Overview of the Implementation of Health Promotion Programs for Diabetes Mellitus Patients in Hospital

Introduction: Health promotion is an effort to create people to improve and maintain their health. Improper implementation of Health Promoting Hospital (HPH) can increase recurrence and mortality rates, decrease patient satisfaction, and increase patient care costs in hospitals. Various epidemiological studies show a tendency to increase the incidence and prevalence of Type 2 Diabetes Mellitus in various parts of the world. The WHO organization predicts a large increase in the number of Type 2 Diabetes Mellitus patients in the coming years. Objective: This study aims to describe the implementation of health promotion programs in Type 2 Diabetes Mellitus patients in the hospitals. Method: The type of this research is a descriptive analysis with a quantitative approach. The population in this study were outpatients for Type 2 Diabetes Mellitus at the Internal Medicine Polyclinic in Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital. The sampling technique used is quota sampling, the number of sample used is 440 patients. The instrument used is a questionnaire. Data analysis in this study used categorical description analysis. Result and Discussion: The results showed that 83.3% (out of 233 DM patients at Panembahan Senopati Hospital Bantul) and 64.3% (out of 207 DM patients at PKU Hospital Yogyakarta City) stated that health promotion at the hospital was good. The results of the study on patient assessment standards and patient information and intervention standards also showed good results. Conclusion: So it can be concluded that health promotion in Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital in general is good.


Introduction
Health promotion programs are designed to change the orientation of the health system. Not only focusing on disease and treatment, but also focusing on efforts to prevent disease. Health Promoting Hospital (HPH) has a very important role, especially for individuals and contextual factors that shape individual behavior. The aim is to prevent and reduce the incidence of disease and improve people's welfare. In addition, HPH is also focused on preventing disease complications that can reduce medical costs (Kusumo, 2020).
The implementation of health promoting hospital in Indonesia within more than 15 years is still not optimal. Several strategic issues related to the implementation of HPH are that there are still hospitals that have not made policy about HPH in health services (Permenkes, 2012). One of the reasons why HPH implementation is not optimal is because the hospital does not have specific unit to carry out health promoting hospital (Prahesti, 2018). In addition, promotive and preventive services are also mostly still carried out by first-level (primary) health facilities (Amiri et al., 2016).
If hospital health promotion is not implemented properly, the patient's health behavior will also be not good so that complications can arise (Graham & Sibbald, 2019). In addition, poor implementation of HPH can also increase patient care costs in hospitals, increase recurrence and mortality rates, and decrease patient satisfaction (Erenoglu, 2019).
Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia that occurs due to abnormalities in insulin secretion, insulin action or both. DM is currently a global health threat. Based on the cause, DM can be classified into 4 groups, namely type 1 DM, type 2 DM, gestational DM and other types of DM (PERKENI, 2021). Various epidemiological studies show a tendency to increase the incidence and prevalence of type 2 DM in various parts of the world. The WHO organization predicts a large increase in the number of type 2 DM patients in the coming years. The World Health Organization (WHO) predicts an increase in the number of type 2 DM patients in Indonesia from 8.4 million in 2000 to around 21.3 million in 2030. The prediction of the International Diabetes Federation (IF) also shows that in 2019 -2030 there will be an increase in the number of patients. DM from 10.7 million to 13.7 million in 2030 (Williams et al., 2020).
One of the causes of the high prevalence of DM is the lack of preventive and promotive programs. The low proportion of health spending budgeted by the Government of Indonesia is the main cause of the failure of various preventive and promotive programs (Kusumo Mahendro Prasetyo, 2021) The purpose of this study is to describe the implementation of health promotion programs in patients with Type 2 Diabetes Mellitus at Panembahan Senopati Hospital Bantul and PKU Muhammadiyah Hospital Yogyakarta. This study had several limitations. One of them is this study only using quantitative methods, therefore qualitative methods are needed to learn more about the description of the implementation of health promotion in hospitals.

Method
The type of research used is descriptive analysis research with a quantitative approach. The population in this study were outpatients for Type 2 Diabetes Mellitus at the Internal Medicine Polyclinic Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital. The sampling technique used is accidental sampling, and the formula used to determine the number of samples is the slovin formula. The samples used were 233 patients at the Panembahan Senopati Bantul Hospital, and 207 patients at the PKU Muhammadiyah Yogyakarta Hospital. The instrument used in this study was a questionnaire about health promoting hospital (HPH) for Type 2 Diabetes Mellitus patients. The questionnaire was compiled by researcher with reference to the HPH standard according to the Minister of Health Regulation of Republic Indonesia No. 44 of 2018 concerning the Implementation of Health Promoting Hospital, and based on the Guidelines for the Management and Prevention of Type 2 Diabetes Mellitus from PERKENI 2021. The validity test carried out on this research instrument is content validity, namely by professional judgment. Reliability testing using Cronbach's alpha. Data analysis in this study used univariate data analysis, namely categorical description analysis. The categories of PKRS implementation by hospitals are divided into four categories, namely very good, good, not good, and very bad.

Result Characteristics of Research Respondents
Based on the results of the study, it showed that most of the outpatient DM patients at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital were aged between 56-65 years. This is evidenced by 50.2% (out of 233 DM outpatients) and 42.5% (out of 207 DM outpatients) aged between 56-65 years.
Based on the results of the study, most of the outpatient DM patients at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital were female. It is proven that 57.5% (out of 233 DM outpatients) and 61.8% (out of 207 DM outpatients) are female.

Patient Assessment Standards
The standard of patient assessment that is evaluated is the assessment of the patient's need for health promotion, prevention of disease progression in patients and assessment of the rehabilitation needs of patients by health workers.

a. Patient Assessment of Health Promotion Needs
The patient's assessment of the need for health promotion is carried out during the initial nursing assessment. During the initial assessment, the nurse identifies the patient's needs regarding the management of DM. Based on the results of the study, it showed that the standard of outpatient DM patient's assessment of the need for health promotion at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital was good. This is evidenced by 63.9% (out of 233 DM outpatients) and 50.7% (out of 207 DM outpatients) who said they were good. A total of 19.7% (out of 233 DM outpatients) and 35% (out of 207 DM outpatients) stated very well.

b. Prevention of Disease Progression in Patients
In this standard, nurses identify the patient's regularity in conducting examinations and treatment to prevent complications from DM. This activity is carried out before the patient is examined by the doctor. Based on the results of the study showed that the standard of preventing disease progression in outpatient DM patients at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital was good. This is evidenced by 76.8% (out of 233 DM outpatients) and 56.0% (out of 207 DM outpatients) who stated that they were doing well. A total of 22.7% (out of 233 DM outpatients) and 43.5% (out of 207 DM outpatients) stated that they were doing well.

c. Patient Rehabilitation Needs
In this standard, nurses identify rehabilitation needs in patients by asking the patient's quality of life. Standard patient rehabilitation needs can be seen in the table below. Based on the results of the study, it showed that the standard of rehabilitation needs of DM patient's outpatient at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital was good. This is evidenced by 78.1% (out of 233 DM outpatients) and 56.5% (out of 207 DM outpatients) who stated that they were doing well. A total of 20.2% (out of 233 DM outpatients) and 40.6% (out of 207 DM outpatients) stated that they were very good.

Overview of the Implementation of Health Promotion Programs for Diabetes Mellitus Patients in Hospital
In this standard, health workers provide information about factors related to the patient's health condition. Health workers need to provide health promotion interventions in each patient service flow.

a. Provision of Information by Health Officers
Doctors provide health education about healthy living behavior (regulating diet, regular exercise, not smoking, maintaining weight, limiting sugar consumption). Standards for providing information by health workers can be seen in the table below. Based on the results of the study, it was shown that the provision of information by health workers regarding factors related to the health condition of outpatient DM patients at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital was good. This is evidenced by 78.5% (out of 233 DM outpatients) and 59.4% (out of 207 DM outpatients) who stated that they were doing well. As many as 13.3% (out of 233 DM outpatients) and 32.4% (out of 207 DM outpatients) stated that they were very good.

b. Conducting Health Promotion Interventions in Every Flow of Health Services
Patients receive health information during the initial nursing assessment and at the time of the doctor's examination. The standard of health promotion intervention in each patient's health care flow can be seen in the table below. Based on the results of the study, it was shown that the health promotion intervention in each outpatient health care flow for DM patients at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital had been carried out well. This is evidenced by as many as 80.7% (out of 233 DM outpatients) and 65.2% (out of 207 DM outpatients) who stated that they were doing well. A total of 16.7% (out of 233 DM outpatients) and 33.8% (out of 207 DM outpatients) stated that they were very good.

Health Promoting Hospital
The results showed that overall hospital health promotion at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital were mostly in the good and very good categories. The implementation of health promotion in hospitals can create quality hospitals that meet hospital accreditation standards both nationally and internationally. The integration of health promotion in patient care through improved communication and effective education can also achieve quality improvement and patient safety (Permenkes, 2018). Based on the results of the evaluation conducted by the hospital accrediting agency, it showed that most of the sentinel incidents were caused by ineffectiveness in communication, both between care professionals, and between care professionals and patients. In addition, good and sustainable HPH implementation can create behavioral and environmental changes based on patient needs (Permenkes, 2015).
One of the reasons for the poor implementation of HPH is the hospital has not given special attention to the development of health promotion. As revealed by (Meliala, 2019) in his research on health promoting hospital, that some hospitals have not given special attention to the development of health promoting hospital. One of example is the issue of funding. Sources of funding and efforts to implement partnerships with external parties are still lacking is a weakness of the Hospital unit. The impact is that there are not a few program activities that should be part of the HPH unit program but are owned and implemented by other units. In this study, the hospital under study already had a HPH unit (Groene & Jorgensen, 2005).

Patient Assessment Standards
Based on the results of the study, in general the patient assessment standard at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital was good. In the standard of patient assessment of the need for health promotion at Panembahan Senopati Bantul Hospital, 63.9% said it was good, and 19.7% said it was very good. Meanwhile, at PKU Muhammadiyah Yogyakarta Hospital, 50.7% of patients said it was good, and 35.3% said it was very good. Assessment of health promotion needs for patients is carried out based on a patient assessment form, by analyzing the form. The existence of a health promotion assessment for patients is needed to know the full target profile as a basis for determining the need for health promotion activities. One of the health promotion needs assessments for patients is evidenced by the results of the Diana Dewi Hestia, Mahendro Prasetyo Kusumo/KESANS Overview of the Implementation of Health Promotion Programs for Diabetes Mellitus Patients in Hospital identification carried out by the care professional at the initial assessment, and write it in the patient's medical record. Health Promotion needs assessment carried out, including: smoking status; history of alcohol consumption; physical activity; nutritional status; socioeconomic status; disease history; and other risk factors (Permenkes, 2018). In addition, health workers also need's to examine several aspects of additional assessment so that education can be effective for patients. The additional assessments include: beliefs and values of the patient and the patient's family regarding the health condition; literacy skills (at least the ability to read); level of education; language use; emotional barriers and motivation to change; physical and cognitive limitations; patient's willingness to receive information (Yaghoubi et al., 2019).
The patient's assessment standard is also assessed as an effort to prevent disease progression in DM patients by health workers. Efforts to prevent disease development carried out by Panembahan Senopati Bantul Hospital were considered good by 76.8% of respondents, and 22.7% of respondents considered very good. Meanwhile, at PKU Muhammadiyah Yogyakarta Hospital, 56% rated it good, and 43.5% rated it very good. The assessment carried out in this standard is an assessment of patient compliance in taking medication, regularity of patients in carrying out routine controls, and regularity of patients in checking blood sugar regularly.
The results of the assessment that have been carried out need to be recorded in the patient's medical record as a basis for planning health promotion programs for patients and families. After that, reassessment is carried out when the patient returns home. Reassessment is carried out by the health workers in charge of the patient. The results of the follow-up re-assessment can be used as material for referrals for patients to sources in the community (Permenkes, 2018).

Patient Information and Intervention Standards
Based on an analysis of the patient's information and intervention standards, it was generally considered good. In this standard, the thing that assessed is the provision of information by health workers regarding factors related to the patient's health condition, and patient health promotion interventions in each patient service flow.
The provision of information by health workers for DM patients at Panembahan Senopati Bantul Hospital was considered good by 78.5% of respondents, and was considered very good by 13.3% of respondents. Meanwhile, in PKU Muhammadiyah Yogyakarta Hospital, 67% of respondents considered it good, and 32.4% of respondents considered it very good.
Intervention of health promotion is a systematic effort by applying health promotion methods and strategies as a result of health promotion assessment. It aims to change the patient's behavior, in order to identify risk factors for the disease, increase the ability to overcome disease risk factors, make the right decisions in dealing with health problems, and avoid the recurrence of the same behavior (Schwarz et al., 2019).
One of the health promotions carried out on patients and their families is by providing information and education about risk factors for disease according to the patient's needs. The results of providing information and education by professional care providers to patients and their families are recorded in the medical record form (Permenkes, 2012). To carry out health promotion interventions, it is also necessary to have Communication, Information and Education media about risk factors for Diabetes Mellitus. That is including nutritional status, physical activity status, smoking, history of alcohol consumption, socioeconomic factors, and other risk factors. Health workers also need to carry out information and education activities regarding the diagnosis of Diabetes Mellitus, the use of drugs obtained, including potential side effects of drugs, the effective and safe use of medical equipment, food, diet and nutrition, pain management, rehabilitation techniques, ways to proper hand washing, and how to prevent diabetic feet. The results of providing information and education by health workers to patients and their families are recorded in the medical record form (Febrian et al., 2020).
Based on the results of the analysis showed that the standard of patient assessment as well as the standard of information and intervention in DM patients at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital were good. Good HPH activities are expected to improve the patient's quality of life. The results of this study are in line with research (Sari, 2018) which shows that health promotion at RSI Fatimah is good, where the hospital has ensured that there are health promotion activities in every health service procedure. This is also in accordance with the results of research by Afshari et al., (2016) which proves that the promotion of hospital health in Canada has succeeded in supporting the prevention of chronic diseases and the reduction of health inequities.

Patient Intervention Standards in Every Health Service Flow
In providing health promotion interventions in each patient management flow, Panembahan Senopati Bantul Hospital received a good rating from 80.7% of respondents, and very good from 16.7% of respondents. Meanwhile, PKU Muhammadiyah Yogyakarta Hospital received a good rating from 65.2% of respondents, and very good from 33.8% of respondents.
Patients need to get health promotion interventions in every patient service flow. Among them are at registration, initial assessment, doctor's examination, even at the cashier. Implementation of health promotion in outpatients, because the limited time of service is not proportional to the large number of patients, additional education can be carried out in a professional manner in their field of training health workers to become educators, by gathering patients, patient families, introducing patients in a room and conducting education, and group discussions, on the diagnosis and control of risk factors (Vidal-Alaball et al., 2020). The use of teaching aids such as panthoms, flipcharts, leaflets, posters and other educational video shows really helps the educational process, for that precise and detailed media is needed. What needs to be noted is that education is carried out based on disease diagnosis groups, the implementation of education must pay attention to demographics, social status, literacy, and willingness to receive information (Groene & Jorgensen, 2005).

Overview of the Implementation of Health Promotion Programs for Diabetes Mellitus Patients in Hospital
Health promotion can be started in the registration room. When a patient enters the hospital building, the first thing they must visit is the registration room. This initial contact with the hospital needs to be met with health promotion. The welcome was in the form of a warm greeting that could make them feel at ease in the hospital. In this room, information is provided about the hospital which may include hospital management, doctors or nurses on duty, available services, as well as information about disease, both prevention and how to get treatment for the disease. One of the information media used in this room can be in the form of a poster in the form of a neon box containing photos of friendly doctors and nurses accompanied by the words "Welcome, We are Ready to Help You" or something similar. Other media that can be prepared in this room include leaflets, factsheets, and TV (Permenkes, 2018).
Education must be given to all patients, which every hospital workers who serves patients takes the time to answer patient questions regarding his illness or medication, or behavior that should be done. In addition, a special room is also provided for outpatients who need consultation or want to get information. This consultation room is provided at the polyclinic and is served by health workers in accordance with the relevant polyclinic. The task of serving in this consultation room can be rotated among the existing health workers, namely those who are not on duty in the polyclinic, are assigned to work in the consultation room. Consultation should be done on an individual basis. However, it is possible to do a group consultation (5-6 patients at once), if the circumstances allow. The consultation room should be equipped with various communication media or teaching aids as needed. Effective communication media used here, for example, are flash cards, anatomical pictures or models, and presentations using OHP or laptops and LCDs (Amiri et al., 2016).
Health promotion can also be done at the cashier. In this farewell room, the patient/relative did not stay too long. However, health promotion should still be present, namely to convey warm greetings and good-bye, hopefully getting healthier. It should also be said that whenever a patient needs help again, they can come back to the hospital (Yaghoubi et al., 2019).

Conclusion
Based on the results of research and discussion, it can be concluded that health promotion activities for Diabetes Mellitus patients at Panembahan Senopati Bantul Hospital and PKU Muhammadiyah Yogyakarta Hospital are generally good.
It is hoped that the hospital management will evaluate and monitor the implementation of the hospital health promoting hospital (HPH), especially in providing information and health promotion interventions to patients. It is hoped that it can be the basis for future researchers to conduct research on other aspects of health promoting hospital (HPH) Diana Dewi Hestia, Mahendro Prasetyo Kusumo/KESANS Overview of the Implementation of Health Promotion Programs for Diabetes Mellitus Patients in Hospital