THE “DOKTOR MUDA” HEALTH PROMOTION PROGRAM – A PROCESS EVALUATION

NASRUDDIN JAAFAR, K OMAR, J AHMAD, W S WAN HUSSEIN,and Z.A MANAF

(Supported by University of Malaya Research Grant F0717/2003B)

ABSTRACT
Compared to outcome evaluation, very few studies focused on evaluating the process leading to long-term sustainability problems. This is a “child-to-child” health promotion model for primary schoolchildren called the “Doktor Muda” (DM) where they are empowered to give health education and conduct activities. After ten years running, what made it self-sustainable? Objective: to evaluate key factors responsible for the sustainability of these programs. Method: Self-administered questionnaires were sent to 2804 DM's. Results: Over 90% agreed that it increased their knowledge, contributed to self-development, enjoyable, appropriate, effective, efficient and acceptable. Between 50-89% said the program changed their attitude, they practiced healthier lifestyle, can teach others, better perceived by peers, influenced their career choice and the content was adequate. However less than one-half (42%) still had lack confidence in public speaking. Qualitative evaluation from several focused group discussions (FGD) with 54 DM's corroborated the findings while adding to better understanding of underlying reasons. FGD on 41 parents, 15 teachers and 14 administrators suggest that the program was self-sustainable because the process of peer education freed teachers of much didactic teaching, promoted self-esteem among DM’s, improved communication and public speaking skills and enhanced the school image. The school’s health environment improved from the DM’s surveillance report. These benefits are over and above the increase in health knowledge which was the main objective of the Health Education Unit. Thus the beneficial impact was felt by all stakeholders. Conclusion: The main reason for sustainability was that the process satisfied the needs of all stakeholders who see the results worthwhile. It is the development of the personal character of the DM’s while teaching and helping other children which were most appreciated by all.

1.
INTRODUCTION
1.1
THE CONCEPT OF “HEALTH PROMOTING SCHOOLS”.
What is a “ Health Promoting School” ? - “A school with healthy setting for living, learning and working”. (WHO, 1996).

A health promoting school should have these five characteristics (WHO, 2003).

1.
fosters health and learning.
2.
engages health and education officers, teachers, students, parents and community leaders to promote health.
3.
strives to promote a healthy environment (for staff, community, outreach, programs, recreation, social support etc).
4.
implements policies, practices and other measures that respects individual’s self esteem, opportunities for success, acknowledge good efforts and personal achievements.
5.
strives to improve the health of school personnel, families and community members as well as students, and works with community leaders to help them understand how the community contributes to health and education.

  In order to create health and prevent disease, a “ Health Promoting School” must:
1.

Prevent leading causes of death, disease, and disabilityby making a strong case for incorporating health and oral health promotion as an integral part of school activities or curriculum.

Eg: In Oral health, Nutrition, Diet, Sedentary life, Tobacco abuse, Injuries, Violence, Drugs, Alcohol, HIV/AIDS/STD, Helminths etc.

2.
Influence health-related behaviours by improving knowledge, attitude, beliefs, values, skills, social support.

The “health promoting school” must focus on:

  1. Caring for oneself and others.
  2. Making healthy decisions.
  3. Taking control over life’s circumstances.
  4. Creating conditions that are conducive to health ie. Policies, services, physical and social conditions.
  5. Build capacities for: peace, education, income, equity, food, shelter, a stable eco-system, social justice and sustainable development.

 

1.2
PROBLEMS IN IMPLEMENTATION
  1. How do we operationalize the Ottawa Charter (1986) strategies, into the school system or setting?
  2. How can we integrate it into the school’s activities or curriculum?
  3. How can we integrate oral health into general health activities? (Sheiham & Watt, 2000)
1.3
PREVENTING HEALTH PROBLEMS IN MALAYSIA - WHO’S RESPONSIBILITY?
1.3.1
Health problems in 12-year-old SCHOOLCHILDREN (MOH, 2001) (in order of prevalence)
HMIS Family Health Report (Dept of Public Health, 2001)
(1994)
%
(2001)
%
1. Eye & visual problems
52.0
73.1
2. Other skin problems
45.5
46.7
3. Head lice infestation
92.5
35.9
4. Skin disease
6.1
5.7
5. Worm infestation
21.9
2.5
6. Learning handicaps
1.5
1.0
7. Heart problems
1.7
0.9
8. Anaemia
0.3
0.9
9. Ear & hearing problems
0.8
0.4
10. Skeletal retardation
0.2
0.1
 
Oral Health Division Ministry of Health, 2003
(1994)
(2001)
1. Dental caries prevalence
60.0
55.0
* Other seasonal endemic health problems:

Endemic vector borne = Dengue, malaria,
Endemic outbreaks = Cholera, Typhoid

 
1.3.2
Health problems in TEENAGERS (15-year old schoolchildren) (MOH, 2001) (in order of prevalence)
HMIS Family Health Report (Dept of Public Health, 2001)
(1994)
%
(2001)
%
1. Eye & visual problems
51.5
2.5
2. Other skin problems
36.7
31.5
3. Head lice infestation
13.5
5.3
4. Skin disease
3.6
3.8
5. Worm infestation
9.9
0.7
6. Learning handicaps
0.4
0.8
7. Heart problems
1.6
0.8
8. Anaemia
0.3
0.2
9. Ear & hearing problems
0.8
0.2
10. Skeletal retardation
0.2
0.1
 
Oral Health Division Ministry of Health, 2003
(1994)
(2001)
1. Dental caries prevalence
75.0
60.0

Other “health” problems:

  1. Moral problems? (eg. School bully, sexual promiscuity, unwanted pregnancy, baby dumping, HIV/AIDS)
  2. Smoking, Drug abuse & glue sniffing.
  3. Illegal racing.
 
1.3.3
Health problems in ADULTS: 10 principal causes of deaths in MOH Hospitals 2001 (in order of prevalence)
(Dept of Public Health, 2001)
(1994)
%
(2001)
%
1. Heart & Dis. of Pulmonary Circulation
17
15.8
2. Septicaemia
9
13.7
3. Malignant Neoplasms
9.3
4. Cerebrovascular esp. strokes
10
9.3
5. Accidents (esp. Motor Vehicle Accidents)
10
7.9
6. Perinatal mortality
10
5.9
7. Digestive system disease
4.7
8. Pneumonia
4.7
9. Nephritis & nephrotic syndrome
3.7
10. Ill defined conditions
2.6
 
Oral Health Division Ministry of Health, 2004
(1990)
(2000)
1. Dental caries prevalence
94.6
90.3
2. Edentulous adults (“dentally dead”)
10.4
8.2
 
1.3.4
LONG-TERM PUBLIC HEALTH NATIONAL CONCERNS
  1. Communicable Diseases: HIV/AIDS/STD, Endemic vector borne diseases, Remerging disease eg. TB, Hospital infections.
  2. Non-communicable Disease (with modifiable risk factors): Tobacco smoking, Diabetes, Hypertension, Hypercholesterolemia, Obesity, Sedentary lifestyle, Mental stress, Cancers? = (Poor Diets + No exercise + Smoking + Drinking).
(Health Facts Malaysia, Ministry of Health 1994 and 2001)(MOH Annual Report 2001)
Recent Concerns:
SARS, Bird-flu, Imported “smoke-haze” problems etc.

The implications of all these health problems trends are twofold:

  1. First: all preventive programs have to be targeted to schoolchildren leading to a huge expectations and responsibility to schools and teachers!
  2. Second: the majority of these conditions have common risk factors related to lifestyles & poor public and personal health behaviour which are only amenable through a COMMON RISK FACTOR APPROACH.

1.4
THE PROBLEM WITH TRADITIONAL APPROACHES IN PREVENTING DISEASE: A CRITICAL ANALYSIS
The traditional approach of health education and disease prevention can be described as top-down, adult-led, professional based initiatives and interventions. These approaches are the anti-thesis to the spirit of health promotion which are to enable self-empowerment, self-esteem, community based and bottom-up initiatives. The latter approach makes it more relevant to the consumer, and thus promotes sustainability in the long-term. The following is a summary of the consequences of traditional approach to prevention of health problems.

PROBLEM 1: Single Disease Approach


Result:
  • 1. Strategies & recommendations may not be relevant to the target populations’ lifestyles.
  • 2. It does not focus on the main determinants of disease - thus “victim-blaming”.
  • 3. It failed to appreciate that (almost) all disease are multi-factorial and the causes are common.
PROBLEM 2: Lack of co-ordination between Multiple Agencies interested in the same problem.

Result:
  • 1. It wastes manpower, money and material (3M) - due to duplication of efforts.
  • 2. There is always a shortage of manpower (both professional and non-professional) to carry out planned activities.
  • 3. Client fatigue (same customer is being “troubled” by multiple providers in numerous programs esp. teachers).
PROBLEM 3: Top-down, Provider-defined Problems & Intervention Programs.

Result:
  • 1. Assumed empty vessel, passive recipients mentality.
  • 2. Lack of feeling of ownership of the program.
  • 3. Create dependence on governments’ effort.
  • 4. Does not enable people to control over, and improve their own health (Ottawa Charter 1986)
  • 5. It is not sustainable beyond the launching campaign by the authorities.

“Health is everybody’s business”

Proposed Strategies? Ottawa Charter for Health Promotion (1986)

The Ottawa Charter for Health Promotion (1986) was one of the first attempts to get the idea of widening the scope of public health to include enabling, mediating and facilitating functions. This was accepted internationally and is summarised by the following five guiding principles:

1. Build a healthy public policy.
2. Create supportive environments.
3. Strengthen community action.
4. Develop personal skills.
5. Reorient the health services (& programmes) towards prevention.

However the main problem with such lofty global principles was how can the principles be locally implemented, within the context of the Malaysian school system?
 

1.5
THE CONCEPT OF THE DOKTOR MUDA PROGRAM
1.5.1
Definition of terms & Strategies

The Doktor Muda Program is defined as a school-based health promotion program for primary schoolchildren using the concept of empowerment aimed at producing a group of students who values health and acts as an agent to promote healthy lifestyles to their peers, the school community and their families.

The Doktor Muda is defined as a specially selected group of students chosen by the school teachers based on a set of criteria, trained to increase their knowledge and skills based on the Doktor Muda Training Module and to act as an agent of change to improve the health knowledge, attitudes and practices among their peers.

The objectives of the Dr Muda program are to:

  1. Enable students to help themselves, their friends and families to practice a healthy lifestyle.
  2. Enable them to be a role-model to their peers.
  3. Facilitate and help health personnel and school to carry out health education and promotion activities.
  4. Involve the teachers and the school community to improve the level of children’s health.
  5. Encourage the parents to be aware of children’s health.
  6. Improve co-operation between the Health and Education Department to promote healthy practices.

The strategy adopted were based on:

  1. smart partnership between all stakeholders i.e. Health Department, Education Department, School Authorities, Parents/Guardian, Private sector and other non-government organizations.
  2. Multi-sectoral health committee formed at the school, district, state and national level.
  3. School autonomy to choose candidates.
  4. Flexible training module according to the schools’ needs.
  5. School based program using available facilities.
  6. Peer-to-peer teaching in delivering health messages.
  1.5.2 Historical development
   
The Doktor Muda Program was first introduced in Malaysia in 1989 as an experimental program in Pahang and followed by Kelantan, following the principles outlined by the Health Promoting Schools concept. Basically it is a child-to-child health education and promotion program for primary schoolchildren designed to spread the burden of health education to all affected parties.

In Pahang, a pilot project was started in a primary school in Pekan in 1987. It was not taken up continuously and the problem of sustainability occurred while the initiators were trying to find the right formula to ensure acceptance. It was later in the early 1990’s that the project was revived and evolved positively till the present day The current coverage of the program is about 27% of primary schools (n=140) spread across 12 districts. About 3109 of the students in these schools (about 2% of total schoolchildren) have been trained as Doktor Muda in 2004 (Jabbar, 2005).

In Kelantan it started in 1991 as a pilot project in 2 schools. By 1996 it was established in 16 schools. By 2003, 97 primary schools in 10 districts have implemented the program and the total strength of Dr Muda in Kelantan was 3965.

  1.5.3 The rationale for adopting this strategy
   

In order to be acceptable to the school, teachers and the education system,, certain basic rules were adopted. These are:

1. Must not disrupt normal classes.

  • More acceptable to parents & teachers.
  • Does not increase perceived burden to teachers.
2. Must be community-centred and multi-sectoral.
  • Create sense of commitment to program
  • Create sense of ownership
  • Enable them to increase control over their own health. Thus - more cost- effective & cost-efficient

3. Must use existing resources, facilities and fit into the existing school system.

  • sustainable in the short term
  • sustainable in the long term
  • more adequate coverage.
1.5.4 How It Is Implemented
a)

The Flow Chart OF Selection Of Candidates

CLASS TEACHER CHOOSES A FEW “SUITABLE CANDIDATES” BASED ON GIVEN CRITERIAS*

STATE HEALTH EDUCATION DEPT. COORDINATES THE TRAINING MODULES

SUCCESSFUL CANDIDATES ARE OFFICIALLY APPOINTED AS “DOKTOR MUDA”

DOKTOR MUDA PLANS AND IMPLEMENTS HEALTH RELATED ACTIVITIES FOR THE SCHOOL COMMUNITY

b)

The Doktor Muda’s Selection Criteria.

  1. Standards 4-6 (ages 10-12yr), * Limited to between 25 -35 students per school.
  2. Good academic record,
  3. Show leadership traits among class mates,
  4. Enjoy helping others,
  5. Healthy, clean & presentable,
  6. Self-interest in becoming junior doc
  7. Received permission from parents.
c)

Job Description Of Doktor Muda:

  1. Team member for health surveillance in school.
  2. Influencing healthy school environment.
  3. Role model & facilitator for peers.
d)

Main Health Promotion Activities Of Doktor Muda:

  1. Act as a role model for healthy behaviours and lifestyles.
  2. Helps to create a healthy school environment which is clean and safe by active surveillance.
  3. Help teachers and health personnel to conduct health related activities in schools. (Eg. record annual students health report card for weight, height, eye test, personal hygiene, oral/dental health inspection, helps in health campaigns etc.)
  4. Report to teacher/Health education Officers of health problem in school (eg. incidences of vomiting, diarrhoea, injuries, school cleanliness etc.)
  5. Treat minor injuries (first-aid)
  6. Records health activities in a Health Report Book.
  7. Participates in Doktor Muda Conventions.
  8. Visits health facilities eg. hospitals, clinics.
  9. Helps to organize health related activities and campaigns eg. health quiz, drawing, essay, public speaking etc. to increase awareness on the importance of health maintenance in their school .

 

e)

Main Topics Covered In Training Module

There are 10 main scopes covering 27 teaching/learning units. The ten scopes are:

Module Scope

No. of Teaching / Learning units
(Each unit session lasts 1 - 1.5 hours)

1. Doktor Muda. 4 units: Responsibilities of Dr Muda/ Health facilities/ Health measurements/ Public speaking & Communication skills
2. Personal hygiene 3 units: hand hygiene / body & hair/ nails.
3. Environmental hygiene 2 units: school environment / toilets
4. ORAL HEALTH 2 units: oral hygiene maintenance/ injury prevention
5. Mental health 4 units: self-esteem/ interpersonal skills/ how to say-NO/ positive thinking skills.
6. Prevention of disease 2 units: Dengue/ Malaria
7. Safety and Injury prevention 3 units: personal safety/ accident prevention/ first aid.
8. Healthy nutrition and diet 3 units: healthy eating/ breakfast/ food premises.
9. Healthy lifestyles 3 units: don’t start smoking/ exercise/ weight watch.
10. Healthy teenagers 1 unit: introduction to teenage world (sex education)
Total = 10 scopes 27 teaching / learning units (minimum)
Note: Additional health issues which are important locally as decided by the School Health Committee (eg. HIV/AIDS, Road safety, drug & substance abuse etc) can be included and speaker / trainers may be invited as needed.
   
f)

Evaluation of Program:

  1. Of the Doktor Muda = pretest / posttest questions, essays, demonstration of skills, written health report / health diary. Official graduation ceremony + certificate
  2. By asking teachers: knowledge, attitude, behaviour.
  3. By asking parents: through questionnaire.
  4. By observing peer: group reaction to DM.
  5. By observing changes in the school environment.
    g)

The Doktor Muda Training Module - Methods

Trained by a multi-disciplinary team comprising health education officers, medical doctors, dentists, nurses, dental nurses, teachers and invited speakers through:

Lectures, Demonstrations, Debates, quizzes, Role-playing, Report writing, Public speaking, Visits to a health centre, local hospital, food preparation areas, dental clinics etc.

    h)

Duration and Time

27 unit sessions of 1-2 hours each. Minimum of 27 hours required.

The teaching / learning units may be stretched over two years to reduce burden.

Senior Dr Muda’s may be asked to teach new candidates.

Held on school co-curriculum days.

1.5.5 SOME ACTIVITIES OF DOKTOR MUDA (illustrations)

VISITING HEALTHCARE FACILITIES
DM HELPING TEACHERS RECORD HEALTH STATUS DATA
DM HELPING IN DENTAL INSPECTION
DM CHILD-TO-CHILD TEACHING
DM LEADING PHYSICAL EXERCISES
CARING FOR THE SCHOOL ENVIRONMENT

1.5.6 ANNUAL END-OF-YEAR STATE LEVEL DOKTOR MUDA CONVENTION (Illustrations)

Besides the state level convention, the national level convention was introduced recently in 2004 and planned to be conducted biannually.

  • DM CONFERENCE – Poster Competition
  • DM CONFERENCE - Role Play Competition
  • DM CONFERENCE – Group Singing Competition
  • DM CONFERENCE – Interschool quiz
  • DM CONFERENCE - Oratory Competition
  • DM CONFERENCE – Drawing Competition
  • DM CONFERENCE – Scrap Book & Essay Competition
  • DM CONFERENCE - Exhibition Competition
  • DM CONFERENCE – DM OF THE YEAR AWARD
  • & DM SUPERVISOR OF THE YEAR

 

1.6
EVALUATION OF THE DOKTOR MUDA PROGRAM
 

The reasons for doing evaluation are:

  1. to provide information to policy makers, sponsors, planners, administrators, parents and families, the community and participants.
  2. to provide feedback for project planning and further development.
  3. to monitor progress and make improvements.
  4. to document the experiences for future reference and to share with others, especially international audience.
  5. to encourage other communities to develop their own models by sharing this experience.

The program has evolved through the times and in its present format seems to be the most acceptable and sustainable. There are two main types of evaluation that are most relevant to evaluating school health initiatives viz. Process and Outcome evaluation (WHO, 2003). In Malaysia, outcome evaluation based on epidemiological surveys of health and oral health of school children are regularly done and reported by the Ministry of Health through the Health Management and Information System (HMIS). Outcome evaluation of the Doktor Muda program has been done by independent evaluators (Azizam, 2004). However process evaluation seems to be lacking.

Process evaluation assesses what and how well the interventions, planned or not planned, have been implemented, to whom and when (WHO, 2003). This study will report on the process evaluation of the Doktor Muda Program (DM) after about fifteen years of implementation in the state of Kelantan.

2. AIM AND OBJECTIVES
  Aim:
  • To assess how well the program have been implemented (planned or unplanned) from the view of the target group (ie. schoolchildren), the teacher-in-charge, the parents and health personnel involved in Kelantan.
Objectives
  • to evaluate the perceived impact of the DM Program by the four major stake holders ie. The school child, their teachers, their parents and the program administrators.
  • To identify the strengths, weakness, opportunities and threats to the DM program.
3. MATERIAL AND METHOD
 

The material and method of evaluation was divided into four parts to represent the different stakeholders.

PART 1: Evaluation of DOKTOR MUDA Perception about the program.

  1. Quantitative Evaluation via self-filled questionnaire. (n=2804)
    NOTE: (Total no. of DM in state = 3965) (Response rate = 70.7 %)

    * Reliability of CHILDREN’S QUESTIONNAIRE N=2804
    (Cronbach’s Alpha = 0.70)
  2. Qualitative Evaluation via Focused Group Discussion (FGD) (n=54)
  3. Qualitative Evaluation via face-to-face personal interview (n=1)
    NOTE: This DM won the National DM Champions trophy and certificate in 2004.

PART 2: Evaluation of TEACHERS Perception about DM Program .

  1. Via Focused Group Discussion (n=15)
    NOTE: Total no. of eligible DM teachers = 97 i.e. one teacher/facilitator per school.
  2. Via face-to-face personal interview (n=1)
    NOTE: This teacher was in-charge of training the DM who won the state level competition and National DM champion in 2004.

PART 3: Evaluation of PARENTS perception about their DM child.

  1. Via self-filled questionnaire (n=41)
    NOTE: Sample consists of PARENTS of DM from two primary schools, in two districts (i.e. Pak Badol Primary School, Bachok District (n=17) and Tok Uban Primary School, Pasir Mas District (n=24).

PART 4: Evaluation of ADMINISTRATORS perception about the DM program

  1. Via Focused Group Discussion (n= 14)
    NOTE: Sample consists of Doctor, Dentist, Health inspectors, public health nurses, Others who were involved in training in the DM program.
4. RESULTS
4.1 QUANTITATIVE ANALYSIS
  Table 4: OVERALL SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE JUNIOR DOCTOR questionnaire respondents (N=2804)
GENDER (N=2804)
ETHNICITY (N=2804)
AGE (N=2804)

Males 37.2 %
Females 62.8 %

 

Malay 98.1 %
Chinese 1.9 %
Indian < 0.1 %

9 yr-old 1.4 %
10 yr-old 20.3 %
11 yr-old 39.6 %
12 yr-old 38.8 %

Total 100.0
Total 100.0
Total 100.0
  Table 4A. COMPARATIVE EVALUATION OF PERCEPTION OF IMPACT OF THE PROGRAM BY DIFFERENT STAKEHOLDERS
A) IMPACT ON KNOWLEDGE, ATTITUDE AND PRACTICE
Questionnaire statement (items)

Doktor Muda views (N=2804)*
% agreement

Doktor Muda views
(N=54)
% agreement

Parents views (N=41)
% agreement

Teachers views (N=16)
% agreement

Adminis-trators views
(N=14)
% agreement
1. Increased knowledge among Doktor Muda (DM’s)
96.9
100.0
97.6
100.0
92.8
2. DM’s attitude has changed since joining the program.
75.0
96.3
87.8
93.3
92.8
3. DMs practiced a healthier lifestyle in daily practice.
86.7
75.9
92.7
93.3
92.8
  Table 4B. COMPARATIVE EVALUATION OF PERCEPTION OF IMPACT OF THE PROGRAM BY DIFFERENT STAKEHOLDERS
B) IMPACT ON SELF-CONFIDENCE AND SELF-ESTEEM
Questionnaire statement (items)

Doktor Muda views (N=2804)*
% agreement

Doktor Muda views
(N=54)
% agreement

Parents views (N=41)
% agreement

Teachers views (N=16)
% agreement

Adminis-trators views
(N=14)
% agreement
4. DMs can teach other children & peers and influence them
69.5
87.1
82.9
93.3
85.7
5. Friends opinion on DM have changed for the better
76.1
90.7
53.7
100.0
78.6
6. Confidence to talk about health to family, friends, public
42.0
64.8
80.5
80.0
93.3
  Table 4C. COMPARATIVE EVALUATION OF PERCEPTION OF IMPACT OF THE PROGRAM BY DIFFERENT STAKEHOLDERS
C) IMPACT ON PERSONAL DEVELOPMENT AND FUTURE CAREER
Questionnaire statement (items)

Doktor Muda views (N=2804)*
% agreement

Doktor Muda views
(N=54)
% agreement

Parents views (N=41)
% agreement

Teachers views (N=16)
% agreement

Adminis-trators views
(N=14)
% agreement
7. This program influenced career choice (wants to be doctor)
74.3
83.3
85.4
100.0
85.7
8. This program has contributed to personal development
96.2
NA
80.5
100.0
85.7
  Table 4D. COMPARATIVE EVALUATION OF PERCEPTION OF IMPACT OF THE PROGRAM BY DIFFERENT STAKEHOLDERS
D) OVERALL EVALUATION OF THE PROGRAM
Questionnaire statement (items)

Doktor Muda views (N=2804)*
% agreement

Doktor Muda views
(N=54)
% agreement

Parents views (N=41)
% agreement

Teachers views (N=16)
% agreement

Adminis-trators views
(N=14)
% agreement
9. DM enjoyed the program and not difficult
92.9
96.3
85.4
93.3
100
10. DM did not like some parts of the program
NA
63.0
14.6
66.7
100
11. The training program is ADEQUATE
85.0
81.5
70.7
40.0
50.0
12. The training program is APPROPRIATE
95.3
81.5
97.6
86.7
100.0
13. The training program is EFFECTIVE
96.3
76.0
92.7
73.3
71.4
14. The training program is EFFICIENT
96.4
87.0
85.4
40.0
64.3
15. The training program is ACCEPTABLE
93.1
87.0
92.7
93.3
100.0
4.2 QUALITATIVE ANALYSIS
 
A qualitative analysis of the focused group discussions and personal interviews yielded the following summary of some of the strengths, weaknesses, opportunities and threats related to the program implementation.
4.2.1

STRENGTHS (it benefited all stakeholders)

BENEFITS TO HEALTH INDICATORS

  1. Improved personal hygiene in school eg. less lice problems, better oral hygiene
  2. Improved health surveillance eg. less eye infections, cholera outbreaks, skin disease etc.

BENEFITS TO THE SCHOOL ENVIRONMENT

  1. Better health awareness & self-empowerment.
  2. Better co-operation between agencies.
  3. Facilitated dental care delivery and prevention - less fear & anxiety.
  4. Positive publicity for the schools involved through winning health competitions.
  5. Perceived status of Dr Muda as a co curricular activity on par (if not more desirable) than other uniformed bodies such as scouts and red crescent.

PERSONAL BENEFITS TO DOKTOR MUDA

  1. Increased confidence, self-esteem & creativity.
  2. Enhanced leadership skills.
  3. Communication and oratory skills.
4.2.2

WEAKNESSES

  1. Frequent changes in membership of health committee, headmaster and teacher-in-charge leads to confusion about the main objectives of the programme.
  2. Lack of suitable training venue and facilities like audio-visual aids and computers in many schools.
  3. Lack of financial support, equipment and uniforms from either the Ministry of Health and/or Ministry of Education.
  4. Coordination of speakers / trainers to visit schools at appointed times.
4.2.3

OPPORTUNITIES

  1. Dissatisfaction (among parents and peers) of those not chosen to become Doktor Muda.
  2. Dissatisfaction among some school teachers who did not receive enough certificates of appointment due to the larger Dr Muda quota in their schools.
  3. The parents like the visits by university professors which their children tell them and find it very motivating for their children’s academic success.
4.2.4

THREAT

  1. The majority of parents don’t even know of the existence or were not exposed to the Junior Doctor program.
  2. Invited speakers who are professionals (eg nurses, doctors etc.) from the administrators group are perceived by the Doktor Muda as less effective communicators than their own school teacher.
5. DISCUSSION
 

Many studies done elsewhere have shown that the peer teaching method is effective in promoting healthy behaviors as compared to adult-led teaching (Mellanby et al 2000; Szilagyi 2002). In Malaysia, there is no doubt there is a demonstrable improvement in knowledge among the Doktor Muda and the majority adopted healthier practices and attitudes (Azizam, 2004).

In the present study, an interesting finding in the evaluation of process is that besides the transfer of knowledge and changes in attitudes of the Dr Muda, other value-added benefits such as the improvement of soft-skills, oratory skills, improvements in the school’s health environment, and perceived impact on their future career are highly valued.

The most important factor in ensuring sustainability is the fact that the process of implementation of the program blended well into the schools co-curriculum system which the school is supposed to carry out anyway. The official Dr Muda certificates issued by the health authority to certify those who have been successful and appointed as Dr Muda helped them to secure places in prestigious boarding schools. This was an unintended positive outcome.

6. CONCLUSION
  6.1

 

The evaluation of this project showed that:

  1. The DOKTOR MUDA MODEL can be used as one of the “health promoting school” concept because it is proven to be practicable, effective and sustainable.
  2. It is sustainable because it meets most of the needs, concerns and expectations of all the significant stakeholders viz. THE CHILDREN, THEIR PARENTS, THE TEACHERS AND THE HEALTH AUTHORITIES by creating a WIN-WIN situation.
 

6.2

The opportunities to improve may be summarised as follows:

  1. The children still feel they are not confident in public speaking; however the other stakeholders don’t think so.
  2. The children demand more practical hands-on session including external visits and training sessions outside the school compounds to make it more enjoyable, challenging and interesting.
  3. The teachers and administrators think that the program coverage and content is inadequate, but clients ie. teachers and Dr Muda themselves do not agree. Thus efforts to increase sophistication of contents should be prevented.
  4. The teachers think that the running of the program is inefficient and disagree with other stakeholders. The teachers demand more involvement by (a) health personnel for eg. Doctors, nurses etc.; (b) recognition of their effort eg. via certificates for children and teachers, and (c) financial support from the Ministry of Education or Ministry of Health to run the training programs efficiently. However their greatest grievance is the lack of financial support for which they had to personally sacrifice their own money, transport, family time whenever there was any shortfall in resources.
  5. The parents want their children to gain as much knowledge, experience and develop their personal and leadership character to become future community leaders and doctors. They are very appreciative of the schools efforts. But they don’t have any idea that their children don’t like some parts of the program.
  6. The program administrators (health personnel) wanted the teachers to be more involved, to train and prepare themselves to take over the responsibility of training Doktor Muda in future. However OVERALL , all the stakeholders agree that this is an excellent program and it should be continued with more support and commitment from the Ministry of Health and Ministry of Education. The current level of financial support is felt to be insufficient especially from the teachers’ point of view.

7. RECCOMENDATION
  • We recommend that this model of HEALTH PROMOTING SCHOOL should be adopted, adapted, further developed and evaluated across the nation as well as worldwide.
  • The WHO could be the lead agency to disseminate the health promoting school model which have been successful and sustainable (such as this model) to other countries facing professional manpower constraints in making health education and promotion equitably distributed.
  • The oral health component, being integrated as part of the general health promotion program in schools, benefited from this smart partnership. The Doktor Muda thus complemented the work of the School Dental Health Services to convey the message of good oral health maintenance to their peers, teachers and families.
8. REFERENCES

Azizam MA (2004). Acceptance of health messages among Doktor Muda in the Junior Doctor Program in Maran District Pahang. MSc report (Corporate Communications Dept., Faculty of Modern Languages and Communication). Universiti Putra Malaysia. (In Bahasa Malaysia).

Department of Public Health, Ministry of Health Malaysia (2001). Annual Report 2001. Kuala Lumpur: Ministry of Health Malaysia.

Health Education Division, Ministry of Health Malaysia (2003). Laporan Tahunan (Annual Report) 2003. Kuala Lumpur: Ministry of Health Malaysia. (In Bahasa Malaysia).

Health Education Division, Ministry of Health Malaysia (2004). Modul Program Doktor Muda Sekolah Rendah (The Junior Doctor Program for Primary Schools Module Book). Kuala Lumpur: Ministry of Health Malaysia. (In Bahasa Malaysia).

Health Education Division, Ministry of Health Malaysia (2004). Kertas Kerja Program Doktor Muda (The Junior Doctor Program – Working Paper). Kuala Lumpur: Ministry of Health Malaysia. (In Bahasa Malaysia).

Health Department, Kelantan (2003). Modul Program Doktor Muda (Junior Doctor Program Module). Kota Bharu Kelantan: Health Education and Promotion Unit. (In Bahasa Malaysia).

Jabbar A (2005). Head of Health Education & Promotion Unit, State of Pahang - personal communication. Interviewed on 20.5.2005.

Oral Health Division, Ministry of Health Malaysia (2004). National Oral Health Survey of Adults 2000 (NOHSA 2000). Putrajaya: Oral Health Division, Ministry of Health Malaysia. November 2004.

Oral Health Division, Ministry of Health Malaysia (2005). Oral healthcare in Malaysia. WP Putrajaya: OHD Ministry of Health Malaysia. April 2005.

Mellanby AR , Reesa JB, Tripp JH. (2000). Peer led and adult led school health education: a critical review of available comparative research. Health Education Res 15: 533-45.

Public Health Institute, Ministry of Health Malaysia (1996). Promosi Kesihatan di Malaysia: status semasa, isu dan cabaran (Health Promotion in Malaysia: current status, issues and challenges). Report of proceedings of Health Promotion Seminar at Ming Court Hotel, Port Dickson: Public Health Institute Ministry of Health Malaysia. (In Bahasa Malaysia).

Szilagyi T (2002). Peer education of tobacco issues in Hungarian communities of Roma and socially disadvantaged children. Cent Eur J Public Health 10: 117-20.

Sheiham A and Watt RG (2000). The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol 28: 388-406.

Watt R.G et. al. (2004). Oral health promotion – Evaluation toolkit. London: Stephen Hancocks Ttd.

WHO (1996). Research to improve implementation and effectiveness of school health programmes. Report of the school working group and WHO expert committee on comprehensive school health education and promotion. Geneva: WHO.

WHO (2003). Oral Health Promotion: an essential element of a health promoting school. WHO Series on School Health Document Eleven. Geneva: WHO, UNESCO, EDC Inc.

 

1) Nasruddin Jaafar - Professor, Dept. of Community Dentistry, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, Malaysia.

2) K Omar, and J Ahamd - Head, Health Education and Promotion Unit, States of Kelantan and Pahang (respectively), Ministry of Health, Malaysia.

3) W S Wan Hussein - Lecturer, Dept of Policy and Business Strategy, Faculty of Business & Accounting, University of Malaya.

4) Z A Manaf - Professor, Dept. of Educational Psychology & Counselling, Faculty of Education, University of Malaya.


 

Last updated: 9 February, 2006  

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