ABSTRAKPERMASALAHAN: HIV/AIDS dan Hepatitis B merupakan masalah kesehatan masyarakat yang sangat penting karena belum ditemukan obatnya sampai saat ini. Wanita usia subur, khususnya yang berpenghasilan rendah pengunjung Puskesmas semakin rentan terhadap risiko penularan kedua penyakit tersebut. Sampai saat ini belum ada model upaya promotif dan preventif di Puskesmas yang mengintegrasikan pelayanan penyakit menular seksual (PMS) ke dalam pelayanan BP/KIA/KB di Puskesmas.
TUJUAN PENELITIAN: Mengembangkan model intervensi guna menurunkan risiko infeksi PMS termasuk HIV/AIDS dan Hepatitis B bagi wanita usia reproduksi wanita hamil dan peserta KB berpenghasilan rendah melalui keterpaduan program PMS dengan program kesehatan reproduksi di klinik KIA/KB dan BP di Puskesmas daerah perkotaan dan pedesaan.
METODA PENELITIAN: Desain penelitian adalah Kuasi eksperimen, yaitu one group pre dan post test tanpa kelompok kontrol. Dalam intervensi ini dilakukan observasi awal, intervensi dan observasi akhir tanpa menggunakan kelompok kontrol
Pengumpulan data pre intervensi adalah: a) survei PSP (Pengetahuan, Sikap & Praktek) terhadap 400 ibu pengunjung BP/KIA/KB yang dipilih secara acak dan b) skrining terhadap 1200 ibu pengunjung BP/KIA/KB menggunakan sediaan basah dan pewarnaan Gram. Selain itu, dilakukan studi kualitatif dengan melakukan wawancara mendalam 4 dokter Puskesmas; Diskusi Kelompok Terarah (DKT) masing-masing 4 kelompok petugas Puskesmas dan ibu usia reproduksi pengunjung BP/KIA/KB; pengamatan pelayanan BP/KIA/KB dan data Iayanan suntik dan penggunaan jarum & syringe (tabung jarum suntik).
Sedangkan pada post intervensi yang dikumpulkan adalah data survei PSP pada 400 ibu pengunjung ' BP/KIA/KB; studi kualitatif pada petugas Puskesmas (dokter, paramedis, petugas lab); pengamatan pada pelayanan BP/KIA/KB serta data layanan suntik dan penggunaan jarum & syringe.
Lokasi penelitian adalah di 4 wilayah Puskesmas, yaitu 2 di perkotaan (Puskesmas Kec. Koja dan Ciracas di DKI Jaya) dan 2 di pedesaan (Puskesmas Kec. Pamanukan, Kab. Subang dan Kec. Pulomerak Kab. Serang, Jabar).
Analisis data kualitatif dilakukan secara content analysis. Hasil survei disajikan dalam distribusi frekwensi, tabulasi silang PSP yang berkaitan dengan PMS, HIV/AIDS, Hepatitis B & kebiasaan suntik dengan membandingkan pre dan post intervensi dan membandingkan lokasi perkotaan dan pedesaan. Uji kemaknaan dilakukan dengan Chi-square. Dari skrining PMS dikemukakan hasil yang dilakukan oleh Puskesmas dan konfirmasi pemeriksaan oleh Bag. Ilmu Penyakit Kulit & Kelamin, FKUI/RSCM.
HASIL PENELITIAN: Karakteristik responden sebelum dan sesudah intervensi tidak berbeda. Dua diantara lima responden baik di kota maupun desa menderita infeksi PMS/ saluran reproduksi. Bila dilihat secara keseluruhan intervensi penyuluhan yang dilakukan berdampak pada kenaikan proporsi responden yang mengetahui HIV/AIDS & bahaya penggunaan jarum suntik tetapi tidak memiliki dampak pada PSP yang berkaitan dengan PMS dan Hepatitis B. Perubahan pengetahuan petugas Puskesmas sebagai hasil intervensi cukup baik tetapi belum memiliki dampak positif terhadap praktek interaksi antara petugas-pasien maupun sterilisasi alat. Namun dari data pelayanan suntikan sekalipun proporsi yang disuntik di BP baik perkotaan maupun pedesaan (kecuali Pamanukan) relatif meningkat tetapi penggunaan jarum suntik berulang berkurang. Demikian juga penggunaan syringe berulang juga turun tetapi rasionya belum mencapai 1:1.
Dampak intervensi yang belum nyata dan signifikan ini dapat disebabkan antara lain penyuluhan yang dilakukan hanya intensif pada saat terjadwal sesuai kegiatan proyek, sesudah itu berjalan tetapi kurang intensif, penyuluhan hanya terbatas di Puskesmas sehingga jangkauannya terbatas, sedang yang terpajan penyuluhan mungkin tidak terpilih sebagai sampel, jarak antara selesainya penyuluhan terjadwal dan evaluasi relatif panjang (6 bulan). Dilain pihak, perubahan PSP pada pengunjung maupun petugas memerlukan waktu relatif lama.
KESIMPULAN DAN SARAN: Kejadian infeksi PMS dan saluran reproduksi di kalangan WUS pengunjung BP/KIA/KB di perkotaan maupun pedesaan cukup tinggi yaitu sekitar 43,5%. Teknik pemeriksaan PMS sederhana dapat dilakukan di Puskesmas dengan pelatihan dan kualitas tenaga yang memadai dan supervisi yang baik. Sesudah intervensi, PSP WUS mengenai PMS dan Hepatitis B tidak banyak berubah_ Namun pengetahuan tentang HIWAIDS dan bahaya penggunaan jarum suntik berulang meningkat demikian juga kesediaan membayar sendiri jarum/syringe bertambah. Sekalipun interaksi petugas-pasien dan praktek sterilisasi alat di Puskesmas belum banyak perbaikan dan ada kenaikan permintaan suntik di BP tetapi penggunaan jarum dan syringe berulang terjadi kecenderungn penurunan. Telah dikembangkan model intervensi berupa pelatihan petugas Puskesmas mengenai manajemen dan pencegahan PMS termasuk HIV/AIDS, Hepatitis B & Pencegahan pemberian suntikan berulang serta materi baku yang terdiri dari silabus dan bahan serta penunjang pelatihan. Selain itu juga dikembangkan model serupa bagi ibu pengunjung BPIKIAIKB di Puskesmas termasuk materi dan penunjang penyuluhan.
Disarankan agar pelaksanaan penyuluhan bagi pengunjung BP di Puskesmas hendaknya tidak dilakukan secara bersamaan dengan pengunjung Klinik KIA/KB. Perlu adanya pemantapan teknik penyuluhan bagi petugas pelaksana, khususnya KIA/KB. Evaluasi dampak dan hasil akhir model ini sebaiknya dilakukan minimal sesudah kegiatan penyuluhan berjalan 6 bulan sehingga perubahan pada kebiasaan dan praktek dapat terlihat lebih nyata.
Model skrining PMS di Puskesmas secara sederhana dapat dikembangkan lebih lanjut pada program Paket Ibu Bayi (Mother Baby Package-WHO) yang akan dikembangkan pemerintah dalam waktu dekat. Disarankan, hal ini perlu ditindaklanjuti dengan pemegang kebijakanlpengelola program di Departemen Kesehatan.
ABSTRACTIntervention to Reduce Risk of HIV/AIDS And Hepatitis B Among Low Income Reproductive Age Women Attending an Ambulatory/ Mother & Child Health And Family Planning Clinic at The Puskesmas in DKI Jakarta And West Java, 1994-1996THE RESEARCH PROBLEM: In Indonesia, HIV/AIDS and Hepatitis B have become major and critical public health problems. At present there is no cure for these two diseases. The low income married women of reproductive age (MWRA) are becoming more and more susceptible to the risk of infection of sexually transmitted diseases (STDs) including HIV/AIDS. Currently a model of integrating STD services into the existing ambulatory/mother & child health (MCH/family planning (FP) services in the Puskesmas is nonexistent).
THE RESEARCH OBJECTIVES: To develop an intervention model in reducing the risk of STDs including HIV/AIDS and Hepatitis B infection for low income MWRA through integrating STD services into MCH/FP services in the Puskesmas both for urban as well as rural areas.
METHODOLOGY OF THE STUDY: The design of the study was one group pre and post test without a control group (a Quasi-experimental design). A measurement was conducted at the beginning of the study then followed by intervention and evaluation! measurement after the intervention. Three different measurements were conducted prior to the intervention period namely a (a) KAP (Knowledge, Attitude & Practice) survey on STD/HIV/AIDS, Hepatitis B and Danger of Reuse of Needles and Syringes among randomly selected 400 MWRA visiting ambulatory/MCH and FP clinics, (b) STD screening using wet-mount and Gram stain among 1200 of the similar clinic attendants, and (c) qualitative assessments: in-depth interviews were conducted with 4 PHC doctors, each four FGDs (Focus Group Discussion) with public health center personnel and selected MWRA were performed. Observation were made on the interaction of the health personnel and the clients and the sterilization techniques took place in the PHC.' After the intervention, a similar KAP survey was conducted among another 400 MWRA attending the above same facilities and in-depth interviews with PHC personnel and observation of the personnel-client interaction, sterilization techniques. Data concerning injection practices and the use of needles and syringes were also collected before and after the intervention.
Content analysis technique was used to analyse the qualitative data. Frequency distribution and cross tabulation were used to depict the results of the KAP survey describing pre and post intervention status or urbanlrural differences. Chisquare test was performed as required. The results of the STD screening was shown as it was conducted by PHC lab technicians and rechecked by the Dept of Dermatovenerology of the School of Medicine, the Univ. of Indonesia) RSCM General Hospital.
RESULTS OF THE STUDY: Social demographic characteristics of the respondents pre and post intervention was quite similar. Two out of five respondents both in the urban and rural areas suffering of STD/Reproductive Tract Infection (RT9. The intervention seems to have an effect on the increase of the proportion of the respondents who knew about HIV/AIDS and the danger of reusing needles and syringes. However, it has no effect on the PSP of the respondents concerning STD and Hepatitis B. There was a change in the knowledge of the PHC personnel concerning STD, HIV/AIDS and Hepatitis B, yet there was no apparent effect on the pattern of interaction between providers and the clients and the sterilization technique in the PHC. Although there is an increased proportion of injection demands in the ambulatory clinic both in the urban and rural areas (except Pamanukan) there was a decrease on the reuse of the needles as well as the syringes. The ratio of the use of syringe were close to I:1.
The impact of the intervention was not prominent and significant due to others among the following factors: the intensive health education probably took place during the tight schedule of the project only, after the recommended schedule it took place unregularly; health education was limited in the Puskesmas, therefore the coverage is limited; those who were exposed to the health education were likely not selected as the sample of the survey, and the interval between completed recommended health education intervention and the evaluation was too long. On the other hand change of practice especially among the MWRA attending the PHC and also the personnel of the PHC took a relatively longer time.
CONCLUSIONS AND RECOMMENDATIONS: STD and RTI infection among the MWRA attending the PHC clinic both in the urban and rural were relatively high about 43.5%. Simple technique of screening STD at the PHC was feasible with appropriate training and relatively good quality of lab technician and good supervision. After the intervention the KAP of the MWRA concerning STD and Hepatitis B was likely to remain unchanged. However, their knowledge concerning HIV and AIDS and the danger of using needles and syringes were increased. There was also an increase on the willingness of the client to pay for the disposable needle and syringe for the injection. Although the interaction of the client and the health personnel as well as sterilization technique at the Puskesmas was still unsatisfactory and there was an increased demand of injection in the ambulatory clinic, overall there is a reduction on the reuse of the needles and syringes. An intervention model including training for the PHC personnel concerning management and prevention of STD including HIV/AIDS, Hepatitis B and Prevention of Reuse of Needles and Syringes. It also made available of the module of training of the MWRA including health education materials. It is recommended that the ambulatory clinic visitors should be not be the same health education target audience with the MCH and FP clinic attendants. It is also recommended to retrain the skills on health education among the PHC personnel. The final output evaluation should be conducted at least after six months of the health education intervention so that substantial change of practice took place among both MWRA and PHC personnel. The experience of conducting STD screening in the Puskesmas could be useful in the upcoming promotion program of the WHO's Mother Baby Package by the Ministry of Health. An advocation should be made to follow-up the result of this study to both program holder and decision makers at the Ministry of Health.
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