Primary care providers should be alert to travel-related infections. Around 10-40% of returning travelers from all destinations and 15-70% of travelers from tropical settings experience ill health, either overseas or upon returning home.1 A systematic approach concentrating on possible infections should be undertaken based on the patient's travel location, immunization history, presence of malaria chemoprophylaxis at the destination, other potential exposures, incubation period, and clinical presentation.2-3 The World Health Organization (WHO) website is constantly being updated on specific travel-related infections and recent geographical outbreaks. In this paper, we report a case of severe falciparum malaria in a returned traveler.
The Well Man & Well Woman's Clinic in Ipoh Hospital provides screening for coronary risk factors and early detection of cancer. This retrospective review of 1095 patients screened between April and December 1995 showed 48% had one or more coronary risk factors--1 risk (29%), 2 risks (14%), 3 or more risks (5%). Modifiable risks included hypertension (10%), obesity (9%), diabetes mellitus (8%) and smoking (7%). Sixteen abnormal Papanicolaou smears and six cancers (three cervical, two breast and one ovarian) were detected. Public response was good. There is a need for clinics offering comprehensive screening in Malaysian primary health care.
Study site: The Well Man & Well Woman's Clinic in Ipoh Hospital
A 30-year-old Iban woman presented to a rural primary healthcare clinic located along the Batang Rejang in Sarawak. She had a 2-day history of rash, which started over her trunk and later spread to her face and limbs. What started out as individual erythematous maculopapular spots later coalesced to form larger raised blotches. The rash was extremely pruritic and affected her sleep, and hence her visit. The rash was preceded by high grade, persistent fever that was temporarily relieved by paracetamol. She also complained of malaise, arthralgia and myalgia. Her appetite had been poor since the onset of the fever. She lived in a long house at the edge of the jungle. Although she did not have a history of going into the jungle to forage, she went regularly to the river to wash clothes. Clinically, she appeared lethargic and had bilateral conjunctival injection. Her left anterior cervical lymph nodes were palpable. There were erythematous macules measuring 5 to 15 mm distributed over her whole body but predominantly over the chest and abdominal region (Figure 1). An unusual skin lesion was discovered at the right hypochondriac region. This lesion resembled a cigarette burn with a necrotic centre (Figure 2). There was no evidence of hepato-splenomegaly. Examination of the other systems was unremarkable. On further questioning, the patient admitted being bitten by a ‘kutu babi’ or mite 3 days before the onset of her fever.
Backgrounds: The study aimed to survey for FD in a primary care setting in a population known to have an extremely low prevalence of Helicobacter pylori (H. pylori) infection, with the hypothesis that in such a population, dyspepsia should have been relatively less common.
Methods: The Rome III FD Diagnostic Questionnaire was translated into the Malay language and later tested for reliability. A prospective cross-sectional survey was then performed involving 160 Malay patients attending primary care clinic after informed consent. Patients positive for symptoms of FD were subjected to upper endoscopy and exclusion of H. pylori infection. Univariable and multivariable analyses were used to test for associated risk factors.
Results: The back-translated questionnaire was similar to the original English version and was reliable (Cronbach Alpha-coefficient 0.85). Of the 160 surveyed subjects, 19 of them (11.9%) had symptoms of FD. With exclusion of erosive diseases (3/160 or 1.9%) from endoscopy, 16 subjects or 10% had FD. None of the 19 subjects were positive for H. pylori infection. Epigastric pain syndrome was present in 11/16 (68.8%) and the rest, overlap with postprandial distress syndrome. With multivariable analysis, a married status (OR = 8.1; 95% CI 1.0-36.5) and positive psychosocial alarm symptoms (OR = 3.8; 95% CI 1.0-14.0) were associated with FD. Of those married subjects, females were more likely to have FD and psychosocial symptoms than men (6.3% vs. 1.9%), P = 0.04.
Conclusions: FD was more common than one had expected among Malays attending primary care clinic in an area with low prevalence of H. pylori.
Keywords: Functional dyspepsia, Malays, Rome III, Females, Marriage, Psychosocial alarm
Questionnaire: Rome III Functional Dyspepsia Diagnostic questionnaire; Red Flag Questionnaire; Psychosocial Alarm Questionnaire; Hospital Anxiety Depression Scale; HADS
Study site: primary care clinic within the university hospital of Universiti Sains Malaysia (USM)
This case report illustrates a 40-year-old woman who presented with chest discomfort that was subsequently diagnosed to have metabolic syndrome. Metabolic syndrome is a common condition associated with increased cardiovascular morbidity and mortality. As primary care providers, we should be detect this condition early, intervene and prevent appropriately before complications occur.
Citation: A case study on institutional development in the water and sanitation sectors and integration of PHC with rural water supply and sanitation in Malaysia. Manila: World Health Organization, Regional Office for the Western Pacific; 1985
Elbow injuries are common in children. Supracondylar fractures occurred in 16% of all pediatric fractures. Supracondylar fractures can be classified into 4 types according to the Gartland classification, depending on the degree of the fracture present in the lateral radiograph. This case highlights the case of a child with a Gartland Type I fracture. A misdiagnosis of this fracture will compromise the management of the injury with regards to immobilization and subsequent care. As this injury can be managed on an outpatient basis, primary care frontliners need to be aware of the condition.
Introduction: The incidence of diabetes mellitus (DM) is increasing globally and it is associated with significant morbidity and mortality. The importance of a better quality of diabetes care is increasingly acknowledged. Objective: This clinical audit was conducted to assess the quality of care given to type 2 DM patients in public primary care clinics. Methods: A clinical audit was conducted in two selected urban public primary care clinics, between April and June of 2005. The indicators and criteria of quality care were based on the current Malaysian clinical practice guidelines for type 2 DM. A structured pro forma was used to collect data. Results: A total of 396 medical records of patients with type 2 DM were included in this audit. Most of the patients had measurements of fasting blood glucose and blood pressure recorded in more than 90% of the visits over the previous one year. Twenty-seven percent of the patients had glycosylated haemoglobin (HbA1c) done every 6 months with a mean of 8.3%. Only 15.6% had HbA1c values less than 6.5 %. Fifty percent had blood pressure controlled at 130/80 mmHg and below; and 13.0% had low density lipoprotein cholesterol values of 2.6 mmol/L or less. The majority of the patients were overweight or obese. Conclusions: The quality of diabetes care in this study was
found to be suboptimal. There is a gap between guidelines and clinical practice. Certain measures to improve the quality of diabetes care need to be implemented with more rigour.
The National Clinical Practice Guideline in Tuberculosis (TB) was designed to improve the quality of tuberculosis care. However, it remains unknown whether primary care doctors adhere to it well. This audit aims to assess the quality of care in the process of TB contact tracing in a primary care setting. Methods: Data on TB contact tracing from 1st February 2013 to 15th February 2013 was obtained retrospectively from all medical records of diagnosed pulmonary TB in a public primary care clinic. All patients who fulfilled the inclusion and exclusion criteria were included in the study. Results: A total of 102 medical records of adult TB contacts were recruited. The median age of the TB contact was 34 (IQR=10) years and 65 % were male. Seventy two percent of the adult TB contact had a TBIS 10C3 form created, and 95% of the medical records were fully documented. History taking and physical examination were recorded on 97% and 99% of patients respectively during the first follow-up at the polyclinic. Eighty five percent and 100% of the patients had a chest-x-ray and sputum direct smear for acid-fast bacilli done respectively. The turn-up rate for the first, second, third and fourth visit was 100% to 32%, 10% and 2% respectively. Conclusion: The quality of care for adult TB contacts tracing in this clinical audit was found to be suboptimal. There is a difference between the current national guidelines and practice in the clinic. Certain measures to improve the quality of care for adult TB contact tracing
are urgently needed.
Situated learning characterises the learning that takes place in the clinical environment. Learning in the workplace is characterised by transferring classroom knowledge into performing tasks and this may take various forms. In the medical education field, the cognitive apprenticeship instructional model developed by Collins (2016) supported this learning in the workplace setting due to its common characteristics of apprenticeship. This paper analysed two concrete learning situations in a Malaysian undergraduate and an Omani postgraduate learning environment. Both learning situations occurred in the primary healthcare outpatient setting. The cognitive apprenticeship model was used to identify characteristics of the individual learning environments and discusses factors that stimulate learning. Attention was paid to the role of reflection in stimulating learning in the described settings. The paper provided the context in both institutes, described the learning situation and provided an analysis based on the theoretical framework. Based on the analysis of the situations, solutions to problems in the two settings were suggested.
Gait and balance disorder are among the most common causes of falls in elderly and often lead to injury, disability and loss of independence. However, there might be a discrepancy between elderly’s perception of their own walking ability, balance, risk of fall with doctor’s evaluation. The aim of this study was to compare perception of the elderly’s walking ability, balance and risk of fall with clinical assessment. This cross sectional study was done in a Primary Care Clinic which involved elderly > 60 years using systematic random sampling. Participants completed a self-administered questionnaire comprising of sociodemographic data and question assessing their perception of ability of walking, balance and risk of fall. Actual clinical assessment was done using Tinetti Performance Oriented Mobility Assessment. Most of the participants perceived they had good walking (84.4%) and balance ability (77%). A small proportion (11.5%) agreed that they are at risk of fall. There was a good agreement in walking ability (k: 0.702, p:
OBJECTIVE: This study aimed to compare the evidence-based practices of primary care physicians between those working in rural and in urban primary care settings.
RESEARCH DESIGN: Data from two previous qualitative studies, the Front-line Equitable Evidence-based Decision Making in Medicine and Creating, Synthesising and Implementing evidence-based medicine (EBM) in primary care studies, were sorted, arranged, classified and compared with the help of qualitative research software, NVivo V.10. Data categories were interrogated through comparison between and within datasets to identify similarities and differences in rural and urban practices. Themes were then refined by removing or recoding redundant and infrequent nodes into major key themes.
PARTICIPANTS: There were 55 primary care physicians who participated in 10 focus group discussions (n=31) and 9 individual physician in-depth interviews.
SETTING: The study was conducted across three primary care settings-an academic primary care practice and both private and public health clinics in rural (Pahang) and urban (Selangor and Kuala Lumpur) settings in Malaysia.
RESULTS: We identified five major themes that influenced the implementation of EBM according to practice settings, namely, workplace factors, EBM understanding and awareness, work experience and access to specialist placement, availability of resources and patient population. Lack of standardised care is a contributing factor to differences in EBM practice, especially in rural areas.
CONCLUSIONS: There were major differences in the practice of EBM between rural and urban primary care settings. These findings could be used by policy-makers, administrators and the physicians themselves to identify strategies to improve EBM practices that are targeted according to workplace settings.
Matched MeSH terms: Primary Health Care/organization & administration*
In today's highly competitive health care environment, many private health care settings are now looking into customer service indicators to learn customers' perceptions and determine whether they are meeting customers' expectations in order to ensure that their customers are satisfied with the services. This research paper aims to investigate whether the human elements were more important than the nonhuman elements in private health care settings. We used the internationally renowned SERVQUAL five-dimension model plus three additional dimensions-courtesy, communication, and understanding of customers of the human element-when evaluating health care services. A total of 191 respondents from three private health care settings in the Klang Valley region of Malaysia were investigated. Descriptive statistics were calculated by the Statistical Package for Social Sciences (SPSS) computer program, version 15. Interestingly, the results suggested that customers nowadays have very high expectations especially when it comes to the treatment they are receiving. Overall, the research indicated that the human elements were more important than the nonhuman element in private health care settings. Hospital management should look further to improve on areas that have been highlighted. Implications for management practice and directions for future research are discussed.
Matched MeSH terms: Primary Health Care/standards*
The aim of this study was first to analyse the prescribing habits of primary care doctors with a view to providing feedback which may help them to rationalise their prescribing. This analysis was helped by comparing the prescribing practices in two different settings and thus highlighting anomalous differences. The second aim of this study was to obtain data on the diagnoses being made in primary care settings in Malaysia as this information, though available from other countries, is limited here. Lists of the most commonly prescribed drugs and most common diagnoses made are provided, together with tables showing the most commonly prescribed drugs for the ten most common diagnoses. Differences in prescribing habits between the two settings are discussed and possible reasons are suggested.
Patient satisfaction plays a crucial role in ensuring utilization of healthcare services, continuity of care, and compliance towards treatment. Thus, this study aimed at determining the level of patient satisfaction with the services provided by the UKMMC primary care clinic. A descriptive cross-sectional study involving 317 patients attending the clinic from February to March 2011 was carried out. They were selected through systematic random sampling. Using a validated self-administered Patient Satisfaction Questionnaire-46 (PSQ-46) in English and Malay versions, general satisfaction and satisfactions with five different subscales (doctors, nurses, accessibility, facilities and appointment) were assessed. A majority of the patients (93.1%) were generally satisfied with the overall services. Among the five subscales, patients were most satisfied with the doctors (96.5%), but only 35.6% of the patients were satisfied with the facilities. The proportions of patients who were satisfied with other subscales were: 86.1% (appointment), 82.0% (nurses) and 68.1% (accessibility). There was a significant association between each of the subscales and the general satisfaction (p
A 45-year-old Malay housewife was seen at a health clinic with the chief complain of recurrent lower abdominal pain for 9 months. The pain was colicky in nature and occasionally it radiated to the back. There was no history of fever, vaginal discharge or any urinary or bowel symptoms. She had been using an intrauterine contraceptive device (IUCD Cu250) for the past 5 years. The last change of the IUCD was 2 years ago. Her annual pap smear results were normal. She had been to many primary care clinics and was reassured by the doctors that her symptom was due to her IUCD. She was prescribed mefenamic acid repeatedly for the past 9 months. However her symptoms worsen and she was worried because prior to this she did not have similar problems. Her physical examination was unremarkable. On pelvic examination, the IUCD string was visualised, indicating that her IUCD was still in-situ. Her cervix was pink and healthy. There was no abnormal vaginal discharge.
BACKGROUND: Managed care is one of the means advocated for health care reforms. The Malaysian government has proposed managed care for its citizens. In the Malaysian private health care sector, managed care is practised on a small scale with crude risk adjustment. The main determinant of an individual's health service utilization is their health status (HS). HS is used as a risk adjuster for capitation payment. Prescribed medications represent a useful source for HS estimation. We aimed to develop and validate a medication-based HS estimate and to incorporate it in the Andersen model of health service utilization. This is a preparatory step in studying the feasibility of developing a model for risk assessment in the Malaysian context.
METHODS: Data were collected retrospectively from an academic year from computerized databases in University Sains Malaysia (USM) about users of USM primary care services. A user is a USM health scheme beneficiary who made at least one visit in the academic year to USM-assigned primary care providers. Socio-demographic variables, enrolment period, medications prescribed and number of visits were also collected. Chronic illness medications and some non-chronic illness medications were used to calculate the Long-Term Therapeutic Groups Index (LTTGI) which is an estimate of the HS of users. Using a random 50% of users, weighted least square methods were used to develop a model that predicts a user's number of visits. The other 50% were used for validation.
RESULTS: Socio-demographic variables explained 15% of variability in number of primary care visits among users. Adding the LTTGI improved the explanatory power of the model to 36% (P < 0.001). A similar contribution of the LTTGI was noted in the validation.
CONCLUSIONS: The Long-Term Therapeutic Groups Index was successfully developed. Variability in number of primary care visits can be predicted by LTTGI-based models.
Matched MeSH terms: Primary Health Care/utilization*
OBJECTIVE: To examine impressions of public healthcare providers/professionals (PHCPs) who are working closely with family medicine specialists (FMSs) at public health clinics.
DESIGN: Cross-sectional study.
SETTING: This study is part of a larger national study on the perception of Malaysian public healthcare professionals on FMSs (PERMFAMS).
PARTICIPANTS: PHCPs from three categories of health facility: hospitals, health clinics and health offices.
MAIN OUTCOME MEASURES: Qualitative analyses of written comments of respondents' general impression of FMSs.
RESULTS: The participants' response rate was 58.0% (780/1345), with almost equal proportions from each public healthcare facility. A total of 23 categories for each of the 648 impression comments were identified. The six emerging themes were: (1) importance of FMSs; (2) roles of FMSs; (3) clinical performance of FMSs; (4) attributes of FMSs; (5) FMS practice challenges; (6) misconception of FMS roles. Overall, FMS practice was perceived to be safe and able to provide effective treatments in a challenging medical discipline that was in line with the current standards of medical care and ethical and professional values. The areas of concern were in clinical performance expressed by PHCPs from some hospitals and the lack of personal attributes and professionalism among FMSs mentioned by PHCPs from health clinics and offices.
CONCLUSIONS: FMSs were perceived to be capable of providing effective treatment and were considered to be important primary care physicians. There were a few negative impressions in some areas of FMS practice, which demanded attention by the FMSs themselves and the relevant authorities in order to improve efficiency and safeguard the fraternity's reputation.
Study site: Klinik Kesihatan, Hospitals, Malaysia