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Translation, adaptation and pilot testing of the Pictorial Fit-Frail Scale (PFFS) for use in Malaysia - The PFFS-Malay version (PFFS-M)

Ahip SS, Shariff-Ghazali S, Lukas S, Abdul Samad A, Mustapha UK, Theou O, et al.

Malays Fam Physician, 2021 Jul 22;16(2):27-36.
PMID: 34386161 DOI: 10.51866/oa1036

Background: Frailty is an important health issue in an aging population; it is a state of vulnerability that renders the elderly susceptible to adverse health outcomes, including disability, hospitalization, long-term care admission and death. Early frailty stages are recognizable through screening and are reversible with targeted interventions. To date, however, there is no screening tool for use in Malaysia. The English Pictorial Fit-Frail Scale (PFFS) is a visual tool that assesses a person's fitness-frailty level in 14 health domains, with higher scores indicating higher frailty.
Objective: The aim was to translate and adapt the English PFFS for use in Malaysian clinical settings.
Methods: The original English PFFS underwent forward and backward-translation by two bilingual translators to and from the Malay language. A finalized version, the PFFS-Malay (PFFS-M), was formed after expert reviewers' consensus and was pilot tested with 20 patients, 20 caregivers, 16 healthcare assistants, 17 nurses and 22 doctors. Score agreement between patients and their caregivers and among healthcare professionals were assessed. All participants rated their understanding of the scale using the feasibility survey forms.
Results: A total of 95 participants were included. There were high percentages of scoring agreements among all participants on the scale (66.7% to 98.9%). Overall feedback from all respondents were positive and supported the face validity of the PFFS-M.
Conclusion: The PFFS-M reflects an accurate translation for the Malaysian population. The scale is usable and feasible and has face validity. Reliability and predictive validity assessments of the PFFS-M are currently underway.
The Pictorial Fit-Frail Scale Malay Version (PFFS-M): Predictive Validity Testing in Malaysian Primary Care

Ahip SS, Theou O, Shariff-Ghazali S, Samad AA, Lukas S, Mustapha UK, et al.

J Frailty Aging, 2024;13(1):35-39.
PMID: 38305441 DOI: 10.14283/jfa.2023.35

The purpose of this study was to evaluate the association between Pictorial Fit Frail Scale-Malay version (PFFS-M) and adverse outcomes, such as falls, new disability, hospitalisation, nursing home placement, and/or mortality, in patients aged 60 and older attending Malaysian public primary care clinics. We assessed the baseline PFFS-M levels of 197 patients contactable by phone at 18 months to determine the presence of adverse outcomes. 26 patients (13.2%) reported at least one adverse outcome, including five (2.5%) who fell, three (1.5%) who became disabled and homebound, 15 (7.6%) who were hospitalized, and three (1.5%) who died. Using binary multivariable logistic regression adjusted for age and gender, we found that patients who were at-risk of frailty and frail at baseline were associated with 5.97(95% CI [1.89-18.91]; P=0.002) and 6.13 (95% CI [1.86-20.24]; P= 0.003) times higher risk of developing adverse outcomes at 18 months, respectively, than patients who were not frail. The PFFS-M was associated with adverse outcomes.
Integrated Service Delivery Model in Primary Care to Improve Frailty in Older Malaysians: GeKo Integrated Service Delivery

Ahip SS, Ting CY, Abdillah MAB, Tan YJ, Sabri SAB, Theou O, et al.

J Frailty Aging, 2024;13(3):313-318.
PMID: 39082778 DOI: 10.14283/jfa.2024.42

BACKGROUND: This study aimed to evaluate the implementation stage of Malaysia's GeKo-Integrated Service Delivery (ISD) model for frailty management in primary care and explore its effectiveness in improving frailty scores.
METHODS: The implementation stage of Malaysia's first three GeKo- ISD clinics was assessed using the WHO-ICOPE (Integrated Care of the Older Persons) scorecard. This involved evaluating documents related to the GeKo services and conducting in-depth interviews with key informants identified from those documents. The efficacy of GeKo-ISD was assessed by documenting the change in mean frailty scores between baseline and 3 months post intervention, measured by the Pictorial Fit Frail Scale Malay Version (PFFS-M), in patients who received GeKo-ISD care from October 2022 to April 2023.
RESULTS: All three GeKo clinics achieved the sustaining implementation level, scoring a total of 50 out of 52. The paired t-test reported a significant reduction (p= 0.001) in the PFFS-M scores from baseline to 3 months after the GeKo-ISD intervention. The mean (SD) scores were 8.6 (4.6) at baseline and 7.0 (4.1) at 3 months post-intervention.
CONCLUSION: GeKo-ISD is a comprehensive approach of integrated care for older people, leveraging existing public funded primary care infrastructure. It shows promise, was impacted by the pandemic but now, with support from the government, exists in 32 centers across one state in Malaysia.
The Pictorial Fit-Frail Scale-Malay version (PFFS-M): reliability and validity testing in Malaysian primary care

Ahip SS, Ghazali SS, Theou O, Samad AA, Lukas S, Mustapha UK, et al.

Fam Pract, 2023 Mar 28;40(2):290-299.
PMID: 35950311 DOI: 10.1093/fampra/cmac089

BACKGROUND: This study investigated the reliability and convergent validity of the PFFS-Malay version (PFFS-M) among patients (with varying educational levels), caregivers, and health care professionals (HCPs). PFFS-M cutoffs for frailty severity were developed.
METHODS: This is a cross-sectional study from 4 primary care clinics where 240 patients aged >60 years and their caregivers were enrolled. Patients were assigned to a nurse or a health care assistant (HCA) for 2 separate PFFS-M assessments administered by HCPs of the same profession, as well as by a doctor during the first visit (inter-rater reliability). Patients were also administered the Self-Assessed Report of Personal Capacity & Healthy Ageing (SEARCH) tool, a 40-item frailty index, by a research officer. The correlation between patients' PFFS-M scores and SEARCH tool scores determined convergent validity. Patients returned 1 week later for PFFS-M reassessment by the same HCPs (test-retest reliability). Caregivers completed the PFFS-M for the patient at both clinic visits. Classification cut-points for the PFFS-M were derived against frailty categories defined through the SEARCH tool.
RESULTS: The inter-rater (intraclass correlation coefficient [ICC] = 0.92 [95% CI, 0.90-0.93)] and test-retest (ICC = 0.94 [95% CI, 0.92-0.95]) reliability between all raters was excellent, including by patients' education levels. The convergent validity was moderate (r = 0.637, p < 0.001), including for varying educational background. PFFS-M categories were identified as: 0-3, no frailty; 4-5, at risk of frailty; 6-8, mild frailty; 9-12, moderate frailty; and >13, severe frailty.
CONCLUSION: PFFS-M is a reliable and valid tool with frailty severity scores now established for use of this tool in primary care clinics.
Fulltext The Pictorial Fit-Frail Scale: Developing a Visual Scale to Assess Frailty

Theou O, Andrew M, Ahip SS, Squires E, McGarrigle L, Blodgett JM, et al.

Can Geriatr J, 2019 Jun;22(2):64-74.
PMID: 31258829 DOI: 10.5770/cgj.22.357

Background: Standardized frailty assessments are needed for early identification and treatment. We aimed to develop a frailty scale using visual images, the Pictorial Fit-Frail Scale (PFFS), and to examine its feasibility and content validity.
Methods: In Phase 1, a multidisciplinary team identified domains for measurement, operationalized impairment levels, and reviewed visual languages for the scale. In Phase 2, feedback was sought from health professionals and the general public. In Phase 3, 366 participants completed preliminary testing on the revised draft, including 162 UK paramedics, and rated the scale on feasibility and usability. In Phase 4, following translation into Malay, the final prototype was tested in 95 participants in Peninsular Malaysia and Borneo.
Results: The final scale incorporated 14 domains, each conceptualized with 3-6 response levels. All domains were rated as "understood well" by most participants (range 64-94%). Percentage agreement with positive statements regarding appearance, feasibility, and usefulness ranged from 66% to 95%. Overall feedback from health-care professionals supported its content validity.
Conclusions: The PFFS is comprehensive, feasible, and appears generalizable across countries, and has face and content validity. Investigation into the reliability and predictive validity of the scale is currently underway.