to 27 health clinic and 3 Hospital in Malacca.

“MBAR ZONE” 1. Melaka International Trade Centre (MITC) 2. World Legacy City 3. Alor Gajah main town 4. Jasin main town 5. Melaka Raya

“QUIT LINE” 1. Quit Smoking Services via the phone is a collaboration of effort with MBAR 2. The function is to interview / counseling the smoker, ex – smoker and passive smoker 3. Operational hour : 8 am till 5 pm working hours.

SLIDE Health Clinic Jasin workflow for quit smoking service 2 1. The meeting was attended by Family Medicine Specialist, Medical Officer, Nurses, Medical Assistant, Pharmacist and Secretary. 2. Scope of task is divided into registration, screening, counseling and treatment. 3. Target client for the first monthe is 15 clients. • Teenager 14 – 19 years old: 4 clients • Adult (COPD): 3 clients • Diabetic and hypertensive patient: 3 clients • Clinic staff / family: 5 clients 4. First client registered is on 29th December 2010 5. Second meeting has been held in February 2011 with the Family Medicine Specialist. 6. Conclusion from restructurize the quit smoking services team consists of • Family Medicine Specialist (1) • Medical Officer • Pharmacist (1) • Medical Assistant Officer (1) • Nurse (1) • Community Nurse (3) • Secretary (1) • Dental Officer

Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Quit Smoking Team and duty 3 SENARAI AHLI SENARAI TUGAS PASUKAN

Family Medicine • Facilitator and monitoring the quit smoking programme. Specialist • Referral case • Beginning of treatment with CHAMPIX and evaluation after treatment.

Medical Officer • Referral case

Pharmacist • Dispensary Champrix/ Nicotine patch/ Gum • Counselling on how to take the medication such as Champrix/ Nicotine patch / gum and the side effect of the medication.

Medical Assistant • Appointment with patient for counseling session Officer • Preparing the client record book • Online registration for quit line / manual • Updating the patient record and quit smoking reten. • Health education and motivation in quit smoking services.

Nurse • Referral case and distribution of the health promotion material.

Community Nurse • Referral and distribution of the health promotion material.

Secretary • Registration of the new cases from screening, referral by the specialist, medical officer, dental officer, out patient and repeatiting case (follow up case).

Dental Officer • Referral case

SLIDE Check list for the Quit Smoking Clinic 4 • Manual registration (manual / online – “QUIT LINE”) • Prepare the client Health record book • Registration in the screening book / appointment book and Patient record book. • Appointment with the client for counseling. • TO give Health Education and motivation in quit smoking. • Distribution of the health promotion material. • Monitoring the client health status when at the clinic or via phone. • Updating the client details. • Help in doing the evaluation after treatment. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Patient Screening / referral case SLIDE 5 • CVD Screening counter • Treatment room for medical officer and Family Medicine Specialist. • ‘Walk-in’ • Referral from 1 Clinic / Dental Clinic / 1 Stop Centre / Other department

Appointment SLIDE 6 New case: Monday – Friday Follow up case: Every Wednesday from 2 – 5 pm (counseling)

Innovation SLIDE 7 3rd meeting with Family Medicine Specialist is on March 2011. Suggestion and opinion about producing the appointment book, referral slip and caunselling check list. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Patient Screening / referral case 8 General Counter Secretary

Vital signs Community measurement nurse

Quit Date Counselling Paramedic

Champix Family Medicine counselling Specialist

Follow up/ Register quit line Counselling

SLIDE Flow chart for new patient management 9 General Counter

Treatment room Referral from others Dental / CVD / BSSK (medical officer or / wak FMS) 1SC / K1M / OPD

Treatment room Treatment room Treatment room (Community (Community (Community Nurse) Nurse) Nurse)

Start to open Appointment / Appointment / Appointment / appointment Counselling Counselling Counselling book

Counselling Counselling by Quit date Counselling by Checklist Paramedic Register a Quit Paramedic Line

Refer Counselling or Counselling or FMS start treatment start treatment (champix) (champix)

Give appointment Follow up and Follow up and counselling counselling card Checking on the status (smoke or Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot totally stop)

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SLIDE Counselling room 10

Promotion Material

Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Quit smoking services’ s plan of action reten 12

SLIDE Issues and Suggestion 13 No Issues Suggestion

1. Less referral • Distribute the referral form to health facility such as dental clinic/ from other school unit / Health Office / other unit in District office such as health facility inspectorat / BAKAS / vector / PLKN / 1 stop centre / 1 Malaysia • Only 61 clinic. client since • Referal can be done from the Head of the unit and Rujukan boleh Mac – Oct / dibuat oleh mana2 ketua unit i.e improperly medical officer / 2011 medical assistant or other health officer. I.e 8 - 9 • Referal form should be user friendly client / • Referal form that been given by MBAR is a bit complicated and month. difficult for non - health officer to fill up the form. Number • Promotion technique should improvise in view to increase the of patient Head of Unit awareness by referring the staff who willing to quit is far from smoking to the health clinic. smokier population. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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2. Lack of • To send the health officer for training with the selected trained counseling counselor. skill among • Psyhiatry department do have counselor in hospital setting. the health • Select the health officer which are interested, approachable and care officer sustainable and most • Makesure that the health officer does not have too many of the staff peripheral job (multitasking) therefore, commitment in the is not really programe can be continue (eg: Medical Assistant Officer / commited Pharmacist – “champion of the program” with this programme.

3. No specific Prepare an allocation of budget to build a setting for this room for programme such as counseling room and other equipment which counseling at are needed such as furniture and etc Out Patient Department – Health Clinic Jasin. Most of the medical assistant counsels the patient in the office which is condusive and no privacy.

4. No specific • One of the reason which lead to failure of the programme is the land phone continuous communication (evidence based – BMJ August 2011) at out patient • Medical assistant is suggest to do schedule for communication department. via phone with the client especially for client who finished their follow up or in the treatment (either by treatment or counseling Medical or combination) - CPG recommendation eg: 5 clients / week assistant have (communication checklist should be prepare) to use the • Even though there is phone communication by MBAR, health staff same line with need to have continuous communication other unit. • With the client because the rapport has been started from clinic and we should have the sense of belonging to the program.

5. Equipment is • Allocation budget for the equipment need to evaluate the not complete improvement of the lung after quit smoking (PEFR pre & post quit – no PEFR / smoking phase). Monitoring the status after quit smoking sneed Spirometry to be done by (CO – analyser) machine / CO • Beside it may helps to give motivation to the client from not – analyszer smoking by evaluating the lung function. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Health Clinic Seberang Jaya Pulau Pinang 1 Brief Intervention In Smoking Cessation

SLIDE Services in Health Clinic Seberang Jaya 2 Primary Care Family Medicine Supporting Specialist Out Patient Treatment Maternal and child clinic Laboratory Emergency treatment Child Pharmacy and supply Chronic disease Post natal X RAY services Mental health Oral contraception Physiotherapist Health promotion / health Home visit Dietician screening Quit Smoking Servces Health screening / pap Promotion and smear Intervention center for BSSK screening, exercise, DM class, Hypertension, Hypercholesterolnemia and stress. Pre – marriage HIV screening Special child need (CBR) Fundus camera services Annoynoumous HIV Pre pregnancy services Ultrasound services screening Medication inspection ARV treatment services Dental Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Clinic Profile SLIDE 3 • Built in 1998 • Operated : 22nd October 2000 • Type of the clinic: type 2 • Location : Jalan Perpustakaan, Bandar Sunway,Seberang Jaya, Seberang Perai Tengah, Pulau Pinang • Vastness : 2 acres • MS ISO 9001certification : 2000– April 2004 • Recertification : 24Julai 2007 – 22 April 2010 • MS ISO 9001 certification : 2008 (audit SIRIM 7-9.4.2010)

SLIDE Operational Area Profile 4 1. Habitation number : 3 (2,4,6), Kg Sama Gagah, • Kg Permatang Pauh • Tun Hussein Onn 2. Population : More than 80 000 people( 2009) 3. Ethnic : Malay (50%), Chinese (35%) Indian (10%) & Lain – lain (5%) 4. Occuption : Government servant and industrial

SLIDE Total Staff 5 Unit Number of staff Main counter 11 Record 9 Out patient 17 Pharmacy 13 Laboratory 9 PPKK 2 Maternal and child 17 X-ray 2 Dental 18 Total 98 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Total Attendance at Outpatient Department 6 133,176 Jumlah Kedatangan Pesakit Luar

80,769

63,338

2009 2010 2011

SLIDE Quit Smoking Rate at Health Clinic Seberang Jaya 7 Year No. Client No. of No. Of client who Type of treatment Defaulter registered Visit quit smoking in 2009 No. of rate NRT & Caunselling No. of rate client Counselling only client

2009 38 30 6 15.7% 19 14 10 26.3%

2010 56 56 2 3.5% 36 20 14 25%

2011 72 45 15 20.8% 44 17 20 27.8%

SLIDE Standard Procedure of referral and management 8

Client JPL (OPD) Promotion Appointment Services Referred by Unit (2 staffs) medical officer Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Strengthening System For Treating Tobacco Dependence In Klinik Kesihatan Seberang Jaya 9

Objective 1 1. Improvise the promotion among the client in the clinic about the danger of smoking and also about the quit smoking service via the brief intervention at any angle of the clinic and health promotion unit. 2. Improvise the screening among the patient at health clinic. 3. Ensure the elevation of the quit rate at quit smoking service in health clinic. 4. Elevate the promotion among the Seberang Jaya community. 5. Increase the awareness and quit rate among the health officer in Health Clinic Seberang Jaya.

Method of Implementation 1. Briefing from Health State Office 2. Structurize the plan of action 3. Training workshop for the health officer 4. brief intervention implementations 5. Promotion about quit smoking services 6. Monitoring

Workshop for plan of action of “System Change for Tobacco Dependent” at SLIDE Heatlh Clinic Seberang Jaya, 1s February 2012 10

Panel member for plan of action : 1. Seberang Jaya District Officer 2. KPP NCD from Health State Office 3. KPP from Family Health, Health State Office

Flow chart of referral SLIDE Farmasi 11

OPD Quit Client Registration MCH Promotion Smoking Clinic KKSJ Dental Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Management of BRIEF INTERVENTION at all angle of the health clinic

Registration OPD Pharmacy

Client

Clinical Brief Clinical Brief MCH Intervention Intervention

Promotion

Clinical Brief Dental Intervention

Quit Smoking Clinic KKSJ

Clinical Brief Intervention Training SLIDE 12 1st February 2012 and 8th March 2012

Alert Card Intervention for client SLIDE 13 Alert card is place at the main counter and Medical Officer’s treatment room

Image: Front and back page of the alert card Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Total staff that has been trained for the clinical brief Intervention SLIDE 14 Unit No. of Staff No. of trained stadd % trained Main counter 11 5 46% Record 9 2 22% Out patient 17 7 41% Pharmacy 13 5 38% Laboratory 9 0 0% PPKK 2 1 50% Maternal and child 17 7 41% X-ray 2 0 0% Dental 18 3 17% Physiotherpay 1 0 0% School unit 12 5 42% Driver 3 2 67%

SLIDE Promotion for Quit Smoking Activity related to “ how dangerous of smoking 15 and smoking clinic” promotion among client Program was held on 28th February 2012 and launched by the District Officer. Exhibition of posters and Quiz has been done during the promotion session. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Elevate the promotion among the Seberang Jaya community about the danger of smoking and quit smoking service 16 Continous promotion at health clinic seberang Jaya: 1. “Jom Berhenti Merokok” corner at health clinic Seberang Jaya 2. Wheel fortune for “Impian Berhenti Merokok” at health clinic Seberang Jaya 3. Promotion box “Tak Nak Rokok” at health clinic Seberang Jaya 4. Streamer “Perkhidmatan Berhenti Merokok” and “bahaya merokok” 5. Talks about the danger of smoking at the waiting hall

SLIDE “Jom Berhenti Merokok” corner 17 Material for promotion

SLIDE Objective 2 18 Elevate the screening process among the smoker at Seberang Jaya Health Clinic.

Detection system status for each manager via the status stamp cop at main counter - new client only.

Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Objective 3 19 Ensure the elevation of the quit rate at quit smoking service in health clinic.

Established a team for quit smoking service. Therefore, defaulter tracing can be done via phone for any future activity.

Organized a specific room for quit smoking service with full equipped and management of patient can be done smoothly at level 1 Health Clinic.

To train new helath officer for quit smoking service (current staff which are trained are 1 family medicine specialist and 1 Medical Assistant Officer). Now we have 1 Pharmacist dan 1 Medical Officer which are trained

1. To ensure all staff are trained for handling the quit smoking services and good in delivering counselling via the Training course on how to manage the quit smoking service. 2. To provide ebough supply of champix and Nicorrete Gum. 3. Appointment will be given if there is no staff available

Other events that been organized such as: 1. CME KKSJ 16/5/2012 - Helping patient to stop smoking 2. “Berhenti Merokok” course organized by State Health Office - Februari 2012 3. CME KKSJ 4/7/2012 – Management of quit smoking service

Objective 4 SLIDE Elevate the promotion among the Seberang Jaya community. 20

1. Quit smoking camp at Health Clinic Seberang Jaya facility will be held on 19th July 2012 –Kem “Selamat Tinggal Rokok” Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Objective 5 21 Increase the awareness and quit rate among the health officer in Health Clinic Seberang Jaya. 1. Individualize meeting session with the staff

In April 2012, there are workshop / course of danger of smoking on 1st Februari 2012 and 8th March 2012

SLIDE Objective 5 22 Screening of smoker Detection system established via the main counter for new patient. Beside there are 227 patient which are new cases has been detected via this method.

Attendance to quit smoking service unit Since Jan - June 2012 there are 163 client which attended the unit for the service but 58 people has been registered to the service (Quit date- action phase)

Total Race Gender Age Month 2012 case M C I L L P <18 >18

JAN - JUNE 58 38 8 12 57 1 1 57

Obvious increasing trend of client attendancy to quit smoking service SLIDE 23

Quit rate Quit rate for Jan – Jun 2012 will be announce in Jan 2013. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Challenges SLIDE 24 1. Expand the Clinical Brief intervention training to Xray staff and Physioterapist. 2. Time hindrance and the effort of client to come to the quit smoking unit. 3. Quit Smoking Service • High defaulter rate • To train more staff • Staff need to have more exposure

Improvements SLIDE 25 1. Continous training to staff. 2. Train dedicated staff in managing the quit smoking service unit. 3. To train more staff and give a lot of exposure regarding the quit smoking service management. 4. Increase the staff involvement regarding the ‘brief intervention’ technique. 5. Use the support group in view to increase the promotion. Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Health Clinic 1 Demography of the Kuala Berang District

SLIDE Profile of the Health Clinic 2 1. Health clinic Kuala Berang is the only 1 out of 4 clinics in Hulu Terengganu District 2. In the Kuala Berang habitation with immensity 7021.164 hectar 3. Population is roughly around 72,000 people 4. 7 community clinics 5. Launched by Health Minister Datuk Saadon bin Zubir pada 1964. 6. It was knowns as Hospital Desa Kuala Berang in 1994, but the building has changed its name to Health Clinic Kuala Berang because the function has been take over by new hospital which is Hospital Hulu Terengganu yang baru. Clinic status 1. Upgraded to Helath Clinic type 3 2. Since 2008, the upgrading procee still going on and estimate to start operating in (? 2012). 3. Temporary place : • Out patient : Hospital Hulu Terengganu building • Maternal and child clinic : Vector building at Hulu Terengganu district. • Dental clinicL renting a place at Multiuse hall Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE Services 3 • CVD screening at health camp and outreach • BSSK screening • Mental Health screening • Colorectal screening • Smoker screening (3A)- quit soking service • NCDP 1 Malaysia : 1. Comunity: Kg Pasir Nering 2. Department: Majlis Daerah Hulu Terengganu dan Pejabat Daerah Hulu Terengganu

SLIDE Workload at UPL 4

Total patient / perday

OPD attendance 180 – 250

OPD patient which been seen by medical officer 60 ( average)

OPD patient which been seen by medical assistant 140 ( average) Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE 5 Organization chart

Family Medicine Specialist (1) Advisor

Dental Officer Medical & Health Pharmacist (1) Officer (3)

Medical Assistant (4) Health Nurse (1) Community Nurse (2)

Assistant Attendant (1)

SLIDE 6 Job and duty FMS M&HO PPP & JK JM PPK

Advisor Manager Accept client Appointment Register client Referral center Counselor leader Caunselor Register QSS screening Iniatiate Treating and Reten Do basic Filing treatment and accept the Refer case examination handling the referral case whne needed -Ht,Wt,BMI, difficult case Iniatiate CO,PEFR CME treatment with Take client FMS supervising history Fagerstorm Defaulter tracing Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Early client screening Screening at the main counter SLIDE Identify client • BSSK/ Chronic disease 7 • Walk-In case • Health camp • Dental clinic • Referral from Hospital / Department / Goverment / School / Privatize sector

Client Management Smoke Not smoking / ex smoker/ Client who does not want to stop Concept 3A

Unsure to stop Willing to stop

Concept 5R Registered QSS according to 5 A concept

Client Management for Quit Smoking Service SLIDE Flow chart of quit smoking service management 8

Client registration Use the QSS registration book

Evaluation and determine the level of nicotine addiction (FAGERSTROM)

Physical examination and clinical test Use the QSS health record book Client treatment

Non – pharmacology pharmacology

Follow up treatment

Referal Maintaining the status free from smoking Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot Monitoring

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SLIDE 9 Referral letter Cop yang digunapakai untuk saringan awal Screening counter / Counseling / General counter Examination room for 5A

MEROKOK 3A DONE

YA TIDAK TELAH BERHENTI TARIKH

B/P KLINIK BERHENTI MEROKOK

P/R SETUJU TIDAK SETUJU

TEMP TEMUJANJI

B/W

R/R

SLIDE 10 Quit Smoking Clinic – Patient’s folder

SLIDE 11 Equipment for the Quit Smoking Clinic 1. Sphygomomanometer and Stethoscope 2. Weight machine and height measurement equipment 3. BMI chart 4. Peak Flow Meter 5. CO Breath Analyzer 6. Peak Flowmeter Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Medication SLIDE 1. Champix 12 2. Nicotine gum

Guidelines / manual SLIDE 1. Small book / pamphlet – guidance in quit smoking 13 2. Record book for client 3. Material for QSS 4. CPG (Treatment of Tobacco Use and Dependence 2003)

Documentation and record SLIDE 1. Folder / kad Klinik Berhenti Merokok 14 2. Registration book a. New case b. Follow up case 3. Reten QSS 1/04

Achievement for the Quit Smoking Service at Health Clinic Kuala Berang SLIDE 15 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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SLIDE 16 Brief Intervention for Quit Smoking Clinic client

Total agreed and Total client came to the Month Total 3A screening referred with Quit Smoking Service appointment to clinic (QSS)

March 23 10 0

April 18 8 1

May 40 16 1

June 28 11 0

Total 109 45 (41.3%) 2 (4.4%)

SLIDE 17 Total client which already quit (based on total patient of the year)

Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Achievement for the Quit Smoking Service at Health Clinic Kuala Berang SLIDE 18 Case Total Case Regstered (JAN – JUNE 2012) CVD Screening 2 BSSK Screening 1 Out patient 11 ( 57.9 %) Dental Clinic 2 Staff 1 NCDP1M 0 (5 Counselling in group) Health Camp 2 Total 19

Total client which already quit (based on total patient of the year) SLIDE 19

Quit rate SLIDE Total client which already quit Total client registered Quit rate (%) 20 Jan - June 2011 July - Dec 2010 7 9 77.8% July – Dec 2011 Jan - June 2011 5 7 71.4% Jan - June 2012 July - Dec 2011 7 15 46.7% July - Dec 2012 Jan - June 2012 ? 19 ??? Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Total client which already quit based on treatment

SLIDE Duration study 21 Activity Avergae time

Registration 10 minutes Basic examination – height , weight , Fagerstorm tets, CO2 anayzer and PEFR

Counseling and treatment 25 minutes

SLIDE Challenges 22 1. Non – strategic Infrastrukture for intergrated concept. 2. Lack of QSS promotion at all level. 3. Too many screening and activites in the clinic 4. Lack of staff and big workload. 5. Time factor for counseling session. 6. Lack of awareness among the young smoker 7. Defaulter 8. Client worried about the side effect of quit smoking, eg: gained weight, fatique and so on. 9. Lack of enforcement about the signage of “ smoking is prohibited in the public area” 10. Smoker lack of knowledge about the law in Islam regarding smoking Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Improvement suggestion SLIDE 23 1. To elevate the promotion of quit smoking service at health clinic 2. Train more staff for this programme – counseling session by staff and pharmacist. 3. Special appointment day for the client 4. To give effective 3A counseling so client would not default the appointment date. 5. Elevate promotion in school, instituition and pre – marriage course. 6. To make sure the client is easy to be contact in case of default. 7. Establish the enforcement of the “do not smoking” in the public area. 8. To make all the religious bodies, NGOs and mosques to get involve in promoting smoking cessation Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Pilot Project of Quit Smoking Programme in Health Clinics

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Appendix 2 Topic 1: Tobacco Burden in Malaysia

Tobacco Use – Prevalence (NHMS 2006 VS GATS 2011)

Adult Current Cigarette Smoker (GATS) Current Smoker (NHMS3) Overall Daily Occasional

Overall 22.9 20.6 2.2 21.5

Male 43.6 39.4 4.0 46.4

Female 1.0 0.7 0.3 1.6

FCTC • International legal tool to curb global tobacco epidemic • Protect public health • Provide level playing field for tobacco control esp. in developing countries • Malaysia became a party in Dec 2005

WHO FCTC - Article 14 • Demand Reduction Measures Concerning Tobacco Dependence and Cessation • Guidelines on Article 14

Assist Parties in meeting their obligations under Article 14 of the WHO FCTC, drawing on the best available scientific evidence and taking into account national circumstances and priorities Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Topic 2: Tobacco Addiction Smoking Related Diseases and Its Impact Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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What are the tobacco-related diseases? Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Topic 3: Smoking Cessation Services at Primary Care Level

MechanismsMechanisms for Tobacco for Tobacco Control Control WHO FrameworkWHO Framework Convention Convention on on Tobacco Tobacco Control Control (WHO (WHO FCTC) FCTC) • Foundation1. Foundation stone stonein the in globalthe global fight fight against against thethe tobaccotobacco epidemic epidemic

MPOWERMPOWER • Six cost-effective measures to reduce the demand for tobacco 1. Six cost-effective measures to reduce the demand for tobacco • Six2. tobaccoSix tobacco control control policies policies toto helphelp countries build build on onWHO WHO FCTC FCTC commitmentscommitments • A technical3. A technical tool tool kit kitto tohelp help countries countries fulfil fulfil the the promise promise of the of WHO the FCTC WHO FCTC

NHMS 2011 NHMS 2011 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Quick Smoking Services

ACTIVITY INDICATOR TARGET RESULT JAN - MAC Quit smoking service Quit rate at health clinic Quit Rate 15% 15.2% Health Clinic which Amount of health 326 415 implementing the quit clinic with the quit smoking clinic smoking service

ACHIEVEMENT FOR QUIT SMOKING SERVICES AT HEALTH CLINIC IN MALAYSIA 2011

No States No of Health No of No of Client Quit Rate (%) Clinics Client quit from providing registered smoking the service 1. 9 67 9 13.4 2. 21 121 17 14.0 3. Pulau 12 376 40 10.6 4. 57 2627 188 7.2 5. Selangor 28 432 44 10.2 6. 20 221 56 25.3 7. Melaka 26 414 114 27.5 8. Johor 38 420 32 7.6 9. 65 575 30 5.2 10. WP & KL 14 316 116 36.7 11 Terengganu 39 317 31 9.8 12 25 2055 279 13.6 13 43 809 109 13.4 14 17 285 81 28.4 15 WPKL 1 20 1 5.0 TOTAL 415 9,055 1,147 15.2 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Smoking intervention

Topic 5: Brief intervention 3As, 5As and Diseases Impact Jadual: Borang Fagerstrom untuk menilai tahap ketagihan nikotin

Question Answers (mark your alternative)

How soon after you wake up do you Within 5 minutes 3 ______smoke your first cigarette 6 – 30 minutes 2 ______31- 60 minutes 1 ______After 60 minutes 0 ______

Do you find it difficult to refrain from Yes 1 ______smoking in places where it is forbidden No 0 ______e.g. in church, at the library, in cinema, etc.?

Which cigarette would you hate most to The first one in 1______give up? The morning? All 0 ______others?

How many cigarettes do you smoke per 10 or less 0_____ day? 11-20 1_____ 21-30 2_____ 31 or more 3_____

Do you smoke more frequently during Yes 1______the first hours after waking than during No 0______the rest of the day?

Do you smoke if you are so ill that you Yes 1______are in bed most of the day? No 0______

0 – 3 Low Nicotine Dependence Total: 4 – 6 Moderate Nicotine Dependence 7 -10 High Nicotine Dependence Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Topic 6: Management of Quit Smoking Services at Health Clinic Flow chart of early screening for Quit Smoking Service at Health Clinic

Identify client Identify client 1. BSSK / chronic diseases patient 2. Walk in case 3. Health Campk / PKS / PPKP 4. Referral from Government Sector / School / Private

Client

Management

Not a smoker Fx= smoker Smoker

Evaluate the level of readiness in quiting

High Education Not Ready Ready

Register for quit smoking services Flow chart for management of client at Quit Smoking Clinic

Client Registration

Evaluation and determine the addiction Level of nicotine Health record book

Physcial examination and clincal investigation

Treatment

Non-Pharmacology Pharmacology

Follow up treatment 1st month: every week 2nd-3rd month: every Referral 2 weeks 4th-6th month: every month Status a quiter monitoring activity

Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot Monitoring

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Topic 8: Pharmacological Intervention in Smoking Cessation Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Bauer LA. Clinical PK Handbook 2006. Chap 1, p. 8 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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Kroon L. Drug interactions with smoking. Am J Health-Syst Pharm; 64: 2007 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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CV ADR in the news: July 14, 2011 Pilot Project of Quit Smoking Programme in Health Clinics Diseases Impact in Health of Quit Smoking Programme Project Pilot

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