The Implementation of Indonesian Standards for Health Promotion in Hospitals: A Self-Assessment Study in a Private Hospital in Depok City

Introduction

In 2018, the Indonesian Ministry of Health developed specific documents related to implementation of health promotion program in a hospital.^1,2 This regulation mandates that hospitals should implement health promoting hospital (HPH) standards. The standard includes four key areas, namely 1) health promotion policy and management, 2) health promotion assessments for patients, families, staff, visitors, and the surrounding community, 3) health promotion interventions, as well as 4) monitoring and evaluation of health promotion activities.² This standard was an update of the previous standard launched in 2014, when during its development, the Government adopted the World Health Organization Standards for Health Promotions in Hospitals with several adjustments. ¹ The 2006 Standards for health promotion in hospitals contained five standards including management policy, patient assessment, patient information and intervention, promoting a healthy workplace, continuity and cooperation.³

Later, the International Network of Health Promoting Hospitals and Health Services launched a new standard in 2020 with new standards including demonstrating organizational commitment for HPH, ensuring access to the service, enhancing people-centered health care and user involvement, creating a healthy workplace and healthy setting, and promoting health in the wider society. ⁴ The concept of health promoting hospitals is primarily based on the health promotion principles outlined in the WHO Ottawa Charter, emphasizing the reorientation of healthcare services as one of five key action areas for comprehensive health promotion development.⁵ The health promoting hospitals concept centered on an organizational development strategy aimed at reorienting governance, policy, workforce capability, structures, culture, and relationships to enhance the health outcomes of patients, staff, and community populations.⁶ Therefore, health promoting hospitals play a pivotal role in promoting health patients, staff, visitors and community members.⁷

Various international studies have been conducted on the implementation of HPH,^8,9 as well as the impact on staff satisfaction and other stakeholders.^10,11 In Indonesia, studies at three Muhammadiyah hospital in Jakarta examined the implementation of six standard based on the 2012 ministry of Health guidelines.¹² Another study in Jakarta reported different results, showing that hospitals were not ready to implement health promotion according to the 2011 standard.¹³ Additionally, there is a related study, which analyses the impact on patient loyalty.¹⁴ However, the study related to the implementation of health promoting hospital standards in line with 2018 ministry of Health guideline has not been conducted. Therefore, this study aimed to describe the implementation of HPH standards at one private hospital in Depok City, Indonesia, through a self-assessment approach.

Methods

This cross-sectional study was conducted at a private C Class hospital in Depok city. Indonesia divides hospital classes into four classes, ranging from class A to class D. Class C hospitals must have a minimum of 100 inpatient beds, while class B and A hospitals must have a minimum of 200 and 250 inpatient beds, respectively. The city is located next to Indonesian capital city of Jakarta. Data collection was carried out from October to December 2023. In this study, we employed one of the purposive sampling techniques, namely total sampling, by selecting all staff members of the HPH unit within the hospital as participants. The HPH unit in the hospital consists of 20 personnel from various departments, including customer service, medical information, nursing, and the medical department and infection prevention and control unit. The HPH unit is tasked with overseeing and implementing health promotion across all hospital programs and activities, including HPH planning, information, education, and communication (IEC), and community empowerment; formulating guidelines and media for health promotion; and conducting monitoring and evaluation. We strictly selected personnel from the HPH unit for the research sample, as hospital staff outside this unit lacked knowledge of the managerial processes and HPH activities, which could introduce bias in their responses if they were included as respondents in this study.

A total of twenty healthcare professionals, including nurses, physiotherapists, laboratory technicians, midwives, and pharmacists, were selected as samples using a non-probability method. The questionnaire consisted of two parts. The first part covered the socio-demographic details of the respondents, including age, gender, profession, and work experience. Meanwhile, the second part assessed health promoting hospital standards. This study adopted the assessment based on the guidelines issued by the Indonesian Ministry of Health in 2018. The standard included four components, namely policy and management, assessment, intervention, as well as monitoring and evaluation with 13, 6, 12, and 4 questions, respectively. Responses to each question used a 4-point Likert scale to show the level of agreement, ranging from strongly disagree to strongly agree, regarding the implementation of each component of the four standards. We use an even number of points on the scale to minimize the effect of the social desirability bias.¹⁵

In the policy and management standard, assessment includes the existence of written regulations and guidelines issued by hospital leaders that support the implementation of health promotion for patients, families, hospital staff, hospital visitors, and the surrounding community to ensure optimal, coordinated, and sustainable health promoting hospital standard. Assessment standard covered the implementation of health promotion assessments for these parties so hospital staff understand the target profile as a basis for determining health promotion activity needs. Health promotion intervention standard explored systematic efforts by applying methods and strategies based on assessment results to change the behavior of patients, families, staff, visitors, and the surrounding community so they are able to identify disease risk factors, improve the ability to manage the factors, make appropriate health-related decisions, and avoid recurring illnesses due to the risky behaviors. The monitoring and evaluation aimed to determine the extent to which health promoting hospital standards were achieving objectives and sustainable according to standard.²

Before data collection, the content validity of the questionnaire was tested by reviewing the questionnaire with hospital management experts. Data collection was conducted using an online form distributed by hospital management to the health promoting hospital team. Prior to answering the questionnaire, respondents received an explanation of the research objectives and purposes in the initial informed consent form. The respondents who consented to complete the questionnaire agreed with the research’s informed consent. Respondents who agreed to participate completed the questionnaire, with no penalties for those who declined, and electronic money worth 25,000 IDR (approximately 1.25 USD) was provided. This study received ethical approval from the University of Indonesia Hospital with an approval number S-078/KETLIT/RSUI/XI/2023. Descriptive analysis was performed to show the quantity, mean, and standard deviation to describe the socio-demographic characteristics as well as the components of health promoting hospital standard using SPSS version 29.0.

Results

The majority of respondents were female (n = 16, 80.0%) aged 31 to 40 years and had an average of 8.65 years of employment. The respondents included 12 nurses, 4 laboratory technicians, 2 midwives, 1 physiotherapist, and 1 pharmacist, as reported in Table 1. Figure 1 shows the scores for each health promoting hospital standard, with a maximum score of 100. Assessment standard had the highest average score at 73.72, followed by the intervention at 72.71. Meanwhile, the lowest score was found in monitoring and evaluation standard, at 67.82. Table 2 shows the scores for each component within each standard. The results reported that almost every component within each standard had an average score below three which means that the staff did not agree with the good implementation of each component. The components with an average score of 3 or above included the availability of guidelines for assessing health risk factors, the availability of IEC (Information, Education, and Communication) media on disease risk factors, as well as activities providing information and education on general health.

Table 1 Sociodemographic Characteristics

Table 2 Score of Health-Promoting Hospital per Component in Each Standard

Figure 1 Average score per standard of health promoting hospital.

Discussion

The implementation of health promoting hospital standards has not achieved optimal scores, particularly the policy and management standards as well as monitoring and evaluation with scores of 69.81 and 67.82, respectively. Comparisons with studies from other countries were challenging due to variations in assessment standards; however, the standards employed in various international studies demonstrated similarities across several sub-standards. Multiple studies in Azerbaijan and Iran indicate that the management standards and health promotion policies in hospitals were suboptimal, with scores ranging from 35.29 to 73.33.^16–18

This study implies that the policies and management practices to support the sustainable and well-coordinated implementation have not been well established. In practice, the authors view health promotion activities are primarily focused on patients, with minimal attention given to promotion for healthcare workers, visitors, and the surrounding community near hospitals. Studies conducted in Indonesia also showed that the programs aimed at creating smoke-free areas have not been optimally implemented.¹⁹ It might be caused by the low prioritization of health promoting hospitals in hospital missions.²⁰ Organizational changes oriented towards becoming a health-promoting hospital are necessary. One of the studies identified four strategies to aid in the early stages of hospital redevelopment, namely engaging actors, planning and training, learning from the past, and increasing managerial engagement.²¹ Various stakeholders, such as the city health office, government-owned primary healthcare centers, and community organizations could be involved to support the implementation. Additionally, continuous education and training, particularly staff responsible for managing the health promoting hospital standard, are needed to improve health promotion management and activities.

Numerous studies in Indonesia indicate that the execution of health promotion in hospitals is suboptimal due to the insufficient quantity and quality of human resources in these institutions. The restricted capacity of healthcare professionals to conduct health education and communication may impede health promotion initiatives.²² The scarcity of health workers imposes a burden on the staff of the health promotion unit. This leads to suboptimal management and health promotion activities in hospitals.²³ Hospital managers could organize training sets to improve health professionals knowledge and skills related to health promotion activities in hospitals.²⁴ The subpar evaluation of Health Promoting Hospital Standards may adversely affect the efficacy of health promotion activities within hospitals. If health promotion in hospitals is not executed effectively, the benefits of Health Promoting Hospitals including the enhancement of comprehensive medical and nursing services, the promotion of healthier behaviors and lifestyles, the prevention of diseases among healthcare workers and patients, and the increased engagement of health workers, patients, and the community—cannot be achieved.^25,26

There are several notes that can be taken regarding the Indonesian health promotion in hospitals guidelines. The guideline requires ongoing development and may reference those established by the International Network of Health Promoting Hospitals and Health Services, acknowledging updates have been made in the guideline that emphasize more on patients’ or consumers’ rights, primary health care, quality enhancement, environmentally sustainable health care, and health-literate organizations. The Ministry of Health can collaborate with various stakeholders, including hospital associations and academics, to jointly develop self-assessment tools for guideline implementation. These tools can assist hospitals in the execution of health promotion initiatives.

This study has several limitations. This study only included a private hospital located in an urban area and might not represent conditions in Indonesia. This study solely employs the self-assessment method to assess the implementation of standards, disregarding other methods such as objective measures, observation and document analysis. In future studies, mixed-method methods should be adopted to provide a more in-depth depiction of the standard implementation. Furthermore, an Indonesian version for health-promoting hospital standard self-assessment should be established to facilitate ongoing internal enhancement, realign the organization’s strategy to effectively tackle comprehensive health system challenges, and genuinely transform the organization into a health-promoting environment.⁴

Conclusion

In conclusion, health promoting hospital standard, including policy and management, assessment, intervention, as well as monitoring, and evaluation, needs an improvement to enhance the effectiveness of the implementation. Management and policy standards as well as monitoring and evaluation were the standards that should be prioritized to enhance the effectiveness of the implementation. In this context, training for healthcare leaders and workers to enhance awareness of the significance of health promotion in hospitals and to improve their knowledge and skills in managing and implementing health promotion initiatives should be provided. Moreover, hospital leaders possess the capacity to formulate policies and technical regulations that facilitate the execution of regular monitoring and evaluation activities. This will enable the outcomes of these activities to augment and sustain health promotion initiatives in hospitals.