COMMUNITY HEALTH VISIT

SEREMBAN

NEGERI SEMBILAN DARUL KHUSUS

JULY 2015

MBBS

PHASE 1

INTERNATIONAL MEDICAL UNIVERSITY

1
 TABLE OF CONTENT

NUM.. CONTENTS PAGE NUMBER

1 Acknowledgement 3
2 Section 1 : Organization of District Health Report
1.1. Introduction to Health Care System in Malaysia 5
1.2. Seremban Health Clinic 8
1.2.1. Organisational Structure and Primary 9
Health Care of KK Seremban
1.2.2. Roles and responsibilities of the staff 13
1.2.3. Programmes in KK Seremban 14
1.3 Discussion 15
1.4 References 17
1.5 Appendix 19
3 Section 2 : Community Health Survey Report 21
2.1. Introduction 22
2.2. Objective 23
2.3. Methods and Material 24
2.4. Survey Findings 26
2.5. Discussion and Conclusion 44
2.6. Limitation 48
2.7. Reflection 50
2.8. Reference 51
2.9. Appendix 52
4 Section 3 : Research Project Report 58
3.1. Abstract 59
3.2. Introduction
3.2.1. Background 60
3.2.2. Problem Statement 60
3.2.3. Objective 60
3.2.4. Terms Definition 61
3.3. Literature review 63
3.4. Methods and Materials 65
3.5. Study Findings 68
3.6. Discussion and Conclusion 85
3.7. Limitation 94
3.8. Reliability, Sensitivity and Specificity 96
3.9. References 97
3.10. Appendix 103

2
ACKNOWLEDGEMENT

First of all, I would like to express my whole-hearted gratitude to Almighty God for

making sure this survey a success. I would also would like to thanks the following

people for their ceaseless support and hardwork :

i. Seremban Health Clinic and its staff for accommodating us and allowing us to

do our project in the clinic.

ii. All the respondents for being co-operative ,understanding and willing to be

interviewed by us

iii. Community medicine lecturers : for their constructive advices, sharing of

knowledges and guidance

iv. My group 1 leader, and all group members for being there with me through

thick and thin during this project

v. My family and friends for being supportive and inspiring

vi. Everyone who contributed directly or indirectly in making this assignment a

success

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 Section 1:
Organization of
District Health
Report

4
1.1 Introduction to the Health Care System in Malaysia1

The health care system is defined as a complex of facilities,organizations and trained

personnel engaged in proving health care within a geographical area. Malaysia
inherited a health system from the British upon independence in 1957 but with
services based mainly in urban areas. Health care services were expanded as a
post-independence priority, particularly for the economically disadvantaged and the
rural population.

As in the chart2 above, health care in Malaysia is headed by the Ministry of Health
(MOH) and it is assisted by deputies at the ministerial level and directors.
Organization in our health care system consists of:

Federal Level State Level Ditrict Level

•Policy formation •Co-ordination •Implementation
•Medical •Two-tier System
•Health •Health Center
•Management •Community clinic
•Technical/Support

Health centres are provided for, one per 15 000 to 20 000 population, while
community clinics are one per 2 000 to 4 000 population.

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 Overview of Current Malaysian Health System3

Currently, Malaysia‟s health care system can be classified into both government-run
universal health care public system and a co-existing private health care system.
The private health sector provides mainly curative and diagnostic health services in
urban areas. In fact, most primary care in urban areas is currently provided by
private practitioners. Since private sectors are not given any subsidies and are
charged based on fee for service basis, thus it is more common among employers
who can claim health benefits from their company insurance as well as those in the
higher income brackets.

On the other hand, public sectors are funded by government fully to provide
necessary medical assistance at an affordable and accessible level to the public.
The public sector provides about 82% of inpatient care and 35% of ambulatory care
while the private sector provides about 18% of inpatient care and 62% of ambulatory
care.

The Malaysian health care system also requires doctors to perform a compulsory
four years‟ service (including 2 years of housemanship and 2 years government
service) with public hospitals to ensure sufficient manpower maintained in these
hospitals for general population.

The public sector, in turn, can be divided into three levels, based on the care it
provides (which is simplified in the chart below):

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 Tertiery •Referral/regional hospitals
•Specialized consultative care
care

Secondary •District hospital

•Primary care
care physicians/specialists

Primary and •In contact with patient

•General practitioner/
Family physicians
preventive care •Health clinic, polyclinics

Primary care is provided for the local community and it is the first place for patients
come to get consultation. The eight essential health services (ELEMENTS) under
the primary health care include4:

Education for health

Locally endemic disease control
Expanded program for Immunization
Maternal and child health(including responsible parenthood)
Essential drugs
Nutrition
Treatment for communicable and non-communicable disease
Safe water and Sanitation

Some chronic illnesses like hypertension and asthma also usually treated in primary
care.

As for secondary health care, it refers to medical specialists , like cardiologists,who

are referred by primary health care to their patients. Hospital Sungai Petani and
Hospital Putrajaya is some of the hospitals that are in this category.

Lastly, tertiary health care is specialised in doing investigations and treatments and
provide excellent specialist care for the highly specialised area of medicine. One of
the well known cardiology center , National Heart Institute(IJN) is under tertiary
health care.

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1.2. Seremban Health Clinic

Klinik Kesihatan Seremban was first established on 16 th January 2000 and is located
on Jalan Rasah, Seremban. The clinic is under the responsibility of the Seremban
District Health Officer .

The clinic is also an integration of the outpatient department of the Seremban

General Hospital, Jalan Zaaba Polyclinic, MCH Clinic , 1Malaysia Clinic and Desa
Mambau Clinic. The clinic‟s jurisdiction is divided into six areas which are Orange
area (Seremban), Red area(Seremban Town Area), Green area (Ampangan), Sea-
blue area(Rantau), Yellow area (Rasah) and Dark-blue area (Labu).

Seremban has a distinct population of 536,147 in which around 343, 739 population
are comprised of 20 to 59 years old adults. Out of this, the clinic receives 1,300
patients on average per month from all the above mentioned areas. In the year 2013,
the clinic receives 232, 937 patients in the outpatients department and 6, 958
diabetic cases which is quiet remarking for a health clinic.

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1.2.1. Organisational Structure and Primary Health Care of Seremban Health Clinic

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The chart above illustrates the extended and simplified form of organisational
hierarchy for the Seremban Health Clinic. The Health Director of Seremban district
heads the organisation chart of the clinic, followed by the medical officer.

There are three levels of services offered by this clinic to its patients. The first level
of services includes outpatient services, maternal and child health care, pharmacy
services and venupuncture. This is followed by the second service level, which
includes family medicine specialist services, laboratory and pathology services,
radiology, occupational and physiotherapy services, non communicable disease
control unit and occupational health department. Lastly, school health services,
administration and IMU are included the third level services.

The management is further divided into administration department, the outpatient

department, the pharmacy department, the laboratory department, X-Ray
department and etc as can be seen below.

 Outpatient Department

Headed by the Medical Officer, the outpatient department (which is also the primary
health care clinic), is staffed with medical assistants and nurses to aid in treatments.
The Medical Officer‟s rooms is used for treating patients and also use as a
consultation room. Routine patient checkups and treating patients and maternal
pregnancy screenings and checkups are carried out in these rooms. On-call duty is
done by MO‟s to ensure medical assistance is available to the public all time. The
Outpatient department also educates the public on significant health issues in
addition to treat emergency cases and perform minor surgeries.

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 ● Maternal and Child Health Care Department

The Maternal and Child Health Care department(also headed by MO and a Head
Nurse) monitors the health of pregnant mothers , mothers who have given birth and
newborns via routine checkups and pregnancy screening by medical officers as well
as provide ultrasound services. Vaccination is also provided for the newborns and
children up to age 15.

Among the vaccinations that are made available are BCG, Hepatitis B,DTaP, Hib,
Polio and etc.

 Pharmacy Department

 Dispensary

 Counselling on medical compliance

 Regularly check on contents of drugs, cosmetic and traditional

medicine

 Acquisition and Stock supply

 Medication packaging

Laboratory department

This department is responsible to collect samples from the patients and to do

laboratory tests. The tests include clinical lab test such as FBC, ESR , urine tests
and pregnancy tests. They also do preparation of test and reagent storing in addition
to preparing medium and standard solution suspension.

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X-Ray department

X-ray department gives a clear explanation to the patients regarding the proper
procedure and preparation before doing x-ray as well as do a routine checkout of the
x-ray machine.

Other service- Meeting room

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1.2.2 Roles and Responsibilities of the staff at the clinic

As can see in the organisational chart,The Head of Klinik Kesihatan Seremban is the
District Health Officer (U52,is in charge of all health services and administrative
matters in the district and is assisted by district health officer U52 and a medical
officer U48. Other members of the clinic staff include Medical Assistants, Nurses,
Community Nurses, Assistant Nurses, Radiographer,Pharmacy Officer, Lab
Technician,Health Care Assistants,the Public Relation , Assistant Clerks , Drivers,
Cleaners and Security Guards.

Personnel Role/Duty

Medical  Provide initial assessment ,diagnosis, treatment and

Officer management to patient
 Ensure proper care to all patients
 Do inspections in Health Center and MCH Department
 Examination and management of pregnant mothers without
provoking any complications
 Refer emergency cases to Hospital Tuanku
Jaafar,Seremban
Medical  Assist Medical Officer in examination and treatment of
Assistant patient
 Measure vital signs (temperature, blood pressure and etc)
 Collect samples for lab tests, give injections and apply
bandages
Nurse  Patient registration and maintenance of medical records
 Assisting doctors in minor surgical procedures
 Ensure all instruments and equipment are sterile, available
and in good condition
 Training junior members of health care team
 Provide basic counselling for patients
 Promoting health education in schools
Pharmacist  Pharmacy administration and management
and pharmacy  Ensure correct medication is dispensed to the patient
assistant according to the prescription
 Responsible for the inventory
Medical  Maintain and prepare laboratory equipment and solutions
Laboratory  Ensure the tests are done correctly and reliable
technician  Send samples of complicated tests to Hospital Tuanku
Jaafar for further analysis
Radiographer  Give clear explanation regarding the procedure to the
patients
 Ensure safety of patient before and after the procedure

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1.2.3. Programmes carried out in Seremban Health Clinic.

Among them are counseling on pre-pregnancy for Diabetic and Hypertensive female
patients, a talk on awareness on non communicable diseases (mainly Diabetes
Mellitus, Hypertension and Cancer), advisory talk on health for older people and
special health talk on Diabetes Mellitus for Muslims during Ramadan. Since obesity
is on the rise, a special talk on diet and exercise for school kids and teenagers are
also done once in a year. The funds for these health programmes are allocated by
the State Health Department , ensure the health activities are done smoothly for the
benefit of the public without any financial problem.

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 1.3. Discussion

Throughout the two-days attachment at the Seremban Health Clinic, I had a chance
to observe the strength and weakness of the clinic and the opportunity it has been
offered and the threat it might come across.

First and foremost, the clinic provides a good facility to the public and is located in a
strategic place that almost all of the Seremban population can reach this clinic within
15 minutes. Since this clinic is located near to Tuanku Jaafar hospital, any serious
cases or samples that needed immediate attention can be sent to the hospital as fast
as possible, thus reduce chances of mortality rate in this clinic.

Second, the staffs in the clinic are friendly and serve well to the public. Most of the
patients are of the older group and children, and by helping them nicely, it surely will
attract more patients. Up graded radiation treatment room, Mantoux test and a
kitchen set up to demonstrate healthy cooking for diabetics are something that we
can‟t normally see in other clinics, thus can be considered as this clinic‟s strength.
According to a study done in Malaysia, eighty six percent of patients with active
tuberculosis had a positive Mantoux test 5, thus, it is important to have this test in
clinics for the early detection of TB.

A lot of educational talk is also given mainly to diabetic patients, and it seems to
produce fruit when a steep decrease in diabetic patient noted from 2011 (14,101
patients) to 2012 (6141 patients). This clinic also did not forget its staff‟s safety as
fire drill is done once in a month.

Despite this advantage, several weaknesses of this clinic have also been noted.
There were not much attention given to TB or dengue awareness as only a handful
of posters were seen around the clinic. This might lead to reduce awareness among
the public . Since this clinic receives a lot of patients, and the input of patient data is
done in the traditional way, thus, slow administration of patient was observed.
According to the public opinion,this might cause burden toward working population in
weekdays thus, they might seek treatment in other private clinics6.

In addition, there was no methadone clinic unlike most of other clinics that have been
studied by my peers, thus putting higher risk of drug abuse incidence in this clinic. A
retrospective study on the effectiveness of methadone maintenance therapy(MMT)
among opiate-dependents registered with Hospital Raja Perempuan Zainab II Kota
Bharu, Kelantan by Premilla Devi et al on 2012 shows that the MMT program is
effective in treating heroin and opiate dependence with a significant reduction in the
mean score of the Heroin Q Score7. This shows the need to have a methadone clinic
to control any possibility of drug abuse in the community.

This clinic has a lot of chances to upgrade their service. Since this is a government
funded clinic, thus, it can utilise the funds given to do more awareness activity of
other diseases, not only in clinics but also at nearby schools. Although awareness

15
talk seems to benefit other patients, different kind of activities should be done to
allow people of other age group to seek help in this clinic without hesitation and
educate the public more. Telehealth 8 also can be done by the doctors to consult with
specialists from other urban hospitals to provide specialist service for patients
without the need of hiring new specialist to the clinic. This will, in turn, patient will feel
more secure with the diagnosis that being provided.

One important threat that this clinic might face is that, due to time constraint, not
enough time can be allocated per patient, there is a chance of medical doctors to not
be able to talk about medicine compliance or drug abuse with patients. A study on
Medication adherence among hypertensive patients, of primary health clinics in
Malaysia in 2012, concludes that intervention programs are needed as medication
adherence rate was found to be low among primary care hypertensive patients in
Malaysia9. However, this matter can be handled by the clinic by fixing a talk
appointment on weekends with the patients that are being administered with
medicine that need compliance or risk of abuse.

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1.4. References

1. Safurah Jaafar, Kamaliah Mohd Noh,Khairiyah Abdul Muttalib.Malaysia

Health System Review. : Asia Pacific Observatory on Health Systems and
Policies; 2013.
www.wpro.who.int/asia_pacific_observatory/hits/series/Malaysia_Health_Syst
ems_Review2013.pdf malaysia health system review (accessed 21th July
2015).

2. Ministry of Health. Organization Chart.

http://www.moh.gov.my/english.php/pages/view/3 (accessed 23 July 2015).

3. Vanessa Santhakumar. MALAYSIA'S AUSTERITY DRIVE AND HOW THIS

WILL AFFECT THE PUBLIC HEALTHCARE SYSTEM.
http://globalhealthandpolicy.blogspot.com/2015/07/malaysias-austerity-drive-
and-how-this.html (accessed 24 July 2015).

4. DAISY JANE ANTIPUESTO RN MN. Primary Health Care Definition, Goal,

Principles and Strategies. http://nursingcrib.com/nursing-notes-
reviewer/primary-health-care-definition-goal-principles-and-strategies/
(accessed 25 July 2015).

5. Yaacob I1, Ahmad Z.. . Clinical significance of Mantoux test in Malaysian

patients. Sep 1990; 3(45): . http://www.ncbi.nlm.nih.gov/pubmed/2152084
(accessed 15 August 2015).

6. Bernama. Public or private hospitals? The choice is yours Read more:

http://www.theborneopost.com/2011/02/18/public-or-private-hospitals-the-
choice-is-yours/#ixzz3ifLNlyd3.
http://www.theborneopost.com/2011/02/18/public-or-private-hospitals-the-
choice-is-yours/ (accessed 5 August 2015).

7. Jeganathan Premila Devi, Ab Rahman Azriani, et al, The Effectiveness of

Methadone Maintenance Therapy Among Opiate - Dependants Registered
with Hospital Raja Perempuan Zainab II Kota Bharu, Kelantan Oct-Dec 2012;
4(19): . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629676/ (accessed 15
August 2015).

8. The Malaysian health system.

https://www.justlanded.com/english/Malaysia/Services/Health/The-Malaysian-
health-system (accessed 4 August 2015).

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9. Azuana Ramli, Nur Sufiza Ahmad, and Thomas Paraidathathu. .Medication
adherence among hypertensive patients of primary health clinics in
Malaysia 2012; (6): . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437910/
(accessed 18 August 2015).

10. All the data shared by the Organisational Team.

18
1.5. Appendix

1.6.

Figure 1: Clinic waiting area Figure 5: Room for making splints

Figure 2: Laboratory Room Figure 6: X-Ray Room

Figure 3: Radiation Room Figure 7: Physiotherapy Room

Figure 8: Vaccine storage room

Figure 4: Radiation Room

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Figure 9: Screenings that are done in Figure 11: Drug Storage
clinic

Figure 10: Kitchen to demonstrate

healthy cooking for diabetics Figure 12: Medical Equipment used by MO

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 Section 2:
Community Health
Survey Report

21
2.1. Introduction

General Household Survey (GHS) is a multi-purpose continuous survey that is

done to collect data in respect of the socioeconomic characteristics of the
population. Our survey was done in several residential areas around the
Seremban Health Clinic. This covers
………………………………………………………… Since this household survey
only covers a small portion of Seremban, thus it is unlikely that the findings can be
used to represent Seremban population as a whole. However, hopefully some
important aspects that are highlighted in this report can be used for a larger scale
survey in the future or help Seremban Health Clinic in providing health services to
the population by knowing exactly which household aspects that may influence the
health of respondents.

This household survey was conducted with the purpose of studying the
demographic characteristic of the households near Seremban Health Clinic and
thus to understand not only the socioeconomic factors of the town, but also to
obtain information about the chronic disease prevalence among the community.
Apart from that, various characteristics that contributes to better living conditions
and health status, such as health seeking behaviour and vector or pest problems
was also done as a part of this survey.

Map showing KK Seremban and study areas 1

22
2.2. Objectives

The objectives of the household survey are as follows:

 To describe socio-demography of the study area

 To identify common vectors and pests
 To study the relationship between ethnicity and prevalence of diabetes in the
community
 To identify the relationship between level of income and health seeking
behaviour in the community

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2.3. Methods and Material

Methodology

The allocated area of study was Seremban in the state of Negeri Sembilan with a
population of 372, 917. Seremban is situated about 60 kilometres south from Kuala
Lumpur and about 30 kilometres inland from the coast2. A large number of hospitals
and medical centres are situated in Seremban including Tuanku Jaafar Hospital,
Columbia Asia Medical Center, Seremban Specialist Hopital and Mawar Hospital.

To ensure the success of this survey, the group comprising of 31 students divided
into three teams: research team, household survey team and organization team. A
survey questionnaire for the household research was crafted to 4 pages and a total
of 26 questions. The questions for the survey were classified broadly under the
categories of respondent‟s general socio-demography, working environment, pest
control, food, nutrition and health and health seeking behaviour. These categories
further comprised of a variety of for a more complete and comprehensive study of
the town Seremban.

Strict time and logistical constraints warranted the use of a convenience sampling
technique to obtain the required information for the study. The survey was conducted
over the course of 2 working days from 4 housing areas located within the study area
to obtain a diverse sample of the population. The sample size for the study was
based on convenience sampling.

The outline of survey questions was provided by Community Medicine Faculty and
the group re-phrases the questions by adding or removing irrelevant questions. The
questionnaires were re-read several times by the team members to make sure no
overlapping between the questions and are easy to understand. Translation to Malay
language for the questionnaires was also prepared to give a better understanding of
the questions. During the survey, the questions were asked by the team members to
respondents to make sure the respondents‟ understandings are similar to each
other.

Descriptive statistics were employed in the formulation of the results of the survey
with the use of the SPSS version 22.0 program to aid in data entry and analysis.
Microsoft Excel was also used to provide better data interpretation at some points.

24
A brief summary of the details of the study is listed below for an overview:

Study area Housing Estates enclosed by Lebuhraya Utara-Selatan and

Jalan Rasah

Target Population Households in study area

Sample Households in

Sample Size 245

Sampling Convenience sampling

Technique

Study Design Community based cross-sectional study

Study period 2nd-3rd July 2015

Study tool Pre-coded questionnaires through face-to-face interviews

with Malay translation

Statistical Analysis SPSS version 22

Inclusion Criteria Malaysian residents over 18 years old and residing in Taman

Exclusion Criteria • Residents below 18 years old

• Non-Malaysians

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2.4. Survey Findings

Results

Presented below are the significant findings from the survey of the 245 households
in the Seremban area. Some explanation is given for important variables.

2.4.1. General Socio-Demography

2.4.1.1. Gender

Gender Frequency Percentage (%)

Male 115 46.9

Female 130 53.1

Total 245 100.0

Of all the respondents that we surveyed, 53.1% of them are female whilst only
46.9% are male. The main reason for the disproportionate value is the time frame
that we used to carry out the survey. Since the survey was done on weekdays, from
8 a.m. to 5 p.m., most of working males was not at home to do the survey. Thus,
most of our respondents were housewives. Hence, gender variable does not reflect
the true number of men and women in Seremban.

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 2.4.1.2. Race

Race Frequency Percentage (%)

Malay 31 12.7

Chinese 98 40

Indian 116 47.3

Total 245 100.0

The Indians made the biggest proportion of respondents by 47.3%. This is followed
by the Chinese at 40% and merely 12.7% of Malays.

2.4.1.3. Age

Age Total

<20 4 (1.6%)

20-29 34 (13.9%)

30-39 35 (14.3%)

40-49 43 (17.6%)

50-59 46 (18.8%)

> / = 60 83 (33.9%)

Total 245 (100.0%)

The age is satisfying given that most of our respondents are from the age of 20 and
above. The majority of the respondents are 60 years old and above, at about 33.9%.
This is followed by 50-59 years old at 18.8%, 40-49 years old at 17.6%, 14.3% of the
thirties and around 14% by twenties. Only a mere amount of 1.6% of respondents is
below 20.

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 2.4.1.4. Marital Status

About 73.1% of the respondents are married,while 19.6% of them are single. A mere
amount of 4.1% of the respondents are found to be divorced wile the rest make up
the widow population.

2.4.1.5. Number of children

Out of the 73.1% of the married respondent population, about 57.5% have one to
three children. Around 23.3% of the married respondents have no children. There
are some houses that have up to seven and above people ,which will be much
crowded, thus might lead to poor hygiene status.

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 2.4.1.6. Highest Education Level

Highest Level of Education

50
45
40
35
Percentage

30
25
20
15
10
5
0
Non- Primary High Pre-U Bachelor' Doctorat
Diploma Master's
educated school school College s Deg e
Percentage 6.9 9 46.9 5.3 11.4 16.7 3.3 0.4

Most of our respondents have their education level till secondary school at 46.9%.
This is followed closely by 37.1% of respondents who had their education level up to
tertiary level. However, it can be also seen that 9% of the respondents only reach the
primary level of education and surprisingly, amidst this country‟s fast pace
development, still there is as many as 6.9%, who did not receive any formal
education. But, this correlates with the majority of our respondents, who were above
60‟s and it was normal to have lesser educational opportunities in the past.

29
 2.4.1.7. Living Duration in the respective taman

The majority of respondents (31%) has been living in their respective taman for 10
years. This is followed closely by those living in their taman for more than 31 years.
About 24.9% of our respondents have been living in selected taman for 11 to 20
years and the rest of them, for 21 to 30 years.

2.4.1.8. Housing Income

Income
45
40
35
30
Percentage

25
20
15
10
5
0
≤ 1000 1001-3000 3001-5000 5001-10000 >10000
Valid Percent 24.7 42.1 19.1 9.8 4.3

The majority (42.1%) of respondents are from the bracket of income RM1001 to
3000. This could be attributed to the different field of work which would have an
influence on monthly income. This followed by 24.7% of respondents with income of
less than RM1000, most probably the retiree‟s and the students. Around 33.2% of
the respondent population have an income of RM3001 and above, well correspond
with the majority of the working population.

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 2.4.2. Working Environment

2.4.2.1. Occupation
Student
3.7%

Retiree
20.6%

Employed
57.2%
Housewife
17.3%

Unemployed
1.2%

More the half of our respondents were occupied by the working population. This is
followed by the retiree‟s at 20.6%, housewives at 17.3% and students at 3.7%. The
least amount of 1.2% is taken by the unemployed population. Among the employed
residents, a large amount of 63.6% is a semi – professional workers. Professional
population covers 20.5%, while non-professional workers make up the rest. The
occupational grouping of professional, semi-professional and non-professional was
done following Barbados Standard Occupational Classification 3.

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 2.4.2.2. Awareness of health risk in occupation

The majority of the respondents are not aware of any health risk related to their job
while 13.5% of respondents are well aware of health dangers related to their
occupation. Some of the risk the respondents are aware of are accidents, burns, eye
problems, cardiac problem and stress.

2.4.2.3. Have you ever suffered from work related sickness/injury?

93% of our respondents have not experienced any sickness or injury related to their
occupation and the rest population had suffered from job-related sickness at least
once. This data correlate well with 2.4.2.2. Since the majority of respondents not
aware of health risk related job, thus even if they had one before, they are unable to
classify it as work injury.

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 2.4.3. Pest Control
2.4.3.1. Do you have pest around your house?

No
41% Yes
59%

More than half of the households (59%) are infested with pests while the rest of the
households are free from pest problem.

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 2.4.3.2. Type of pests

Types of Pest
Yes No

68.2% 77.6% 78.0%

98.0% 93.1%

31.8% 22.4% 22.0%

2.0% 6.9%
Mosquitoes Cockroaches Houseflies Rats Ants

Mosquitoes
16.3%

5.31% 3.67%

Cockroaches Rats
6.1% 4.1% 9.3%

The pests that found out to be amiss in the households are the mosquitoes,
cockroaches, houseflies, rats and ants. Among them, mosquito (31.8%) and
cockroaches (22.4%) found to cause problems in the household. 22% of household
have a rat problem, while around 6.9% of household have serious ant problems. In
the chart below, some overlapping between the pests can be seen. Mosquito and
cockroaches, in total give problem with 5.3% of households, while the cockroaches
and rats are problematic in 4.1% households and 3.67% of household having
difficulty with rats and mosquitoes.

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 2.4.3.3. Fogging frequency

Most of the respondents (45%) show their dissatisfaction , saying that no fogging has
been done while 38% of respondent says fogging activity is only done when there is
a dengue case and even in that situation,fogging is only done on the roads,not inside
the houses. About 15% of respondents told us that the fogging is done once in a
month while 2% of respondents have seen fogging done once a week.

35
 2.4.4. Food, Nutrition and Health

2.4.4.1 Daily diet

The majority of our respondents (88.6%) consumes both meat and vegetables, thus
having balanced diet every day. 10.2% of respondents found to be vegetarians and
small amount of 1.2% respondents only eat meat.

36
 2.4.4.2 Anyone in the family suffers from a chronic disease?

22.0%
20.8% 12.7%

Chronic Illnesses
50

40
Percentage

30

20

10

0
Diabetes Hypertension Asthma Osteoporosis CHD
Percentage 35.1 43.3 7.8 5.7 13.1

64.3% of the respondents have family members with chronic disease. Among them,
43.4% of the respondent‟s family members suffer from high blood pressure and this
is followed closely by diabetics at 35.1%. It can be seen that hypertension and
diabetes overlap of 22%. About 13.1% of household have chronic heart disease
patients, 7.8% of asthmatic patients and 5.7% of osteoporosis patients.
Nevertheless, 35.7% of household members do not suffer from any of the diseases.
Data of other chronic illnesses were not included as they only represent a small
amount of percentage.

37
 2.4.4.3. Have you ever smoked? And if yes, for how long have you been
smoking?

There are a good amount of 80.4% respondents being non-smokers. But, 19.6%
respondents admit that they smoke. Among them, 14.6% respondents found to be
smoking for less than 10 years while 30.2% respondents have been smoking for 10
to 30 years. Sadly a large number of respondents (55.2%) have been smoking for
more than 30 years.

2.4.4.4. How many cigarettes do you smoke per day?

Among those who do smoke, half of the amount, smoke more than 40 cigarettes (or
more than 2 packs) per day, which give rise to main concern. 44.7% respondents
found to smoke 20 cigarettes and less while the rest smoke more than 20 to 40
cigarettes per day. This division is made based on the number of cigarette sticks (20)
in a pack.

38
 2.4.4.5. Is there any other member in your household that smokes? And if
yes, how many household members that smokes?

The prevalence of nonsmokers in household is 77.1%, while 22.9% respondents

have other members in the family who do smoke. Among this number,by excluding
the respondents themselves, 78.6% of household have a smoker, 17.9% household
have two more smokers and 3.5% of households have three family members who do
smoke.

39
 2.4.4.6. Do you consume alcohol? If yes, how often and what type of alcoholic
drink you consume?

The majority of the respondents (75.8%) does not consume any alcoholic drink while
the rest of them (24.2%) do drink alcohol. Among those people, 56% drinks once in a
week, while around 10% consume alcoholic drinks 3 to 7 times a week. 34% of the
respondents consume alcohol on a monthly basis.

Among the drinking population, beer found to be the most popular drink at 59.6%.
This is followed by whisky at 22.8%, wine at 14.1% and lastly other types of drinks at
3.5%.

40
 2.4.4.7. Is there any other member in your household that consumes alcohol?

Around 74% of respondents deny having family members who consume alcohol,
while 25.6% of respondents do have members in household that drink alcohol.

2.4.4.8. Frequency of exercise/week

Percentage

1 to 3 times a 4 to 6 times a 7 times a week

Do not exercise
week week and above
Series1 38.90% 11.90% 19.70% 29.50%

About 70% of respondents do exercise weekly while 29.5% of respondents do

not do any exercises. This might be because of insufficient time as most of
our respondents are working or maybe due to health conditions (retiree/senior
citizens). Among those who do exercise, 38.9% do physical activity one to
three times a week, while 19.7% do exercise 7 times and above . the rest of
them do exercise at least 4 to 6 times a week.

41
 2.4.5. Health seeking behaviour
2.4.5.1. If you are sick, do you seek medical assistance?

Many of the respondents do seek medical help is they felt sick while 15.5% of
respondents treat themselves without seeking any help.

2.4.5.2. Where do you normally seek for medical assistance?

Many of the respondents prefer the government clinic as the top choice to seek
treatment at 52.2%.This is chased by private clinic with 44.1%. Others prefer
traditional medicine at 1.6%,whilst 2% opt for other means of help.

42
 2.4.5.3. Do you go to the health clinic/hospital for annual healh checkup?

The majority of our respondents (57.6%) does annual health checkup by going to a
health clinic or hospital while the rest of respondents do not go for an annual health
checkup.

43
2.5 Discussion

Most of the respondents were female aged above 40 years old who were
housewives or retirees. This is because the survey was done during office
hours when other family members went out for working or in school. As a part
of the survey study, we did a study on occupation and income, common
pests and vector, household monthly income, a place to seek treatment,
ethnicity and diabetes prevalence in the chosen study area.

First and foremost, the relationship between occupation and the amount of
monthly income was established. According to the data obtained earlier, it is
found that 57.2% of the respondents were employed, while 20.6% were
retirees and 17.3% of them were housewives. As for the monthly income,
42.1% of the respondents earned between RM 1,001 and RM 3,000 monthly
while 19.1% of the respondents earned between RM 3,001 and RM5, 000 per
month. About 20.6 % of the respondents are retired and receive a pension.It
can be seen that, although half of the respondents in this survey are currently
working, their monthly income stands between RM1, 001 and RM 3,000. This
might be attributed to the different job scope which would have an influence
on monthly income. Also, 24.3% of the respondents had an income of less
than RM 1,000 per month, which could be accounted for since 20.6% of the
respondents are retired and receive pension.

Next, the link between pest problem and fogging was found. Based on the
data acquired, it can be seen that, 59.2% of the households are infested with
pests and the main pest found to be mosquitoes at 31.8%, which is very
surprising given that the respondents are living in well-planned housing areas
with proper sewage system, electricity and water management but still facing
vector amiss. Thus, it is either the respondents own habit of uncleanliness or
the problem lies within the authority. On the other hand, fogging was not
done in 44% of the households whilst in 38% of the households, fogging was
only done when there is dengue case. Even in that situation, respondents
complain that the fogging activities are only carried out on the street and not
inside the housing compound.

Our results correlate well with Vector Borne Disease Control Program by
Disease Control Division of Ministry of Health. According to the document, the
most common vector borne diseases are malaria and dengue, which both are
transmitted by mosquitoes4. Regarding the fogging activity, it too correlates
with the percentage in Strategic Plan for Control and Prevention of Dengue
released by Ministry of Health5, in which, it is stated that at the current
moment only 40% of fogging activity was done accompanied with reports of
dengue cases. However, it was expected that 85% of fogging activity should

44
 be done effectively right after the onset of a dengue case in the plan which is
not seen in our data.

Thirdly, the level of monthly income and health seeking behavior in the
community found to have a significant association. The relationship between
these two variables was tested using the Chi square test and the level of
significance was set at p < 0.05. Odds ratios were computed at 95%
confidence interval.

Monthly Types of Medical Assistance (%)

Household Total Chi P value

Government Private Traditional Square
Income
(×2)

0 1 (100) 0 (0) 0 (0) 1 (100) 30.495 <0.05

</= 1000 31 (59.6) 20 3 (5.3) 54 (100)

(35.1)

1001-3000 63 (64.7) 34 1 (1) 98 (100)

(34.3)

3001-5000 20 (44.4) 25 0 (0) 45 (100)

(55.6)

5001-10000 5 (26.1) 17 0 (0) 22 (100)

(73.9)

>10000 3 (30) 7 (70) 0 (0) 10 (100)

Total 123 (54.5) 103 4 (1.7) 232 (100)

(43.8)

As can be seen in the above table, those who earned between RM1,001 and
RM 3,000 monthly largely prefers government clinic and almost less than half
of that amount prefers private clinic. However, as the monthly income
increases, the respondents prefer private clinic compared to the government
clinic as can be seen in the group earning RM 3,001 and above.

This finding is fairly similar to a study done on health seeking behavior in the
Malaysian population by Amal AM, Paramesarvathy R, et al 6. Their results too
showed that those from lower income groups were more likely to seek

45
 treatment from government health facilities compared to those from higher
income groups. This is probably because government clinics provide
affordable treatment and the close proximity of the government clinics to the
residents.

As for the high income group, they seek health assistance at private clinic
might due to having health insurance to cover the health expenses or they
simply believe better treatments are given in private clinics.

It can be seen that traditional medicine is only opted by 4 respondents in total

and this might be because of more faith in western medicine by the relatively
educated population.

And lastly, the relationship between ethnicity and prevalence of diabetes in

the community is established. The association between these two variables
was tested using the Chi square test and the level of significance was set at p
< 0.05.

Ethnic Anyone in the family Total Chi P

household suffers from square value
diabetes (x2)

Yes No

Malay 4 27 31 21.954 <0.05

(12.9%) (87.1%) (100.0%)

Chinese 25 (25.5%) 72 98
(74.5%) (100.0%)

Indian 57 (49.1%) 59 116

(50.9%) (100.0%)

Total 86 158 245

According to the obtained data, Indian comprises almost half of the diabetic
population, while 25.5% of Chinese are found to be diagnosed with diabetes.
Malay population only covers 13% of the diabetic population. This data is in
contradiction with the National Diabetes Registry Report7 that states that
57.6% of Malays, 18.7% of Chinese and 23.1% of Indians in Negeri Sembilan
are diagnosed with diabetes.

46
This inconsistency in the data would be due to the survey being carried out in
an Indian-populated area, where 47.3% of residents interviewed are Indians,
thus causing bias in the result.

Conclusion

In conclusion, the majority of respondents (42.1%) have an income bracket

between RM 1,001 and RM 3,000 monthly and this income group seek public
health care. Other than this, mosquitoes (31.8%)found to be the main pests in
the households. In the study area, Indian found to be diagnosed with diabetes
on a large scale compared to other ethnicity, but this fact does not represent
the total diabetic prevelence in Malaysia due to the inappropriate percentage
of the race compared to this country‟s true number and small sample size.
The main reason for the unbalance in the race was because the survey is
done in the fasting month of Ramadan, thus most of Malay people feel
reluctant to do our survey.

47
2.6 Limitation

There were some limitation in doing this survey.

1. Questionnaire
- Since the questionnaires have to be prepared in a short time, thus the
reliability of the questions were not well established. This is overcome
by proofreading of the questionnaire by several group members to
make sure the questions are easy to understand and no overlap
present among them.

2. Interviewer
- Interviewing techniques of questioning and wording were not
standardized due to time constraint, thus each and every interviewer
might interpret the question according to their own understanding.
However, efforts were made to translate our questionnaires to Malay to
give a better understanding of each questions overall.

3. Respondents
- Not all respondents were co-operative to participate in this study. Some
whole heartedly participate in this study while most of them just rush
through the questions due to the timing of the visits during working
hours.

- As we did the survey on working hour, most of the houses in the study
area were empty and due to time constraint, we were not able to get
back to the houses. Thus, the sample size was limited over a wide area
of study and the obtained data does not reflect the whole residents in
the chosen area

- The study sample also bias towards having more Indian respondents
than other races as the chosen study area happened to have more
Indian residents and since the survey done in the fasting month,
Malays were reluctant to do the survey. Thus, there were limited
respondents from different ethnicities.

- As for some information that were asked in the questionnaire were

quite personal, such as monthly household income, some of the
respondents were reluctant to let us know the details causing
information bias. Recall bias also occurs when some of the
respondents cannot recall exact answers to the question, such as age,
as most of our respondents were abuve 60 years old.

48
The limitation towards study sample was reduced as we chose the housing
areas based on our convenience (via convenience sampling) as they were all
located near to the clinic.

49
2.7 Reflection

This household survey gave me a wonderful and unbelievable experience and

lessons which are quite useful for my life now and in near future.

Firstly, I realised that teamwork is an essential essence in determining the

success of this survey. Along this two week journey, each and everything
needed teamwork. Starting from the moment where we elect our group leader
till the end of the presentation of our findings, I realised that co-operation is
what‟s making this survey a memorable journey for us. Through this survey
and research process, I and my team members were able to pinpoint health
issues in the community8 that needed our, the future doctors, utmost
attention, and concentrate on one of the issues.

Next, I also had a chance to improve my communication skill in par with the
IMU learning outcome8 with those I never knew before. Since our cohort is
large and we usually have no chance to mingle around, this survey gave me
an opportunity to get to know most of my fellow colleagues better.

Apart from this, by exposing myself to the respondents, I got a good outlook
on how community members behave toward medical students. Although we
were shunned from most of the respondent‟s house under the scorching hot
sun, but this experience taught me that we might not achieve everything in our
life as we expected, but if we keep moving towards our goal, we will achieve
aim at the end of the road.

This survey allows us to have a good insight on how a study if being

conducted and analysed, as in IMU learning outcome 8. Although this is my
first time taking part in conducting survey and it was not as productive or
effective as we wanted, but the feel I get and the lessons I learned throughout
this process was more than enough to conduct a survey by myself.

Lastly, although I viewed this two-week journey as a burdensome process at

the beginning, at the end of this, I realised that I still have a lot to learn and
medicine is not only about the lecture notes and exams but also includes the
way you approach the patients and communicate with them. This will help me
to get close to patients without a hint of unnecessary hesitation and provide
the best treatment or solution that a doctor can possibly give to her patient, in
the future.

On a second thought, it might be helpful if students were given an introduction

letter from the university in the future to convince the respondents about the
survey, which might give rise to a better experience and survey result.

50
 2.8. References

1. Wikimapia.
http://wikimapia.org/#lang=en&lat=2.707465&lon=101.947718&z=15&m=b&s
how=/33528352&search=taman%20ban%20aik (accessed 23 July 2015).

2. ICT Department, MPS. Majlis Perbandaran Seremban.

http://web.archive.org/web/20080108022157/http://www.mpsns.gov.my/mps_
v2/BI/profile_history.htm (accessed 13 August 2015).

3. Government of Barbados, Ministry of Employment. Barbados Standard

Occupational Classification; https://labour.gov.bb/images/BARSOC.pdf
(accessed 13 July 2015).

4. Mathew. What are common vector-borne diseases, and how do they

commonly spread among vertebrate. http://www.enotes.com/homework-
help/what-common-vector-borne-diseases-how-do-they-466324 (accessed 22
July 2015).

5. MOH. VECTOR CONTROL INMALAYSIA.

http://webcache.googleusercontent.com/search?q=cache:xnpD7wLuKdEJ:ww
w.actmalaria.net/files/vector_control/vc_policy/vc_malaysia.pdf+&cd=1&hl=en
&ct=clnk (accessed 1 August 2015).

6. N.M.Amal, R Paramesarvathy, et al. Prevalence of Chronic Illness and Health

Seeking Behaviour in Malaysian Population: Results from the Third National
Health Morbidity Survey (NHMS III) 2006. #0 March 2011; 66(1): .
http://webcache.googleusercontent.com/search?q=cache:66C5kjUGR10J:ww
w.e-mjm.org/2011/v66n1/NHMS_III_Malaysia.pdf+&cd=1&hl=en&ct=clnk
(accessed 26 July 2015).

7. MOH. Findings. National Diabetes Registry Report 2009-2012; 1(): .

http://webcache.googleusercontent.com/search?q=cache:sqo4pz5hdRcJ:ww
w.moh.gov.my/index.php/file_manager/dl_item/526d6c735a58567762473968
5a43394f595852706232356862463945615746695a58526c633139535a5764
7063335279655639535a584276636e5266566d3973587a46664d6a41774f56
38794d4445794c6e426b5a673d3d+&cd=1&hl=en&ct=clnk#15 (accessed 13
August 2015).

8. IMU. Learning outcome of IMU. http://www.imu.edu.my/imu/test/about/vision-

a-quality (accessed 13 August 2015).

9. All the data shared by the Survey Team

51
 2.9. Appendix

In this section, following documents are attached:

2.9.1. Survey Questionnaire

2.9.2. Originality Report for Reflection Essay

52
2.9.1. IMU Bukit Jalil – ME213 G1 FORM
GENERAL SOCIO-DEMOGRAPHY / SOSIO-DEMOGRAFI LAZIM

1. Name / Nama : __________________________________________________

2. Date of birth / Tarikh Day / Hari: _____ Month / Bulan: _____ Year / Tahun: _____
lahir
3. Gender / Jantina o Male / Lelaki
o Female / Perempuan

4. Race / Bangsa o Malay / Melayu

o Chinese / Cina
o Indian / India
o Others / Lain-lain: ____________________

5. Marital status o Single / Tunggal

Status perkahwinan o Married / Berkahwin
o Divorced / Bercerai
o Separated / Berpisah
o Widow / Janda

6. Number of children : ____________________

Bilangan anak
7. Number of household : ____________________ members / ahli
members
Bilangan ahli keluarga
8. Highest degree or level o No schooling completed / Tidak bersekolah
of school you have o Primary school (UPSR) / Sekolah rendah
completed: o High school (SPM) / Sekolah tinggi
Tahap pendidikan o Pre-U College level (A-level, SAM, IB, STPM) / Pra-U Kolej
anda: o Diploma / Diploma
o Bachelor’s degree / Ijazah sarjana muda
o Master’s degree / Ijazah sarjana
o Professional degree/ Ijazah profesional
o Doctorate degree / ijazah doktor falsafah

9. How many years have : ____________________ years / tahun

you been living here?
Berapa tahun anda
tinggal di kawasan
perumahan ini?

10. What is your current : RM _________________ per month / sebulan

monthly household
income?
Berapakah pendapatan
anda setiap bulan?

53
IMU Bukit Jalil – ME213 G1 FORM
WORKING ENVIRONMENT / SUASANA PEKERJAAN

11. Occupation : ____________________

Pekerjaan
12. Number of years in current occupation
Bilangan tahun dalam bidang
pekerjaan sekarang
13. Are you aware of any health risk
related to your work?
Adakah anda sedar tentang sebarang
risiko kesihatan yang terlibat dalam
pekerjaan anda?
14. Have you ever suffered from work
related sickness or injury?
Pernahkah anda mengalami trauma
atau kecederaan berkaitan dengan
pekerjaan anda?
: ____________________ years / tahun
o Yes / Ya
Please specify / Sila nyatakan:
________________________________________
o No / Tidak
o Yes / Ya
Please specify / Sila nyatakan:
________________________________________
o No / Tidak

PEST CONTROL / KAWALAN PEROSAK

15. Are any pests a problem in and around the house?

Adakah wujudnya masalah perosak di kawasan perumahan anda?
o Yes / Ya
Please specify / Sila nyatakan: ____________________
o No / Tidak

16. How many times is fogging activity carried out in your neighborhood per month?
Berapa kali aktiviti pengasapan dijalankan di sekitar kawasan perumahan anda setiap bulan?
__________ per month / setiap bulan

54
IMU Bukit Jalil – ME213 G1
FOOD, NUTRITION AND HEALTH / MAKANAN, KHASIAT DAN KESIHATAN
17. Your daily diet consists of? (Please tick in
circle)
Diet anda terdiri daripada? (Sila tanda
dalam bulatan)
o Meat only / Daging sahaja
o Vegetable only / Sayur-sayuran sahaja
o Meat and vegetable /Daging dan
sayur-sayuran
18. Anyone in the family suffers from a chronic
disease?
Adakah ahli keluarga anda yang
menghadapi penyakit kronik?
a. How many family members?
Berapa bilangan ahli keluarga?
__________ members / ahli
*If none, ignore the next question
*Jika tiada, abaikan soalan
berikutan
b. Please specify the diseases.
Sila nyatakan penyakit-penyakit
tersebut.
o Diabetes mellitus / Kencing manis
o High blood pressure / Tekanan
darah tinggi
o Asthma / Asma
o Osteoporosis / Osteoporosis
o Heart disease / Penyakit jantung
o Others: Please state / Lain-lain:
Sila nyatakan
19. Have you ever smoked?
Pernahkah anda merokok?
o Yes / Ya
o No / Tidak
a. If “Yes”, how many years have you
been smoking?
Jika “Ya”, berapa tahun anda
merokok?
__________ years / tahun
If “Yes”, how many cigarettes do you smoke
per day?
Jika “Ya”, berapa batang rokok anda
menghisap setiap hari?
__________ sticks per day / rokok sehari
FORM
20. Is there any other member in your
household that smokes?
Adakah sesiapa dalam keluarga anda yang
juga merokok?
o Yes / Ya
o No / Tidak
a. If “Yes”, how many members in your
household that smokes?
Jika “Ya”, berapa orang dalam keluarga
anda yang merokok?
__________ members / ahli
21. Do you consume any alcohol?
Adakah anda mengambil minuman keras?
o Yes / Ya
o No / Tidak
a. If “Yes”, how often do you drink
alcohol?
Jika “Ya”, berapa kerap anda mengambil
minuman keras?
__________ per week / seminggu
b. If “Yes”, what type of alcoholic drinks?
Jika “Ya”, apakah jenis minuman keras
tersebut?
o Beer / Bir
o Whisky / Wiski
o Wine / Wain
o Others / Lain-lain
22. Is there any other member in your
household that consumes alcohol?
Adakah sesiapa dalam keluarga anda yang
juga mengambil minuman keras?
o Yes / Ya
o No / Tidak
23. Frequency of exercising per week:
Kekerapan anda bersenam seminggu:
__________ times per week / kali
seminggu

55
IMU Bukit Jalil – ME213 G1 FORM
HEALTH SEEKING BEHAVIOUR / TINGKAH LAKU UNTUK KESIHATAN

25. If you are sick, do you seek medical 24. Do you go to the health clinic / hospital for
assistance? annual health checkup?
Jika anda sakit, adakah anda Adakah anda pergi ke klinik kesihatan /
mendapatkan bantuan perubatan? hospital untuk pemeriksaan kesihatan setiap
o Yes / Ya tahun?
o No / Tidak o Yes / Ya
o No / Tidak

26. Where do you normally seek for medical

assistance? (Please tick circle)
Di manakah anda selalu mendapat
bantuan perubatan? (Sila tanda dalam
bulatan)
o Government clinic / Klinik kerajaan
o Private clinic / Klinik swasta
o Traditional medicine / Perubatan
traditional
o Others / Lain-lain:
____________________

END OF QUESTIONNAIRE / TAMAT BORANG SOAL SELIDIK

THANK YOU / TERIMA KASIH

56
2.9.2.

57
 Section 3:
Research Project
Report

58
3.1 Abstract

Diabetes mellitus (DM) is a highly prevalent condition affecting about 347 million
people worldwide1. In addition to its numerous clinical implications, DM also exerts a
negative effect on patient‟s sleep quality. Other comorbidities like hypertension, and
smoking in diabetics and how these variables affect diabetics sleep quality is also
discussed in this report. Impaired sleep quality disrupts the adequate glycemic
control, regarded as corner stone in DM management and also lead to many
deleterious effects causing a profound impact on health related quality of life. This
article outlines various variables leading to impaired sleep quality among diabetics
and delineates the link between sociodemographic factors and diabetes mellitus.
Potential interventions and lifestyle changes to promote healthy sleep among
diabetics need to be emphasised to slow down progression of diabetic complication.

Keywords: Diabetes mellitus, type 2, Sleep quality, Quality of life, Hypertension,

Smoking, Sociodemographics, PSQI

59
3.2 Introduction

3.2.1. Background

Since World Diabetes Day launched on 14 th November by the International Diabetes

Federation (IDF) and World Health Organization (WHO) in 1991, it has become the
primary awareness campaign of the global diabetes community 2. Despite campaigns
to create awareness on the effect of diabetes launched every year, this non-
communicable disease is rapidly rising as a global health care amiss that is
threatening to reach pandemic levels by 2030. In 2003, an estimated 194 million
adults had diabetes worldwide (5.1%). This prevalence increased to 6.0% in 2007,
and is predicted to increase to 7.3% (380 million) by 20253. In Malaysia, the 2011
National Health and Morbidity Survey showed that the prevalence of type 2 DM for
adults aged 18 years and above was found to be 15.2% with 8.0% of previously
undiagnosed with diabetes4. In addition, several studies indicate poor sleep quality
in diabetic patients, including difficulty in falling asleep or staying asleep, which in
turn, affect their life quality. According to the National Sleep Foundation, 63% of
American adults do not get enough sleep needed for good health, safety, and
optimum performance5. Not to forget, with hypertension and smoking, rate of
complication has dramatically increased in diabetic patients by worsening
cardiovascular end point and through insulin resistance 6. Overall, it is therefore
important to understand the link between sleep qualities and type 2 diabetes mellitus
and association of hypertension and smoking with T2DM to reduce progression to
complication and to help in establishing better patient management.

3.2.2. Problem Statement

What is the association of sleep quality and Type 2 Diabetes Mellitus?

3.2.3. Research Objectives

The objectives of the research study are as follows:

● To investigate the association of sleep quality with diabetes mellitus Type 2

● To compare the sleep quality among diabetic and non-diabetic patients
● To compare the association of hypertension, smoking and sleep quality with
diabetes mellitus Type 2

60
3.2.4. Terms Definition

i. Type 2 Diabetes Mellitus (T2DM)7

According to 2015 ICD-10-CM under endocrine, nutritional and metabolic

diseases E00-E89 , Diabetes mellitus is defined as a disease in which your blood
glucose, or sugar, levels are too high. With type 2 diabetes, the more common type,
your body does not make or use insulin well. Without enough insulin, the glucose
stays in your blood. Over time, having too much glucose in your blood can cause
serious problems. It can damage your eyes, kidneys, and nerves.

ii. Hypertension8

High blood pressure, defined as a repeatedly elevated force of the blood against
artery wall exceeding 140 over 90 mmHg -- a systolic pressure above 140 or a
diastolic pressure above 90 or current use of antihypertensive medication (in
accordance with the guideline JNC7).

iii. Never smoke9

Adults who have never smoked a cigarette in their entire lifetime.

iv. Current smoker9

Adults who are currently smoking cigarettes every day (daily) or some days
(nondaily).

v. Ex/ Previous smoker9

Adults who have smoked in their lifetime, but say stop once diagnosed with diabetes
mellitus

vi. Subjective sleep quality10

This is how restful you feel your sleep has been. It is important because no matter
how many hours that you are asleep, if you don‟t feel rested, it will affect you during
the day

vii. Sleep latency10

This is the length of time between going to bed and falling asleep.

viii. Sleep duration10

This is the total length of time you spend asleep during the whole night. The amount
of sleep each person needs varies. In this study, we follow the data by National
Institutes of Health, thus, most healthy adults need between seven and a half to nine
hours of sleep per night.

61
 ix. Habitual sleep efficiency10
This is the proportion of time that you are asleep over the total time spent in bed.

x. Daytime dysfunction10

If you are having trouble concentrating during the day, doing everyday activities, or if
you lack energy or feel sleepy during the day.

xi. Arousal11

Abrupt changes from sleep to wakefulness or from a “deeper” stage of non-REM

sleep to a "lighter" stage

xii. Nocturnal polyuria12

Defined as a nocturnal urinary output, including the volume of the first void in the
morning of >33% of the total daily output

62
3.3 Literature Review

Studies regarding type 2 diabetes mellitus and its association with sleep quality have
been done since long ago.

A study in August 7, 2012 namely Relation of sleep quality and sleep duration to type
2 diabetes mellitus: a population-based cross-sectional survey was conducted by
Dr.Peian Lou et al 13. This study revealed that “both poor quality of sleep and
short sleep duration (≤6 h) were associated with increased prevalence of
diabetes. Compared with the group with good quality of sleep and 6–8 h sleep
duration, diabetes was the most prevalent in individuals with poor sleep quality and
≤6 h sleep duration (OR 1.41, 95% CI 1.07 to 1.85) and in those with poor sleep
quality who slept ≥8 h (OR 1.39, 95% CI 0.85 to 2.26), even after adjustment for a
large number of further possible factors” .Thus, the results suggest that sleep of poor
quality and short duration is associated with diabetes.

Another study on “Impact of subjective sleep quality on glycemic control in Type 2

Diabetes mellitus” 14 in January 3rd 2011 also demonstrates that, both, poor sleep
quality and less-efficient sleep are significantly correlated with worse glycaemic
control in patients with type 2 diabetes mellitus. In this study, the total PSQI score
and sleep efficiency (P < 0.05) were found to significantly correlated with the level of
HbA1C. Logistic regression analysis showed the adjusted odds ratio (OR) of sleep
efficiency for HbA1C level was 6.83 [OR = 6.83, 95% confidence interval (CI) =
2.04–22.8, P = 0.002]. The adjusted ORs of worse glycaemic control for the
poor sleep quality group was 6.94 with regard to the group of good sleep
quality (OR = 6.94, 95% CI: 1.02–47.16, P < 0.05).

Moreover a study by Chao CY et.al15 in June 2011 on sleep duration and newly
diagnosed type 2 Diabetes Mellitus among Taiwanese population has establish a
profound link between sleep duration and diabetes mellitus. Based on his studies
short (<6.0 hours) sleepers had a higher risk of being diagnosed with diabetes; and
the odds ratio were 1.55 (95% confidence interval). This study shows that
reduction in sleep duration alters glucose metabolism, predisposing one to diabetes
mellitus. Thus, sleep quality and diabetes mellitus has a two-way relationship and
both can give rise to one another.

Another study in 2014 by Bing-Qian Zhu et.al16 on sleep quality and its impact on
glycaemic control in patients with type 2 diabetes mellitus shows that patients with
T2D have high sleep disorder rate negatively impacting glycaemic control. The PSQI
score was 8.30 ± 4.12 and the sleep disorder incidence rate was 47.1% among
diabetic patients. Patients with HbA1c ≥ 7% had significantly lower PSQI global and
factor scores (p < 0.01) versus the control group.

63
“Sleep Quality and Quality of life in adults with Type 2 Diabetes” by Faith S.Luyster
et.al17 also found out through her study in 2011, reveal that more than half of the
participants (55%) of a total of three hundred subjects with T2DM were “poor
sleepers”, according to the Pittsburgh Sleep Quality Index and these results suggest
that poor sleep is common in type 2 diabetes and may adversely impact quality of
life.

According to a study by Landsberg et.al 18 on 2004, hypertension occurs in

approximately 50% to 80% of patients with type 2 diabetes in the US population.
Another prospective cohort study19 in the United States reported that type 2 diabetes
mellitus was almost 2.5 times as likely to develop in subjects with hypertension as in
subjects with normal blood pressure.

As for the link between T2DM and smoking, case-control study by Ostrauks et al20 in
2009, clearly states that there is an increased risk of type 2 diabetes in current
smokers (OR=2.41; 95% CI 1.07–5.44) vs. non-smokers. In addition, there was an
association between the disease and duration of smoking (OR=2.47; 95% CI 1.03–
5.93 for 40 years or more) vs. non-smokers, and those who had been smokers for 10
or more pack-years had twice the risk of diabetes (OR=2.17; 95% CI 1.07–4.40) vs.
non-smokers.

64
3.4 Methods and Material

Methodology

The allocated area for study was Seremban Health Clinic in the state of Negeri
Sembilan. The clinic receives patients from six sub-districts/areas: Seremban,
Seremban town area, Ampangan, Rantau, Rasah and Labu.

To conduct this research study, a study questionnaire comprises a total of 30

questions in English with direct translation to Malay language was prepared. After
understanding the objectives of the research, the questionnaire was created by
taking into account the type, wording and format of questions and answers. The
questions were then evaluated, pre-tested among the group members and revised.
The final copy of questions for the study was classified broadly under the five
categories of participant‟s general detail, details on diabetes mellitus and high blood
pressure, lifestyle and Pittsburgh sleep quality index. The divisions further
encompassed of a variety of sub-questions.

The PSQI is a score derived from a self-rated questionnaire consisting of nine

questions that assess a wide variety of factors related to sleep quality in the previous
month. These included estimates of sleep duration and latency as well as frequency
and severity of specific sleep-related problems. The nine questions were grouped
into seven component scores, each weighted equally on a 0–3 scale. The seven
components were then summed to yield a global PSQI score (range: 0–21); higher
scores indicate worse sleep quality. The seven components of the PSQI are:

(i) subjective sleep quality,

(ii) sleep latency,
(iii) sleep duration,
(iv) sleep efficiency,
(v) sleep disturbances,
(vi) use of sleeping medications and
(vii) daytime dysfunction.

According to Buysse et al 21, patients with a PSQI score of equal and more than 5 is
defined as „poor sleepers‟. Accordingly, in this study design, a PSQI score <5 was
also conventionally defined as „good sleep quality‟ and a PSQI score of equal or
more than 5 was defined as „poor sleep quality‟. No questions were allowed to be
missing as it will affect the total score.

The survey was conducted over the course of 2 working days from outpatient
department and diabetic clinic at Seremban Health Clinic 1 and 2. The sample size
for the study was based on convenience sampling.

65
The outline of survey questions was provided by Community Medicine Faculty and
the group adjust the questions according to the study and make sure of no
overlapping present between the questions. During the survey, the questions were
asked by the team members to participants to ensure similar understanding among
the participants.

The statistical group used all the obtained data for data entry and analysis. As for
data entry and statistical analysis, Statistical Package for Social Sciences (SPSS)
version 22.0 program was used mainly and Microsoft Excel was used to input raw
data. For data analysis, chi square test was used with a confidence level of 95% and
p value of 0.05. A p value less than 0.05 was considered as significant unless stated
otherwise.

66
A brief summary of the details of the study are listed below for an overview:

Study area Seremban Health Clinic 1 and 2, Seremban, Negeri Sembilan

Target Population Type 2 Diabetic patients in KK Seremban and KK Seremban

2
Sampling Frame All patients in outpatient department and diabetic clinic

Sample Size 247

Sampling Convenience sampling

Technique (With a response rate of 90.1%)

Study Design Cross-sectional study

Study period 2nd- 3rd July 2015

Study tool Pre-coded self-prepared questionnaires (includes Pittsburgh

Sleep Quality Index (PSQI))through face-to-face interviews
with Malay translation

Statistical Analysis  SPSS version 22

 Chi square test
- Confidence level : 95%
- P value : 0.05
 Odds Ratio

Statistical 0.05 unless otherwise stated

Significance

Operational  PSQI score less than 5 : good sleep quality

division  PSQI score equal or more than 5 : poor sleep quality

Inclusion Criteria  Malaysians and non-Malaysians

 18 years old and above
 with comorbidities of hypertension and smoking
 Patients in Seremban and Seremban 2 Health Clinic

Exclusion Criteria  Residents below 18 years old

 Type 1 Diabetes Mellitus

67
3.5 Study Findings/Results

Presented below are the significant findings from the study and some explanation is
given for important variables.

3.5.1. Location of Visit

Klinik Kesihatan
Seremban 2
24.7%

Klinik Kesihatan
Seremban
75.3%

A large proportion of our study is comprised of patient from Klinik Kesihatan

Seremban by 75.3%. The rest of the patients are from Klinik Kesihatan Seremban 2.

3.5.2. Control group and experimental group (Have you been told by a doctor that
you have diabetes mellitus?

T2DM Status

negative positive
T2DM T2DM
49.8% 50.2%

Amid these participants, 50.2% are diagnosed with Type 2 Diabetes Mellitus thus,
act as the experimental group while the rest of the participants act as a control
group.

68
Comparison between experimental group and control group.

3.5.3. Participant‟s General Details

3.5.3.1. Gender and Age

30.0%
25.0%
26.30%
24.30%

Percentage
Male 20.0%
48.6% 15.0%
16.20%
Female 10.0% 12.10%
51.4% 10.10%
5.0% 6.90% 4.10%
0.0%
less than 30-39 40-49 50-59 60-69 70-79 80 and
30 above
Age
40
35
30
25
Frequency

20
15
10
5
0
Gender M F M F M F M F M F M F M F
Age Group < 30 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 ≥ 80
Diabetic 0 0 5 2 3 7 16 24 19 14 12 15 3 4
Non-diabetic 15 10 3 7 9 11 11 14 16 11 7 6 1 2

Age Chi-square value 39.421 Gender p-value 0.57

P-value < 0.001

The majority of the participants were female at 51.4%, closely followed by the males
at 48.6%. There is no significant statistical difference in prevalence of T2DM
between both male and female subjects. It can be seen that the prevalence of
diabetes mellitus increases with age, with highest prevalence (26.3%) in the age
group of 50 to 59; the prevalence seems to decrease from age 60 onwards.

69
3.5.3.2. Level of Education

Distribution of DM and Non-DM Subjects

against Education Level
120%
100%
Percentage

80%
60%
40%
20%
0%
No education Primary Secondary Tertiary
Non- Diabetic 26.7 33.3 51.5 70.8
Diabetic 73.3 66.7 48.5 29.2

Education Chi-square value 18.028

Level P-value 0.001

From the bar chart, it can be clearly seen that the higher the education level, the
lower the prevalence of diabetes mellitus. Around 73% of diabetic patients do not
have educational background, and the number decreases rapidly as the level of
education increase. At tertiary level of education, only 29.2% of patients are
diagnosed with T2DM while a good number of 70.8% is free of diabetes. It can be
concluded that level of education inversely related to percentage of diabetic patients.

70
 3.5.3.3. Frequency of T2DM among subjects of different ethnicity and family history
status

Ethnicity Family T2DM Total

Family Chi-square value 12.809
history of Yes No
T2DM History P-value 0.002
Odds ratio 2.59
Malay + 20 20 61
– 5 16 (24.7%)
Chinese + 32 24 98 Ethnicity Chi-square value 4.267
– 16 26 (39.7%) P-value 0.23
Indian + 32 14 78
– 13 19 (31.6%)
Other + 5 3 10
– 1 1 (4.0%)
Total 124 123 247

Ethnicity
39.70%

31.60%
24.70%

4%

Malay Chinese Indian Others

Ethnic

39.7% of Chinese patients participate in this study, followed by 31.6% of Indians and
24.7% of Malays. The rest of the participants are from other ethnics. Our result
showed no statistical significance between ethnicity and prevalence of DM, with a p-
value more than 0.05. The major three races had very similar representation of
diabetes in our study.

32 Chinese patients found to have T2DM predisposition in the family and eventually
have been diagnosed with T2DM, while 24 Chinese patients are free from T2DM
despite having a positive family history of T2DM. In contrast, in spite of having a
negative family history of T2DM, 16 Chinese patients were diagnosed with T2DM.
Overall, our data depict family history of DM is associated with a higher incidence of
DM (Odds Ratio: 2.59) with 95% of confidence level being 1.53 – 4.38.

71
3.5.3.4. Frequency of DM and Non-DM subjects against monthly income

100
90
Monthly Chi-square value 4.533
80
income
70 P-value 0.476
60
Frequency

50
40
30
20
10
0
< 1000 1000-1999 2000-2999 3000-3999 3999-4000 > 5000
Positive 87 17 10 3 3 4
Negative 75 17 11 7 7 6

In the diabetic population, it can be concluded that, the higher the income, the lower
the prevalence of being diagnosed with T2DM. The same trend also can be seen in
the non-diabetic population.

3.5.4. Diabetes Mellitus

3.5.4.1. How many years have you had diabetes mellitus?

30.0%

25.0%

20.0%
Percentage

15.0%

10.0%

5.0%

0.0%
more
less than 1 to 5 6 to 10 11 to 15 16 to 20
than 20
1 year years years years years
years
Series1 27.50% 26.80% 14.80% 13.40% 4.70% 12.80%

Among the diabetic participants, 27.5% have been diagnosed with T2DM for less
than a year, while 26.8% has T2DM for 1 to 5 years. This is caught up by those who
were diagnosed with T2DM for 6 to 10 years (14.8%), 11 to 15 years (13.4%), more
than 20 years (12.8%) and 16 to 20 years (4.7%).

72
3.5.4.2. Females Only (Have you ever been pregnant? If yes, do you have a history
of gestational diabetes mellitus?)

Not No
been Gestational
pregnant Diabetes
18.1% 15.4%

Had
Been Gestational
Pregnant Diabetes
81.9% 84.6%

Among female participants, 81.9% have been pregnant, while the rest has not been
pregnant before. And among those who had been pregnant, 84.6% has a history of
gestational diabetes.

3.5.5. High Blood Pressure

3.5.5.1. Have you been told by doctor that you have high blood pressure?

No
44.1%
Yes
55.9%

More than half of participants (55.9%) have been diagnosed with high blood
pressure.

73
3.5.5.2. How many years have you had high blood pressure?

35.0%

30.0%

25.0%
Percentage

20.0%

15.0%

10.0%

5.0%

0.0%
more
less than 1 to 5 6 to 10 11 to 15 16 to 20
than 20
1 year years years years years
years
Series1 7.20% 31.90% 21.70% 16.00% 8.00% 15.20%

Among the hypertensive participants, 31.9% have been diagnosed with high blood
pressure 1 to 5 years. Those who have been hypertensive for 6 to 10 years
accounted for 21.7%, and this is followed by hypertensive for 11 to 15 years at 16%.
Only 7.2% patients are recently diagnosed as hypertensive.

3.5.5.3. Are you on any medications to control your high blood pressure?

No
5.8%

Yes
94.2%

Among the hypertensive patients, 94.2% are on medication for high blood pressure,
while 5.8% are not under ant drugs for high blood pressure.

74
3.5.5.4. Do you have any other health condition(s) besides diabetes mellitus and/or
high blood pressure?

Yes
No 46.2%
53%

In total, of 247 patients, more than half (53%) have no other condition besides
diabetes mellitus and/or high blood pressure, while 46.2% admit having another
illness.

3.5.6. Lifestyle

3.5.6.1. How many times do you exercise a week?

40.0%
35.0%
30.0%
25.0%
Percentage

20.0%
15.0%
10.0%
5.0%
0.0%
1 to 3 times a 4 to 6 times a 7 times and Do not
week week above a week exercise
Series1 35.10% 11.30% 17.70% 35.90%

About 64.3% of respondents do exercise weekly while 35.9% of respondents

do not do any exercises. Among those who do exercise, 35.1% do physical
activity one to three times a week, while 17.7% do exercise 7 times and
above.The rest of them do exercise at least 4 to 6 times a week.

75
3.5.6.2. How long do you exercise per session?

70.0%

60.0%

50.0%
Percentage

40.0%

30.0%

20.0%

10.0%

0.0%
less than 60 more than 120
60 to 120 minutes
minutes minutes
Series1 57.90% 39.60% 2.50%

Among the respondents who do exercise, more than half of them do exercise less
than 60 minutes per session. 39.6% do exercise for one to 2 hours per session and
the rest do exercise more than 2 hours per session.

3.5.6.3. Have you ever smoked?

The majority of respondents (76.9%) are non-smokers while the rest of them did
smoke previously (9.3%) and 13.8% of them are currently smoking.

76
3.5.6.4. How many years have you been smoking?

Among the smokers, 52.6% have smoked for more than 20 years, followed by
15.8%, who have been smoking for 16 to 20 years. 14% of respondents have
smoked for 6 to 10 years, while 7% and 8.8% of smokers have been smoking for 11
to 15 years and 1 to 5 years respectively. Smokers for less than a year comprises of
1.8%.

3.5.6.5. How many sticks do you smoke per day?

Among the smokers, 38.6% smoke more than 20 sticks per day, followed closely by
26.3% of smokers who smoke 1 to 5 sticks per day. Those who smoke 6 to 10 sticks
per day and 16 to 20 sticks per day have a difference of only 1.8%. The least amount
of 5.3% smokes 11 to 15 sticks of cigarette per day.

77
3.5.6.6. Are you currently using alternative medicine? (traditional medicine, herbs,
ointments, others)

No
77.7%

Yes
22.3%

The majority of the respondents is not using any alternative medicine currently while
22.3% say yes to alternative medicine.

3.5.7. Pittsburgh Sleep Quality Index

3.5.7.1. During the past month, what time do you usually go to bed at night?

A large proportion of respondents go to bed at 9 p.m. to 11 p.m.. This is followed by

35.6% of respondents who go to bed between after 11 p.m. and 9 a.m. mornings.
Only 1.6% of respondents go to bed before 9 p.m..

78
3.5.7.2. During the past month, how long do you usually take to fall asleep each
night?

About 56.3% of respondents just take less than 30 minutes, followed by 36.8% of
respondents who takes up to an hour to sleep. The sleep latency steeply decreases
as less than 5% of respondents take 2 hours to sleep and the rest take more than 2
hours to sleep.

3.5.7.3. During the past month, what time do you usually wake up in the morning?

The majority (75.3%) of respondents wakes up between 5 to 7 a.m., followed by

those (19.4%) who wake up after 7 a.m. and 5.3% of respondents wakes up before
5o‟clock in the morning.

79
3.5.7.4. During the past month, how many hours of actual (uninterrupted) sleep did
you get at night?

According to the National Institutes of Health 22, most healthy adults need between
seven and a half to nine hours of sleep per night to function at their best. Thus,
based on this division, more than half (61.1%) of respondents get a sleep duration of
less than 7 hours of actual sleep at night while the rest of the respondents do get 7
hours and more hours of uninterrupted sleep at night.

80
3.5.7.5. During the past month, how often have you had trouble sleeping because
you.

During the past month, how often have Not Less Once or Three or
you had trouble sleeping because you during than twice a more
the past once a week times a
month week week

a. Cannot get to sleep within 30 50.6% 16.6% 12.6% 20.2%

minutes (125) (41) (31) (50)
b. Wake up in the middle of the night 30.7% 13.0% 15.8% 40.5%
or early morning (76) (32) (39) (100)
c. Have to get up to use the bathroom 22.7% 14.2% 18.2% 44.9%
(56) (35) (45) (111)
d. Cannot breathe comfortably 85.8% 4.5% 3.6% 6.1%
(212) (11) (9) (15)
e. Cough or snore loudly 60.0% 16.6% 7.2% 16.2%
(148) (41) (18) (40)
f. Feel too cold 80.6% 7.7% 4.0% 7.7%
(199) (19) (10) (19)
g. Feel too hot 60.3% 15.0% 12.6% 12.1%
(149) (37) (31) (30)
h. Have bad dreams 70.4% 19.0% 6.5% 4.1%
(174) (47) (16) (10)
i. Have pain 67.2% 8.1% 9.7% 15.0%
(166) (20) (24) (37)
j. Other reason(s) 83.0% 6.1% 4.0% 6.9%
(205) (15) (10) (17)

For less than once a week, respondents have sleeping problem due to feeling too
hot (15%) , same amount of respondents (16.6%) cannot get sleep within 30 minutes
or they cough or snore loudly and about 19% had bad dreams. As for having sleep
problem once or twice a week, 12.6% of respondents say that they can‟t fall asleep
within 30 minutes, around 15.8%, says they wake up in the middle of the night or
early morning and 18.2% says that they have to use toilet frequently. The same
criteria had an increase in the number of respondents (20.2 %, 40.5% and 44.9%
respectively) as more respondents suffer from the reasons three or more times in a
week.

81
3.5.7.6. During the past month, how often do you take medicine to help you sleep?

0.8%
2.4%
3.2%
Not during the past
month
Less than once a week

Once or twice a week

93.5% Three or more times a

week

The majority of the respondents do not consume any medication to sleep, but there
is a significant 3.2% of respondents, who take medicine three or more times in a
week.

3.5.7.7. During the past month, how often have you had trouble staying awake while
driving, eating meals, or engaging in social activity?

Although the majority of 58.3% had no trouble staying awake, 15% of respondents
experience daytime dysfunction three or more times in a week, followed by 14.2% of
respondents for once or twice a week and 12.6% of respondents for less than once a
week.

82
3.5.7.8. During the past month, how much of a problem has it been for you to keep
up enthusiasm to do things?

Around 65.2% of respondents had no problem in maintaining their enthusiasm to do

things. While 12.1% have problems in keeping up enthusiasm to work less than once
a week, same amount of 11.3% of respondents have problem in upholding the
interest in work more than once a week.

3.5.7.9. During the past month, how would you rate your sleep quality overall?

More than half of respondents (63.6%) have rated having good sleep quality, while
18.2% reportedly have a very good sleep quality. Causing concern, 13.8% of
respondents have bad sleep quality and less than 5% had a very bad sleep quality.

83
3.5.7.10. Global PSQI score

About 25% of respondents receive a global PSQI score of less than 5 (indicative of
good sleep quality) while the rest of them receive a score of equal or more than 5,
which is indicative of poor sleep quality

84
3.6 Discussion

In this study, we found robust and significant positive association between sleep
quality and Type 2 Diabetes Mellitus. Significant findings of important variable will be
discussed below with suitable graphs and charts.

i. Sociodemographic section

Our study shows that the occurrence of Diabetes Mellitus has positive
correlation with age, with a chi-square value of 39.421 and a p value of less
than 0.001. An increase in the incidence of DM is noted until age group of 50 to 59,
but the DM prevalence decreases from age 60 onwards. This data is supported by a
study on north of Iran population by Veghari 23 in 2010, which states that there was a
positive and significant correlation between age and blood glucose.

Also, our study shows no statistical difference between genders in the

occurrence of T2DM with a p-value of 0.57. A study on the European population in
2001 by Gale et.al24, correlates with our result. However, these results found to
contradict with the study that was carried out by Miharjda 25 in 2014, in which, higher
prevalence of DM observed in females compared to males among the Indonesian
population. The variation between these studies might be due to different dietary
practices in different population.

Our study also shows that the level of education is inversely related to the
percentage of diabetic patients with chi-square value of 18.028 and a p-value
of 0.001. Our result is further supported by another study by Mei Tang et.al 26 on
gender-related differences in the association between socioeconomic status and
self-reported diabetes in 2002, in which prevalence of DM increases with decrease in
attainment of education independent of other factors. A study by Sacerdote27 and et
al. that compared participants with a high educational level against participants with
a low educational level of which the latter had a higher risk of T2DM also supports
our study result. This might be because lower levels of education are associated with
a poor awareness about diabetes and other diseases. Hence, these people will lack
the knowledge about control & prevention regarding diabetes and its complications,
thus predisposing them to have DM.

However, our result is contradicted with a study conducted by I.S.Madjid et.al 28 in

November 18th, 2012, on the effect of educational status on the relationship between
obesity and risk of type 2 diabetes. The result from this study suggests that risk of
diabetes is independent of educational status.

In addition, our results of this study showed a significant positive link between
having a family history of DM and the prevalence of T2DM (Odds Ratio: 2.59;
95% of confidence level being 1.53 – 4.38). According to the odd ratio obtained,
respondents with positive family history of T2DM are 259% more likely to diagnose
with T2DM than those without a T2DM family history. Our result correlates with
studies conducted by RA Scott et al 29 in 2013 which showed an association between
family history of type 2 diabetes and a higher incidence of T2DM (HR 2.72, 95% CI
85
2.48, 2.99). The same goes for another similar study by Annis et al30, in the US that
indicate 44% higher prevalence of T2DM in subjects with positive family history of
T2DM.

No statistical significance was acquired between different ethnicity and

occurrence of T2DM with a p-value of more than 0.05 even with similar
representation from all three ethnics (Chinese, Indians and Malays) was present in
our study. This result is opposed by a study31 showed that Indians have the highest
OR for the presence of diabetes among the ethnic groups, which is 2.71 as
compared to 1 in Malays and 0.86 in Chinese.

Our study shows inverse correlation between monthly income and the
prevalence of T2DM (chi-square value: 4.533, p-value: 0.476). This is supported by
a study in Korea by Jongnam Hwang et al 32 in 2014, which indicate that individuals
with the lowest income were more likely to have type 2 diabetes than those with the
highest income (OR 1.35; 95% CI 1.08 to 1.72)

Thus under sociodemographic section it can be concluded that :

- Prevalence of T2DM increases with age

- There is no statistical difference between T2DM occurrence and
gender
- Strong link between a positive family history of T2DM and incidence
of T2DM noted
- The lower the educational level, the higher the risk of getting
diagnosed with T2DM

Sociodemographic Variable p-value / odd ratio

Age Less than 0.001
Gender 0.57
Education level 0.001
Family history 0.002 / OR: 2.59
Ethnicity 0.23
Income 0.476

86
 ii. Diabetes Mellitus and Sleep Quality

Diabetic Status Sleep Quality Total

Poor Good

Diabetic 95 29 124
(76.6%) (23.4%)

Non-Diabetic 80 43 123
(65.0%) (35.0%)

Total 175 72 247

According to the table above, our data shows that an increase in the prevalence of
Type 2 Diabetes Mellitus is associated with poor sleep quality (76.6%) amongst
T2DM in the Seremban population who went to Seremban Health Clinic 1 & 2. Only
a small percentage of 23.4% of DM subjects admit that they have good sleep despite
having T2DM. Global PSQI score of more than five, which is indicative of poor sleep
quality, has a higher association with T2DM subjects with an odds ratio of 1.76
at confidence level 95% (Chi-square value: 4.004; p-value< 0.04) compared to
those with a global PSQI score less than 5.

A study by Lou et al13, 2012, in China shows the similar odd ratio and result with our
study. This cross-sectional study was conducted among the Chinese population of
age 18-75, suggests that both poor quality of sleep and short sleep duration (≤6 h)
were associated with increased prevalence of diabetes. This correlates with our
study outcomes given that PSQI evaluates each individual's sleep latency as part of
the component score which contributes to the global PSQI score. Another study by
Salim Surani et al.1 also concluded that up to 33.3% of patients with DM suffered
from concomitant sleep disorders, as compared with 8.2% of controls without DM.

There are several possible mechanisms to explain the association between poor
sleep quality and T2DM. Some studies14 shows that sleep deprivation stimulates the
cerebral cortex, cerebral limbic system and hypothalamus to induce catecholamine
secretion (from the sympathetic ganglion and adrenal medulla) and cortisol
secretion(from the pituitary–adrenal system), which then increase the plasma
glucose level. On the other hand, several physiologic experiments 33 have
demonstrated that the blood cortisol concentration and insulin resistance are
increased as a consequence of sleep deprivation.

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 iii. Diabetes Mellitus and Hypertension (chronic comorbidity)

Diabetic Status Hypertension Total

Positive Negative

Diabetic 93 31 125
(75.0%) (25.0%)

Non-Diabetic 45 78 122
(36.6%) (63.4%)

Total 138 109 247

The result of our study of the association between Type 2 Diabetes Mellitus and
Hypertension is revealed that hypertensive subjects are 5.2 times more likely to have
Type 2 Diabetes Mellitus than non-hypertensive subjects (chi square value of
36.958).

A previous cohort study done on a total of 1077 T2DM patients who attended a
diabetes clinic of Universiti Sains Malaysia (USM) teaching hospital in Kelantan by
Abougalambou et al 34. in 2013 , shows the prevalence of hypertension (BP > 130/80
or on medication for high blood pressure) was 92.7%. Our result is further supported
by another cross sectional study25 done on urban Indonesians, which concluded that
hypertensive participants have 2.2‐fold (95% CI 2.0–2.4) increased risk of
hyperglycemia compared with non-hypertensive participants.

A study by James R.Sowers et al 35, in 1995 on DM and Associated Hypertension

disclose that hypertensive disease has been implicated in 4.4% of deaths coded to
diabetes, and diabetes was involved in 10% of deaths coded to hypertensive
disease. Indeed, an estimated 35% to 75% of diabetic complications can be
attributed to hypertension. It also found out that essential hypertension account for
the majority of hypertension in individuals with diabetes, particularly those with
NIDDM (type II diabetes), who constitute more than 90% of people with a dual
diagnosis of diabetes and hypertension. This study result further enhances the
reliability of our study.

A plausible mechanism for the link between DM and Hypertension is proposed by a

study by Bernard M.Y.Cheung et al36 in 2012. Diabetes and hypertension found to
share common pathways such as SNS, RAAS, oxidative stress, adipokines, insulin
resistance, and PPARs as shown in the figure below. These pathways interact and
influence each other and may even cause a vicious cycle.

88
One pathway explaining the link between DM and hypertension is that an impaired
cellular response to insulin predisposes to increased vascular smooth muscle (VSM)
proliferation and tone (the hallmark of hypertension in the diabetic state), which then
contribute to reduce membrane calcium -ATPase activity, increased cellular calcium
levels, and causes a marked impairment in vascular smooth muscle calcium efflux,
leading to hypertension.

Furthermore, T2DM develops when the pancreatic β-cell can no longer maintain the
degree of compensatory hyperinsulinemia that is needed to prevent hyperglycemia
thus predisposes to the development of essential hypertension by acting on normally
insulin sensitive tissues37.

89
 iv. Diabetic Mellitus and Smoking

Diabetic Status Smoking Total

Never Currently Previously

Diabetic 97 10 17 124

Non-Diabetic 93 24 6 123

Total 190 34 23 247

Our result shows that there are more smokers in the control group than in diabetic
subjects. An almost equal number of non-smokers present in diabetic and non-
diabetic group and it is noted that current smokers are mostly non-diabetic. Looking
at the table, it can be said that subjects with T2DM are 0.86 times likely to be
smokers and there are more non-diabetic patients associated with smoking than
diabetic patients with chi-square value of 11.106 and the p-value calculated as
0.004.

Our study findings are on par with a study by Radzevičienė et a.l38 in June 2009, in
Lithuania, in which an increased risk of type 2 diabetes was determined for current
smokers (OR=2.41; 95% CI 1.07–5.44) vs. non-smokers besides having association
between the disease and duration of smoking (OR=2.47; 95% CI 1.03–5.93 for 40
years or more) vs. non-smokers, and those who had been smokers for 10 or more
pack-years had twice the risk of diabetes (OR=2.17; 95% CI 1.07–4.40) vs. non-
smokers. Julie C Will39 also shows the positive correlation between diabetes and
smokers in her study.

On the contrary, our findings result has dissimilarity with the study conducted by
Toshimi Sairenchi et.al40 who concluded that smoking was independently associated
with increased risk of T2DM among elderly women and men & middle-aged men and
women.

Several reasonable biological mechanisms 39 have been advanced to explain an

association between cigarette smoking and incidence of diabetes. Some
investigators have suggested that cigarette smoking generally increases insulin
resistance by altering the distribution of body fat or by exerting a direct toxic on
pancreatic tissue. Another mechanism that may be advanced parallels that proposed
to explain that in the absence of physical activity the modification of glucose into fat
and skeletal muscle cells is impaired thus increases chances of getting T2DM.

90
 v. Sleep Quality with Diabetes Mellitus and additional Comorbidities

Variables Odd Ratio

T2DM 1.00
T2DM + HTN 0.88
T2DM + Smoker 2.75
T2DM + HTN + Smoker Indefinite

According to the tabulation of our data, 74.2% of subjects with both T2DM and
hypertension have poorer sleep quality, which was evaluated using PSQI.

This result is alike as in a previous cohort study done by Fiorentini et al. 41 that
concludes the majority of sleep quality disorders presents in subjects with
hypertension and T2DM. Furthermore, the study also suggests poor sleep quality as
a significant cause for both hypertension and T2DM.

Diabetic Nocturnal Arousal Frequency Total

Status
Never during Less than Once or twice Three or
past month once a week a week more times a
week
Diabetic 26 13 20 65 124
(21.0%) (10.5%) (16.1%) (52.4%)

Non-Diabetic 50 19 19 35 123
(40.7%) (15.4%) (15.4%) (28.5%)

Total 76 32 39 100 247

91
Here, we have highlighted two possible reasons that might have contributed to poor
sleep quality in patients with diabetic and hypertension. First and foremost, increase
in arousal frequency (chi-square value 0f 17.726; p-value 0.001) is noted among
our diabetic subject. This arousal is linked with some reasons such as frequent need
to use the toilet, having nightmares and unable to breath in the middle of sleep by
our diabetic subjects. Indeed, when data of arousal frequency among diabetic patient
is tabulated (see below), around 65.0% of diabetic subject compared to 35.0% of
non-diabetic subjects, has more than 3 awakening in the middle of sleep in a week.

According to several studies, namely done in 2007 by Kamila Jauch-Chara et al42

and by Berit et.al43 in 2013, diminished hormonal counter regulation during sleep
could contribute to accumulation of hypoglycemic attacks in diabetic patients, thus,
might lead to several nocturnal awakening episodes and without any doubt, causes
poor sleep quality.

Diabetic Bathroom usage frequency Total

Status
Never during Less than Once or twice Three or
past month once a week a week more times a
week
Diabetic 22 13 10 79 124
(17.7%) (10.5%) (8.1%) (63.7%)

Non-Diabetic 34 22 26 41 123
(27.6%) (17.9%) (21.1%) (33.3%)

Total 56 35 45 111 247

The second reason for sleep quality is the frequent need to use the bathroom.
Frequent bathroom usage at night (chi-square value: 13.547; p-value: 0.004) noted
to be almost type in type 2 diabetic patients (71.2%) compared to their non-diabetic
(36.9%) counterparts.

This frequent bathroom usage among diabetic subjects might be due to nocturia,
which is a fundamental issue in diabetic patients. An overproduction of urine due to
solute diuresis (nocturnal polyuria) or an inability of the bladder to store normal
quantities of urine (reduced bladder capacity), or a combination of these factors
might cause diabetic patients use the toilet frequently at night.

A study44 among Taiwanese women aged 20-59 years, by Hsieh CH et al. on June
2007 concludes the prevalence of nocturia increased significantly with diabetes
mellitus (p = 0.024) and another study by Kingler HC et al45 in 2009 concludes that
nocturnal polyuria had a high impact on bothersome score on quality of life and
strong associations with poor health.

92
In conclusion, subjects with T2DM are more predisposed on having poor sleep
quality and hypertension. Diabetes mellitus type 2 by itself or together with
hypertension (chronic comorbidity) and smoking do have a profound effect on sleep
quality in diabetic patient.

Variables Odd Ratio

DM + Sleep quality 1.76
DM + Hypertension 5.2
DM + Smoking 0.86

Thus, sleep quality should be emphasized as an important component in the

management of patients with diabetes mellitus and early recognition of poor sleep
quality among patients with T2DM helps to slow down diabetic complications.

93
3.7 Limitation

There were some limitations in doing this survey.

1. Questionnaire

- PSQI score:

The PSQI was not scored throughout a one month period due to time constraint.
This can be overcome by extending the period of research to get a more reliable
data on global PSQI score.

- Self-reported information

Questions about sleep quality and duration of sleep were only asked to the
respondents. This might give rise to information bias unintentionally by the
respondents as they might not aware of certain happenings that might be related to
the question. Alternatively, the bed partners of the respondents should be
interviewed as well.

2. Interviewer

- Interviewing techniques of questioning and wording were not standardized

due to time constraint, thus each and every interviewer might interpret the question,
according to their own understanding, but efforts were done to translate the
questionnaires to Malay to give an overview of what kind of answers are expected.
Furthermore, since it was hard to hold onto a respondent for a long time to complete
the questionnaire, some of the interviewers have no option other than rush through
some questions.

3. Respondents

- We were not able to screen the subjects due to time constraint. Thus, this
might have a bias towards the control as there might be subjects that have not been
diagnosed with diabetes or hypertension yet. This can be overcome by using four
tests46:
 FPG ≥7.0 mmol/L or ≥ 126 mg/dL [Grade B, Level 2 ] and recommends
confirmation with a repeated screening test on a separate day
 A1C ≥6.5% [Grade B, Level 2 ]
 2hPG in a 75 g OGTT ≥11.1 mmol/L [Grade B, Level 2 ]
 Random PG ≥11.1 mmol/L [Grade D, Consensus]

94
- We were not able to control some well-known risk of DM (such as BMI) or
measure other contributing factors (like obstructive sleep apnoea due to obesity or
other emotional factors that might affect subject‟s sleep), thus unable to rule out
other factors that might interfere with the present data. Furthermore, we had no
information about the subject‟s medical supervision status, hence unable to check
the validity of data provided.

- As we did the survey on working hour, most of the respondents were rushing
to obtain their medication and get back to their work. A more proper timing for the
survey might contribute to a better outcome of result.

- Small sample size of 247 subjects also affects the reliability of the result due
to higher variability. This can be overcome by recruiting a larger sample size as this
will lead to a smaller standard deviation, thus guarantee the outcome of our study
result.

- The study sample also has some area that gives rise to bias as there was a
limited diversity among the chosen subjects. This can be overcome via recruiting a
greater diversity of subjects as in includes more subjects with higher income. Either
way, we tried to reduce as much as possible by randomly select our study sample.

- As for some information that were asked in the questionnaire were quite
personal, such as monthly household income, some of the respondents were
reluctant to let us know the details causing information bias. Recall bias also occurs
when some of the respondents cannot recall exact answers to the question.

95
 3.8 Reliability, Sensitivity and Specificity
3.8.1. Reliability47

The reliability of this study was calculated using Cronbach‟s Alpha. The reliability
statistics obtained as follow:

Cronbach’s N of Items
Alpha
.741 14

Since a reliability coefficient of .70or higher is considered ”acceptable" in most social

science research situations, thus having an alpha coefficient for the four items is
.741, suggesting that the items have relatively high internal consistency.

3.8.2. Sensitivity and Specificity of PSQI

According to a research done on PSQI, Buysee et al 21 found out that a global PSQI
score greater than 5 yielded a diagnostic sensitivity of 89.6% and specificity of
86.5% (kappa = 0.75, p less than 0.001) in distinguishing good and poor sleepers.

96
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3.10. Appendix

In this section, following documents are attached:

3.10.1. Survey Questionnaire

103
IMU Bukit Jalil – ME213 G1 FORM NO: __________
QUESTIONNAIRE / BORANG SOAL SELIDIK

A. Date of visit: B. Location of visit:

Tarikh lawatan: Lokasi lawatan:
o 02 July / Julai 2015 o Klinik Kesihatan Seremban / Rasah
o 03 July / Julai 2015 o Klinik Kesihatan Seremban 2

PARTICIPANT’S GENERAL DETAILS / MAKLUMAT ASAS PESERTA

5. Gender: DIABETES MELLITUS / KENCING MANIS

Jantina: 1. Have you been told by a doctor that you have
o Male / Lelaki diabetes mellitus?
o Female / Perempuan Pernahkah anda diberitahu oleh doktor bahawa
anda ada kencing manis?
o No / Tidak
6. Age: o Yes / Ya
Umur:
__________ years / tahun
2. When were you told by a doctor that you have
diabetes mellitus?
7. Level of education: Bilakah anda diberitahu oleh doktor bahawa anda
Tahap pendidikan: ada kencing manis?
o No schooling / Tidak bersekolah o Age below 18 years / Umur kurang 18 tahun
o Primary school / Sekolah rendah o Age 18 years and above / Umur 18 tahun dan
o Secondary school / Sekolah menengah ke atas
o Tertiary education / Pengajian tinggi
o Others / Lain-lain
Please specify / Sila nyatakan: 3. How many years have you had diabetes mellitus?
__________ Sudah berapa tahun anda ada kencing manis?
o <1
o 1-5
8. Ethnicity: o 6-10
Kaum: o 11-15
o Malay / Melayu o 16-20
o Chinese / Cina o >20
o Indian / India
o Others / Lain-lain
Please specify / Sila nyatakan: 4. Does anyone in your immediate family have
__________ diabetes mellitus?
Adakah sesiapa dalam keluarga terdekat anda
yang ada kencing manis?
9. Monthly income: o No / Tidak
Pendapatan sebulan: o Yes / Ya
o < RM 1,000
o RM 1,000 – RM 1,999 *Immediate family: parents, siblings, children,
o RM 2,000 – RM 2,999 spouse.
o RM 3,000 – RM 3,999 *Keluarga terdekat: ibubapa, adik-beradik, anak-
o RM 4,000 – RM 4,999 anak, suami isteri.
o RM 5,000 and above / dan ke atas

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15. For Females Only / Untuk Perempuan Sahaja
Have you ever been pregnant?
Pernahkah anda mengandung?
o No / Tidak
o Yes / Ya
*If “No”, ignore the following question.
*Jika “Tidak”, abaikan soalan berikutan.
16. Do you have a history of gestational diabetes
mellitus (diabetes during pregnancy)?
Pernahkah anda mengalami kencing manis
semasa mengandung?
o No / Tidak
o Yes / Ya
HIGH BLOOD PRESSURE / TEKANAN DARAH
TINGGI
17. Have you been told by the doctor that you
have high blood pressure?
Pernahkah anda diberitahu oleh doktor
bahawa anda ada tekanan darah tinggi?
o No / Tidak
o Yes / Ya
*If “No”, ignore the two following questions.
*Jika “Tidak”, abaikan dua soalan berikutan.
18. How many years have you had high blood
pressure?
Sudah berapa tahun anda ada tekanan darah
tinggi?
o <1
o 1-5
o 6-10
o 11-15
o 16-20
o >20
19. Are you on any medications to control your
high blood pressure?
Adakah anda mengambil sebarang ubat
untuk mengawal tekanan darah tinggi anda?
o No / Tidak
o Yes / Ya
FORM NO: __________
10. Do you have any other health condition(s) besides
diabetes mellitus and/or high blood pressure?
Adakah anda mempunyai masalah kesihatan selain
daripada kencing manis dan/atau tekanan darah
tinggi?
o No / Tidak
o Yes / Ya
If “Yes”, please specify / Jika “Ya”, sila
nyatakan:
______________________________
______________________________
LIFESTYLE / GAYA HIDUP
11. How many times do you exercise a week?
Berapa kali anda bersenam seminggu?
__________ per week / seminggu
*Exercise includes brisk walking, jogging,
swimming, sports, others EXCEPT simple walking.
*Senaman termasuk berjalan pantas, jogging,
berenang, sukan, lain-lain KECUALI berjalan biasa.
12. How long do you exercise per session?
Berapa lamakah anda bersenam setiap sesi?
__________ minutes per session / minit sesesi
13. Have you ever smoked?
Pernahkah anda merokok?
o No / Tidak
o Yes, currently / Ya, masih
o Yes, previously / Ya, dahulu
*If “No”, ignore the two following questions.
*Jika “Tidak”, abaikan dua soalan berikutan.
14. How many years have you been smoking?
Sudah berapa tahun anda merokok?
o <1
o 1-5
o 6-10
o 11-15
o 16-20
o >20
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 IMU Bukit Jalil – ME213 G1 FORM
20. How many sticks do you smoke per day? 21. Are you currently using alternative
Berapa batang rokok anda merokok medicine? (traditional medicine, herbs,
sehari? ointments, others)
o 1-5 Adakah anda sedang menggunakan ubat-
o 6-10 ubat alternatif? (ubat tradisi, herba,
o 11-15 ulam-ulaman, salap, lain-lain)
o 16-20 o No / Tidak
o >20 o Yes / Ya
PITTSBURGH SLEEP QUALITY INDEX / INDEKS KUALITI TIDUR PITTSBURGH

24. During the past month, what time do you 22. During the past month, what time do you usually
usually go to bed at night? wake up in the morning?
Sepanjang bulan lalu, apakah masa anda Sepanjang bulan lalu, apakah masa anda biasanya
biasanya masuk tidur? bangun pada waktu pagi?
Time / Masa: __________ Time / Masa: __________

25. During the past month, how long do you
usually take to fall asleep each night?
Sepanjang bulan lalu, berapa lamakah anda
biasanya mengambil untuk tidur setiap
malam?
Minutes / Minit: __________
23. During the past month, how many hours of
actual (uninterrupted) sleep did you get at night?
Sepanjang bulan lalu, berapakah jam anda dapat
tidur nyenyak pada waktu malam?
Hours / Jam:__________

For the questions below, please tick one box per row.
Untuk soalan-soalan di bawah, sila tanda satu kotak setiap baris.
22. During the past month, how often have you had Not during Less than Once or Three or
trouble sleeping because you the past once a week twice a week more times a
Sepanjang bulan lalu, berapa kerapkah anda month Kurang Sekali atau week
mempunyai masalah tidur kerana anda Tiada daripada dua kali Tiga kali
sepanjang sekali seminggu atau lebih
bulan lalu seminggu atau lebih
seminggu
a. Cannot get to sleep within 30 minutes
Tidak boleh tidur dalam tempoh 30 minit
b. Wake up in the middle of the night or early
morning
Terjaga pada tengah malam atau awal pagi
c. Have to get up to use the bathroom
Perlu bangun untuk menggunakan tandas
d. Cannot breathe comfortably
Tidak boleh bernafas dengan selesa
e. Cough or snore loudly
Batuk atau berdengkur dengan kuat
f. Feel too cold
Merasa terlalu sejuk

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 g. Feel too hot
Merasa terlalu panas
h. Have bad dreams
Mengalami mimpi buruk
i. Have pain
Mengalami sebarang kesakitan
j. Other reason(s), please describe, including how
often you have trouble sleeping because of this
reason(s).
Lain-lain sebab, sila jelaskan sebab-sebab lain
termasuk berapa kerap anda mempunyai masalah
tidur oleh sebabnya.
27. During the past month, how often do you take
medicine to help you sleep?
Sepanjang bulan lalu, berapa kerapkah anda
mengambil ubat untuk membantu anda tidur?
28. During the past month, how often have you had
trouble staying awake while driving, eating meals, or
engaging in social activity?
Sepanjang bulan lalu, berapa kerapkah anda
mempunyai masalah berjaga semasa memandu,
semasa makan, atau semasa melibatkan diri dalam
aktiviti sosial?
29. During the past month, how much of a problem has it
been for you to keep up enthusiasm to do things?
Sepanjang bulan lalu, berapa banyak masalah anda
melalui untuk bersemangat dalam sebarang perkara
yang dilakukan?
30. During the past month, how would you rate your Very good Good Bad Very bad
sleep quality overall? Sangat baik Baik Buruk Sangat buruk
Sepanjang bulan lalu, bagaimanakah anda akan
menilaikan kualiti tidur keseluruhan anda?
Pittsburgh Sleep Quality Index (PSQI) adapted from:
Buysse D.J., Reynolds C.F., Monk T.H., Berman S.R. and Kupfer D.J. (1989). The Pittsburgh
Sleep Quality Index (PSQI): A new instrument for psychiatric research and practice.
Psychiatry Research 28(2): 193-213.
Available at: http://www.opapc.com/uploads/documents/PSQI.pdf

END OF QUESTIONNAIRE / TAMAT BORANG SOAL SELIDIK

THANK YOU / TERIMA KASIH

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