Download KNOWLEDGE AND PRACTICE ON CALCIUM SUPPLEMENT

KNOWLEDGE AND PRACTICE ON CALCIUM SUPPLEMENT AMONG
PRIMARY CARE PATIENTS ATTENDING OUTPATIENT CLINIC AT
PUSAT PERUBATAN PRIMER UKM
PRIMARY INVESTIGATOR : DR AIDA BT JAFFAR
K13591
FAMILY MEDICINE DEPARTMENT
CO INVESTIGATOR
: DR FATHIMA BEGUM BT SYED MOHIDEEN
P49543
FAMILY MEDICINE DEPARTMENT
Page
TABLE OF CONTENT
CHAPTER
I
1
INTRODUCTION
1.1
Introduction
3
1.2
Research Justification
4
1.3
Literature Review
4
1.4
Research Questions
7
1.5
Research Objective
7
1.6
Conclusion
8
CHAPTER
II
METHODOLOGY
2.1
Introduction
9
2.2
Background of the Study
9
2.3
Study Design
9
2.4
Target Population
9
2.5
Sampling Frame
10
2.6
Sampling Unit
10
2.7
Sampling Method
10
Inclusion and Exclusion Criteria
10
2.7.1
1
2.8
Sample Size
11
2.9
Study Tools
11
2.10
Study Protocol
12
2.11
Data Analysis
13
2.12
Research Ethics
13
2.13
Research Variables
13
2.13.1 Dependent Variables
13
2.13.2 Independent Variables
13
2.14
Variables Definition
14
2.14.1 Dependent Variables
14
2.14.2 Independent Variables
14
2.15
Conclusion
15
APPENDICES
A
Patient Infomation Sheet
16
B
Consent Form
20
C
Questionnaire
22
D
Working Activity Schedule
29
E
Budget
30
2
CHAPTER I
INTRODUCTION
1.1
INTRODUCTION
Calcium is an important mineral in the body for structure and physiological
function. It is abundantly found in the body structure whereby 99% of calcium is
found in the bone and teeth whereas another 1% of body calcium is required for
muscle and vascular contraction, vasodilatation, blood clotting, nerve transmission,
intracellular signaling and also for hormonal secretion (1). Knowing its function in the
blood, serum calcium is tightly regulated by the brain and kidney, thus does not
fluctuate with changes in the dietary intake of calcium. The bone, on the other hand is
used as a reservoir for and as source of calcium to maintain the constant concentration
of calcium in the blood, muscle and intracellular fluids (1).
Calcium can be found naturally in dairy foods like milk. Studies show that milk is
a good source calcium and magnesium (2). Previously, it was thought that those
patients taking calcium as supplementation to replace for low dietary calcium intake
may have magnesium deficiency. Magnesium deficiency can lead to increase in
parathyroid hormone that assists in reabsorption of magnesium in distal convoluted
tubule. But parathyroid hormone promotes calcium release from the bone, thus
resulting in osteoporosis with time (2). Magnesium although are able to be replaced by
supplementation, studies shows that magnesium supplementation for longer than 2
weeks however does not cause significant changes in bone resorption as it still can
occur causing osteoporosis at long run (3)(4)(5).
However, Green et al (2) in their study on acute effect of high calcium milk
showed that high calcium skimmed milk with or without additional magnesium has no
additional impact on serum parathyroid hormone or bone resorption that can cause
osteoporosis. But as dietary calcium like milk calcium is absorbed more slowly thus it
is better than taking elemental calcium. Yet for those not tolerating milk calcium,
elemental calcium can still be considered as it important to maintain adequate intake
of calcium everyday for bone health.
3
Vitamin D on the other hand, is a fat-soluble vitamin that is naturally present in
very few foods and also produced endogenously when the skin is exposed under the
sun (6). Vitamin D helps in calcium absorption in the gut and assists calcium to play
its physiological role. For instance, Vitamin D plays an important role in bone growth
and remodeling, thus preventing osteoporosis (6).
1.2
RESEARCH JUSTIFICATION
According to Malaysian Osteoporosis guideline 2012, calcium supplementation may
be required when the dietary calcium is inadequate. Nevertheless, the practice of
calcium supplementation has its own risk and benefit. Regan et al (7) in their study on
‘Why US Adults Use Dietary Supplements?’ shows that calcium is the second most
preferred supplement used after multivitamin. The user’s reported that their
motivation for calcium use is bone health (74%) but sadly 75% of their supplement
decisions are being made without the recommendation of a health professional.
Therefore, this study aimed to assess our primary care patient’s knowledge and
practice on calcium supplement and the associated sociodemographic factors
1.3
LITERATURE REVIEW
Bone continuously remodels. This physiological process is closely related to
human age and nutritional intake. There is constant resorption and deposition of
calcium into the bone whereby bone formation exceed resorption in periods of growth
in children and adolescents. Whereas in early and middle adulthood, both process are
relatively equal. However, in aging adults particularly in postmenopausal women,
bone breakdown exceeds formation, resulting in bone loss and increasing the risk of
osteoporosis and fracture(1).
Based on a study, Dietary calcium intake in postmenopausal Malaysian
women by Chee et al 2002 (8), shows that calcium intake is low among Malaysian
women. The mean calcium intake from the dietary records was 447.4 ± 168 mg/day
and from the FFQ it was 498.7 ± 211 mg/day. This is far behind than what is
4
recommended by the National Coordinating Committee on Food and Nutrition 2005,
Ministry of Health Malaysia. Based on National Coordinating Committee on Food and
Nutrition 2005, women aged more than 50 years old, should take at least 1000mg of
calcium per day (9). However, the recommendation refers to total intake per day for
both dietary and supplementation knowing the fact that our population generally takes
low calcium in their diet as shown by Chee et al (8). Nevertheless, Chee et al (8) study
shows that most of the calcium source was from diet as recommended, for instance,
vegetables and bean sources (32%), dairy products (26%), eggs, meat and seafood
(16%) and cereals (12%)(8).
Clinical Guidance on the Management of Osteoporosis 2012, suggest calcium
supplementation may be given when dietary intake is insufficient (10).This is because
calcium deficiency leads to reduction in bone mass due to the increase resorption of
calcium from bone for physiological function of the body. Therefore, contributes to
the development of osteoporosis among elderly in particular (11). As a consequence,
fracture to even trivial injury becomes common, especially among women and this is
associated with high disability and poor quality of life, increase in healthcare cost and
increase in mortality (12).
Similar to our guideline, Australian guideline also recommends diet with
sufficient calcium intake (13). However, supplements can be given for people at risk
of calcium deficiency yet are not meeting the recommended dietary intakes to prevent
fractures. Supplements are usually combined with Vitamin D as this promotes calcium
absorption.
Clinical Guidance on the Management of Osteoporosis 2012, also recommends
vitamin D supplements even among children and expectedly among adults who are
deficient of vitamin D (10)(14). As for the requirement, those adult who are 50 year
old or more, National Coordinating Committee on Food and Nutrition 2005, Ministry
of Health Malaysia recommends 400 IU of vitamin D per day (9). And expectedly,
elderly who are lack of outdoor activities, immobile, institutionalized and diet lack of
vitamin D will benefit from 800 IU per day (14). In addition, Vitamin D
supplementation has also shown improvements in muscle strength, balance and risk of
falling, and also improves in survival (15) (16).
As for the calcium supplements, there are many types available. Commonly,
there are calcium carbonate, lactate, citrate and gluconate. Among these, calcium
5
carbonate has the highest elemental calcium that is about 40%, followed by citrate
21% and lactate 13% (10). In our clinical setting, calcium carbonate and lactate are
commonly used. Calcium carbonate is absorbed most efficiently with food as its
absorption is dependent on gastric acid for absorption (17). Nevertheless, percentage
of calcium absorbed depends on total elemental calcium in a calcium supplement (1)
and calcium carbonate has the highest elemental calcium that is about 40% (10). As
recommended, for maximum absorption, the amount of calcium taken should not be
more than 500mg to 600mg per dose. But for those patients needing more than 600mg
of calcium supplement per day, the dose can be taken as divided doses (10).
However, some of this absorbed calcium will be eliminated in sweat, urine and feces
and this amount is affected by the type of dietary intake (1). For instance, taking
coffee and tea can modestly increase calcium excretion and reduce absorption (18).
Nevertheless, there is another study showing that moderate intake of caffeine that is
one cup of coffee or 2 cups of tea per day in young women has no negative effects on
bone (19).
Use of calcium supplement has a conflicting report, whereby some data
suggest that excessive use of calcium supplementation is associated with
cardiovascular event (myocardial infarction and stroke) (20)(21)(22)(23)(24). In
addition, from a meta-analysis, calcium supplement taken without vitamin D increases
the risk of MI (21). However, the risk of cardiovascular events observed in these
studies involves high doses of calcium supplements (1000-2000mg). Lower doses are
considered to be safe (10). Similarly, in a systemic review; calcium supplements do
not significantly increase the risk of nephrolithiasis or renal colic if taken in
recommended doses (25). In addition, based on NHANES 2005-2006 study shows
that high intake of calcium beyond the recommended dietary allowances provide no
benefit for lumbar and hip bone mineral density in older adult (50-70y.o) (26).
Another issue is that, there are some patients who rather be on calcium
supplementation than taking dairy foods which are known to have high calcium level
but can cause high serum cholesterol. From a systemic review which shows that the
effects of dairy foods on Coronary Heart Disease, it is proven that calcium rich food
are not associated with a higher risk of Coronary Artery Disease (27).
Recently U.S PSTF, published an article on 7th May 2013, suggesting against
daily supplementation with 400 iu or less vitamin D3 and 1000mg or less of calcium
6
for the primary prevention of fractures in noninstitutionalized post-menopausal
women (D recommendation) (25). This is because the current evidence is insufficient
to assess the balance of the benefits and harms of combined vitamin D and calcium
supplementation for the primary prevention of fractures.
1.4
RESEARCH QUESTIONS
1) What is the knowledge of primary care patient’s calcium supplement?
2) How is the practice on calcium supplement among our primary care patients?
3) Does sociodemographic factor influence the level of knowledge and practice
on calcium supplement?
1.5
RESEARCH OBJECTIVE
1.5.1
General Objective
To study on knowledge and practice of calcium supplement among primary care
patients attending outpatient clinic in Pusat Perubatan Primer, UKM.
1.5.2
Specific
1) To describe the knowledge on calcium supplement among primary care patient
2) To describe the practice on calcium supplement among primary care patient.
3) To describe the association between knowledge and practice on calcium supplement
4) To describe the association between knowledge, practice on calcium supplement and
sociodemographic factor among patients attending outpatient clinic in Pusat Perubatan
Primer, UKM.
7
1.6
CONCLUSION
It is important to know primary care patients‘ understanding and practice on calcium
supplement as calcium supplement has its own risk and benefit.
8
CHAPTER II
RESEARCH METHODOLOGY
2.1
INTRODUCTION
Cross sectional study will be conducted among primary care patients attending
outpatient clinic at Pusat Perubatan Primer, Universiti Kebangsaan Malaysia.
2.2
STUDY BACKGROUND
The study will be conducted in Outpatient Clinic, Pusat Perubatan Primer, Universiti
Kebangsaan Malaysia. There are 2 groups of patient attending this clinic. Those walk
in cases for acute problems and the other groups are on appointment basis, attending
for chronic diseases mainly diabetes, hypertension with or without complications.
There are also patient attending for asthma and chronic airway disease. This clinic
located at Bandar Tasik Selatan, Cheras.
2.3
STUDY DESIGN
Cross-sectional study
2.4
TARGET POPULATION
All patients attending outpatient clinic (age more than 20), Pusat Perubatan Primer,
Universiti Kebangsaan Malaysia.
9
2.5
SAMPLING FRAME
All patients attending outpatient clinic (age more than 20), Pusat Perubatan Primer,
Universiti Kebangsaan Malaysia who meet the inclusion and exclusion criteria.
2.6
SAMPLING UNIT
Patients attending outpatient clinic (age more than 20), Pusat Perubatan Primer,
Universiti Kebangsaan Malaysia who meet the inclusion and exclusion criteria from
1st April 2013 to 31st June 2013.
2.7
SAMPLING METHOD
Systematic sampling
2.7.1
Inclusion and exclusion criteria
i. Inclusion criteria for this study:
a. Adult, age more than 20.
b. Malaysian
c. Consented participant
ii. Exclusion criteria for this study:
a. Unable to read, write or understand Malay or English language (questionnaire only
available in Malay or English version).
b. Patient with underlying malignancy and hyperparathyroid
c. Patient with medical problem requiring calcium as supplement
10
2.8
SAMPLE SIZE
The sample size calculation for this study design was done using the formula as below
(Kish L. 1965):
Sample size, n = (Z1-α)²P(1-P)
D²
n
=
sample size
Z
=
Z statistic for confidence interval, Z1-α = 1.96 (standard value for
normal distribution data at significant value or alpha (α) at 0.05)
P
=
prevalence or expected prevalence is 0.5*
D
=
degree of significant
*After many literature review done, there is no similar study elsewhere, thus expected
prevalence used in this study will be 50% or 0.5.
Sample size, n = (1.96)² 0.5 (1- 0.52)
0.05²
= 365
Considering 10% drop out in view of possible incomplete questionnaire or unmet
inclusion and exclusion criteria. Therefore the sample size needed for this study is 402
respondents.
2.9
STUDY TOOL
A questionnaire will be developed for this study on knowledge and practice of
calcium supplement among primary care patients in 2 main languages that is in
Bahasa Melayu and English. This questionnaire is based on literature reviews
regarding calcium supplement and is divided into 3 parts:
Part A: Assess on sociodemographic data has 6 items.
Part B: Assess on knowledge of calcium supplement has 12 items
11
Part C: Assess on practice on calcium supplement has 12 items
At total there are 30 questions.
This questionnaire will be discussed by the expert panel involving 1 Orthopedic
specialist, 2 Family Medicine Specialist, and a pharmacist. Later, the questionnaire
will be translated backward and forward before the pilot test.
2.10
STUDY PROTOCOL
Approval from Ethics
Excluded
from study
if disagree
Patients attending outpatient
clinic are chosen by systematic
sampling
Subjects briefed on the study, consent
taken and given questionnaire. Both
groups of patients, taking and not
taking calcium supplements will be
included in the study
Data Collection
Data analysis and report writing
12
2.11
DATA ANALYSIS
Data will be analyze using SPSS software version 22.0. The analysis will use
descriptive statistics for all study variables and all items in the questionnaire. Chisquare will be used to test for significant association between categorical variables of
socio-demographic factors, practice and knowledge on calcium supplement.
Parametric test will be used for normal distribution data while non-parametric test will
be used for non-normally distributed data. The results are considered to be significant
if p < 0.05.
2.12
RESEARCH ETHICS
This research will be conducted on a voluntary basis where the selected respondents
will voluntarily agree to take part in this study. All respondents will be briefed
regarding the manner and purpose of this research. All respondents who agree to take
part in this study will have to give their written consent to participate in this research.
Permission to carry out this study will be acquired through a written consent from
Research Ethics Committee in Universiti Kebangsaan Malaysia.
2.13
STUDY VARIABLES
2.13.1 Dependent variable
Knowledge and practice on calcium supplement
2.13.2 Independent variables
Socio-demographic factors
i. Gender
ii. Age
iii. Ethnicity
iv. Level of education
13
v. Employment status
vi. Household income
2.14
VARIABLES DEFINITION
2.14.1 Dependent variable
Practice will be measured in percentage and knowledge on calcium supplement will
be categorized into three groups based on the marks from likert scale
2.14.2 Independents variables
i. Gender
Gender is categorised into male and female.
ii. Age
Age of the case respondent is defined as the age of patient based on the date of birth
stated in MyKad.
iii. Ethnicity
Ethnicity is categorised into Malay, Chinese, Indian or Others. ‘Others’ denotes all
other ethnics not belonging to the three major races.
iv. Level of education
Refer to the latest formal education level of patients and will be classified into none,
primary, secondary and tertiary.
14
vii. Employment status
Employment status will be defined as working and not working.
viii. Household income
Household income is defined as the total income for all the members of a household in
Malaysian Ringgit for typical month.
2.15
CONCLUSION
In conclusion, a cross sectional study will be conducted in Out Patient Clinic, Pusat
Perubatan Primer, Universiti Kebangsaan Malaysia. A total sample size of 402
respondents attending this clinic will have to answer the research questions of this
study. Finally, the data collected will be analysed using the SPSS version 22.0
software to generate the descriptive and analytical statistics.
15
APPENDIX A
PATIENT INFORMATION SHEET
Research Title
Knowledge and practice on calcium supplement among primary care patients
attending outpatient clinic at Pusat Perubatan Primer, UKM
Introduction
Calcium supplement is taken as an addition to our nutritional intake by some patients.
However, there are some patients who find that it is not necessary. Use of calcium
supplement is still controversial by some patients, thus this study is done to see
patients knowledge and practice on calcium supplement
What would this involve?
Patients are asked to sign the consent form before participating in the study. Patients
need to answer a questionnaire on the knowledge and practice on calcium supplement.
The benefits
This study will identify the reason patient request for calcium supplement.
The risks
No risks involved in this study as it doesn’t involve any procedure.
Confidentiality
The results of the data obtained will be reported in a collected manner with no
reference to a specific individual. Hence, the data from each individual will remain
confidential.
Do I have to take part?
The participation into this study is voluntary. If you prefer not to take part, you do not
have to give reason and your decision will not affect the intervention.
The right to withdraw
Any respondents has the right to withdraw their consent at any time should they feel
uncomfortable at any stage of the research. No penalties will be given to those who
withdrawn.
Payment and compensation
You do not have to pay for participating in this study. Similarly, no payment is
available to you for participating in this study.
16
If I have any questions, whom can I ask at any time point of study?
Dr. Fathima Begum bt Syed Mohideen (019-2782611)
Jabatan Perubatan Keluarga,
Fakulti Perubatan,
Pusat Perubatan Universiti Kebangsaan Malaysia,
Jalan Yaakob Latif,
Bandar Tun Razak,
56000 Cheras, Kuala Lumpur.
17
LAMPIRAN A
MAKLUMAT UNTUK PESAKIT
Tajuk penyelidikan
Kajian mengenai pengetahuan dan amalan penggunaan kalsium sebagai supplemen
oleh pesakit yang menghadiri klinik pesakit luar di Pusat Perubatan Primer, UKM
Pengenalan
Supplemen kalsium dianggap sebagai nutrisi tambahan oleh sesetengah pesakit.
Walau bagaimana pun, sesetengah pesakit merasakan tidak perlu untuk mengambil
kalsium tambahan ini atas sebab yang mereka ketahui sendiri. Penggunaan kalsium
sebagai nutrisi tambahan masih kontroversi bagi sesetengah pihak. Oleh yang
demikian, kajian ini bertujuan untuk mengetahui pendapat para pesakit yang
menghadiri klinik pesakit luar, tentang penggunaan kalsium ini.
Apa yang akan dilakukan?
Pesakit diminta untuk menandatangani borang keizinan sebelum mengambil bahagian
dalam kajian ini. Pesakit perlu menjawab soal selidik berkaitan penggunaan dan
pengetahuan mengenai kalsium sebagai nutrisi tambahan.
Faedah penyelidikan
Kajian ini akan mengenalpasti sebab penggunaan kalsium di kalangan pesakit luar.
Risiko
Kajian ini tidak melibatkan sebarang risiko dan tidak melibatkan sebarang prosedur.
Kerahsiaan
Keputusan yang diperolehi akan dimaklumkam secara keseluruhan dan tidak merujuk
pada nama individu. Maka maklumat dan keputusan dari setiap pesakit adalah sulit.
Perlukah saya mengambil bahagian?
Penglibatan dalam penyelidikan ini adalah secara sukarela. Sekiranya anda tidak
bersetuju, anda tidak perlu memberikan sebab dan ini tidak menjejaskan intervensi
yang akan diberikan.
Hak untuk menarik diri
Pesakit boleh menarik diri dari penyelidikan ini pada bila-bila masa tanpa
menjejaskan intervensi yang diberikan.
Bayaran dan pampasan
18
Anda tidak akan dikenakan apa-apa bayaran dan anda juga tidak akan dibayar bagi
penglibatan dalam penyelidikan ini.
Jika saya ada sebarang pertanyaan, siapa boleh saya hubungi?
Dr. Fathima Begum bt Syed Mohideen (019-2782611)
Jabatan Perubatan Keluarga,
Fakulti Perubatan,
Pusat Perubatan Universiti Kebangsaan Malaysia,
Jalan Yaakob Latif,
Bandar Tun Razak,
56000 Cheras, Kuala Lumpur.
19
APPENDIX B
CONSENT FORM FOR PATIENT
Research Title:
Knowledge and practice on calcium supplement among primary care patients
attending outpatient clinic at Pusat Perubatan Primer, UKM .
I ____________________________________(name), NRIC: ___________________,
have read the information of this study and have also been given the explanation by a
doctor about the purpose of this document. I understand the aims of the study
including its risks and benefits. I *agree/disagree to participate in the study as stated
above.
I *would like to know/don’t want to know the result of this study (*delete where
necessary)
Signature : _____________________
Date : _____________________
Witness
Medical Officer
Name :
Name :
IC no :
IC no :
Signature :
Signature :
Date:
Date:
20
LAMPIRAN B
BORANG KEIZINAN DARIPADA PESAKIT
Tajuk kajian
Kajian mengenai pengetahuan dan amalan penggunaan kalsium sebagai supplemen
oleh pesakit yang menghadiri klinik pesakit luar di Pusat Perubatan Primer, UKM.
Saya _____________________________(nama) no. KP: ______________________,
telah membaca maklumat tentang kajian ini dan juga telah diberi penerangan oleh
doktor tentang dokumen ini. Saya faham akan tujuan kajian ini termasuk berkaitan
risiko dan manfaatnya . Saya *bersetuju/tidak bersetuju untuk mengambil bahagian
dalam kajian yang telah dinyatakan di atas ini.
Saya *ingin mengetahui/tidak ingin mengetahui keputusan penyelidikan ini
(*potong mana yang tidak berkenaan)
Tandatangan : _______________________
Tarikh : ________________
Saksi
Pegawai Perubatan
Nama :
Nama :
No KP :
No KP :
Tandatangan :
Tandatangan :
Tarikh :
Tarikh :
21
LAMPIRAN C
Part A
1) Age (in years) =______
2) Gender
Male
Female
3) Ethnicity
Malay
Chinese
Indian
Others
4) Level of education
None
Primary
Secondary
5) Employment status
Working
Not working
6) Household income =________________
22
Tertiary
Part B
For questions in Part B and Part C please circle 1 if you strongly disagree and circle 5 if you strongly agree
with the statement given.
Strongly
Disagree
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
.
11.
12.
The following are important part of bone health.
a) Calcium
b) Vitamin D
c) Exercise
Calcium requirement increases with increasing age
Daily requirement of calcium is the same for both
women and men of the same age.
The following foods are good source of calcium.
a) Milk
b) Yogurt and cheese
c) Green leafy vegetables
d) Fish such as sardines, mackerel, tuna,
anchovies
e) Cod liver oil
Calcium from food is better absorbed into body
than calcium from supplements
When dietary intake of calcium is inadequate,
calcium supplement may be needed
Calcium supplement should be taken at divided
doses if daily requirement is more than 600mg
Calcium supplement is not safe to be taken at high
doses than recommended
Calcium supplement has side effects like
constipation
Calcium supplements should not be taken together
with;
a) High iron foods (eg:liver) or iron tablets
b) Alcohol
The following foods are good source of Vitamin
D.
a) Milk
b) Egg yolk
c) Oily fish such as sardines, mackerel, tuna,
salmon
d) Cod liver oil
e) Sunlight
Vitamin D helps body to absorb calcium
23
Disagree Uncertain Agree
Strongly
Agree
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
1
2
3
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5
1
1
1
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2
2
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3
3
3
4
4
4
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5
5
1
1
2
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3
3
4
4
5
5
1
2
3
4
5
1
2
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5
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3
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5
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5
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5
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1
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5
5
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
Part C
If you decided to choose disagree or strongly disagree for question 1 in Part C, please do not proceed to next
questions in Part C (that means you should not answer question 2 onwards).
1.
2.
I take calcium supplement in the past 1 year
I take calcium supplement because I cannot get
enough calcium from daily diet
3. I am taking calcium supplement to prevent myself
from fracture
4. I followed doctors suggestion to take calcium
supplement
5. I will not follow suggestion from family or friends
in taking calcium supplement
6. I take calcium supplement every day in past 1 year
7. I take calcium supplement according to the
recommended dose
8. I do not take calcium that was given by doctors to
my family or friends
9. I take calcium supplements with food
10. I often discuss with doctor regarding calcium
supplement.
11. I understand well regarding doctor explanation on
calcium supplement.
12. I take Vitamin D with calcium supplement
Strongly
Disagree
1
1
Thank you very much for your cooperation.
24
Disagree Uncertain Agree
2
2
3
3
4
4
Strongly
Agree
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
APPENDIX D
WORK ACTIVITY PLANNING (GANNT CHART)
Dis 2013
Proposal submission
Data collection
April 2014
Jun 2014
August 2014
/
/
Data analysis
/
Thesis submission
/
25
APPENDIX E
BUDGET
PERKARA UTAMA
AMAUN ATAU KUANTITI
JUMLAH (RM)
Alat tulis (Pen)
440 X RM 1
440.00
Pen drive (4GB)
1
50.00
Percetakan jurnal
1
100.00
Token
RM 5 X 440
2,200.00
Fotokopi:
RM0.10 x 10
(440 set)
440.00
RM 100 x 4
400.00
i. Borang Maklumat
Pesakit, Borang
Keizinan Menyertai
Kajian dan Borang
Soal- Selidik
Translators
JUMLAH
RM 3630
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References
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