Primary health care is essential for equitable, cost-effective and sustainable health care. It is the cornerstone to achieving universal health coverage against a backdrop of rising health expenditure and aging populations. Implementing strong primary health care requires grassroots understanding of health system performance. Comparing successes and barriers between countries may help identify mutual challenges and possible solutions. This paper compares and analyses primary health care policy in Australia, Malaysia, Mongolia, Myanmar, Thailand and Vietnam. Data were collected at the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) Asia-Pacific regional conference in November 2017 using a predetermined framework. The six countries varied in maturity of their primary health care systems, including the extent to which family doctors contribute to care delivery. Challenges included an insufficient trained and competent workforce, particularly in rural and remote communities, and deficits in coordination within primary health care, as well as between primary and secondary care. Asia-Pacific regional policy needs to: (1) focus on better collaboration between public and private sectors; (2) take a structured approach to information sharing by bridging gaps in technology, health literacy and interprofessional working; (3) build systems that can evaluate and improve quality of care; and (4) promote community-based, high-quality training programs.
Type 2 diabetes mellitus (T2DM) may be independently associated with testosterone deficiency syndrome (TDS). Both conditions are linked with reduced quality of life and cardiovascular comorbidities. The magnitude of TDS among T2DM men and its predictors has still not been well established in Malaysia. This study aimed to determine the prevalence of TDS and its predictors among men with T2DM attending a government health clinic in Kuching, Sarawak. TDS severity and level of serum total testosterone were also explored. A cross-sectional study was conducted involving 360 respondents. Aging Males Symptoms Scale (AMS) score > 26 and serum total testosterone ≤ 12 nmol/L were used to diagnose TDS. The prevalence of TDS in current study was 19.7%. Multivariate analysis showed that determinants for TDS included age (Adjusted OR 1.061: 95% CI 1.020; 1.103), Iban ethnicity (Adjusted OR 2.469: 95% CI 1.154; 5.283) and a waist circumference equal or greater than 90 cm (Adjusted OR 3.655: 95% CI 1.472; 9.081). However, there was no significant association between TDS and the level of serum total testosterone (p = 0.581). We concluded that the prevalence of TDS in this study was relatively low. The severity of this condition may not be influenced by testosterone level. Physicians might consider a diagnosis of TDS if elder diabetic men with abdominal obesity present to primary care clinics with clinical features of hypogonadism. Health care providers also might consider lowering their threshold to screen for TDS among Iban men with T2DM.
The prevalence of pain complaints as a reason for patient-doctor encounters in the local primary care setting is unknown. We performed a cross-sectional survey of such encounters in one public primary care clinic (KK) and 17 general practice clinics (GP), from the city of Seremban, Negeri Sembilan, Malaysia. Reasons for visits were recorded by doctors in KK and medical students in GP using a structured questionnaire. Morbidity data was coded using the International Classification of Primary Care (ICPC-2). A total of 2234 encounters were recorded (80.9% from KK, 19.1% from GP). The overall prevalence of pain complaints was 31.9% with a significant difference between the two cohorts (KK 28.7% and GP 45.2%, p<0.001). Musculoskeletal pain complaints were more common in KK than GP (40.9% versus 29.7%, p<0.05). Of the 3 main ethnic groups in Malaysia (Malay, Chinese and Indian) the Indian patients at KK had the highest prevalence of pain complaints and the Chinese at the GP had the lowest. Thus pain was a common complaint in the two different primary care settings studied. Some of the differences observed are probably due to the differences in the healthcare seeking behaviour of patients consulting at these two settings as well as differences in the payment systems.
The Primary Health Care approach in Malaysia was first tried out in Sarawak, East Malaysia in 1982. In 1984, the Vector Borne Disease Control Program, Kelantan decided to adopt the Primary Health Care approach as an additional strategy in its effort to control malaria in the state, which then experienced an increase in malaria cases. Much effort was directed at creating the awareness and stimulating the interest of health staff and communities to adopt the strategy. Kelantan was made the model state. The paper gives an outline of the process involved and some characteristics of PHC workers. A study was carried out among health workers, community members and health staff on their knowledge and involvement in PHC in three states, including Kelantan. In view of the overall success of this approach, and the weaknesses which have been identified possible solutions have been suggested and should be acted upon.
INTRODUCTION: Non-communicable diseases (NCD) is a global health threat. the Chronic Care Model (CCM) was proven effective in improving NCD management and outcomes in developed countries. Evidence from developing countries including Malaysia is limited and feasibility of CCM implementation has not been assessed. this study intends to assess the feasibility of public primary health care clinics (PHC) in providing care according to the CCM.
METHODOLOGY: A cross-sectional survey was conducted to assess the public PHC ability to implement the components of CCM. All public PHC with Family Medicine Specialist in Selangor and Kuala Lumpur were invited to participate. A site feasibility questionnaire was distributed to collect site investigator and clinic information as well as delivery of care for diabetes and hypertension.
RESULTS: there were a total of 34 public PHC invited to participate with a response rate of 100%. there were 20 urban and 14 suburban clinics. the average number of patients seen per day ranged between 250-1000 patients. the clinic has a good mix of multidisciplinary team members. All clinics had a diabetic registry and 73.5% had a hypertensive registry. 23.5% had a dedicated diabetes and 26.5% had a dedicated hypertension clinic with most clinic implementing integrated care of acute and NCD cases.
DISCUSSION: the implementation of the essential components of CCM is feasible in public PHCs, despite various constraints. Although variations in delivery of care exists, majority of the clinics have adequate staff that were willing to be trained and are committed to improving patient care.
Topical corticosteroids are common medications prescribed for skin problems encountered in the primary care or dermatology clinic settings. As skin conditions comprise of around 20% of cases seen in primary care, this article written to guide readers, especially non-dermatologists on the appropriate potency of topical corticosteroids to be chosen for skin problems of patients and to list the side effects both local and systemic.
BACKGROUND: Early Dementia Questionnaire (EDQ) was developed as a screening tool to detect patients with early dementia in primary care. It was developed based on 20 symptoms of dementia. From a preliminary study, EDQ had been shown to be a promising alternative for screening of early dementia. This study was done to further test on EDQ's reliability and validity.
METHODS: Using a systematic random sampling, 200 elderly patients attending primary health care centers in Kuching, Sarawak had consented to participate in the study and were administered the EDQ. Geriatric Depression Scale (GDS) was used to exclude patients with depression. Those who scored >21 MMSE, were retested using the EDQ. Reliability was determined by Cronbach's alpha for internal consistency and construct validity was assessed using confirmatory factor analysis (principle component with varimax rotation). Test retest Intraclass Correlation Coeeficient (ICC) was used to determine the reliability of the scale.
RESULTS: The result showed that the sensitivity and specificity for EDQ was 71.2% and 59.5%. The overall Cronbach's alpha coefficient was good which was 0.874. Confirmatory factor analysis on 4 factors indicated that the Cronbach's alpha for each domain were acceptable with memory (0.741), concentration (0.764), emotional and physical symptoms (0.754) and lastly sleep and environment (0.720). The Intraclass Correlation Coefficient between the first EDQ score and the retest EDQ score among those with MMSE of >21 showed a very strong overall agreement, ICC = 0.764, N = 160, P <0.001.
CONCLUSIONS: The results of the validation study showed that Early Dementia Questionnaire (EDQ) is a valid and reliable tool to be used as a screening tool to detect early dementia in primary care.
INTRODUCTION: The aim of this study was to determine the extent to which primary care doctors assessed patients newly diagnosed with hypertension for the risk factors of cardiovascular disease (CVD) during the patients' first clinic visit for hypertension. The study also aimed to examine the trend of assessment for CVD risk factors over a 15-year period.
METHODS: This retrospective study was conducted between January and May 2012. Data was extracted from the paper-based medical records of patients with hypertension using a 1:4 systematic random sampling method. Data collected included CVD risk factors and a history of target organ damage (TOD), which were identified during the patient's first visit to the primary care doctor for hypertension, as well as the results of the physical examinations and investigations performed during the same visit.
RESULTS: A total of 1,060 medical records were reviewed. We found that assessment of CVD risk factors during the first clinic visit for hypertension was poor (5.4%-40.8%). Assessments for a history of TOD were found in only 5.8%-11.8% of the records, and documented physical examinations and investigations for the assessment of TOD and secondary hypertension ranged from 0.1%-63.3%. Over time, there was a decreasing trend in the percentage of documented physical examinations performed, but an increasing trend in the percentage of investigations ordered.
CONCLUSION: There was poor assessment of the patients' CVD risk factors, secondary causes of hypertension and TOD at their first clinic visit for hypertension. The trends observed in the assessment suggest an over-reliance on investigations over clinical examinations.
Major depression is a common condition seen in the primary care setting, often presenting with somatic symptoms. It is potentially a chronic illness with considerable morbidity, and a high rate of relapse and recurrence. Major depression has a bidirectional relationship with chronic diseases, and a strong association with increased age and coexisting mental illnesses (e.g. anxiety disorders). Screening can be performed using clinical tools for major depression, such as the Patient Health Questionaire-2, Patient Health Questionaire-9 and Beck Depression Inventory, so that timely treatment can be initiated. An accurate diagnosis of major depression and its severity is essential for prompt treatment to reduce morbidity and mortality. This is the first of a series of articles that illustrates the approach to the management of major depression in primary care. Our next articles will cover suicide risk assessment in a depressed patient and outline the basic principles of management and treatment modalities.
Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel's opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.
OBJECTIVE: Shared decision-making has been advocated as a useful model for patient management. In developing Asian countries such as Malaysia, there is a common belief that patients prefer a passive role in clinical consultation. As such, the objective of this study was to determine Malaysian patients' role preference in decision-making and the associated factors.
DESIGN: A cross-sectional study.
SETTING: Study was conducted at an urban primary care clinic in Malaysia in 2012.
PARTICIPANTS: Patients aged >21 years were chosen using systematic random sampling.
METHODS: Consenting patients answered a self-administered questionnaire, which included demographic data and their preferred and actual role before and after consultation. Doctors were asked to determine patients' role preference. The Control Preference Scale was used to assess patients' role preference.
PRIMARY OUTCOME: Prevalence of patients' preferred role in decision-making.
SECONDARY OUTCOMES: (1) Actual role played by the patient in decision-making. (2) Sociodemographic factors associated with patients' preferred role in decision-making. (3) Doctors' perception of patients' involvement in decision-making.
RESULTS: The response rate was 95.1% (470/494). Shared decision-making was preferred by 51.9% of patients, followed by passive (26.3%) and active (21.8%) roles in decision-making. Higher household income was significantly associated with autonomous role preference (p=0.018). Doctors' perception did not concur with patients' preferred role. Among patients whom doctors perceived to prefer a passive role, 73.5% preferred an autonomous role (p=0.900, κ=0.006).
CONCLUSIONS: The majority of patients attending the primary care clinic preferred and played an autonomous role in decision-making. Doctors underestimated patients' preference to play an autonomous role.
Study site: Primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Chronic disease management presents enormous challenges to the primary care workforce because of the rising epidemic of cardiovascular risk factors. The chronic care model was proven effective in improving chronic disease outcomes in developed countries, but there is little evidence of its effectiveness in developing countries. The aim of this study was to evaluate the effectiveness of the EMPOWER-PAR intervention (multifaceted chronic disease management strategies based on the chronic care model) in improving outcomes for type 2 diabetes mellitus and hypertension using readily available resources in the Malaysian public primary care setting. This paper presents the study protocol.
Objectives: The average consumption of sugar in the Malaysian population has reached an alarming rate, exceeding the benchmark recommended by experts. This article argues the need of a paradigm shift in the management of sugar consumption in the country through evidence derived from addiction research.
Methods: “Food addiction” could lead to high levels of sugar consumption. This probable link could accelerate the development of diabetes and obesity in the community. A total of 94 reports and studies that describe the importance of addiction theory–based interventions were found through a search on PubMed, Google Scholar, and Academic Search Complete.
Results: Research in the field of addiction medicine has revealed the addictive potential of high levels of sugar intake. Preexisting health promotion strategies could benefit from the integration of the concept of sugar addiction. A targeted intervention could yield more positive results in health outcomes within the country.
Conclusion: Current literature seems to support food environment changes, targeted health policies, and special consultation skills as cost-effective remedies to curb the rise of sugar-related health morbidities.
Keywords. sugar addiction, food environment, health promotion, non communicable diseases, dietary habits, health policies
OBJECTIVE: This study was conducted to determine the validity of the 9-item Patient Health Questionnaire (PHQ-9) (Malay version) as a case-finding instrument for depression among women in a primary care clinic.
METHODS: A cross sectional study was conducted in a primary care clinic in Malaysia. Consecutive adult women patients who attended the clinic during data collection were given self-administered questionnaires, which included the PHQ-9 (Malay version). Systematic weighted random sampling was used to select participants for Composite International Diagnostic Interviews (CIDI). The PHQ-9 was validated against the CIDI reference standard.
RESULTS: The response rate was 87.5% for the questionnaire completion (895/1023), and 96.8% for the CIDI interviews (151/156). The prevalence of depression was 12.1% (based on PHQ-9 scores of 10 and above). The PHQ-9 had a sensitivity of 87% (95% confidence interval 71% to 95%), a specificity of 82% (74% to 88%), positive LR 4.8 (3.2 to 7.2) and negative LR 0.16 (0.06 to 0.40).
CONCLUSIONS: The Malay version of the PHQ-9 was found to be a valid and reliable case-finding instrument for depression in this study. Together with its brevity, it is a suitable case-finding instrument to be used in Malaysian primary care clinics.
Questionnaire: Patient Health Questionnaire; PHQ-9; General Health Questionnaire; GHQ-12; Composite International Diagnostic Interview; CIDI; Generalized Anxiety Disorder scale; GAD-7
OBJECTIVE: To determine the diagnostic accuracy of the two questions with help question (TQWHQ) in the Malay language. The two questions are case-finding questions on depression, and a question on whether help is needed was added to increase the specificity of the two questions.
METHOD: This cross sectional validation study was conducted in a government funded primary care clinic in Malaysia. The participants included 146 consecutive women patients receiving no psychotropic drugs and who were Malay speakers. The main outcome measures were sensitivity, specificity, and likelihood ratios of the two questions and help question.
RESULTS: The two questions showed a sensitivity of 99% (95% confidence interval 88% to 99.9%) and a specificity of 70% (62% to 78%), respectively. The likelihood ratio for a positive test was 3.3 (2.5 to 4.5) and the likelihood ratio for a negative test was 0.01 (0.00 to 0.57). The addition of the help question to the two questions increased the specificity to 95% (89% to 98%).
CONCLUSION: The two qeustions on depression detected most cases of depression in this study. The questions have the advantage of brevity. The addition of the help question increased the specificity of the two questions. Based on these findings, the TQWHQ can be strongly recommended for detection of depression in government primary care clnics in Malaysia. Translation did not apear to affect the validity of the TQWHQ.
This Diabcare-Asia project was initiated to study the status of diabetes care and prevalence of diabetic complications in Asia and this study was done to evaluate the above in primary private healthcare in Malaysia. A total of 49 private clinics participated in this study from which a total of 438 patients were included and analysed. The majority of patients (96.5%) had type 2 diabetes mellitus and 81.4% had BMI > or =23 kg/m2. Only 12.0% of the patients had their HbA1c measured in the preceding 12 months. As for glycaemic control only 20% of the patients had HbA1c <7% and 11% had FPG < 6.7 mmol/L. As for lipid levels, only 12.3% of the patients had total cholesterol < 4.8 mmol/L; 30.9% had HDL-cholesterol > 1.2 mmol/L and 49.8% had triglycerides < 1.7 mmol/L. Despite the high proportion of patients having dyslipidaemia. only 12.4% of the patients were on lipid lowering therapy. As for blood pressure, 55.9% of the patients had systolic pressure > or =140 mmHg and 40.9% had diastolic pressure > or =90 mmHg. However, only 32.4% of the patients were on antihypertensive medication. Only 37.4% of the patients admitted to adhering to diabetic diet regularly and 32.0% exercised regularly. As for glucose monitoring only 6.9% of the patients did home blood glucose monitoring and 6.2% did home urine glucose. There was also a high complication rate with the commonest being neuropathy (30.1%) followed by background retinopthy (23.5%), albuminuria (22.9%) and microalbuminuria (20.4%). In conclusion, the majority of diabetic patients treated at the primary care level were not satisfactorily controlled and this was associated with a high prevalence of complications. There is an urgent need to educate both patients and health care personnel on the importance of achieving the clinical targets and greater effort must be made to achieve these targets.
Type 2 diabetes mellitus (T2DM) brings about an increasing psychosocial problem in adult patients. Prevalence data on and associated factors of diabetes related distress (DRD) and depression have been lacking in Asia. This study aimed to examine the prevalence of DRD and depression, and their associated factors in Asian adult T2DM patients. This study was conducted in three public health clinics measuring DRD (Diabetes Distress Scale, DDS), and depression (Patient Health Questionnaire, PHQ). Patients who were at least 30 years of age, had T2DM for more than one year, with regular follow-up and recent laboratory results (< 3 months) were consecutively recruited. Associations between DRD, depression and the combination DRD-depression with demographic and clinical characteristics were analysed using generalized linear models. From 752 invited people, 700 participated (mean age 56.9 years, 52.8% female, 52.9% Malay, 79.1% married). Prevalence of DRD and depression were 49.2% and 41.7%, respectively. Distress and depression were correlated, spearman's r = 0.50. Patients with higher DRD were younger (OR 0.995, 95% CI 0.996 to 0.991), Chinese (OR 1.2, 95% CI 1.04 to 1.29), attending Dengkil health clinic (OR 1.1, 95% CI 1.00 to 1.22) and had higher scores on the PHQ (OR 1.1, 95% CI 1.04 to 1.06). Depression was less likely in the unmarried compared to divorced/separately living and those attending Dengkil health clinic, but more likely in patients with microvascular complications (OR 1.4, 95% CI 1.06 to 1.73) and higher DDS (OR 1.03, 95% CI 1.02 to 1.03). For the combination of DRD and depression, unemployment (OR 4.7, 95% CI 1.02 to 21.20) had positive association, whereas those under medical care at the Salak health clinics (OR 0.28, 95% CI 0.12 to 0.63), and those with a blood pressure > 130/80 mmHg (OR 0.53, 95% CI 0.32 to 0.89) were less likely to experience both DRD and depression. DRD and depression were common and correlated in Asian adults with T2DM at primary care level. Socio-demographic more than clinical characteristics were related to DRD and depression.
BACKGROUND: The chronic care model was proven effective in improving clinical outcomes of diabetes in developed countries. However, evidence in developing countries is scarce. The objective of this study was to evaluate the effectiveness of EMPOWER-PAR intervention (based on the chronic care model) in improving clinical outcomes for type 2 diabetes mellitus using readily available resources in the Malaysian public primary care setting.
METHODS: This was a pragmatic, cluster-randomised, parallel, matched pair, controlled trial using participatory action research approach, conducted in 10 public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Patients who fulfilled the criteria were recruited over a 2-week period by each clinic. The obligatory intervention components were designed based on four elements of the chronic care model i.e. healthcare organisation, delivery system design, self-management support and decision support. The primary outcome was the change in the proportion of patients achieving HbA1c care setting.
TRIAL REGISTRATION: Registered with: ClinicalTrials.gov.: NCT01545401 . Date of registration: 1st March 2012.
Background Information on the extent of high-risk prescribing for nonsteroidal anti-inflammatory drugs (NSAIDs) across developing countries is scarce. Objectives This study examines the prescribing pattern for NSAIDs in primary care, assesses the extent of high-risk NSAIDs prescribing and identifies associated factors. Setting 129 public and 416 private primary care clinics in Malaysia. Methods Data were derived from the National Medical Care Survey 2014, a cross-sectional survey on primary care morbidity patterns and clinical activities in Malaysia. Types of NSAIDs, indications for NSAIDs use and proportion of high-risk NSAIDs prescribing were assessed. Factors associated with high-risk NSAIDs prescribing were identified with a multivariable logistic regression. Weighted results, adjusted for sampling design and non-response were presented. Main outcome measures Prescribing pattern of NSAIDs, proportion of high-risk NSAIDs prescribing and its associated factors. Results Among the 55,489 patients who received NSAIDs, diclofenac was the most frequently prescribed NSAID (40.5%, 95% CI 40.1-40.9%), followed by mefenamic acid (29.2%, 95% CI 28.8-29.6%). The commonest indications for NSAIDs use were musculoskeletal condition and respiratory tract infection, both at 17.8% (95% CI 17.4-18.1%). A total of 22.9% (95% CI 22.6-23.3%) patients received high-risk NSAID prescriptions. Of these, 47.8% (95% CI 46.9-48.7%) did not receive adequate gastroprotection despite being at risk, 24.8% (95% CI 24.0-25.5%) were prescribed NSAIDs despite having cardiovascular comorbidities and 22.4% (95% CI 21.7-23.2%) were prescribed high-dose NSAIDs. The odds of receiving high-risk NSAID prescriptions increased with the number of drugs prescribed (OR 1.23, 95% CI 1.06-1.43) and the number of diagnoses in one visit (OR 2.21, 95% CI 1.71-2.86). The odds of being prescribed high-risk NSAID prescriptions were lower in patients with secondary (OR 0.52, 95% CI 0.35-0.77) and tertiary education (OR 0.39, 95% CI 0.22-0.68) compared to patients without formal education. Patients' citizenship, indication for NSAID prescriptions and whether a medical certificate was issued were also significantly associated with the likelihood of receiving high-risk NSAID prescriptions. Conclusions A quarter of NSAIDs prescribed in Malaysian primary care setting is categorised as high-risk prescribing. Targeted strategies are necessary to improve patient safety.