CASE REPORT: Interprofessional Collaboration in the Management of Scabies Re-infestation: A Single Case Study in a Rural Area of East Nusa Tenggara Province, Indonesia

CASE REPORT Mr. A presented with complaints of itching and reddish patches on his stomach, palms and fingers for about three weeks. The patient had been diagnosed with scabies infestation three times before and had previously been declared cured. Dermatological exam on this patient showed erythematous papules, rounded, well-defined, discrete spread and multiple measuring 0.2 x 0.2 cm on patient’s hand fingers, palm and abdomen. Excoriation and lichenification were also noticed (Figures 1, 2 and 3).

The presence of cuniculi were no longer found and some parts had undergone lichenification, marked by darkened skin color due to chronic scratching.
The patient is a clove trader who often goes from one village to another to collect cloves. Every time he stops in a village, the patient will stay at a relative's house. He never brings personal towels and gloves while traveling. Often the towels and sarongs that are used by the host are lent to him. He always borrows towels and sarongs from the owner of the house where he is staying. Every time he comes home from traveling, the patient will suffer from itching which causes his wife and children to also get similar itching.

FORMULATION OF THE PROBLEM
Scabies is a skin disease caused by Sarcoptes scabiei variant hominus. The clinical manifestation that appears is a very intense itching sensation on the erupted skin accompanied by the appearance of papules, nodules and vesicles 1 . The World Health Organization (WHO) included In Indonesia, the prevalence of scabies in 2008 was 5.60% -12.96%. In 2009, the prevalence of scabies was 4.9-12.95% and the latest data obtained from the prevalence of scabies in Indonesia in 2013 was 3.9 -6%. Although the prevalence of scabies has decreased from year to year, it is still ranked the third most frequently occurring skin disease out of the twelve main skin diseases identified in Indonesia 4 .
The prevalence of scabies in East Nusa Tenggara, a province in the eastern area of Indonesia, is not specifically recorded because it is put together in the category of unspecified skin diseases, where other skin diseases are included in the top 10 diseases (3.56%) 5 . Medical records data of one Medical Center in Ende Regency, East Nusa Tenggara Province shows that there were 1,257 cases of scabies from January to December in 2019. Out of all of the cases, 421 cases were reinfestation of scabies. The definition of scabies reinfestation is scabies manifestation that occurs after the previous scabies infection was declared cured 6 .
Scabies treatment is easy and has a high cure rate, but if it is not massive and simultaneous, reinfestation and sequelae can occur easily. Itchy sensations are very intense, especially at night causing the decreasing quality of a person's sleep which has an impact on their performance on the next day. Other possible sequelae include cellulitis, abscesses, and even bacteremia and sepsis 7 . Further impact includes worse skin damage, disability, stigma, and socioeconomic problems 8 . Considering that the neglected impact of scabies is quite extensive, scabies management requires collaboration from various professions or by the approach also known as Interprofessional Collaboration (IPC) 9 .  12,13 . IPC can also reduce complications experienced by patients, length of hospital treatment, staff turnover, undesirable events and mortality 14,15,16 .
Scabies reinfestation cases are best managed by the doctors, clinical laboratory assistants, pharmacists and nurses who collaborate to perform history taking and physical examinations, supporting examinations such as skin scrapings, determining the diagnosis and prescribing of drugs, compounding topical drugs and explaining drug usage, and educating the patient about the importance of personal and environmental hygiene. The results of IPC in treating the patient resulted in resolving the scabies syndromes, healed his excoriations and healed any skin secondary infections. The patient was well informed to be able to prevent the scabies transmission to his closest family members and friends and he also did not show any signs and symptoms of scabies reinfestation.
This research was qualitative research with a single case study method. The single case study provides better understanding of the case by revealing specific, unique, and detailed aspects 17 . The research objective was to explore the management of scabies reinfestation using an IPC approach at the Lio Sehat Medical Center, in East Nusa Tenggara Province, Indonesia. The researchers had the theoretical presupposition that if the IPC domains, namely values, teamwork, communication and roles and responsibilities, were implemented in the management of scabies, then the result of the treatment will be more optimal.
The case is about a 30 year old male who had scabies reinfestation. He suffered from scabies manifestation three times before and had previously been declared cured after receiving treatment. However, he revisited the clinic approximately a month later with the exact same complaints as before and was diagnosed as scabies reinfestation.
The case was chosen because it was a good example of how scabies can reinfest in someone for multiple times when preventive measures were not taken. It also showed how someone's lifestyle and daily habits, including local culture, can contribute in scabies reinfestation. The management of this case is best approached by applying IPC to ensure optimal services both in curative and preventive approaches.
Purposive sampling technique was used to select informants based on inclusion and exclusion criteria. The inclusion criteria were doctors, laboratory assistants, nurses and pharmacists who are currently working at the Lio Sehat Medical Center, involved in the management of scabies reinfestation cases using an IPC approach and willing to participate. Meanwhile, the chosen scabies reinfestation case was the one patient who was willing to participate and who did not have other comorbidities.
The research was conducted at the Lio Sehat Medical Center located in Ende district, East Nusa Tenggara during its working hours. Study of medical documents was conducted before the observations and interviews. It consisted of studying patient's medical records and the Standard Operational Procedures (SOP) of the clinic related to IPC in the management of scabies. The patient's medical records were studied to ensure that he was diagnosed as scabies and had recovered before having another current manifestation (reinfestation). The observations on the case management were performed involving five informants during clinic working hours. Each informant was interviewed twice, with the first interview was performed right after the case management and the second after two weeks to clarify their statements. Data saturation was achieved in the data analysis process when no new theme was obtained and the experiences that were documented begin to have similarities or repetitions.
Prior to conducting the research, all of the subjects who met the inclusion and exclusion criteria are made aware about the steps of the research. Only those who were willing to participate were included in this research. All of the subjects gave permission to be observed, interviewed and documented by signing the informed consent forms.
The data were analyzed using the interpretive approach. This analysis was done first by identifying domains in the collected information to obtain specific emerging themes. The emerged themes were then interpreted based on the number of scabies cases and the IPC approaches in currently existing theories. Furthermore, a summary was made based on all the existing data to not only see the facts but also to find the connections among them. To ensure the data validation, a triangulation process was performed comparing the data obtained from observations and study documents. Reflexivity was shown by the involvement of other researchers from different backgrounds such as family doctors and public health experts. Data analysis related to scabies reinfestation cases, especially in personal and community transmission, involved an expert in Family Medicine and Primary Health Care. Meanwhile, the data analysis regarding the IPC approach in managing this case involved a Public Health expert.
This study has several limitations. The selection of research subjects was limited in the number of subjects and types of health professionals working in the study site, also the varying length of work period and experience in implementing interprofessional collaboration which is less than 12 months. The number of scabies reinfestation cases that were managed using an IPC approach were only one case so that the results could not represent all cases of scabies re-infestation who are managed similarly.
Apart from these limitations, the single case allows the researchers to conduct a focused observation. The small number of research subjects allows researchers to conduct in-depth interviews well. Those reasons make this case study able to reveal specific, unique and detailed aspects such as cultural elements that affect scabies reinfestation in a person, the specific myths that make it difficult to maintain personal hygiene, underestimation of scabies and impacts of implementing IPC. The data validation of this study used several techniques such as data triangulation, member checks and debriefing. Two other researchers were also involved to confirm the data, thereby validating the trustworthiness of this study results.

SITUATION REGARDING SCABIES REINFESTATION MANAGEMENT WITH CURRENT IPC APPROACH AND THE OBSTACLES
Many cases of scabies are still found and the incidence of scabies manifestation and its reinfestation are still common. Djuanda 20 . It is because scabies is considered harmless since a long time ago. This mindset ultimately makes it difficult to prevent scabies manifestation and its reinfestation because people do not feel threatened by scabies 21 .
As a private primary health facility that has been operating for 10 years, the age of medical personnel working at Lio Sehat is ranging from 25 to 35 years old with 3 to 5 years of work experience. This is important to be noted because the characteristics of the research subjects also influence the dynamics of IPC. A better understanding of the exploration of the application of IPC will be easier to obtain if the complexity of the respondent's characteristics is fully appreciated. At a relatively young age with new work experiences, it is easier for research subjects to collaborate because the traditional hierarchical pattern of the medical world has not yet been formed firmly. This is in line with the suggestion by Soemantri et al. that the introduction of IPC implementation to all health professions in certain health facilities should be started as early as possible before fundamental differences begin to be identified and take root 22 .
The IPC approach in the management of scabies reinfestation also involves the patient in discussions to find the causes of scabies reinfestation. This is an important element in the value / ethical domain were one of the concerns are the patient's involvement in the process of treatment and recovery. 18 This involvement allows the more suitable solutions in line with patient culture, habit and daily routines. An explanation is given to the patient to reduce his tendency to underestimate scabies and becomes more serious in preventing transmission to his closest ones. The patient also experienced behavioral changes in implementing preventive measures against further scabies transmission. Patient involvement in a treatment process with the IPC approach can result in better treatment impacts such as adherence and compliance to treatment regimens and changes in behavior to support the healing process 23 .
The domain of communication is the most important in an IPC. Communication between professions in the management of scabies cases follows the SBAR pattern which is considered to facilitate the delivery of information. SBAR communication is an easy-to-remember pattern to convey a patient's condition that is critical or needs immediate attention and action 24 . The R component in the SBAR stands for recommendations that enable medical personnel to contribute according to their knowledge and competencies in collaborating.
As the most influential domain found in the IPC approach is the communication domain, it also holds the biggest obstacles. Obstacles that are found include differences in language or terms used by doctors and other health professionals. In addition, the difficulty in conducting good communication is influenced by the existing low self-esteem of other health professionals when facing doctors, which is a negative impact from a long-established hierarchical culture in medicine. The limited service hours and the limited numbers of medical personnel are also obstacles in the communication domain. Challenges in communication can create difficulties in performing collaboration, such as difficulty to convey messages or easily arisen misunderstandings. Under these circumstances, medical personnel can fail to perform their roles and responsibilities properly. Therefore, effective and clear communication is one of the many characteristics of an effective IPC team. Through communication, different professions will have the opportunity to understand each other's roles, they can synchronize perceptions about the goals and values of the provided health services and consistently introducing the SOPs of each profession so the authority and competence of each profession are well understood. The results of Reeves and Lewin's research show that different perspectives from medical personnel can influence the collaboration among doctors and other professionals negatively. Thus, all the different SOPs from each profession need to be considered for better integration between patient care and communication among health professions 25 . Some of these problems are expected to be resolved by increasing the quantity of informal communication aside from handling any cases. It is hoped that regular informal conversations will build better relationships among medical personnel, hence increasing a better understanding. Also, conducting regular meetings to discuss any specific cases will provide a better understanding of the roles, responsibilities, abilities and competencies, as well as specific terms that are frequently used by other medical personnel 26 . In line with this approach, a continuous education about IPC for all health professionals is well needed. It is necessary to strengthen the daily practice of IPC with the main goal to increase the quality of patient care with measurable indicators such as patient safety 27 .
Further exploration of this IPC implementation showed that in the domain of roles and responsibilities that there was a balanced distribution of responsibilities between each medical profession involved under their professions. This is one of IPC characteristics where all medical personnel are considered equal partners which allows all professions involved to contribute to the improvement of the patient's condition (patient outcome). The doctor continues to carry out her duty and responsibility in history taking and physical examinations, where she will request laboratory examinations as needed, establishing diagnoses and prescribing drugs for the patient. The clinical laboratory assistant uses her ability and competence to carry out the skin-scrapping lab exam requested by the doctor. The results do not immediately translate into a diagnosis but are returned to the doctor's authority in establishing the diagnosis. Pharmacists prepare the drug receipts prescribed by doctors and provide education about drug dosages and how to apply Permethrin cream to patient's lesions, as well as the side effects that may occur. The education provided by pharmacists is limited to only about drugs. The education and information on personal and environmental hygiene and how to prevent scabies manifestation and its reinfestation are performed by the nurse who was appointed by the doctor.
This roles and responsibility domain affects the teamwork domain positively. The major effect is a collaborative interaction where each member of the IPC team can collaborate their respective knowledge and expertise to improve health services for the patients 28 . The availability of SOPs or written guidelines will make it easier for health professionals to work in a team because every profession understands the roles and responsibilities and boundaries of the other professions. This will encourage the culture that supports the implementation of collaboration 29 . Therefore, in addition to increasing communication skills and fostering appropriate attitudes and traits between personnel, a clear understanding of the roles and responsibilities of each profession in implementing IPC is needed. One profession needs to be introduced to other's roles and responsibilities as early as possible to avoid later misunderstandings in collaboration 30 . Regular meetings, detailed medical records and general SOPs for implementing IPC are urgently needed. Likewise, the confirmation of the roles and responsibilities as well as the competence of each profession must be socialized to see which ones are replaceable and which ones are not when providing care for the benefit of the patients 31 .

IMPACT OF IPC ON THE ASSESSMENT OF SCABIES REINFESTATION.
The IPC approach in cases of scabies reinfestation has a positive impact on the patient and the medical personnel. The patient receives comprehensive care that helps the healing process and prevents further reinfestations. This is as found in a literature review by the Canadian Health Systems Research Foundation which showed supporting evidence that patient health improves when care is provided collaboratively 32 . High levels of patient satisfaction are associated with patient-centered care, in which the patient feels being more involved in a discussion about their health 33 . Patients are often more satisfied with health care services that are delivered to meet their preferences. It is also known as a Shared Decision Making (SDM), a process where health care providers involve patients more actively as partners in decision-making, incorporating both medical evidence and individual patient priorities and preferences. This will result in a less anxious, quicker recovery and increased compliance with treatment regimes 34 .
The immediate impact felt by healthcare professionals who are engaged in collaboration is a feeling of happiness of being useful. This is consistent with the findings of Bosch et al. in their research that showed that there is an increase in patient satisfaction with provided care and also job satisfaction of medical personnel as a result of implementing IPC. Job satisfaction is obtained from a feeling of being useful in contributing to the teamwork to improve patient's health. This will further serve as a source of motivation for improving the performance of each profession involved both as an individual and as a team 35 .

ACTION PLAN
The IPC approach in the case of scabies needs an SOP in any health center where it is demonstrated. It will hopefully ensure the effectiveness of performing each of the domains of IPC in managing scabies. It also requires collaboration with many parties, especially Puskesmas (Government Health Center) in areas where scabies is endemic. This is necessary to take preventive steps such as counseling and public health campaigns, as well as curative actions such as mass scabies medication. Prevention and treatment of scabies can be done on a person-to-person basis but it has low effectiveness in preventing the transmission of scabies and its reinfestation on a large scale. A collaboration involving many parties is needed to perform communal interventions in the form of mass scabies treatments which results in a decrease in the number of scabies manifestation and its reinfestations 36 .

CONCLUSIONS
Interprofessional collaboration as an approach in the management of scabies reinfestation case has a positive impact on patients and the involved medical personnel, resulting in optimal service quality. Further research with the same topic is expected to be conducted with more research subjects involving both private and government health facilities in a designated area. Quantitative research is important to analyze the relationship between the domains of interprofessional collaboration with the success of scabies management.