A Journal of the ASEAN Committee on Science Technology Vol 32 No.2 2015

Editorial Board Editor-in-Chief Prof Emeritus Dr Md Ikram Mohd Said School of Chemical Sciences and Food Technology,Faculty of Science and Technology, Universiti Kebangsaan MalaysiaEditorial Board MembersMalaysia SingaporeDr Ahmad Ibrahim Assoc. Prof Ong Sim HengAcademy of Sciences Malaysia Department of Electrical and Computer Engineering, National University of SingaporeProf Abdul Halim ShaariFaculty of Science, Universiti Putra Malaysia Assoc. Prof Tan Tin Wee Acting Head, Department of Biochemistry,Prof Thong Kwai Lin National University of SingaporeInstitute of Biological Science, Faculty of Science/UMBIO Cluster, Institute of Graduate Studies, ThailandUniversity of Malaya Prof Narongrit Sombatsompop King Mongkut’s University of TechnologyBrunei DarussalamRosita Abdullah Prof Prida WibulswasSenior Special Duties Officer, Head of Science & President, Shinawatra UniversityTechnology, Research & International Division,Ministry of Development Cambodia Phal DesAssoc. Prof Zohrah Sulaiman Vice-Rector, Royal University of Phnom PenhDeputy Vice-Chancellor,Universiti Brunei Darussalam Indonesia Dr Warsito Purwo TarunoMyanmar Minister of Research and TechnologyDr Zaw Min AungDirector General, Department of Technical Nada Marsudiand Vocational Education, Minister of Research & TechnologyMinistry of Science and Technology Lao PDRPhilippines Malaithong KommasithDr Carol M. Yorobe Minister of Science and TechnologyUndersecretary for Regional Operations,Department of Science and Technology Dr Silap Boupha Director, Ministry of Science and TechnologyZenia G. VelascoDirector, Internal Audit Service―DOST Vietnam Dr Mai Ha Director General, Ministry of Science and Technology

Editorial Advisory PanelBrunei Darussalam Lao PDREddie Sunny Dr Maydom ChanthanasinhDeputy Permanent Secretary, Deputy Minister, Ministry of Science andMinistry of Development Technology, National COST ChairmanMyanmar SingaporeDr Ko Ko Oo Prof Low Teck SengNational COST Chairman, National COST Chairman,Deputy Minister, Ministry of Science and Managing Director, Agency for Science,Technology Technology and ResearchCambodia ThailandDr Om Romny Assoc. Prof Weerapong PairsuwanDirector, Institute of Technology of Cambodia Deputy Permanent Secretary, Ministry of Science and TechnologyPhilippinesDr Graciano P. Yumul MalaysiaUndersecretary for R&D, Dr Noorul Ainur Mohd NurDepartment of Science and Technology National COST Chairman, Secretary General, Ministry of Science,Indonesia Technology and InnovationProf Syamsa Ardisasmita, DEADeputy Minister for Science and Technology VietnamNetwork, National COST Chairman Dr Le Dinh Tien Deputy Minister for Science and Technology, National COST ChairmanEditor/Technical Editor Kanesan SolomalaiEx-Academy of Sciences Malaysia Hazrul Liki Academy of Sciences Malaysia Production Manager Kamariah Mohd Saidin Universiti Putra Malaysia Publisher Universiti Putra Malaysia Press

Contents ASEAN J. Sc. Technol. Dev. Volume 32(2), 2015Phase Manifestation and Formation of Nanoemulsions Composed of 85Imidazolium-based Ionic Liquid, Tween 80/Span 80 and Labrafac 94Lipophile WL 1349 104 121 S. H. Ng, P. M. Woi and C. C. Eng 133Utilization of Waste from Natural Rubber Glove Manufacturing Line V. Devaraj, F. I. Nur, A. I. H. Dayang, H. K. Nor and M. N. ZairossaniA Phenomenological Study on the Quality of Life Among Patients withOsteoarthritis Admitted for Rehabilitative Physiotherapy in a PrivateHospital in Kuala Lumpur R. (III) P. Dioso and R.TanggayaDecision Making Processes for a Pregnant Woman Admitted to the Accidentand Emergency Department Requiring Emergency Diagnostic X-ray –A Case Study S. IsmantoDecision Making Processes for a Patient with Cardiac Pacemaker Admittedto the Accident and Emergency Undergoing Magnetic Resonance Imaging –A Case Study F. P. Raditya



ASEAN J. Sci. Technol. Dev.,  32(2): 85 – 93 Phase Manifestation and Formation ofNanoemulsions Composed of Imidazolium-based Ionic Liquid, Tween 80/Span 80 and Labrafac Lipophile WL 1349 S. H. Ng1*, P. M. Woi2 and C. C. Eng2Ionic liquids (ILs) can enhance topical and transdermal delivery, as well as increase the solubilityof sparingly soluble drugs. In the present work, pseudo-ternary phase diagrams of emulsions werecomposed of a mixture of non-ionic surfactants, polyoxyethylene sorbitan monooleate (Tween 80®)and sorbitan monooleate (Span 80®) in weight fraction: 1:1, 1:2, 2:1 and 2:3, LabrafacTM LipophileWL 1349 as an oil phase and 1-hexyl-3-methylimidazolium chloride [(HMIM) (Cl)] as a continuousphase. Emulsion formulations were selected with 10% surfactants from the pseudo-ternary phasediagrams and further prepared at 298.2 ± 0.1 K. Acoustic emulsification method was used toprepare nanoemulsions that were mixed with freshly prepared hydrocolloid gum. The area of thesingle-phase zone in pseudo-ternary phase diagrams that varied with Tween 80® /Span 80® ratio inthe order of 2:1 > 1:1 > 2:3 > 1:2 where Span 80® was replaced by an equivalent weight of Tween80® to form IL-based nanoemulsions. [HMIM] [Cl] tended to create a two-phase system. Additionof carbopol® ultrez 20 copolymer into the continuous phase of the formulations gave single-phasenanoemulsions with good stability. The mixture of surfactants with weight ratio of 1:2 (Tween 80®/Span 80®) showed a good stability with the smallest particle size and greater surface charges in thesystem. These ionic liquid-based nanoemulsions might have the potential in drug delivery systems.Key words: Ionic liquid; pseudo-ternary phase diagram; Carbopol® ultrez 20 copolymer; particle sizeDuring recent decades, a class of environ- used as ‘green’ alternatives to volatile organicmentally friendly solvents, ionic liquids (ILs), solvents for a wide range of applicationshas received growing interest due to their (Eastoe et al. 2005).fascinating and outstanding physicochemicalproperties. Generally, ionic liquids (ILs) consist In recent years, ILs has gained severalof large inorganic anions paired with organic interests for the use in pharmaceuticalcations and are liquefied salts. Properties applications such as solubilization of poorlyof ILs such are low combustibility, wide soluble drugs (Jaitely, Karatas & Florenceelectrochemical window, excellent thermal 2008; Mizuuchi et al. 2008; Moniruzzamanstability, wide liquid regions and exhibit low et al. 2010). IL-based microemulsions hasvapor pressure (Eastoe et al., 2005). On account become an interesting topic (Qiu & Texterof some of their peculiar properties, ILs can be 2008) and has advantages such as they can1 School of Pharmacy, International Medical University, 57000 IMU Bukit Jalil, Kuala Lumpur, Malaysia2 Department of Chemistry, Faculty of Science, University of Malaya, 50603 Kuala Lumpur, Malaysia* Corresponding author (e-mail: [email protected])

ASEAN Journal on Science and Technology for Development, 32(2), 2015dissolve hydrophilic and hydrophobic chemicals The main objectives of this worksubstances and thus widen the use of ILs. are construction of pseudo-ternary phaseOn the other hand, ILs also exhibits anti- diagrams and fabricate imidazolium-basedmicrobial activity that can make them useful IL nanoemulsions. In the design of theas formulation preservatives or active phar- imidazolium-based IL nanoemulsions, 1-hexyl-maceutical ingredients (APIs) (Pernak, 3-methylimidazolium chloride [(HMIM)Sobaszkiewicz & Mirska 2003). (Cl)] was chosen as the hydrophilic IL. The pseudo-ternary IL/Tween 80® -Span 80®/oil ILs have also been studied in classical system consisted of IL stabilized by a mixturecolloid and surface chemistry because of of two nonionic surfactants, polyoxyethyleneits amphiphilic nature, and IL-based sorbitan monooleate (Tween 80® ) and sorbitanmicroemulsions are the most popular (Smirnova monooleate (Span 80®) in Labrafac™ Lipophileet al. 2009; Zech & Kunz 2011). The first IL- WL 1349. In this study, Tween 80® and Span 80®based microemulsion was reported by Gao surfactants were selected because the mixtureet al. (2004) where an IL was used to replace of these surfactants offer many advantages overwater content (Zech et al. 2010). In the ionic surfactants including increased stability,subsequent investigations, various kinds of formulating flexibility and wider compatibility.IL-based microemulsions have been prepared In addition, Tween 80® has hydrophilic PEO(Zech et al. 2010; Harrar et al. 2011; Behera, groups, which have a strong affinity with theDahiya & Pandey 2007; Zhang et al. 2011; imidazolium cation attached in ILs (Lu &Cheng et al. 2007). In most of the studies on IL- Rhodes 2000). Dynamic light scattering (DLS)based microemulsions, the IL, such as 1-butyl- and zeta potential have been used to characterize3-methylimidazolium tetrafluoroborate (C4mim) the nanoemulsion systems.(BF4), was used as a replacement for water (Gaoet al. 2007; Gao et al. 2007). Nevertheless, some Materials and MethodsILs may serve as an appropriate replacement foroil phase, such as 1-butyl-3-methylimidazolium Materialshexafluorophosphate (C4mim) (PF6) (Gao et al.2006; Behera, Malek & Pandey 2009). Long The ionic liquid (IL) used was hydrophilicalkyl chain ILs can also be used as surfactants, 1-hexyl-3-methylimidazolium chloridewhich are named as surface-active ionic liquids [(HMIM) (Cl)] from Sigma-Aldrich Chemical(Zech et al. 2009; Govind et al. 2012). Co. US. Polyoxyethylene sorbitan monooleate (Tween 80®) and sorbitan monooleate (Span 80®) Nanoemulsions are a type of emulsions were used as the hydrophilic and hydrophobicwith uniform, extremely small droplet size, emulsifier, respectively and were purchasedin the range 20–200 nm (Solans et al. 2003), from Sigma-Aldrich Chemical Co. US. The oiland are optically transparent. Nanoemulsions used was Labrafac™ Lipophile WL 1349 andhave gained several interests for the use in was purchased from Gattefosse, France. Themany different applications due to its low thickening agent used was Carbopol® Ultrezviscosity, high kinetic stability against creaming 20 copolymer from Lubrizol, USA.or sedimentation and a large interfacial area(Solans et al. 2003). Nanoemulsions are also Methodsknown as an isotropic mixture of naturalor synthetic oils with surfactants and co- Pseudo-ternary Phase Diagrams of thesurfactants that form fine oil-in-water (O/W) or Emulsions. Labrafac™ Lipophile WL 1349water-in-oil (W/O) with the droplet size usually with surfactants (Tween 80®/Span 80®) mixturebelow 500 nm (Solans et al. 2003). at various weights ranging from 0:100 to 100:0 were weighed. A total weight of 0.5 g mixture 86

S.H. Ng et al.: Nanoemulsions Composed of Imidazolium-based Ionic Liquidwas placed in a 10 ml screw-cap glass tube, ultrasonic cavitation for 5 min. The sonifier tipsubjected to vortex for 30 min, and then stored horn was adjusted to 3 cm below the surfaceat 298.2 ± 0.1 K overnight. An approximately of a 100 ml sample. Ultrasonic cavitation was0.1% by weight of IL was added to the samples performed at the acoustic amplitude of 20%and homogenized for 2 min using a vortex and 0.5 cycles. All samples were kept at roommixer. Next, the samples were centrifuged for temperature, 298.2 ± 0.1 K.15 min at 4000 rpm. Cross-polarized light wasused to visually examine the phase changes of Particle Size Measurements ofthe samples for the determination of anisotropic the Emulsionsand isotropic regions. The different phaseregions were then classified into isotropic (L), DLS technique utilizing a Malvern Zetasizertwo-phase (T) or three-phase (T1). Mixtures of light scattering instrument (Malvern, UK) wasTween 80® and Span 80® with the following used to determine the mean droplet size andratios in weight fraction: 1:1, 1:2, 2:1 and 2:3 size distribution by diluting one drop of thewere used to study the phase behaviour. emulsion system with 10 ml of an aqueous phase containing deionized water. After theEmulsions Compositions from Pseudo- emulsion samples had been equilibrated for 24ternary Phase Diagrams h, the samples were filtered to remove dust or contaminants. Measurements were performedComposition of the selected emulsions at T = 298.2 ± 0.1 K.preparation comprised of 10% surfactantsfrom the pseudo-ternary phase diagram. The Zeta Potential Measurements ofselections of dispersed and continuous phases the Emulsionsof the present phase diagrams comprised 30%(w/w) Labrafac™ Lipophile WL 1349 and 60% Zetasizer Nano (Malvern Instruments, UK)(w/w) IL, respectively. Carbopol® Ultrez 20 was used to perform zeta potential analysis.copolymer was added in the continuous phase Zeta potential values either above or below ±30other than IL as a thickening agent. mV are usually stable emulsions without any coalescence and flocculation of the droplets inEmulsions Preparation the system. Each sample was analyzed thrice, and each analysis consisted of five replicates.An emulsion of selected composition frompseudo-ternary phase diagrams was prepared Results and Discussionthrough acoustic emulsification method.A hydrocolloid gum, carbopol® ultrez 20 Pseudo-ternary Phase Diagrams ofcopolymer, was dispersed in deionized water the Emulsionsat 2% (w/w) and then stored overnight.Ultrasonicator (UP400S Hielscher Sonifier, Phase behaviour provides an essential clue toGermany) of 400 W nominal power and a macroscopic behaviour, as it is an importantfrequency of 24 kHz equipped with a 22 mm factor in the thermodynamic characterizationsonotrode tip was used to prepare emulsions. of the system. In addition, phase behaviourThe system was placed in a custom-built cooling is an intimate way to express molecular orjacket where chilled water passed through the particle or inter-aggregate interactions on ajacket continuously at 3°C. An emulsion monocular level. The basic principle is to mixsample was prepared and homogenized for 5 the components and observe the number andmin at 6000 rpm with a polytron® homogenizer nature of the phases (Pillai & Shah 1996).(Kinematica GmbH, Germany) rotor stator. The Phase diagrams are shown to provide valuablesample was then further homogenized using information on the role played by structures of 87

ASEAN Journal on Science and Technology for Development, 32(2), 2015the polar phase, non-polar phase and surfactant of HMIM Cl/Tween 80® -Span 80®/Labrafac™in determining the properties of the system at Lipophile WL 1349 at T = 298.2 ± 0.1 K wereany composition. As usually stated, regions of investigated. Figures 1 (a), (b), (c) and (d),the emulsion could be characterized by ternary respectively represented the phase diagramsphase diagrams. Here, Tween 80®/Span 80® of three-components system with Tweenwere used as the surfactants, and imidazolium 80®/Span 80® ratios, 1:1, 1:2, 2:1 and 2:3. AIL of 1-hexyl-3-methylimidazolium chloride large amount of IL can be solubilized in the[(HMIM) (Cl])] and Labrafac® Lipophile WL systems with a mixture of two surfactants.1349 were selected as the water and oil phase, Nonionic surfactants in the presence of a secondrespectively. surfactant can dissolve water or oil to form o/w or w/o emulsions (Porras et al. 2008; Kunieda, The transition from turbidity to transparency Nakano & Akimaru 1995). This is because thewas observed to determine the phase boundaries. second surfactant reduces interfacial tension ofThe liquid + liquid equilibrium phase diagrams the system.(a) (b)(c) (d) Figure 1. Pseudo-ternary phase diagram of the HMIM Cl/Tween 80® –Span 80®/LabrafacTM Lipophile WL 1349 three component systems at T = (298.2 ± 0.1) K where L = isotropic region, T = two-phase region, T1 = three-phase region. The weight ratio of Tween 80® /Span 80® (w/w): (a) 1:1; (b) 1:2; (c) 2:1 and (d) 2:3. 88

S.H. Ng et al.: Nanoemulsions Composed of Imidazolium-based Ionic Liquid The phase diagram of HMIM Cl/Tween or minimize any adverse toxicological or80® -Span 80/LabrafacTM Lipophile WL 1349 dermatological effect. To determine the stabilitysystems is shown in Figure 1. A one-phase of the system, hydrocolloid gum, carbopol®region was observed, consisted an isotropic ultrex 20 copolymer [2% (w/w)] was addedregion (L) with the Tween 80® /Span 80® into the continuous phase as a thickeningratio in the order of 2:1 > 1:1 > 2:3 > 1:2, agent. Hydrocolloid gum gave a single-phasewhich indicated that the formation of IL-based with good stability to the emulsions system.emulsions where Span 80® was replaced by an Hydrocolloid gum increased the viscosityequivalent weight of Tween 80®. By comparing of the continuous phase that surrounds thethe results from previous studies (Gao et al. oil droplets and therefore restricting the2006; Chakrabarty et al. 2005) with the results movement of particles. The high dropletobtained in Figure 1, a large amount of IL can concentration enhanced the stability of thebe solubilized in emulsions using much lower emulsions as their movements were blockedweight fractions of the mixture of Tween 80® and by each other (McClements 1999). Thus, thisSpan 80® surfactants. These can be explained in slowed down the creaming rate, followed byterms of interfacial properties provided by the the destabilization of emulsion.mixtures of two different nonionic surfactantsthat are more favourable. Isotropic emulsions Particle Size Measurementssystems significantly affect the effectiveness asa delivery vehicle and shelf life. The sizes and size distribution of colloidal dispersions were characterized by DLS method. In region T (two-phase region) and T1 A sample was irradiated with a laser beam and(three-phase region), phase separation occurred the resulting intensity of the scattered lightin a larger area where phase equilibria were produced by the particles fluctuates at a rate thatnot observed and emulsions were unstable. was dependent upon the particles size. NonionicTwo-phase region was dominant at most parts surfactant weight ratio varying from 1:1, 1:2,of the compositions that showed instability 2:1 and 2:3 were studied. A series of samplesand incapability of the surfactant to work in were chosen from the pseudo-ternary phaseemulsifying Labrafac™ Lipophile WL 1349. diagrams for formulation and further studiedPhase separation was observed for most ratios using DLS method at different surfactantsof imidazolium IL, HMIM Cl in emulsions mixture ratio compositions. Figure 2 showscontaining less than 5% Labrafac™ Lipophile the particle size distribution plots that appearWL 1349, with the sample prepared formed as S-shaped curve for four emulsions.insoluble aggregates that remained at the bottomof the screw-cap glass tube and with a cloudy From the particle size distribution plots,layer at the top. it showed that the particle sizes with the cumulative distribution of 50% are the medianEmulsions Compositions from Pseudo- droplet diameter. Nanoemulsion with weightternary Phase Diagrams ratio of Tween 80® /Span 80® (w/w) of 1:2 had a very small distribution with 50% of the particlesAn emulsion of selected composition from under 176 nm compared to the emulsion withpseudo-ternary phase diagrams comprised weight ratio of Tween 80® /Span 80® (w/w) ofof 30% (w/w) disperse phase, 10% (w/w) 2:3, 2:1 and 1:1, with 50% of the particles undersurfactants and 60% (w/w) continuous 191 nm, 319 nm and 550 nm, respectively. Thephase. Surfactants mixture of 10% (w/w) results demonstrated that for the dispersionsof Tween 80® and Span 80® with ratios: system containing higher concentration of1:1, 1:2, 2:1 and 2:3 were used to avoid Span 80® with weight ratio of Tween 80® / 89

ASEAN Journal on Science and Technology for Development, 32(2), 2015 120Cumulative distribution (%) 100 1:1 80 2:3 60 40 2:1 20 1:1 0 14 33 100 186 386 1094 2614 6241 1 Particle sizes (nm) Figure 2. Cumulative particle size distribution at T = (298.2 ± 0.1) K of 10% (w/w) surfactants. The weight ratio of Tween 80® /Span 80® (w/w): 1:2, 2:3, 2:1 and 1:1.Span 80® (w/w) of 1:2 and 2:3, the particle size Zeta Potential Measurementsdecreased progressively. This observation canbe explained as a result of increasing surfactant Figure 3 shows the zeta potential for emulsionsadsorption around oil interface of a droplet, and at room temperature. Zeta potential for thedecreasing interfacial tension in the system, emulsions was in the range of –45.70 mV towhich favours the formation of nanoemulsions –51.60 mV with the addition of carbopol®with smaller particle sizes (Lamaallam et al. ultrez 20 copolymer. The surface charges of2005). It was observed that for the addition of emulsions with weight ratio of Tween 80® /Tween 80® concentration, there was an obvious Span 80® (w/w), 1:2, 2:3, 2:1 and 1:1 wereshift of the plotted curves into the range of –51.60, –50.10, –48.30 and –45.70 mV,larger particle sizes. With higher surfactant respectively. Zeta potential that gives a valueconcentration of Tween 80®, the emulsions of greater than or less than 25 mV indicatessystem leads to larger interfacial areas and deflocculated and flocculated emulsions,consequently resulted in large particle sizes. respectively (Leiberman, Reiger & Banker 1989). Therefore, no flocculation is observed An addition of a co-surfactant to the in all prepared emulsions. The stability of anemulsions is well known to alter their emulsion can be improved with an increase inparameters. By using a standard practice of the surface charge (Liu et al. 2006).two different surfactants, it can develop anemulsion with optimal long-term stability and The distribution of ions in the surroundingbetter steric stabilization of the droplets. Smaller interfacial region could be affected by thedroplet sizes with greater long-term stability development of a net charge at the particlecan be observed by the addition of imidazolium surface. An electric double layer around eachcations to the formulation that can change the particle would be formed by increasing thearrangement of the surfactants on the surface of concentration of ions of opposite charge to thatoil droplets (Bataller et al. 2004). of the particle close to the surface. Particles tend to repel each other and there was no 90

S.H. Ng et al.: Nanoemulsions Composed of Imidazolium-based Ionic LiquidZeta potential (mV) Carbopol ultrez 20 Hydrocolloid –42 gum –43 1:2 –44 2:3 –45 2:1 –46 1:1 –47 –48 –49 –50 –51 –52 –53 Figure 3. The zeta potential of emulsions at T = (298.2 ± 0.1) K of 2% (w/w) hydrocolloid gum. The weight ratio of Tween 80® /Span 80® (w/w): 1:2, 2:3, 2:1 and 1:1.observation of flocculation if all the particles of the surfactant head groups to bind with ILhad a large negative or positive zeta potential. through the hydrogen bonding with weight ratioThe negative charged surface is due to the of Tween 80® /Span 80® (w/w), 1:2 and 2:3. IL-dissociation of acidic groups on the surface based nanoemulsions might have the potentialof a particle (Kuznesof & Whitehouse 2005). as a drug delivery system.The imidazolium IL, HMIM Cl, in emulsionscontained cations and anions, which have List of abbreviationscontributed to the negative charge on the h hoursurface. HMIM Cl 1-hexyl-3-methylimidazolium Conclusions chloride K kelvinThe present study indicated that the classic ml milliliterO/W emulsions containing hydrophilic mV millivoltimidazolium IL, HMIM Cl were prepared. nm nanometerHMIM Cl was used to replace the water O/W oil-in-waterphase and was successfully incorporated into rpm revolutions per minutethe formulation. DLS was used to estimate w/w weight per weightthe droplet size of selected formulations andexhibited droplet size between the ranges of Acknowledgements176 nm to 550 nm. Zeta potential for emulsions The present work was supported by thewith carbopol® ultrez 20 copolymer were found International Medical University and Universitybetween the ranges of –45.70 mV to –51.60 of Malaya.mV. The increase in hydrophobic emulsifierconcentration resulted in the reduced emulsion Date of submission: September 2015particle size. IL-based nanoemulsions weresuccessfully formulated by a mixture of Date of acceptance: November 2015nonionic surfactants where strong tendency 91

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ASEAN J. Sci. Technol. Dev.,  32(2): 94 – 103 Utilization of Waste from Natural Rubber Glove Manufacturing Line V. DEVARAJ*, F. I. NUR, A. I. H. DAYANG, H. K. NOR AND M. N. ZAIROSSANIMalaysia is the largest producer and exporter of examination and surgical gloves in the world andcurrently faced with mitigating large amounts of waste generated during the glove production process.This waste is mainly generated from glove dipping tanks and is referred as dipping tank coagulum(DTC). It is considered as scheduled waste which requires mandatory disposal by incineration,in compliance to the Scheduled Waste Regulations set by the Department of Environment. Workdescribed in this study showed, DTC samples with a polymer content of >40%, both ash and calciumcarbonate content of <10% and curatives <2% (Sulphur, antioxidants, accelerators and ZnO) whenblended with virgin rubbers (SMR 10 and SMR 20) were found to be suitable for manufacturingvalue-added rubber products. DTC samples with polymer contents of <40% and lower in curativescould still be considered for recycling, by adding higher portions of virgin rubber for manufacturingproducts like shoe soles, carpet underlay and thermoplastic elastomer products. Glove manufacturesshould ideally set up on-site DTC processing facilities at their factory premises equipped withcrepers as well as space to ‘air dry’ the creped DTC samples. Creped samples could be sent to theMalaysian Rubber Board (MRB) for chemical analyses. Factory owners could also present theanalytical results from MRB to the recyclers to obtain a good premium for their processed DTCsamples to be used as raw materials.Malaysia is the largest producer and exporter since 2005. The implementation of Scheduledof examination and surgical gloves in the world Waste Regulations (2005) by DOE requiresand glove industry dominates approximately mandatory and costly disposal by incineration70% of all rubber products exports in the (Department of Environment Malaysia 2005).country, supplying close to 60% of the worldconsumptions (MRB 2012). However, with a Latex Coagulum and Latex Slurryhuge market share of glove export in the world, ‘Wastes’the latex products manufacturing industry is stillfaced with mitigating large amount of ‘wastes’ Standard operating procedure of a glovegenerated by this industry. These wastes production process requires cleaning (once inare mainly generated during compounding, every 3–4 weeks) of dipping tank containingdipping and effluent treatment processes formulated pre-vulcanized latex (PVL), into(Devaraj & Zairossani 2012). Currently NR which the ceramic formers dip and subsequentlyglove manufacturers are experiencing serious go into the heating chamber to undergo gellingchallenges which include increased raw material and subsequently curing (Figure 1a). The DTCand operational costs, coupled with disposal (Figure 1b) wastes are separated and storedcost incurred when the dipping tank coagulum to be collected by DOE approved recyclers,(DTC) has been classified as Scheduled Waste whereas the latex slurry (Figure 1c) is washedTechnology and Engineering Division, RRIM Research Station, Malaysian Rubber Board, 47000 Sungei Buloh, Selangor* Corresponding author (e-mail: [email protected]/[email protected])

V. Devaraj et al.: Utilization of Waste from Natural Rubber Glove Manufacturing Line (a) (b) (c)Figure 1. (a) Former ‘dipping tank’; (b) latex lump and (c) latex slurry in the glove manufacturing line.into the latex slurry pond to undergo pre- possibility of turning DTC as a raw materialtreatment, before the commencement of the for making other rubber products, with the in-effluent treatment cycle. Process flow involved tention of saving substantial amount of disposalin the dipping tank (DT) cleaning and the cost if the DTC could be recycled (Devaraj‘wastes’ generated are as shown in Figure 2 2011). Therefore the objective of this study is(Devaraj et al. 2014). primarily to carry out chemical characterization of DTC and other wastes generated from theStudy by the Malaysian Rubber Board dipping process and to identify ideal blending ratios with virgin rubber (SMR 10 or SMR 20)To ease the burden of latex manufacturing to explore the possibilities of manufacturingindustry with regards to waste disposal, MRB value-added rubber products (Kamarulzamanrecently carried out a study to determine the et al. 2013. 95

ASEAN Journal on Science and Technology for Development, 32(1), 2015 Dipping PVL from DT DT is left Coagulating Latex lumptank (DT) is transferred with remnants the remnants and latex cleaned for recycling/ of PVL, and of PVL by used as diluent slurry once in sediments Ca(NO3)2 wastes3-4 weeks for latex containing filler concentrate and curatives. Figure 2. Process flow involved in dipping tank cleaning and ‘wastes’ generation. Materials and Method SDTA851; sulphur content by Elementar Vario Max CNS instrument; curative agents by thinDTC Sampling and Chemical layer chromatography and the analysis ofCharacterization metals (Ca, Al and Mg) and heavy metal (Zn, Ti, Cd and Pb) by Inductively Coupled Plasma-DTC and latex slurry samples were collected optical Emission Spectrometry (ICP-OES).from five different gloves manufacturing The pathway followed for the full chemicalfactories with varying production capacities. characterization of raw dipping tank wastesFor the purpose of carrying out a full chemical samples are as shown in Figure 3.characterization on dipping tank wastes,coagulated lump and latex slurry were obtained Chemical Characterization offrom participating factories. They were Processed DTCchemically analysed for total solids content(TSC); polymer, calcium carbonate and ash The raw samples (both latex lump and latexcontents by means of thermo gravimetric slurry) were processed by coagulation (onlyanalysis (TGA) via Mettler Toledo TGA/ Coagulum Sample Latex slurry Total Sulphur Total solid Dry ashing ICP Metallic sulphur analyser contents content Acetone extraction Sulphur Extracted rubber* Acetone extract** analyser TGA Acetone TLCCombined extract value sulphur Polymer, CaCO3 Accelerator, antioxidant and ash contents and free sulphur*Purified rubber; **Impurities Analytical method/instrument Substance analysed Figure 3. Pathway for full chemical characterization of DTC. 96

V. Devaraj et al.: Utilization of Waste from Natural Rubber Glove Manufacturing LineRaw Creped and washed Milled Blended with NRFigure 4. Various stages of DTC processing and blending with NR.slurry), creped, washed and subsequently compounds were studied using a Monsantowere air-dried at ambient temperature until a Moving Die Rheometer (MDR 2000) accordingconstant weight was achieved (Figure 4). Air to ISO 6502 at 150°C. The respective curedrying at ambient temperature was to prevent times were measured by t90, scorch time ts2,the processed samples from undergoing maximum torque (MH), minimum torque (ML),further cross-linking if dried in the heat etc. were determined from the rheograph. Thechamber. Chemical characterizations were compounds were then compression-mouldedalso performed on the processed DTC samples at 150°C using the respective cure times, t90.using the similar methods as was done on the Dumb-bell samples with the length of 95 mmraw samples, to investigate the variations in were cut from a 2 mm-thick moulded sheet.their contents. The tensile testing procedure was carried out according to ISO 37. An Instron universalDTC/NR Blends testing machine (Model 4206) operating at 500 mm/min was used to determine the tensileThe processed DTC samples were milled and properties in terms of ultimate tensile strengthobserved for its homogeneity visually. Two-roll and elongation at break. The abrasion resistancemill was also used to investigate the blending (ISO 4649) was measured by moving the testcharacteristics of DTC sample from factory piece across the surface of an abrasive sheetA (DTC-A) with NR (SMR 10). Blends of mounted to a revolving drum, and the resultsDTC-A/NR (90/10 phr) was compared against were normally expressed as abrasion resistanceDTC-A/NR (100/0 phr), as a non-ideal case index compared to a reference or standardscenario. Figure 4 shows various stages of compound. Three test runs were performed forraw DTC processing and subsequent blending each compound (Dayang et al. 2014).with virgin rubber at 10 phr. Blending wassubsequently carried using processed DTC Results and Discussionsamples from factories A, B and C using threedifferent ratios, which include, DTC/NR Chemical Characterization of Raw and(100/0 phr), DTC/NR (70/30 phr) and DTC/ Processed DTC SamplesNR (50/50 phr). Significant differences in results were obtainedStudy on Cure Characteristics and from the two types of samples analyzedPhysical Properties of DTC/NR Blends (latex lump and slurry) for the chemical characterization on raw and processed samplesUsing the blends of DTC/NR from the three (Table 1 and Table 2) on all parametersfactories at various ratios were compounded tested. From Table 1, TSC values for alland the cure characteristics of the rubber samples were determined by summing up the 97

ASEAN Journal on Science and Technology for Development, 32(1), 2015Table 1. Results of chemical characterization of raw DTC.Factories ABC DETest parameters Coagulated lump SlurryMoisture (%) 22.20 32.61 14.67 46.64 55.24Polymer content (%) 62.50 57.82 61.09 8.69 11.45Ash (%) 0.30 0.67 8.73 2.15 1.75Calcium carbonate (%) 12.5 6.60 10.75 36.49 24.62Zinc oxide (%) 0.16 0.43 1.48 0.82 0.66Accelerators and antioxidant (%) 0.20 0.61 0.35 2.40 2.82Total sulphur (%) 1.09 0.81 2.05 2.29 1.75Others* 1.06 0.45 0.90 0.52 1.71*Traces of heavy metal (Ti, Cd, Pb), silicates and degraded rubber found in acetone extract which were not analysed.percentage values for all the parameters as polymer content by virtue of more polymersshown, except the moisture content. The dried per unit volume compared to the raw DTC.samples which refers to the TSC, from Table 1 Nevertheless, the processed samples werewere subsequently processed and dried to ideally much cleaner to carry out the virgindetermine values for the parameters as shown NR blending to determine the optimum ratiosin Table 2. These values (polymer content and required for manufacturing other rubbercuratives) were used as basis for blending with products.virgin rubber for making rubber products. Forcoagulum samples obtained from factories ProcessabilityA, B and C, generally had higher polymercontent (PC) values; ranging from 57.8% to The chemical analyses of the processed DTC62.5%, while the PC values of slurry samples samples (Table 2) would have direct effect onfrom Factory D and E, where notably much the processability and characteristics on anylower, ranging from 8.7% to 11.5%. They had products made from these samples. It wasrelatively higher filler and curative values, observed that DTC-C with higher percentagesrespectively. High in PC values and low in of ash, zinc and sulphur and lower polymerfiller and curative values are considered ideal content as compared to samples from othercompositions for recycling dipping tank wastes two factories, posed difficulties during thefor making value-added rubber products. processing of this sample, compared to DTC-A and DTC-B. In addition, the sheeted sample From the results of the chemical analyses after passing through the two-roll mill wason the processed DTC-A, DTC-B and DTC-C found to be quite brittle and powdery.from the three factories, it was found thatthe washing and creping of the raw samples Cure Characteristicsmanaged to release unreacted antioxidantand accelerators, whereas the fillers and From the cure characteristics profile ofothers metallic contents which might have the blending of NR and DTC-A, DTC-Bbeen embedded into the rubber matrix during and DTC-C, at various ratios displayed incoagulation remained intact. The drying had Figures 5(a), (b) and (c), respectively, thereduced lots of moisture as compared to the minimum and maximum torques increased withraw samples. This had indirectly increased the increasing level of recycled material (DTC). Theoretically, the increase in the maximum 98

V. Devaraj et al.: Utilization of Waste from Natural Rubber Glove Manufacturing LineTable 2. Results of chemical characterization of processed DTC. Factories DTC-A DTC-B DTC-CTest parameters 0.16 Processed DTC 0.20Moisture (%) 87.30 0.21 71.60Polymer content (%) 10.20Ash (%) 2.10 88.80 10.35Calcium carbonate (%) 4.80 0.70Zinc oxide (%) 2.10 8.00 3.40Accelerators and antioxidant (%) 0.40 0.30 0.35Total sulphur (%) 1.70 – 2.05Others* 1.44 1.20 1.85 0.79*Traces elements etc.torque reflects of an increase in crosslink agreement with higher amount of sulphur anddensity and resulting in an additional stiffness zinc content in the raw composition analysesof the rubber blend. Similar trend is also of the DTC. This also contributed to the higherobserved in NR containing DTC-C whereas, crosslinking density in the blends with increasedthis effect is not very obvious for NR containing amount of DTC loadings.DTC-B and DTC-A, respectively. It is alsoobserved that NR containing DTC-C at all Physical Propertiesratios tested, showed the highest values for themaximum torque. De et al. (2007) highlighted In this study, tensile strength and abrasionthat there is the presence of cross-linked gel in resistance were investigated to evaluate thethe recycled rubber which remained without physical properties of the DTC/NR blends.dispersing as a continuous matrix with virgin Generally, materials tend to become weak andrubber, when these two (virgin rubber and brittle with increasing concentrations of DTC.DTC) were blended. As such this phenomenon Figure 6 showed that the variations in tensileexplains the increase in the stiffness with strength of NR vulcanizates with differentintermittent presence of cross-linked gel from blend ratios of DTC from different sources.the recycled rubber, attributing to the maximum The inclusion of DTC at 50 phr loading led totorque. Another possible reason could be, with a decrease in the tensile strength values and athe presence of a high amount of ash in DTC-C significant decrease with further increase ofsample, which prevented the formation of DTC loadings. It was found that the maximumvulcanized sheet from 100 phr of DTC-C, due values of tensile strength decreased withto the highly cross-linked rubber becoming stiff different samples in the order of DTC-C <and brittle. DTC-B < DTC-A. A significant decrease in scorch and cure The abrasion resistance of NR containingtimes were also observed with increasing DTC-A, DTC-B and DTC-C at various ratiosamount of DTC-A, DTC-B and DTC-C loading. are as shown in Figure 7. It also could beA similar trend was also reported by other seen that the abrasion resistance of blendedresearchers (George et al. 2007; Mathew et al. vulcanizates (NR/DTC) gradually decreased as2001; Edirisinghe et al. 2011) with different the DTC contents were increased. The decliningtypes of recycled rubbers. This could be due to of abrasion resistance was more pronounced inthe unreacted curatives still present in the raw NR which was blended with DTC-C sample.DTC samples. The results were clearly in good As mentioned earlier, the high content of zinc 99

ASEAN Journal on Science and Technology for Development, 32(1), 2015Torque (dNm) 40 (a) 35 20 25 30 DTC-A/NR (50/50 phr) 100 phr DTC-A 25 20 15 10 5 0 0 5 10 15 Time (min) Control DTC-A/NR (70/30 phr)Torque (dNm) 40 (b) 35 30 20 25 20 DTC-B/NR (50/50 phr) 15 100 phr DTC-B 10 5 0 0 10 Time (min) Control DTC-B/NR (70/30 phr)Torque (dNm) 40 (c) 35 30 5 10 15 20 25 25 20 DTC-C/NR (50/50 phr) 15 10 5 0 0 Time (min) Control DTC-C/NR (70/30 phr)Figure 5. Cure curve of NR and (a) DTC-A; (b) DTC-B and (c) DTC-C at various ratios. 100

V. Devaraj et al.: Utilization of Waste from Natural Rubber Glove Manufacturing Line 30Tensile strength (MPa) 20 10 0 50/50 70/30 100/0 Control Concentration of dipping tank coagulum/NR (phr) Control DTC-A DTC-B DTC-C Figure 6. Effect of DTC loading on tensile strength of DTC/NR blends.Abrasian resistance index (ARI), % 100 80 60 40 20 0 50/50 70/30 100/0 Control Concentration of dipping tank coagulum/NR (phr) Control DTC-A DTC-B DTC-C Figure 7. Effect of DTC loading on abrasion resistance of DTC/NR blends. 101

ASEAN Journal on Science and Technology for Development, 32(1), 2015and sulphur present in DTC-C had caused the shown in Table 3, periodically. Factory ownersincrease in crosslink density of the blended can present the analytical results from MRB tovulcanizate which subsequently brought about the recyclers to obtain a premium price for theirthe deterioration in its physical properties. processed DTC samples as raw material.Therefore, such behaviour confirmed the need toascertain the ideal blending ratios for inducing Table 3. Processed DTC sample componentsoptimum degree of crosslinking to incorporate requirement for recycling.relatively good physical properties. No. Major components Ideal level CONCLUSION AND (%) RECOMMENDATIONS 1. Polymer > 40As a rule of thumb, the highest percentage of 2. Ash <10recyclable material that could be incorporated 3. Zn <2.0for making value added-product is 40%. This 4. Sulphur <2.0was to maintain the quality of the product. 5. Accelerators and antioxidants <2.0Incorporation of 100 parts of recycle material 6. Calcium carbonate <10had at least 40 parts of polymer and subsequently60 parts of virgin rubber that could be added. DTC samples with polymer contents <40%DTC with lower polymer content needed a and lower in curatives could still be consideredhigher incorporation of virgin rubber which for recycling by adding higher portions ofmade it economically non-viable. Results virgin rubber for manufacturing such as shoealso showed that processed DTC samples soles, carpet underlay and thermoplasticwith higher polymer content and lower in elastomer products. It is suggested that thecuratives were ideal for recycling as compared inferior properties of recycled rubber fromto latex slurry samples with lower polymer DTC could be compensated by the additionand high in filler and curatives. R&D work is of chemicals (for rapturing the cross-links)currently on-going in MRB to evaluate suitable with the adjustment of operating conditions,recycling options for latex slurry samples. among other remedies. All these add cost to theTherefore DTC samples with polymer content manufacturing process.of >40%; both ash and calcium carbonatecontents of <10%; curatives <2 % (Sulphur, Date of submission: November 2015antioxidants, accelerators and ZnO) whenblended with virgin rubbers (SMR 10 and Date of acceptance: January 2016SMR 20) were found to be suitable formanufacturing rubber products with relatively Referencesgood physical properties such shoe sole, carpetunderlay and solid tyres. Table 3 summarizes the Abraham, E, Cherian, BM, Elb, PA, Pothen,processed DTC samples’ required composition LA & Thomas, S 2011, ‘Recent advancesfor ideal recycling purposes. in the recycling of rubber waste’, in Recent developments in polymer recycling, eds A Fainleib Glove manufactures ideally should set up & O Grigoryeva, Transworld Research Network.on-site DTC processing facility at their factorypremises equipped with creepers and space Dayang, HAI, Nur, FI, Devaraj, V & Nor, HKto air-dry the creped DTC samples. Creped 2014, ‘Effect of dipping tank coagulum (DTC)samples can be sent to MRB (G -TACR) for on cure characteristics and physical propertieschemical analyses on the six parameters as of DTC/natural rubber blends’, in International Conference on Plastic, Rubber and Composite (ICPR 2014), Langkawi, Malaysia, June 2014, pp. 20–21. 102

V. Devaraj et al.: Utilization of Waste from Natural Rubber Glove Manufacturing LineDe, D, De, D & Singharoy, GM, 2007, Reclaiming Angewante Makromolekulare Chemie, vol. 215, of ground rubber tire by a novel reclaiming no. 3711, pp. 25–33. agent. I. Virgin natural rubber/reclaimed GRT vulcanizates’, Polymer Engineering & Science, Malaysian Rubber Board 1212, ‘Malaysia’s customs vol. 47, no. 7, pp. 1091–1100. tariff 2012 for rubber and rubber products’, Economics and Rubber Market Division, MRB.Department of Environment Malaysia 2005, Environmental quality (schedule wastes) Mathew, G, Singh, RP, Nair, NR & Thomas, S, regulation 2005, DOE Malaysia. 2001, ‘Recycling of natural rubber latex waste and its interaction in epoxidised natural rubber’,Devaraj, V 2011, Report on ‘Characterization of Polymer, vol. 42, pp. 2137–2165. dipping tank coagulum (preliminary study)’ in 30th JTC Meeting at RRIM Technology Centre, Kamarulzaman, NH, Idris, NF, Veerasamy, D 2013, 21 December. ‘Characterisation of dipping tank coagulum waste from natural rubber glove factories’, inDevaraj, V & Zairossani MN 2012, ‘Sludge-derived Proceedings of International Conference on Waste fuel from latex products manufacturing industry’, Management and Environment (ICWME), August Academy of Sciences Malaysia Science Journal, 2013, Kuala Lumpur, pp. 26–27. vol. 6, no. 1, pp. 15–21. R a j a n , V V, D i e r k e s , W K , J o s e p h , R &Devaraj, V, Nur, F, Fadhilah, I, Dayang, HAI & Noordermeer, JWM 2006, ‘Recycling of NR- Nor, HK, Hidayaty, K 2014, ‘Utilisation of latex based cured latex material reclaimed with coagulum from NR glove manufacturing line’, 2,20-dibenzamidodiphenyldisulphide in a truck Malaysian Rubber Technology Developments, tire tread compound’, J. Appl. Polym. Sci., vol. vol. 14, no. 1, pp. 27–33. 102, pp. 4194–4206.Edirisinghe, DG, De Silva, MIA & Premachandra, Rimez, B, Knappe, S, Pattyn, D & Munck, JD JK, 2011, ‘A novel reclaiming agent for ground 2008, ‘Rubber analysis by advanced thermo- rubber tyre (GRT), part II: property evaluation gravimetric’, in Proceeding of British Plastic and of virgin natural rubber (NR)/novel reclaimed Rubber Institute Conference, BPRI, 22 October. GRT revulcanisates’, Progress in Rubber, Plastics and Recycling Technology, vol. 27, no. 3, pp. Saiwari, S 2013, ‘Post-consumer tyres back into 161–176. new tyres: devulcanization and re-utilization of passenger car tyres’, PhD thesis, University ofGeorge, RS & Joseph, R 1994, ‘The utilisation Twente, The Netherlands. of latex reclaim rubber in natural rubber’, Die 103

ASEAN J. Sci. Technol. Dev.,  32(2): 104 – 120A Phenomenological Study on the Quality of LifeAmong Patients with Osteoarthritis Admitted forRehabilitative Physiotherapy in a Private Hospital in Kuala Lumpur R. (III) P. DIOSO1* AND R.TANGGAYA2The aim of this study is to explore patients’ experiences and how their rehabilitation andphysiotherapy at a private hospital in Kuala Lumpur, Malaysia has affected their quality of life (QOL)due to osteoarthritis (OA). In addition, this study also aims to explore patients’ perspectives of therehabilitation and physiotherapy for their OA before and after which affects moreover their QOL. Theseven domains of the QOL were the physiological, social, financial, environmental, psychological,level of independence and spiritual – aimed to guide the theme of the interview sessions. A qualitative design was used. Of the 50 patients purposively enrolled only six were selectedusing inclusion and exclusion criteria. Thematic analysis addressed the seven domains of the QOLfor data analysis. A 60-minutes interview session was audio-recorded. The rehabilitation therapy was explored on all seven domains of the QOL. Of the six respondentsfour explored their lived experiences on the social and environmental domain, while five on thephysiologic domain. The spiritual, psychological, level of independence and financial domains weremostly explored by the six respondents that have affected their QOL.Key words: Quality of life; physiotherapy; qualitative phenomena, rehabilitation therapy,osteoarthritisThe aim of this study is to explore patients’ healthcare professionals on how to advise OAexperiences and how their rehab at a private patients in improving their QOL.hospital in peninsular Malaysia has affectedtheir quality of life (QOL) due to osteoarthritis The QOL according to the World health(OA). In addition, this study also aims to explore Organization (WHO 1998) measures sevenpatients’ perspectives of the rehabilitation and domains—physiologic, psychologic, environ-physiotherapy which affects moreover their mental, social, level of independence, financialQOL. and spiritual. It is a descriptive term that refers to the functional abilities of a person related to The purpose of this study is to establish a the ordinary tasks of daily living (Fallowfieldconcept of health promotion for other patients 2009).with OA, as it opens avenues on how to improvetheir QOL. It is also hoped that this study An OA, on the other hand is known aswill help promote health-related strategies for the degenerative arthritis or degenerative1 Faculty of Nursing, Lincoln University College, Malaysia2 Physiotherapist,Yayasan Sultan Idris Shah, Ipoh, Malaysia* Corresponding author (e-mail: [email protected])

R. (III) P. Dioso and R. Tanggaya: A Phenomenological Study on the Quality of Lifejoint disease, which are group of mechanical is cost-effective and a coping managementabnormalities relating to degradation of joints, which can improve their working life moreincluding articular cartilage and subchondral qualitatively (Felson 2004).bone that has an effect on a patient’s QOL(Coggon et al. 2001; Brooks 2002; Li et al. It will be beneficial to undertake this2013). study since there is not enough research and/ or literatures published in Malaysia to explore Physiotherapy as a rehabilitative treatment the lived experiences of patients with OAsfor OAs can improve their QOL (Brooks that affects their QOL. However, reviewing2002). They commonly involve active range of similar concepts are also necessary in order tomotion exercises and massage (Brooks 2002; substantiate this research.Coggan et al. 2001). Rehabilitation of OAs inaddition to physiotherapy sessions, in order to Conceptachieve QOL in its broadest sense commonlyinvolves a combination of self-performed The environmental domain is conceptualizedexercises, lifestyle modification, and analgesics by using interventions that comprises a series(Bosomworth 2009). If pain is not reduced, of highlighted daily activities such as chores, asdebilitation or joint replacement surgery may well as leisure. The domain of the patients’ levelbe used to improve their QOL (Tortora & of independence with OAs is conceptualized asDerrickson 2010; Felson 2004). the ability to cope with daily routine especially with jobs (Power et al. 2008; Rosemann et al. Background 2008/2005). Power et al. (2008) also added that QOL measures OA’s severity (the physiologicIn Malaysia, a study has shown that patients domain), depression (the social domain) andwith OAs attending primary care clinics have fatigue (the psychological domain). Fujitarelatively poor QOL pertaining to the physical et al. (2006) says that the physiologic domaindomain and its health-related components is measured by disease progression and(Zakaria et al. 2009). In addition, analgesics treatment. The spiritual domain is measuredin Malaysia are recommended to ensure pain by the thoughts on OA and their forgivenessfree QOL with the full four weeks of check-up and blame for acquiring the illness, and howwith treatment (Chin et al. 2012). This makes they accept the reality that they have OA forregular visits to physiotherapy department life. Lastly, the financial domain measures theimpossible so, a self-management treatment employability of an individual and how they Physiologic Social SpiritualEnvironmental Financial OA’s rehab experienceLevel of independence PsychologicalFigure 1. The concept of the study. 105

ASEAN Journal on Science and Technology for Development, 32(2), 2015keep their employment status to maintain their interviews were undertaken with patientsfinancial needs even with OA (Abdullah et al. (n = 29), general practitioners (n = 9) and2013). practice nurses (n = 4) which was a very appropriate sampling size in a focus group The reviewed concepts will help formulate design that was divided into three groups instrategies on how to explore patients’ QOL with order to explore experiences of the subject withOA. Figure 1 shows the concept of the study. the use of the OA guidebook. Morden et al. 2014 analyzed the data using thematic analysis Literature review which was also very appropriate for this study addressing the seven domains of the QOL.Four literatures inspired this study and alsohelped in the formulation of the concept. The questions adapted from the study of Morden et al. (2014) will focus on The study of Morden et al. (2014) is the the physiologic, environmental and levelfirst literature reviewed, that used a guide book of independence domain with questionsin planning for the rehabilitation as a form of enumerated as:intervention. The concept of this study exploredhow patients used the guidebooks in managing (1) E n g a g i n g i n s o m e f o r m o f s e l f -their OAs to achieve a QOL. management, either self-learned from experience or disseminated via social The findings from the study of Morden et al. networks (physiologic);(2014) were divided into groups—the interviewresults from the healthcare practitioners and (2) Continuing existing physical activitiespatients. The result of the interview from the without worry about damaging jointshealthcare practitioners were further divided or causing additional pain (level ofinto themes—the perceptions on benefits of independence); andpatients and the managing consultations. Thehealthcare practitioners gave positive answers (3) Working with confidence that all forms ofon the themes that explored the good benefits of environments are safe for them to workthe guidebook and how it is easily understood and/or perform their activities of dailyby the patients with OAs. While the result of living (environmental).the interview to the patients also gave a positiveremark on the guidebook by answering the However, the authors (in this case theinterview saying that it clarifies and explains reviewers) must take caution because theOAs well and it provides positive aspects of sample of patients in the study of Morden et al.biomedical information therefore it is very (2014) were all white British. Other ethnicuseful on self-management even if drugs are groups would have explored the guidebookincluded in the manual. on OAs differently due to cultural diversity. Therefore, the physiologic, environmental In addition, the study of Morden et al. and level of independence domains in this(2014) is very appropriate since the concept phenomenological study must be exploredof this study supported self-management to appropriately for the Malaysian ethnic groupsachieve a QOL. Eight subjects in the West in the selected private hospital in Kuala Lumpur.Midlands and North West of England wererecruited to take part: four control practices However, the study of Morden et al. (2014)and four intervention practices. Semi-structured did not consider the social and psychological domains of the QOL. 106

R. (III) P. Dioso and R. Tanggaya: A Phenomenological Study on the Quality of Life This is why the study of Power et al. in the thematic content of this research’s(2008) was selected as the second literature questionnaire.to be reviewed because it focuses on fatiguewhich is very appropriate and useful for the The questionnaires for the interviewconcept of this phenomenological study. In sessions were basically enumerated as:addition, the study of Power et al. (2008) wasvery appropriate to enlighten this research since i. Experience with OA prior to THA,we (the authors) aim to explore the patients’ focusing on disease progression andrehabilitation experiences. treatment, and the impact of OA on the participant’s life (physiologic) The findings on the study of Power et al.(2008) were divided into five themes — fatigue ii. The reason for undergoing the surgicalcharacteristics, factors affecting fatigue, impact procedure and the situationof fatigue, methods of coping with fatigue and the participant was in at the timediscussion about fatigue with significant others. (psychological); andThe subjects with OAs explored the use ofexercise and how to control pain by adhering iii. The participant’s thoughts on OA affectingto pain medications may eventually avoid their spiritual life after surgerydepression — the social and psychological (spiritual).domain. Again and again, adapting the physiologic Power et al. (2008) used audio tapes and domain from the study of Fujita et al. (2006)transcribed verbatim results which also inspired must be explored with caution that is appropriatethis study because it is less complex if subjects’ with the Malaysian ethnic group and cultureanswers were audio recorded. since it is mostly affected by such (Fallowfield 2009; Tortora & Derrickson 2010). The advantage of the study of Power et al.(2008) from the study of Morden et al. (2014) However, Fujita et al. (2006), Power et al.was the highlighted emotional consequences (2008) and Morden et al. (2014) did notand impacts on daily activities such as chores, consider the financial domain that affects theas well as leisure and social activities. However, QOL among patients with OA.both studies did not explore experiences withOAs post-arthroplasty surgery that explored The financial domain according to theforgiveness and blame of the subjects addressing study that was done by Abdullah et al. (2013)the spiritual domain of the QOL. measures the employability of an individual and how they keep their employment status to maintain their financial needs. This is why the Fujita et al. (2006) was The study done by Abdullah et al. (2013)selected to be the third literature to be reviewed. was the fourth literature selected to be reviewedFujita et al. (2006) used a semi-structured because it used a focused group who are obeseinterview session 48 hours after and before and they eventually led to OA affecting theirtotal hip arthroplasty (THA) as a surgical finances. A focused group will be very essentialmanagement for patients with OA. to enlighten the concept of this research because the questionnaires with contents that can be used Lastly, the content of the questions set for the interview involves the financial statusesby Fujita et al. (2006) can also be useful of patients with OAs. 107

ASEAN Journal on Science and Technology for Development, 32(2), 2015 The findings of Abdullah et al. (2013) on The research design can be further dividedthe interviewees’ perceptions and their attitudes into setting and subject designs in order totowards their experiences on OAs for 20 years, strategically discuss the cause-effect variableswas explored to have affected their financial (Groves et al. 2009).domain from past to present. Abdullah et al’s(2013) interview sessions were recorded, The effect variable was the patients’transcribed and coded. Their discussions experiences on the QOL that this researchcentered around six themes. The financial deemed to explore while the causative variabledomain focuses on these questions: was the rehabilitation process (Figure 1). Q1: How do you feel about your financial Setting. One of the reasons why it was best expenditures having daily knee pain? to conduct an interview in Peninsular Malaysia for the setting was because some of the lived Q2: How has having knee pain interfered experiences to be asked to the participants were with your financial life? in English and it was difficult to translate it in the Malay language. In addition, most of the Q3: From what we have discussed so far, prospective subjects in peninsular Malaysia what bothers your financial needs the most are well versed in communicating spoken about having knee pain? English (Ministry of Higher Education 2010). Therefore the medium of communication in Q4: Is any member of your family affected this particular setting was mostly in English or by you having knee pain? in Bahasa Melayu (the two major languages in peninsular Malaysia). Other languages that Q5: What do you personally do to deal with are prominently spoken in peninsular Malaysia your knee pain while working? such as Mandarin and Cantonese (Chinese), Tamil and Hindi (Indian) are not used as the Q6: How do you cope with your knee pain medium of communication. when doing your daily activities? Secondly, the reason why the private Moreover, the four selected studies will hospital was selected as the setting was becausehelp this research design its methodology and subjects with OAs interviewed had a salary rateinterview approach. ranging from RM 3000 and above (Chin et al. 2012; Blixen & Kippes 1999). These patients Methodology (with salary rate of RM 3000 and above) usuallyThis section commences by addressing the experiences difficulties in paying their billsdesign of this research. The description of (Chin et al. 2012; Blixen & Kippes 1999) sincethe setting, subjects, and methods of data OAs was a long-term treatment which requirescollection follows. The method of developing expensive drugs that is likely to affect their QOLthe instruments and how to analyse the data (Zakaria et al. 2009). Lastly, the hospitals incollected will also be explained. Finally, this peninsular Malaysia as a setting can be a safesection ends by explaining the ethics that was place to conduct an interview among OAsconsidered. patients since emergency equipment are more accessible if life threatening situations occursResearch Design that can be triggered because of the interviewA phenomenological qualitative design was sessions (Wolfey & Holley 1997; Roos &the most appropriate to be used in this study Larsen 2003).in order to achieve the aims and purposes set. 108

R. (III) P. Dioso and R. Tanggaya: A Phenomenological Study on the Quality of Life In addition, a private owned hospital Lastly, only adult patients ages 21 andfound in the state of Kuala Lumpur are more above were included.open for research (Zakaria et al. 2009; Chinet al. 2012; Li et al. 2013). The prospective The first exclusion criteria on the othersubjects confined in private-owned hospitals in hand were pediatrics aged 18 years old andparticular do not require too much negotiation below. This is because the aetiology of OAswith researchers unlike in public hospitals is often seen on adult age (Dias et al. 2003;where managements and/or managers do not Jakobsson & Hallber 2002). In addition, QOLwant researchers to explore and disclose their is best explored among adults ages 21 years oldpatients’ illnesses (Chin et al. 2012). and above with OA. Therefore patients who are below 20 years old are also excluded since they Therefore selecting prospective subjects have lesser QOL domains to explore (Wolfey &for this study are easier in a private hospital in Holley 1997).peninsular Malaysia. Secondly, patients who cannot express Subjects. Purposive sampling was used to themselves in spoken English were alsoselect the prospective subjects to be interviewed. excluded especially those patients with OAsThis sampling technique was deemed best to who were born mute and could only use hand-help the researchers find a small sample size sign languages since the interview sessionwhich is accessible for an in-depth interview would audio-tape their answers making signand whose findings can be generalized to the languages inappropriate. Plus even if the signaccessible population rather than the complete languages could be translated into verbal, thetarget population (Denzin & Lincoln 2005; vocal expressions and intonations would not bep. 23; Saldana 2012; p. 74). Inclusion and originally coming from the prospective subjectsexclusion criteria are required in a purposive and might lead to a misinterpretation of thesampling technique (Saldana 2012). desired answers from the subjects. In addition, patients who are disoriented such as those who Patients had to be suffering from OA are old, ages 70 years old and above and are not— a doctor’s diagnosis must be reflected anymore capable of using intellectual reasoningin their patients’ record — as one of the (Dias et al. 2003) are excluded since most ofinclusion criteria. The patients also have to have them cannot give an answer.registered in the past with the physiotherapyoutpatient department in the specific private- Thirdly, patients with OAs who had soughtowned hospital found in Kuala Lumpur between consultations in their community health clinics2013 to present; whether they have undergone or in village hospitals are excluded since thesesurgical treatments or still on the rehabilitation patients rarely expresses themselves in spokenprocess. In addition, exploring patients’ lived English (Zakaria et al. 2009) which this researchexperiences with physiotherapy to achieve a requires. Again and again, translating theirQOL can be more multi-dimensional since answers from other languages or dialects mightthey are from the state of Kuala Lumpur where still cause misinterpretation.lifestyles are diverse (Zakaria et al. 2009). Another inclusion criterion requires from Lastly, foreigners who were not capablethe prospective subjects was to be able to orally of expressing conversational Bahasa Melayucommunicate in English well and could express were excluded since some questions regardingtheir answers to the interviewer in spoken the domains of the QOL had cultural MalaysianEnglish. terminologies (words) which were difficult to 109

ASEAN Journal on Science and Technology for Development, 32(2), 2015be translated in English or have no equivalent assess the loss of cartilage strength leading toEnglish words. an inflammation of the osteons that affects their QOL (Marc et al. 1995). Of the 50 patients enrolled, only sixsubjects were selected to be interviewed. The participants were reminded that theFigure 2 shows how the 44 enrolled participants interview will be audio-recorded (using mobilewere eliminated based on the exclusion criteria. phones) and reassured them that private and confidential information that were culturallyData Collection sensitive and offensive to the MalaysianThe six participants selected, were primarily community would not be disclosed to theintroduced to the study and to its purpose in public. The data collected using a voice recorderdetail. Consent form was signed before the uploaded in an external disc was kept safe in adate and time were set for the interview. The locker as an ethical consideration.date and time for an interview was moreoverat the convenience of both the researcher and All information collected was treated asthe selected participants. confidential and the patient’s identity was kept anonymous. By history, taking during data collectionsuch as the variety of causes or unmodifiable risk Detail of instruments. A hand-held voicefactors i.e. hereditary, genetic developmental recorder found in a mobile phone devicereactions, auto-metabolic degradation and was used to record with up to 60 minutes ofmechanical deficits may help the researchers interview session. These were then transcribed50 patients enrolled using the inclusion criteria10 eliminated who are foreigners who can not speak malaysian terminologies 4th exclusion criterion20 eliminated who are patients from village public hospitals transferred to private 3rd exclusion criterion10 eliminated who does not desire to answer in English 2nd exclusion criterionFour eliminated who are ages 18 to 20 years old Six study participants qualifiedFigure 2. How the six participants were selected. 110

R. (III) P. Dioso and R. Tanggaya: A Phenomenological Study on the Quality of Lifein verbatim by playing, fast-forwarding or Data Analysisrewinding the interview session. Recordinganswers from the enrolled participants will The interviews were transcribed in verbatimadd value to the reliability of the data analysis and reread to ensure they were in a flow andsince the researcher has evidences to prove its focused on the themes—the domains of thefindings (Groves et al. 2009). The transcripts QOL. The data analysis was counterchecked bywere then analysed related to the themes two people who were not involved in the studyexplained in the discussion section. but were experts in the analysis of the domains of the QOL. Where any differences arose, they Detail of the questionnaires as a guide were resolved by discussion and re-interpreted.for the interview session. The domains found Once transcribed, the transcripts were then redon Figure 1 are the themes that addressed the repeatedly before being coded to find emergingquestions. themes and issues, only then would it be finally written in the discussion section. The questions involved were: (1) physical A thematic content analysis was thencapacity before and after physiotherapy, conducted with an open coding system in orderaddressing the physiologic domain; (2) to accommodate emerging themes and issues.Effect on the emotional status and social Member-checking was also used to ensureactivities, addressing the psychological domain; higher validity. This was where the participant(3) Degree of difficulty and its effect on work was called in to check the transcript to ensure itperformance, addressing the environmental was transcribed and coded correctly in Englishdomain; (4) Severity of disease before and according to how the selected participants forafter rehabilitation, addressing the level of this research wanted it analysed. If the Englishindependence domain; (5) Adaptations on how wordings were incorrect as confirmed by theto cope with OA in their social life, addressing subjects (participants), it would then be revisedthe social domain; (6) Knowledge on spiritual by the researcher and re-checked by the selectedmanagement, addressing the spiritual domain participants for final confirmation. Once it wasand (7) Impact of physiotherapy on their ability confirmed to be correct, only then could theto financially cope with their QOL, addressing answers be written in the discussion section.the financial domain. Ethical Considerations In the Malay language it was translatedas (1) Keupayaan fizikal sebelum dan selepas Ethical approval from the private-ownedfisioterapi. The subjects would be further hospital in the state of Kuala Lumpur wasasked in a rephrased sentence Adakah anda sought before the study commenced. Themempunyai masalah-masalah lain yang researchers first had to register as a membermempunyai kekuatan fizikal anda, next is of the National Medical Research Registry;(2) Kesan ke atas status emosi dan aktiviti then the study is registered with the Medicalsosial, (3) Tahap kesukaran dan kesannya ke Research and Ethics Committee who reviewedatas prestasi kerja, (4) Keterukan penyakit the project and provided approval. The studysebelum dan selepas pemulihan, (5) Penyesuaian was also approved by the university researchpada bagaimana untuk menghadapi OA dalam governance and ethics committee.kehidupan sosial mereka, (6) Pengetahuanmengenai pengurusan rohani, (7) Kesan To ensure internal and external validity andfisioterapi kepada keupayaan mereka untuk reliability of the study, the data was collectedkewangan menghadapi QOL mereka. and held confidentially and stored securely. 111

ASEAN Journal on Science and Technology for Development, 32(2), 2015 Findings A 43 year old male sports trainer said that before physiotherapy “it doesn’t affectThe rehabilitation and physiotherapy conducted my working performance actually because myamong six patients in the private hospital nature of work does not need to stand too long.located in peninsular Malaysia explored QOL However due to my knee problem, I’m lesson the level of independence, environmental confident to play badminton too long.”and psychological domain as compared withphysiological, social, spiritual and financial A 51 year old male assistant nurse beforedomains with lesser responses. There were physiotherapy said “my work requires doingphenomenological experiences found among a lot of walking in the ward but it has beenthe six patients during the interview sessions. affecting my working performance due to the pain.” Of the six patients interviewed, one wasa staff nurse, aged 46 years old female with A 50 year dentist before physiotherapygardening as a hobby. Another was a 43 year session said “my work requires doing a lot ofold male sports trainer. The third one is a public walking in the ward but it has been affecting myhealth nurse, a 50 years old female who likes working performance due to the pain.”dancing as a hobby. The fourth one is a 41 yearold female social worker, who likes to read Physiologic Domain Affecting the QOLbooks. The fifth patient interviewed is 51 years After Rehabilitationold assistant male nurse who likes jogging.Lastly, the sixth patient interviewed is a female Of the six respondents, only five exploreddentist who is 50 years old and likes dancing. their lived experiences with physiotherapy and rehabilitation as it affected the physiologic Of the six patients interviewed there were domain of their QOL.four females and two males who had OAs. Thediversity of their job experiences were two The QOL found from a 50 years old femalenurses, a sports trainer, a social worker, a dentist dentist affecting her physiologic domain saidand a physiotherapist. that she “eats calcium tablets and drink milk to prevent joint pain. I also do exercises andEnvironmental Domain Affecting the QOL cycling to improve muscle strength”.Before Rehabilitation Another answer coming from a 51 years oldFour respondents explored their lived assistant male nurse was “severe pain, difficultyexperiences with physiotherapy and rehabilita- to gets up from bed in the morning, but stilltion as it affects the environmental domain of can be tolerate. I felt mild stiffness at my kneetheir QOL. The two other respondents had no joint but it becomes less after doing a couple ofcomments on this specific domain. warming up exercises on the bed”. Before physiotherapy, a 46 year old female The physiologic domain again wasstaff nurse said, “I’ve difficulty going up and emphasized when interviewing a 41 year olddown stairs every morning. I’ve hold out stairs female social worker as she said that “painrailing while going up.” She added that in order has reduced and muscle power also improvedto cope “I often use lift in my working place and after doing the following exercises such as theavoid frequent movement like sitting, standing foot massager and attend reflexology to relieveor squatting.” 112

R. (III) P. Dioso and R. Tanggaya: A Phenomenological Study on the Quality of Lifepain. I also do some simple exercises taught by with my step in the garden. Every time I wantphysiotherapist at home.” to join any social activities, I’ve to think how the activity is going to be held.” Whenever she While the 46 years old female staff nurse socialized with other people she also added thatsaid that “I used hot pack to relieve pain. I also “I’m always being emotional and disappointeddo some simple exercises to feel healthy. I feel if anyone talks about joint disease”.much better after doing some exercises, painhas reduced.” While the patients were socially incomplete, their QOL was achieved because of the spiritual According to a 43 years old male sports domain. It was found that this domain was alsotrainer after rehabilitation said that “I feel much affected after the physiotherapy sessions.better now, in terms of pain and my capacity toplay improved”. Spiritual Domain Affecting the QOL After RehabilitationSocial Domain Affecting the QOL AfterRehabilitation Of the six, only two respondents exploredOf the six interviewees, only four explored their lived experiences with physiotherapy andtheir lived experiences with physiotherapy and rehabilitation as it affected the environmentalrehabilitation as it affected the social domain domain of their QOL.of their QOL. A 51 year old assistant male nurse after After rehabilitation, a 43 year old male rehabilitation therapy said that “first I acceptsports trainer said that his social domain was the fact that I am getting old and already willaffected as he said “think well, generally, in die soon. So I just accept the fact, I always haveterm of quality of life. The only thing is due to be happy and enjoy my life as usual. Like doto my knee pain, I can’t join my friends go for whatever I can do, if there is a pain just rest andbadminton too often. I feel my life is so boring continue my work and pray.”especially during weekends.” However, headded a disappointment that he “always become While a 50 year female dentist afteremotional and disappointed if anyone talks physiotherapy sessions said “sometimes I blameabout my joint disease”. myself for having OA, but I just pray because I know that the therapy works”. A 41 year old female social worker onthe other hand said that “I feel very angry and In order to be successful with theirmentally disturbed. I also always argue with my experience with physiotherapy sessions, ithusband and family members.” was also necessary to psychologically prepare themselves. It was found that this domain The 51 years old assistant male nurse after affected their QOL before and after the session.physiotherapy sessions said that he was “stillable to attend social activities, on and off.” Psychological Domain Affecting the QOL After Rehabilitation A 46 years old female staff nurse afterphysiotherapy said that “sometimes I feel Six respondents explored their lived experiencesfrustrated, because I have to stop and be careful with physiotherapy and rehabilitation as it affected the psychological domain of their QOL. 113

ASEAN Journal on Science and Technology for Development, 32(2), 2015 A 41 year old female social worker said stay home and it is sometimes psychologicallythat “My confidence level has improved. I annoying”.became psychologically prepared to continuethe exercises until end of my life. I know very A 50 year old public health female nursewell about this condition because I used to see said that before attending physiotherapy hermany patients with this following condition psychological confidence in managing painbut after attended Physiotherapy treatment was “not much, all I know is my joint is rubbingI got to know more information about this somewhere and cause pain.”problem.” She added that “I learn many newthings about managing knee pain from the The psychological impact to a 43 year oldPhysiotherapist.” With regards to the impact male sports trainer was “my depression levelin attending physiotherapy she said that “I has gone down. At least I know this is not a lifehave learned how to overcome the pain and threatening disease.” Another psychologicaljoint problems. I am also confident and able to impact in general he added was “after attendingtolerate the pain. Now I am able to walk with physiotherapy rehab, I know how to manageless pain without limping.” pain associated with prolong standing or walking. I knew when to sit and rest before the A 51 year old assistant male nurse says that pain comes. For long distance walk, I will bringbefore attending the physiotherapy sessions his my walking stick along with me.”psychological capacity was “not much. I onlyknew about osteoporosis and gout.” While the While the psychological impact to a 46psychological impact that the physiotherapy year old female staff nurse after experiencinghad given him was “very good. I get more physiotherapy said “I am not afraid about theconfidence in managing my knee arthritis. It’s knee condition, because now I have bettergood for me and helps me a lot. Thanks to the understanding about the following problemPhysiotherapist to help and guided me in all and it is only related to my knee and not affectaspects.” Lastly, the physiotherapy affecting any other part of my body.” She also added thathis psychological life in general “improves my generally, “I am happy that I am able to copeconfidence level because I understand that my with the problem.”knee pain is not a life threatening disease. It canbe improved or maintained.” These psychological, spiritual, social and most of all the physiologic domains were found A 50 year old female dentist before to have affected their independent performancesattending the physiotherapy sessions said that of daily activities.“my psychological confidence was not much;all I know is my joint had wear and tear which Level of Independence Domain Affectingcauses pain.” She added that “before attending the QOL After Rehabilitationphysiotherapy, I have little confidence aboutmanaging joint problem. After attending Six respondents explored their lived experiencesphysiotherapy, the physiotherapist gives more with physiotherapy and rehabilitation as itexplanation and advice about my problem. Now, affects the level of independence domain ofI understand what knee osteoarthritis is and their QOL.how to manage the problem. My psychologicalpoint of view has changed and improved.” After rehabilitation, a 41 year old femaleHowever, she said that one of the limitations social worker said “every time I took painkillerafter attending physiotherapy sessions was “to to relief pain after few sessions of treatment I felt 114

R. (III) P. Dioso and R. Tanggaya: A Phenomenological Study on the Quality of Lifethe pain reduced. My knee joint became flexible adapt or cope with her OA after rehabilitationand easy to walk even for long distances it was she “ignores the pain, and sometimes do lessreally suffering especially in the morning and work.” However, the physiotherapy sessionswhile walking before treatment. Physiotherapy impact her life and say “pain is much relieved,really works for me.” She added that the as I am able to walk longer distances, knee jointlimitations however, was that “I’ve difficulty much stable and no need to use walking stick.”going up and down the van during home visits.I’ve to hold the seat and sometime I have to It was also found that financial domainskneel on the van to get down.” In order to adapt have a significant impact after physiotherapyor cope with the situation, she said “I prefer sessions were conducted among these patientsto walk less and allotted my work to juniors. I with OAs.always does sitting job.” Financial Domain Affecting the QOL A 51 year old male assistant nurse After Rehabilitationcommented on the limits after physiotherapysessions and said that my “fear of fall, scared my Of the six respondents, only two respondentssuperiors. I use stick to balance my walking.” explored their lived experiences with physio-That is why he says that “I wear knee guards therapy and rehabilitation as it affected thewhile walking.” environmental domain of their QOL. A 50 year old female dentist after sometime A 50 year old female public health nurseof rehabilitation process said “actually the pain said that “most of the time I take leave withoutis not so bad. But I feel there is joint stiffness pay from work and prefer to stay home.”and my knee movements are restricted.” On the contrary a 50 year old dentist said A 46 year old female staff nurse after that “it is not much affecting my working life andphysiotherapy said “it was really hurt when I my salary is not affected.” However, she addedwalk on uneven surfaces especially on roads that “in order to ignore the pain enjoying andbefore treatment. I felt more pain in the morning buying food to eat is the expensive solution.”while getting up from the bed. I shake myknees to relieve the pain. After few sessions of Discussionstreatment I feel the pain is reduced and a biteasy to walk.” With regards to its effect on her These six participants were interviewed usingwork performance, she said “I was very careful a standardized interview schedule whichduring my knee movements and little bit slowly helped the researcher to remain in control ofin working.” the interview and to ensure higher validity and reliability of the study findings. Internal While a 43 year old male sports trainer said and external validity and reliability was alsothat in order to adapt or cope with his activities ensured through member checks, informed“every 20-30 minutes I need rest because my consent and verbatim transcription of thegame needs to move a lot.” interviews. The study also received ethical approval from Teesside University and private A 50 year old female public health nurse owned hospital in Kuala Lumpur.said that the limits that affect working life werethat “I become scared of falling, so I use walking The strength of this study was its designstick for support.” She added that in order to — qualitative phenomenological. The lived 115

ASEAN Journal on Science and Technology for Development, 32(2), 2015experiences of the respondents were very However, the researchers were able to useessential in analyzing the qualitative aspect social issues on the next theme which was theof the domains of the QOL after rehabilitation effect on emotional status and social activities.from OAs. Adaptations on How to Cope with OA in However, the weakness of this study their social life. This theme addressed the socialwas its limitation which is (1) The medium domain of the QOL. Most of the participantsof communication and (2) The number of said that the social capacity to socially debatepopulation having only six participants. If the on OA was a form of developing their self-population were saturated (quantitative), it esteem. As they were aware of their illness,would have a quantified interpretation of the after rehabilitation they became more confidentresults. And if it were also conducted in Bahasa in telling their friends about how they feltMelayu, interpretation of the questions might be whenever they went out and socialized witheasier for the interviewees to answer. them. This domain was phenomenologically leading the participants to a QOL. Most of the time, the questions were clearbut the answers were different which was why However, some of the participants stillit was necessary to repeat the same question mislead their answers to how many times theyuntil the authors (researchers) were satisfied filed their sick leaves and how many times theythat the answer was appropriate to be used for missed work. This was a different issue butdata analysis. nevertheless, it was also a part of the themes set for interview called the degree of difficulty The following sections discusshow the data and its effect on work performance.was analyzed. Impact of physiotherapy on their ability toThematic Analysis financially cope with their QOL. This theme addressed the financial domain of the QOL.The questions set for interview were divided Most of the interviewee said that because ofinto themes addressing the seven domains of physiotheraphy their financial statuses werethe QOL. being compromised. This was because they tended to overuse their sick and annual leave as Effect on the emotional status and the need to be operated arose some physicianssocial activities. This theme addressed the advised then to be on complete bed rest. Ifpsychological domain of the QOL. Most of the they began their leave “without-pay”, then theirparticipants said that their knowledge was more budget to pay the hospital bills would also belikely to correlate with how they perceived and compromised. Since they cannot work for athought psychologically. This theme explored living, they just had to face this specific degreeon how the patients with OAs felt about their of difficulty.capability to understand their diseases whichalso gave them emotional encouragement. One of the participants said that her finan-However, their answers sometimes led to social cial needs in addition to their physiotherapydomain as they began to inject stories such as sessions were adequate. Even though medica-how they shared the knowledge with other tions were very expensive and it was bought onfriends and how they socially debated regarding a monthly basis, some were able to afford. Thistheir understanding with OA. 116

R. (III) P. Dioso and R. Tanggaya: A Phenomenological Study on the Quality of Lifewas because the subjects were earning about Knowledge on spiritual management. ThisRM 3000 monthly. addressed the emotional and spiritual domain of the QOL. Only two subjects were able to answer According to Deutsch et al. (2003), both the question appropriate to the domain whichpoverty and inequality of standard of living discussed forgiveness and blamed affecting theirand having more than the basic salary rate does spirituality and emotions. The two subjectsnot necessarily lead to a QOL. However, two were exploring their emotions on how theyof the six participants with more than the basic blamed themselves for having OA and how theymonthly earnings phenomenologically achieved forgave others who contributed to their diseasethe financial domain of the QOL. because they knew that their physiotherapy sessions would phenomenologically soon be The focus of the conversation was led successful, because of prayers.directly to the next theme called physiologicdomain since the harm of losing money could However, there was a thin dividing linebe outweighed by the physiological benefits of between the spiritual and psychological domainphysiotherapy. of the QOL. Most of the subjects’ answered to the psychological fall on the spiritual domain. Physical capacity before and afterphysiotherapy. This theme addressed the Severity of disease before and afterphysiologic domain of the QOL. Most of the rehabilitation. This theme addressed theparticipants answered the questions that focus level of independence domain of the QOL.on their physiologic functioning and how strong Most of the participants said that they hadthey were before they acquired the disease phenomenologically achieved to acquire ancalled OA. The authors had also explored the independent self-management because ofseverity of their disease before and after the the handbooks that were given to them byrehabilitation and physiotheraphy programme the physiotherapists. It included self-drug— how they began to regain their strengths and administration and first aid care for their OA.became better. However, the Malaysian culture Most of the participants were happy whenaffected the physiotherapy’s purpose, one way they began to be independent in taking care ofor the other, in achieving their physiologic themselves.domains leading to a QOL. Degree of difficulty and its effect on work A participant did foot massage from the performance. This addressed environmentalblind; and one practiced an internal Chinese domain which might also have effect on themartial art exercise called Taichi. These two financial domain and level of independence.Malaysian cultures were neither indicated norcontraindicated to physiotherapy. However, it After physiotherapy and rehabilitationhad phenomenologically led to a QOL in the sessions, most of the participants said that theyphysiologic domain. began to feel safe with their environment. They acquired courage to participate in rigorous Most of them began to be emotional and activities with friends as they believed thatspiritual in expressing their answers. The they could manage to cope with an unpleasantdiscussion on the spiritual domain of patients in environment. Even the environment at theirtheir general life was the next question. workplace was becoming more conducive to them and they tended to lessen their sick leaves. 117

ASEAN Journal on Science and Technology for Development, 32(2), 2015 Overall, none of the subjects with OA were hobbies of the patients (Marc et al. 1995).able to focus their answers to the questions set. Repetitive disorders such as tendonitis as theAll of them diverted from one topic to another. effects of hobbies are co-morbidities of OAsNevertheless, the author was able to use their (Jakobsson & Halber 2002). This informationanswers and place it on the appropriate domain is necessary to be asked by physiotherapistsfor interpretation of the findings. among their patients with OA that are for rehabilitation (Morden et al. 2014; Fujita et al. Discussing the findings was important in 2006; Roos & Larsen 2003).order for it to be implied into practice. ConclusionImplications to Practice Phenomenologically, physiotherapy andIn applied physiotherapy, it is important rehabilitation helped OA patients achieve ato address age, gender and hobbies before QOL. However, in this study, not all the domainsimplementing physiotherapy and rehabilitation of the QOL are phenomenologically achieved.sessions among patients with OAs. This was because the study participants had their own perceptions and points-of-views Age is correlated with the application on describing their lived experiences withof physical exercises as it is expected that physiotherapy the most of the time did notmuscular and skeletal system degenerates as require the seven domains of the QOL.humans grow older (Tortora & Derrikson 2010).In addition, gender must also be considered In addition, the answers of the studywhen dealing with patients with OAs. This is participants to the interviews given might havebecause the female gender is more prone to integrated some of the domains such as theskeletal degeneration as calcium in their body psychological, spiritual and social domains oris decreased especially in menopausal age the physiological, environmental and level of(Marc et al. 1995). This menopause syndrome independence domains in one of their answers.decreases bone strengths because estrogenis also decreasing in production. Thereby That is why it was recommended that indecreases calcium production as an effect of future research, a mixed design could be con-decreasing estrogen production (Tortora and ducted so that triangulation of both quantitativeDerrickson 2010). This decrease in calcium and qualitative findings could strengthen thewill be exacerbated by multiple pregnancies discussion and the conclusion.(Felson 2004). The more pregnancies a femalegender experiences, the more calcium they will AcknowledgEmentlose as they grow older (Tortora & Derrickson2010). Special thanks is acknowledged to Teesside University for the supervision given. Many The male gender however, is not prone for thanks as well to Edu Punay for editing thisdecreasing calcium but rather by the activities final written research.or hobbies which they are inclined to (Tortora& Derrickson 2010). Which is why in applied Date of submission: December 2015physiotherapy, it is important to ask about the Date of acceptance: January 2016 118

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ASEAN J. Sci. Technol. Dev.,  32(2): 121 – 132 Decision Making Processes for a PregnantWoman Admitted to the Accident and Emergency Department Requiring Emergency Diagnostic X-ray – A Case Study S. IsmantoThe objective of this study is to apply the decision-making processes for a pregnant woman whowas involved in a motor vehicle accident and admitted to a private middle-class hospital in thecapital of Indonesia requiring radiologic X-ray examination. It also aims to examine and evaluatethe patient who was in her 20th week of gestation in order to provide her with the best emergencycare, diagnostic investigations and treatments. The descriptive, normative and prescriptive models of decision-making are demonstrated. Thedescriptive model used intuition, while the normative model used decision trees as decision optionsand lastly the prescriptive decision used the information processing theory (IPT) to decide on thebest emergency care, diagnostic investigations and treatments for the patient. The IPT dominated the decision-making process; hence an X-ray examination was done thatwas safe for the fetus and the childbearing mother. Decision option was not used since the patientwas in pain and could not understand much of the procedure that was explained. Intuition helpedin the decision-making in order to ensure safe and effective practice.Key words: Decision-making; case study; pregnancy X-ray; A&E; information processing theoryThis case study applies the decision-making Ethics of justice were considered and thisprocesses for a pregnant woman who case study maintained anonymity of patient’s,experienced a motor vehicle accident and healthcare professionals’ and hospital’s name.admitted to a private middle-class hospital in The purpose is to make a world view on howthe capital of Indonesia requiring radiologic a sound decision-making is demonstrated in aX-ray examination. It also aims to examine fast-paced environment.and evaluate the pregnant admitted patient inher 20th weeks of gestation in order to provide Backgroundher with the best emergency care, diagnosticinvestigations and treatments. X-ray is a form of electromagnetic radiation with very high frequency and energy (Eskandar The descriptive, normative and prescriptive et al. 2010), with a wavelength shorter so as tomodels of decision-making was demonstrated have a fairly high permeability of the material.and therefore conclude with a sound decision Therefore, X-rays can be used as diagnostic and(Shaban 2012). therapeutic management in medical radiology.Academy Technical Radio-Diagnostic and Radiotherapy Nusantara, Indonesia* Corresponding author (e-mail: [email protected])

ASEAN Journal on Science and Technology for Development, 32(2), 2015 Radiology services in the capital of It is known that diagnostic X-rayIndonesia have sufficient modalities such as examinations for pregnancy should not beconventional X-ray, fluoroscopy, computerized performed unless the expected benefit to thetomography scans, magnetic resonance imaging, mother or the embryo / fetus exceeds the knownand radiotherapy; thus they have sufficient risks (Damilakis et al. 2002).healthcare professionals at work. They operatefor 24-hours for emergency cases and can The accepted background cumulativeimmediately investigate medical problem. dose of ionising radiation during pregnancy is 5 rad (50 mGy) which is much more than The optimization of protection and safety, the exposure dose of most of the diagnosticwhen applied to the exposure of workers and radiological examinations (Eskandar et al.of members of the public, and of carers and 2010). The risk of microcephaly and severecomforters of patients undergoing radiological mental retardation with high exposure beginsprocedures, is a process for ensuring that the at 10 weeks of gestation. This risk is greatestmagnitude and likelihood of exposures and the at 10–17 weeks, with less risk at 18–27 weeks.number of individuals exposed are as low as There is no proven risk before 10 weeks orreasonably achievable, with economic, societal after 27 weeks even with doses exceeding 500and environmental factors taken into account mGy. Furthermore, a non-threshold, linear,(Agency 2014). Protection procedure aims to dose-related association between severe mentalprevent the occurrence of deterministic effects retardation and radiation has been foundin individuals by keeping doses below the following exposure during weeks 10–17 ofthreshold and to minimize the risk of stochastic gestation, so that even very low doses cause aeffects (Eskandar et al. 2010). Thousands of slight increase in mental retardation incidence.pregnant patients and medical radiation workers This trend reaches 40% at 100 rad (1000 mGy),are exposed to radiation each year. Lack of although it is not statistically significant atknowledge is responsible for great anxiety and doses generated by diagnostic radiographs.probably unnecessary termination of many Nevertheless, until more data are availablepregnancies (Cousins 2008). delineating potential fetal risk, it is prudentTable 1. Possible effects of acute doses of radiation and estimated threshold doses (Eskandar et al. 2010). Gestational Possible effect 1 mGy 10 mGy 50 mGy 500 mGy Threshold dose age Miscarriage Nil Nil Nil Possible (mGy)Up to 1 week 100472–6 weeks Miscarriage Nil Nil Nil Possible 250-50047 Gross malformations Nil Nil Nil Possible 2004710–17 weeks Mental retardation Nil Nil Nil 20% None IQ score decline Gross malformations (–) (–) (–) 15 points Non-threshold Nil Nil Nil Possible 5004718–27 weeks Mental retardation Nil Nil Nil 5% 1205 IQ score decline (–) (–) (–) 4 points 1205Throughoutpregnancy Fetal growth restriction Nil Nil Nil Possible 200–25048 Childhood cancer 0.002% 0.002% 0.1% 1% None Fetal adult cancer 0.006% 0.060% 0.3% 3% None 122

S. Ismanto: Decision Making Processes for a Pregnant Womanto delay non-urgent radiographs during the The obstetrician examining the state of thesensitive period of 10–17 weeks of gestation. woman’s uterus after Doppler was released andTable 1 highlights the possible effects of X-ray says that the fetus remained in good positionto pregnancy in accordance to its gestationional and confirmed that the patient was at her 20age. weeks gestation. The orthopedic palpated the ankle and intuitively diagnosed as a completedThe Case displaced fracture of the left fibula proximal cruris. However, a radiologic X-ray wouldA 35 years old pregnant patient at her 20 weeks verify the palpated complete displaced fracture.of gestation was admitted to the accident andemergency department with suspected fracture After 8 Hours in the Accident andof the left ankle as a result of a motor vehicle Emergency Departmentaccident. Statement was taken by emergencytriage healthcare professionals. The author being the radiographer understood that if X-ray was not done the suspected fracture Patients came to the Emergency Room with of the left ankle of the patient might have athe condition of left ankle pain thus it could not delayed anticipated surgical operation. Inbe freely moved. Physician on duty diagnosed addition, the author also knew that if a fractureand palpated the left ankle which appeared was present, and surgery was delayed andswollen and sore with bluish discolouration. complications could be anticipated to occur hence it might lead to amputation. Table 2Upon Admission to the Accident highlights the complications of fractures if notand Emergency treated, managed and cared for within 8 hours from the time of injury.The physician instructed the nurse in charge togive intravenous Lactated Ringers fluid, 500 The decision was made after havingmilliliters at 5 drops per minute that might help consultation between the radiographer,replace electrolytes that were lost during an radiologist and medical physicist to require aevidence of vasoconstriction as an effect of pain written request form for X-ray examinationand hooked to an oxygen mask at 1 milliliter from the orthopedic surgeon was the initial stepof air to help relax the muscles, thus helped taken during the first 8 hours. A conventionalrelieve the pain. A measurement of blood routine and lateral ankle mortis was requiredpressure with the result 140/80 millimeters of because of low radiation position as wasmercury, saturated partial oxygenation result specifically recommended by the obstetricians.of 90% and heart rate and rhythm of 120 beats The author being the radiographer who wouldper minute at regular beats were assessed. perform radiologic examinations for theThe physician also instructed the midwife pregnant mother should consult the physician.on duty in the delivery room to help checkthe fetal condition by conducting a Doppler Finally, the patient would be asked byultrasonography examination and referred the author to fill out a consent form for ait to the obstetrician in charge. The Doppler radiological examination and approval actionexamination result showed a fetal heart rate of letter from the orthopedic surgeon for the left134 beats per minute which was anticipated by ankle X-ray.obstetricians to be a normal fetal condition. Inaddition to the obstetrician referral, the accident However, the author still discussed decisionand emergency department physician in charge options found on Figure 1, in the form of areferred the patient to the orthopedic surgeons decision tree with orthopedic surgeon. Thesesince a fracture was suspected. 123

ASEAN Journal on Science and Technology for Development, 32(2), 2015Table 2. highlighted the complications of fractures if not treated (Høiness & Strømsøe 1999).Types of closed fractures Complications if untreated within 8 hoursComminuted Embolism, deep vein thrombosis and crush syndromeDisplaced Embolism, systemic hypovolemia and compartment syndromeGreenstick Volkmann’s ischemia and fat embolismSpiral Volkmann’s ischemia and fat embolismOblique Volkmann’s ischemia and fat embolismTransverse Volkmann’s ischemia and fat embolismImpacted Embolism and compartment syndromeX-Ray Mortis view and lateral projection (50% practiced) Yes CT scan ankle (25% practiced) MRI ankle (15% practiced) Transfer to surgery room (90% practiced) No Transfer to regular ward (10% practiced) Figure 1. The decision tree divided into probabilities.options were used for suspected fractures readily positioned), in order to show a clear, twoamong pregnant women that was based on space joint both laterally and medially, usingclinical guidelines in outlining options. 18 × 24 centimeter film tapes placed under the ossa calcaneus, central ray perpendicular toUpon Transfer to the Radiology Room the vertical central point on the ankle joint and lateral thalo-cruralis with 90 centimeter filmThe mortis view and lateral projection was focus distance (FFD) (Whitley et al. 2005).decided upon by the orthopedic surgeon. Theauthor took the patient to the X-ray department The author covered the patient with leadand placed her in the supine position to take Apron 0.5 millimeters Pb thickness up to thethe X-ray of the left ankle, in the anterior- thigh as a form of radiation protection to reduceposterior — basic (Mortice projection) and the scattering of radiation (Kim et al. 2012). Thelateral view, the mid-section and then rotated exposure factor made as low as possible 50 kilothe feet in towards the inside (endo-rotation) voltages peak (kVp) at 6 milliamperes secondsby 20 degrees. The elevation to the lateral (mAs) without using stationary grid (Whitleymalleolus parallel to the medial malleolus of the et al. 2005). The X-ray results were printed bypatient’s left ankle was positioned (in case the the author and delivered to the radiologist to belegs stays straight without rotation, the lateral interpreted. Radiologists gave a written report,malleolus, and the lower medial malleolus are that a visible completed displaced fracture of 124

S. Ismanto: Decision Making Processes for a Pregnant WomanFigure 2. The left mortise view with fracture (see appendix for radiologist’s interpretation).the left lateral and medial malleolus was seen them, such as maternal skull or chest X-ray, ison the X-ray film as intuitively hypothesized. extremely low therefore, the further the target area from the embryo or fetus, the less the Table 3 shows the clinical guidelines for exposure and risk of radiation and vice versaradiographers providing X-rays for a pregnant (Eskandar et al. 2010). The American Collegewoman that was a skill demonstrated by the of Obstetrics and Gynecology (ACOG) statesauthor in this case study. that exposure to <5 rads is not associated with an increase in fetal anomalies or pregnancy Doses for the same procedures vary widely loss. For instance, a chest X-ray gives of <0.001between patients and hospitals. However, the rads, while a pelvic radiograph (Hart 2005).absorbed dose of the embryo or the fetus where Table 4 shows radiation doses for ankle ( lowerthe X-ray beam does not directly irradiate extremity ) X-ray examination is safe.Table 3. Clinical guidelines for radiographers (Whitley et al. 2005; Kim et al. 2012).Stage 1: Re-evaluation Patient was transferred to the examination table and was positioned. Physicians’ orders are transcribed for the target organ to be filmed.Stage 2: Transcription The request was to film the antero-posterior – basicof physicians’ order (Mortice projection) imagery of the ankle and lateral projection. The film tapes with the size of 18 × 24 centimeters is placed under the ossa calcaneus.Stage 3: Proper The position of the object (ankle) is slightly stretched, to the central raypositioning perpendicular to the vertical beam of the X-ray with the central point on the thalo-cruralis joint and ankle laterally with FFD at 90 centimeters gap.Stage 4: Provisions of The patient was covered with lead apron at thickness of 0.5 millimeters ofsafety lead up to the thigh as a form of radiation protection. This will reduce the scattering of radiation. The time factor is made as low as possible exposure of peak kilo voltage at less than 50:6 mAs without using the lisolm grid board. 125

ASEAN Journal on Science and Technology for Development, 32(2), 2015Table 4. Approximate fetal radiation doses of common diagnostic procedures (McCollough et al. 2007). Procedure mSv Mean dose mGy (rad)* Maximum dose mGy (rad)*X-Ray 1 1.4(0.14) 4 (0.4) Abdomen 1.7 2.9 (0.29) 15 (1.5) Kidney, ureter, and bladder 0.02 Less than 0.01 (0.001) Less than 0.01 (0.001) Chest 10 to 20 1.7 (0.17) 10 (1); 0.37 to 2.64 Intravenous urogram/ (0.037 to 0.264) pyelogram 1.3 1.7 (0.17); 3.4 (0.34) Less than 0.01 (0.01) Lumbar spine 0.7 1.1 (0.11); 3.4 (0.34) 4 (0.4); 22 (2.2) Pelvis 0.07 Less than 0.01 (0.001); Less than 0.01 (0.001) Skull 0.04 (0.004) Less than 0.01 (0.001);Thoracic spine 0.7 Less than 0.01 (0.001) 0.03 (0.003)Dental Less than 0.001 (0.0001); 0.2 (0.02) Less than 0.01 (0.001) 0.51 to 1.4 (0.051 to 0.14)Upper/lower extremity Less than 0.01 0.01 (0.001)Mammogram 0.6 Less than 0.05 (0.005)Hip 0.3Computed Tomography 10 8 8 (0.8); 7.6 (0.76) Abdomen Chest 8 0.06 (0.006) 0.96 (0.096); Hand less than 1 (0.1) Lumbar spine Pelvis** Less than 0.005 (0.0005) Less than 0.005 (0.0005) Head Pelvimetry 2.4 (0.24); 7.5 (0.75) 8.6 (0.86); 40 (4) 7.1 25 (2.5) 79 (7.9) 2.3 Les than 0.005 (0.0005) Les than 0.005 (0.0005) 0.2 (0.02) 0.4 (0.04)Fluoroscopy 1.1 (0.11) 5.8 (0.58); 0.56 (0.056) Upper GI 7 6.8 (0.68); 10 (1) 24 (2.4); 130 (1.3) Barium enema** 15 1.1 (0.11) (0.58) Barium swallow*Duplicate values represent different estimations in the literature.**Highlighted rows indicate potential of more than 50 mGy. When managing the pregnant patient, the with radiation and means by which this riskmajor role of the medical physicist was to could be reasonably limited.estimate absorbed dose to the conceptus of apregnant patient from selected diagnostic or The accepted background cumulativeinterventional procedures, either prospectively dose of ionising radiation during pregnancyor retrospectively. The physicist also consulted is 5 rad (50 mGy), which is much more thanwith the radiologist regarding risk associated the exposure dose of most of the diagnostic 126

S. Ismanto: Decision Making Processes for a Pregnant Womanradiological examinations. Current evidence judgment errors (Thompson & Dowding 2002)suggested that there was no increased risk of especially when patients or relatives are keymajor malformations, growth restriction or decision makers (Say & Thomson 2003).miscarriage from radiation doses of <5 rad(50 mGy), compared with background risks Lastly, a prescriptive model uses informationin non-exposed foetuses which were 3%, 4%, processing theory (IPT) as a prescriptive tool toand 15%, respectively. There was also evidence assist practitioners in enhancing decision tasksthat gross congenital malformations would not to analyze sources, principles and findings ofbe increased in a human pregnant population previous research or clinical guidelines withexposed to a dose of <20 rad (200 mGy), algorithms (Shaban 2012). Table 5 summarizeswhich was considered the threshold dose. A the three decision-making models.dose of >250 mGy might be associated witha 0.1% risk of fetal malformation. However, The Prescriptive Decision-makingmicrocephaly, microphthalmia, genital andskeletal malformations, cataracts and small for The IPT used clinical guidelines forgestational age have been clearly observed in radiographers found on Table 3. The guidelinehuman embryos and fetuses exposed to >1000 started with re-evaluation of the physician’smGy (Eskandar et al. 2010). order, followed by the transcription of the order, followed by the proper positioning and Methodology ends with provisions of safety for the patient (Whitley et al. 2005).This section examines and evaluates how thethree basic models of decision-making — the IPT Step One: Cue Acquisitiondescriptive, prescriptive and normative — wereapplied. Physical examination such as assessing the heart rate and rhythm, blood pressure, saturated A descriptive decision is characterized by partial oxygen in percentage and threshold ofunderstanding how individuals make judgments pain were acquired in order to determine theand decisions focusing on the actual conditions, vital signs of the patient (Hart 2005). Bio-contexts, ecologies and environments in which physiologic apparatuses used blood pressurethey are made (Shaban 2012). An advantage and stethoscope for auscultation to see theof the descriptive models is the adequacy in possibility of gestational hypertensions, andsupporting Assumptions made about decision- irregular rhythm of the heart. Doppler ismaking processes with relevant examples from also used to assess the fetal heartbeat and itsa suitable period of observation (Shaban 2012). gestational week (Hart 2005). These cues wereAn example is intuition (Bell et al. 1988). acquired in order to hypothesize on exposure of the embryo or fetus to high dose ionizing A normative model in decision-making radiation could potentially lead to some adverseprocess is characterized by rational, logical health effects. However, the radiation dose toand scientific procedures supported by clear the embryo or fetus that is likely to result fromor probable evidence (Harrison 1996; Offredy any diagnostic procedures should present no1998; Shaban 2012). Statistical analysis with risk of causing any deterministic effects such asdecision trees of large-scale experimental and foetal death, malformation, growth retardation,survey research is representative of a population or mental retardation (Osei & Darko 2012). Buttarget where the findings are information sources more importantly, palpation of the left ankle toin a normative decision (Bell et al. 1988). The determine fracture was an important cue thatadvantages enable decision-makers to minimize was lastly acquired. 127

ASEAN Journal on Science and Technology for Development, 32(2), 2015Table 5. Summary of three decision-making models (Bell et al. 1988; Shaban 2012; Dioso, 2015).Characteristics Normative modelInformation sources Rational, logical, scientific, evidence based decisions.Examples Statistical analysis of large-scale experimental and survey research which isAdvantages representative of a target population where the findings can be applied. Clinical trials that test the efficacy of new medicines and treatments. Enable decision-makers to predict and explain the outcomes of decisions and minimize judgment errorsCharacteristics Prescriptive modelInformation sources Frameworks or guidelines designed to enhance specific decision tasks.Examples Principles and findings of previous scientific research (associated withAdvantage normative models). IPT using clinical guidelines Research-based and evidence-based decision-making.Characteristics Descriptive modelInformation sources Understanding how individuals make judgments and decisions focusing onExamples the actual conditions, contexts, ecologies, and environments in which theyAdvantage are made. Observation, description and analysis of how decisions are made by managers and professionals in relation to their day-to-day responsibilities. Intuition and pattern recognition Adequacy in supporting assumptions made about decision-making processes with relevant examples from a suitable period of observation.IPT Step Two: Hypothesis Generation rad (50 mGy), which was much more than the exposure dose of most of the diagnosticA complete displaced ankle fracture was radiological examinations. The risk ofhypothesized when an oedema was noted and microcephaly and severe mental retardationthe patient could not move the legs without with high exposure began at 10 weeks offeeling pain. Therefore if it was not immediately gestation. This risk was greatest at 10–17 weeks,diagnosed with X-ray, surgery could be with less risk at 18–27 weeks.delayed hence, it would cause decay resultingto an anticipated amputation. Physicians IPT Step Three: Interpretation of Cueshypothesized that an X-ray should be done asa guideline before deciding to undergo surgery. The pregnant patient was having a left completeIt was also hypothesized that the fetus would displaced ankle fracture verified by X-ray. Inbe in safe condition as verified by the Doppler addition, she primarily needed plain Lactatedultrasonography result. Ringers solution as intravenous drip in order to replace the electrolytes that were lost An amount of 0.001 rads doses of lower because of the experienced pain during theextremity (ankle) was recommended to the vehicular accident. In addition, intravenouspatient for 20 weeks gestation. While the fluid replacement was necessary to increase heraccepted background cumulative dose of electrolyte count before surgery, especially forionising radiation during pregnancy was 5 pregnant patients. 128

S. Ismanto: Decision Making Processes for a Pregnant Woman Lastly, pain must be controlled before tissues, like ligaments. For some ankle fractures,undergoing X-ray, since positioning the ankle an MRI scan may be done to evaluate the anklemight induce more anticipated pain. Therefore ligaments (Michelson 2003).oxygen was important to be provided in orderto relax the muscle that was de-oxygenized after The Normative Decision-makingthe accident. Decision options were presented to theIPT Step Four: Hypothesis Evaluation orthopedic surgeon. Understanding the principles, diagnostic value and safety ofIn this step, the patient at 20 weeks gestation imaging to the fetus and the mother, and ofmust be made safe from the X-ray radiation. various diagnostic modalities at differentRadiation protection in diagnostic radiography stages of pregnancy, is essential to select thewas essential if medical exposure to ionising most appropriate imaging modality (Eskandarradiation was to be maintained at a level of et al. 2010), MRI was preferred to CT orminimal acceptable risk. The concept of risk conventional X-rays for a large number ofwas an important one and it was essential medical problems, particularly those connectedthat we reduced risks to the patient and staff with injury or disease of the central nervousthrough the justification, optimisation and system (Eskandar et al. 2010).limitation of radiation exposures. Adaptedfrom National Radiation Protection Board The Descriptive Decision-making(1994) Justification: No practice involvingexposure to radiation should be adopted unless By intuition, the author trusted that the patientit produces net benefit to those exposed or to was positive with fracture of the left ankle.society. Optimisation: Radiation doses and risks This was why in the decision option found onshould be kept as low as reasonably achievable, Figure 1, it recommended surgery withouteconomic and social factors being taken into X-ray. It was also because the findings of theaccount; constraints should be applied to dose vital signs and palpation examination of theor risk to prevent an unacceptable degree left ankle, the patient was positive to have aof exposure in any particular circumstance. complete displaced fracture.Limitation: The exposure of individuals shouldbe subject to dose or risk limits above which the It is important to trust an intuition if it isradiation risk would be deemed unacceptable also based on recognized patterns of previously(Hardy & Boynes 2008). encountered similar cases (Dioso 2015). The author being an expert radiographer could X-ray are the most common and widely intuitively perceive signs of fracture justavailable diagnostic imaging technique. X-ray by means of interview. The author has alsocould show if the bone was broken and whether intuitively hypothesized at the late stage ofthere was displacement (the gap between broken the patient’s admission to the accident andbones). They also showed how many pieces emergency (8 hours after) that signs of fractureof broken bone there were. X-rays might be is evident. Therefore trusting the intuition istaken of the leg, ankle and foot to make sure just the same as looking back at the patternsnothing else was injured. CT scan type of scan of previously encountered cases (Dioso 2015).create a cross-section image of the ankle andsometimes done of further evaluate the ankle However, it is important to take cautioninjury. It was especially useful when fracture using intuition during the early part ofextends into the ankle joint. MRI Scan provide consultation. This is because an intuition is ahigh resolution images of both bones and soft substandard way of decision-making that is 129