Peer Of Group For Chronic Patients In Indonesia

PEER GROUP FOR CHRONIC ILLNESS IN INDONESIA By Mardiyono, PhD (Candidate) Faculty of Nursing, Prince of Songkla University, Thailand

Introduction People suffer from chronic illness such as diabetes mellitus, asthma, cancer, HIV/AIDS, tuberculosis, chronic heart disease, chronic renal failure, chronic lung disease, leukemia, and rehabilitation of drug addiction. Those people must have many problems including physiological, psychological, social, cultural, and spiritual problems. Living with chronic illness, clients should have skill of self-management to handle those kinds of chronic disease. Indonesians prefer to live in group and to do gotong royong. Personal relationship is alike gathering under culturally charged in any society events. It can refer

mutual adjustment or fairly well indefinable value-images of rukun. There are rukun in many subgroups of society associated with gotong royong. The conception of gotong

royong is a representative core tenet of Indonesian philosophy. Gotong royong is reciprocity or mutual aid. People usually help each other or reciprocal assistance when one of community faces problems or adversities (Nasroen, 1967). This capital culture can be helpful for people living with chronic illness. Respect to Indonesian culture capital of rukun and gotong royong, peer group program can be implemented in community to help clients with chronic illness gaining self-management. The new health policy of peer group with chronic illness is proposed by the next year, 2009. The peer group approach can help from someone who is in the same situations of life (Hoey, Ieropoli, White, & Jefford, 2008). The proposed health policy follows the three phases of the health policy process:

1 formulation, implementation, and evaluation or feedback (ICN, 2005). In the formulation phase, clients with chronic illness do not have enough supports from health officers and community. In the peer group, interaction among membership is interrelationship and other benefits from peer counselor and volunteer, shown in Figure 1. Clients can develop personal relationship among people with the same conditions suffering chronic illness i.e. HIV/AIDS and Diabetes Mellitus. Peer counseling is a method for providing information, advice, and emotional support about an illness or a medical conditions by persons who were or still are affected the disease. The peer counselors are community nurses the ones who are previously trained and supervises peer groups (Heisler, 2006). Culture capital and less budget obviously help peer group of chronic illness in community. In the implementation, the Ministry of Health launches peer group of chronic illness as an annual program. The general directorate of public health, province health office and district health office implements the peer group of chronic illness with hospital, non government organization (NGO), foundation, and university, networking as shows in Figure 2. In the evaluation or feed back, the general directorate of public health, province and district health office monitors and reviews progress and outcomes from implementation of peer group of chronic illness. Modification of peer group of chronic illness is possible to achieve effective and high quality outcomes. The expected outcomes of peer group are the clients who can accept life with chronic illness, improve coping with the disease, perform self-care, and have perceived control as well as the quality of life and well-being. The aim of the peer group program is to provide conducive and constructive environment and atmosphere for

2 clients with chronic illness. Furthermore, interrelationship and empowerment among members of peer group can occur as shown in Figure 1.

M1

M2

M8

M7

C1

M3

M0

M6

M4

V1

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Figure 1 Support gained in peer group of chronic illness, © 2008 M1: relationship, M: information, M3: psychological support, M4: social support, M5: spiritual support, M6: social functioning, M7: sharing and counseling, M8: material support, C1: peer counselor, V1: peer volunteer from society, foundation, university and NGO

Problem Statement Various problems of clients with chronic illness emerge in community that discharge planning in hospital does not work effectively to support patients with chronic illness in community and community health nursing program in public health center also does not connect with hospital procedures of discharge planning. In the second problem, they are lack of supports from society and foundations of chronic illness has not created peer group of the clients. Lastly, the third problem is no networking between health officer, hospital, non government organization (NGO), foundation, and university. There are many foundations of chronic illness such as diabetes, heart, cancer, lung, leukemia, and HIV/AIDS foundations, but there is no health policy in the General Directorate of Public Health, province and district health

3 officer to arrange connection among NGO, foundation, hospital, and university for running peer group of chronic illness. For instance, after discharging from hospital, clients of HIV/AIDS face stigma in society, no support from hospital and public health center, and no networking between health officer, hospital, non government organization (NGO), foundation, and university. In the fact, the Provider Initiated Counseling Testing (PICT) agreed upon by all members of the 17th AIDS International Conference in Mexico (Montaner, 2008) does not facilitate clients with HIV/AIDS to have connection with health officer, NGO, foundation and university. Discussion Current law aspect The Ministry of Health (2008) states that the goal of health care system is to achieve the highest community health status by utilizing a synergic, effective, and efficient health development and by involving all nation’s potency, government, private sectors, and the community. In mid-September 1998, new health paradigm was introduced that focuses health development more on the health promotion and prevention than on curative and rehabilitative services. However, there has been no health policy of peer group of chronic illness in national, province, and district level. Social aspect Nasroen (1967) revealed that Indonesian have a good relationship each other in group. Social bunch in formal and informal layer of society can contribute for peer group of chronic illness. It is evidence of integrated health post or “posyandu” in community, which can run firmly in rural area for long time by health volunteer and monthly health supervisor. The social support with immaterial and financial also can survive peer group of chronic illness. Clients with chronic illness currently also attempt to look for adjunctive therapy and they do not only rely on conventional

4 therapies. By involving in peer group, clients will have better information of adjunctive therapy, because mouth to mouth information is more effective than formal information in community. Testimony of proving adjunctive therapy by person in peer group is effective source to learn each other in peer group. For instance, adjunctive cubing therapy can increase volume of CD4 in HIV/AIDS clients and wet cubing therapy is effective to reduce blood glucose level in clients with diabetes mellitus. Peer member will be easily to follow this therapy because directly proving by themselves. Political aspect Since 2006 the Ministry of Health launched a new platform with an initial social mobility to enrich social potency and to improve health care system to achieve Healthy Indonesia 2010 (WHO, 2008a). During 2004-2009, government had increased number of health networking, improved quality of health care center, health care providers, health welfare for poor people, health life style, and early health education to enhance primary health care (Ministry of Health, 2008). The new policy of decentralization in Indonesia is in which the Ministry of Health gives provinces and districts a large autonomy to manage their health program to achieve the national health goal. In particular, the role of nursing in political area increases number of professional nurses to improve quality of nursing contribution in health care system (ICN, 2005). Peer group of chronic illness will strengthen to achieve the goal of province and district health office by building health networking with hospital, NGO, foundation, and university. Economic aspect The implementation of decentralization policy in Indonesia affects on health budget in provinces and districts to run both national and local health program.

5 National budget for health care system is 4% of total budget since 2000 (WHO, 2008a). Regarding the budget constraint of health program, province and district health office will emphasize on health prevention and health promotion in "the Healthy Paradigm of Indonesia Health 2010" rather than on curative services (WHO, 2008b). Peer group of chronic illness do not need much health budget to facilitate public health services, private health capital, university resource, and society capital both foundation and NGO. The most significant support comes from health volunteer and the clients themselves to success the peer group program of chronic illness. The health office also obviously employee few health staffs to empower, coach peer group and initiate collaboration with those parties in Figure 2. Plan of Action Action plan of peer group is divided into four phases. The first phase is to issue officially peer group program of chronic illness in national, province, and district level. The second phase is to inform broadly the new policy of peer group of chronic illness to existing NGO, foundation, public hospital, private hospital, and university. In Figure 2, general directorate of public health in the Ministry of Health, division of health promotion and safety environment in the province health office, section of community health nursing in the district health office, and public health center will build networking among those parties to create peer group of chronic illness, such as diabetes, asthma, chronic heart disease, cancer, chronic lung disease, chronic renal failure, leukemia, rehabilitation of drug addiction, and HIV/AIDS. Peer group of chronic illness should consider the same type of chronic illness, distance of peer center from peer member home, and number of peer members. The third phase is to implement consistently the peer group of chronic illness by peer counselor from the health office and by peer volunteer from foundation,

6 NGO, community, and university or colleges. Health provider of vigilant village is responsible for peer group of chronic illness in countryside or suburb. Key person or leader of peer group should be appointed for organizing the meeting and a preparation. Gathering of peer group of chronic illness can be held monthly. The fourth phase is to evaluate implementation of peer group of chronic illness by health officers in general directorate of public health, division of health promotion and safety environment, and section of community health nursing. Outcomes of the peer group will strengthen the quality of the peer group. Policy Recommendation Peer group of chronic illness is useful for implementing the health promotion and prevention program in group of chronic patients. The peer group supports the program of general directorate of public health focusing on community empowerment, division of health promotion and safety environment, section of community health nursing, and public health center. The peer group should link with the vigilant village and peer counselor by health officer as shown in Figure 1 and 2. Policy recommendation can be divided in to the four phases. Firstly, official order should be made for launching peer group of chronic illness in the Ministry of Health followed by province health office and district health office. Responding on the facts in society, many clients of chronic illness suffer from chronic symptoms and psycho-socio-spiritual problems and many foundations mainly focus on medical treatments and physical problems. They do not have enough support from governments, community, and foundation/NGO in society. Therefore, peer group of chronic illness is an initial program to enhance and empower clients with chronic illness to achieve self-management and self-care of their diseases.

7 Secondly, peer group program of chronic illness should be included in the annual health program in the general directorate of public health in the Ministry of Health, division of health promotion and safety environment in the province health office, and section of community health nursing in the district health office. Peer counselors should be provided for running the program. Peer counselor should create collaboration and networking with public hospital and private hospital for discharge planning, with foundations for facilitating and supporting peer group of chronic illness, NGO and university for health peer volunteer (Figure 2). Thirdly, university and college should support continuously for peer group of chronic illness by allocating health students for field work in the peer group. Public health center is also responsible for running peer group of chronic illness under program of community health nursing. Nurse in charge in community health nursing should organize cadre or health volunteer, health officer in vigilant village, private clinic, and students of health science such as medical, nursing, nutrition, public health, and midwifery students to work together for running peer group by education, couching, counseling, and delivering care to clients with chronic illness. Lastly, evaluation of peer group program should be conducted for monitoring and reviewing outcomes of peer group of chronic illness within period frame. Refinement and modification of the peer group will achieve the quality of community basic community nursing. Strategies and Action of Plan The four pillars of strategy for peer group of chronic illness are as follows: 1. Decentralization of heath plan and budget in the context of broader political decentralization leads the general directorate of public health, province health

8 office and district health office to plan and implement peer group of chromic illness with their own budget. 2. Peer group with chronic illness emphasizes on health promotion and health prevention. Figure 1 explains members of peer group of chronic illness developing interrelationship among each others to health information to promote self-care and self-management related their disease. Interrelationship among members of peer group will develop health behaviors to prevent their own disease and eliminate disease spread if it is infectious diseases. 3. Effective health officers can manage peer group of chronic illness in national, province and district or municipality level to achieve quality basic health services. Health officers can operate networking of peer group of chronic illness with hospital, NGO, foundation, and university in national, province, and district level. 4. Peer group of chronic illness can provide quality of basic health services through a community managed care approach or “Jaminan Pemeliharaan Kesehatan Masyarakat”. Peer group of chronic illness is mainly held by community and health volunteer. Peer counselor comes from health officers, NGO, foundation, and university. Since 2006 the Ministry of Health started a new platform with an initial social mobility to enhance social potency and to improve health care system to achieve “Healthy Indonesia by 2025” as following “Healthy Indonesia by 2010” (Thabrany, 2006). Peer group is an approach to achieve the new vision of health with effectiveness and efficiency. Figure 2 explains that peer group program of chronic illness should be launched in national level by the general directorate of public health of the Health Ministry. Formal collaboration should be afforded with NGO, foundation, hospital, and university to support peer group of chronic illness.

9 In province and district health office, division of health promotion and safety environment also supports peer group of chronic illness by assigning section of collaboration and development of community to build networking among local NGO, foundation, public and private hospital, and university to success the peer group program. In public health center as front line, section of community health nursing encourages health staffs in vigilant village to establish peer group of chronic illness and look for health volunteers or cadres to work together with the clients in peer group. Systematic support is also expected from nursing college or university such as medical, nursing, nutrition, public health, and midwifery students. Conclusion The conclusions of this proposal are two points. Firstly, peer group of chronic illness is appropriate for health promotion and prevention program and budget efficiency of health program. Social and culture potency of ‘gotong royong’ in society are effective to success program of peer group of chronic illness. Political will should be gained to support new health policy in the Health of Ministry. Readiness of province, district health office and public health center is essential to establish and maintain peer group of chronic illness for long term. Secondly, the expected outcomes of clients with chronic illness are to gain knowledge, social support, psychological support, to accept life with chronic illness, to improve coping with the disease, to perform self-care, and to have perceived control as well as the quality of life and well-being.

10 NGO Foundation Private hospital

Ministry of Health

Public hospital University Peer Group

NGO Foundation Private hospital

Province Head of Health

Public hospital University Peer Group

NGO Foundation Private hospital

District Head of Health

Public hospital University Peer Group

Cadre Vigilant village Private Clinic

Public health center

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Peer Group

Figure 2 Networking peer group of chronic illness, © 2008

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