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Fulltext Risk factors associated with incomplete immunisation in hospitalised infants

Norlijah O, Menon BS, Azlyna MYY

Med J Malaysia, 2005 Dec;60(5):563-9.
PMID: 16515106

To determine the immunisation status of hospitalised infants and to examine the potential risk factors associated with incomplete immunisation. Prospective study of infants admitted to a paediatric hospital in Kuala Lumpur, conducted by interviewing carers. Twenty-two percent of infants had incomplete immunisation. The most significant factor that was associated with incomplete immunisation was the carer's lack of knowledge on the timing of the next immunisation (p = 0.005). Other factors that had significant association were the presence of a previous admission to hospital (p = 0.03) and the infant's age of more than 6 months (p = 0.025). The rate of incomplete immunisation in the study population was 22%. An admission to hospital of an infant should be taken as an opportunity to update their immunisation in order to improve the rate of uptake.

Matched MeSH terms: Treatment Refusal*
Fulltext Polio vaccination in Pakistan: by force or by volition?

Khan TM, Chiau LM

Lancet, 2015 Oct 31;386(10005):1733.
PMID: 26545429 DOI: 10.1016/S0140-6736(15)00689-3
Matched MeSH terms: Treatment Refusal/legislation & jurisprudence*
Fulltext Polio vaccination in Pakistan

Khan MU, Ahmad A

Lancet, 2015 Jul 25;386(9991):337.
PMID: 26227462 DOI: 10.1016/S0140-6736(15)61405-2
Matched MeSH terms: Treatment Refusal/legislation & jurisprudence*
Fulltext Lumbar puncture refusal in febrile convulsion

Ling SG, Boey CC

Singapore Med J, 2000 Oct;41(10):485-8.
PMID: 11281439

A descriptive study was carried out on patients admitted for febrile convulsion over a two-year period to determine rate of lumbar puncture (LP) refusal, factors associated with LP refusal and outcome of such patients. From 77 patients indicated and requested for LP, 19 (25%) patients refused the procedure. Refusal of LP was significantly more common among the Malay ethnic group (p = 0.01) but not significantly associated with age,gender or whether the patient was admitted for a first or recurrent febrile convulsion. Half of the patients who refused LP had to be started empirically on antibiotics for meningitis. Patients who refused LP were also 8.5 times more likely to discharge themselves "at own risk" (AOR), compared to other patients with febrile convulsion (p = 0.004). In conclusion, LP refusal is a common problem in the local setting and is a hindrance to the proper management of patients with fever and seizure. Appropriate measures must be carried out to educate the public, particularly those from the Malay ethnic group on the safety and usefulness of the procedure. Reasons for patients discharging AOR following LP refusal also need to be addressed and problems rectified.

Matched MeSH terms: Treatment Refusal*
Fulltext Medication compliance among renal transplant patients: a Hospital Kuala Lumpur experience

Liu WJ, Zaki M

Med J Malaysia, 2004 Dec;59(5):649-58.
PMID: 15889568 MyJurnal

This survey aims to identify prevalence, reasons and predictors of noncompliance among renal transplant patients followed up in Hospital Kuala Lumpur (HKL). All adult renal transplant patients who were at least 6 months post transplant were recruited from 10/2001 till 5/2002. Patients who consented were interviewed by a medical doctor or research assistant based on questionnaire. Noncompliers were defined as those who missed or self adjusted any dose of immunosuppressant within the preceding 4 weeks. Inter-rater agreement was assessed prior by Kappa (K) scores and they were acceptable. Out of 304 patients, 246 patients volunteered; of whom 144 (58.5%) were males. Twenty-one (9.3%) were noncompliers. Reasons for noncompliance included forgetfulness (n=8), financial constraints (n=1), fear of rejection (n=1), side effects (n=9), decision not to take (n=6), difficulty in breaking medication into correct dosages (n=1). Significant predictors of noncompliance were longer duration of transplant noncompliance to other drugs, regular use of nonprescription drugs; the lack of symptoms of fat facial cheeks and infection. Surveillance for noncompliance should not be relaxed as its predictors are diverse and persistent, especially in those who are at high risks.

Matched MeSH terms: Treatment Refusal/psychology*; Treatment Refusal/statistics & numerical data*
Failed magnetic resonance imaging examinations due to claustrophobia

Sarji SA, Abdullah BJ, Kumar G, Tan AH, Narayanan P

Australas Radiol, 1998 Nov;42(4):293-5.
PMID: 9833363

A recognized cause of incomplete or cancelled MRI examinations is anxiety and claustrophobic symptoms in patients undergoing MR scanning. This appears to be a problem in many MRI centres in Western Europe and North America, where it is said to be costly in terms of loss of valuable scan time, and has led to researchers suggesting several anxiety-reducing approaches for MRI. To determine the incidence of failed MRI examination among our patients and if there are any associations with a patient's sex, age and education level, we studied claustrophobia that led to premature termination of the MRI examination in the University Malaya Medical Centre (UMMC) in 3324 patients over 28 months. The incidence of failed MRI examinations due to claustrophobia in the UMMC was found to be only 0.54%. There are associations between claustrophobia in MRI with the patients' sex, age and level of education. The majority of those affected were male patients and young patients in the 25-45-years age group. The patients' education level appears to be the strongest association with failed MRI examinations due to claustrophobia, where the majority of the affected were highly educated individuals. Claustrophobia in MRI is more of a problem among the educated individuals or patients from a higher socio-economic group, which may explain the higher incidence in Western European and North American patients.

Matched MeSH terms: Treatment Refusal/psychology*
Discharges of children from hospital against medical advice

Hong LE, Ling FC

J Singapore Paediatr Soc, 1992;34(1-2):34-8.
PMID: 1303463

A retrospective study on discharges of children from hospital against medical advice or at own risk (AOR) discharges was conducted at our department from March 1981 to February 1990. There were altogether 890 patients giving an average incidence of 2%/year. The racial composition comprised 62.5% Chinese, 28.5% Malay, 7.3% Indian and 1.7% others. The common reasons for AOR discharge includes: (a) Inconvenience of having the child hospitalised (18.4%). (b) Preference of being treated by the general practitioner (15%). (c) Parents think child is well (14%). (d) Preference of being treated by private specialist or other hospital (11.9%) etc. Neonate comprised 16.9%, infants (except neonates) 44%, children > 1-5 yrs 28.6%, > 5-10 yrs 7.7% and > 10 yr 1.9%. The common diagnoses of these children include gastroenteritis (13.9%), febrile fit (13%), upper respiratory tract infection (11.7%), neonatal jaundice (5.7%). In conclusion AOR discharges of children from hospital is not uncommon and more could be done to reduce the incidence.

Matched MeSH terms: Treatment Refusal*
Treatment abandonment in children with cancer: Does a sex difference exist? A systematic review and meta-analysis of evidence from low- and middle-income countries

Palagyi A, Balane C, Shanthosh J, Jun M, Bhoo-Pathy N, Gadsden T, et al.

Int J Cancer, 2021 02 15;148(4):895-904.
PMID: 32875569 DOI: 10.1002/ijc.33279

In this systematic review and meta-analyses, we sought to determine sex-disparities in treatment abandonment in children with cancer in low- and middle-income countries (LMICs) and identify the characteristics of children and their families most disadvantaged by such abandonment. Sex-disaggregated data on treatment abandonment were collated from the available literature and a random-effects meta-analysis was conducted to compare the rates in girls with those in boys. Subgroup analyses were conducted in which studies were stratified by design, cancer type and the Gender Inequality Index of the country of study. Eighteen studies were included in the systematic review and of these studies, 16 qualified for the meta-analysis, representing 10 754 children. The pooled rate of treatment abandonment overall was 30%. We observed no difference in the proportion of treatment abandonment in girls relative to estimates observed in boys (rate ratio [RR] 0.95, 95% CI: 0.79-1.15; P = .61). There was significant heterogeneity across the included studies and in the pooled estimate of RR for girls vs boys (both I2 > 98%). Subgroup analyses did not reveal any effect on abandonment risk. Risk factors for abandonment observed fell into three main categories: socio-demographic; geographic; and travel-related. In conclusion, a high rate of treatment abandonment (30%) was observed overall for children with cancer in included studies in LMICs, although this was variable and context specific. No evidence of gender bias in childhood cancer treatment abandonment rates across LMICs was found. Given that the risk factors for abandonment are context specific, in-depth country-level analyses may provide further insights into the role of a child's gender in treatment abandonment decisions.

Matched MeSH terms: Treatment Refusal/statistics & numerical data*
Improving the utilization of implantable cardioverter defibrillators for sudden cardiac arrest prevention (Improve SCA) in developing countries: Clinical characteristics and reasons for implantation refusal

Singh B, Zhang S, Ching CK, Huang D, Liu YB, Rodriguez DA, et al.

Pacing Clin Electrophysiol, 2018 12;41(12):1619-1626.
PMID: 30320410 DOI: 10.1111/pace.13526

BACKGROUND: Despite available evidence that implantable cardioverter defibrillators (ICDs) reduce all-cause mortality among patients at risk for sudden cardiac death, utilization of ICDs is low especially in developing countries.
OBJECTIVE: To summarize reasons for ICD or cardiac resynchronization therapy defibrillator implant refusal by patients at risk for sudden cardiac arrest (Improve SCA) in developing countries.
METHODS: Primary prevention (PP) and secondary prevention (SP) patients from countries where ICD use is low were enrolled. PP patients with additional risk factors (syncope, ejection fraction

Matched MeSH terms: Treatment Refusal/statistics & numerical data*
Darier disease: a case report

Jalil AA, Zain RB, van der Waal I

Br J Oral Maxillofac Surg, 2005 Aug;43(4):336-8.
PMID: 15993288

The diagnosis of Darier disease of the oral mucosa was made only after biopsying a leukoplakia-like lesion of the palate.

Matched MeSH terms: Treatment Refusal
Fulltext Identification of psychosocial factors of noncompliance in hypertensive patients

Hassan NB, Hasanah CI, Foong K, Naing L, Awang R, Ismail SB, et al.

J Hum Hypertens, 2006 Jan;20(1):23-9.
PMID: 16177812 DOI: 10.1038/sj.jhh.1001930

This cross-sectional study was aimed to identify the predictors of medication noncompliance in hypertensive patients. The study was conducted at the Family Medicine Clinic, Hospital Universiti Sains Malaysia, Kelantan, Malaysia, which is a university-based teaching hospital. All hypertensive patients aged 40 or over-registered from January to June 2004, who had been on treatment for at least 3 months, were screened. Previously validated self-administered questionnaires were used to assess the compliance and psychosocial factors. A total of 240 hypertensive patients were recruited in the study. Of these, 55.8% were noncompliant to medication. Logistic regression showed that age (adjusted odds ratio (OR): 0.96; 95% confidence interval (CI): 0.92-0.997; P: 0.035), patient satisfaction (adjusted OR: 0.97; 95% CI: 0.93-0.998; P: 0.036) and medication barrier (adjusted OR: 0.95; 95% CI: 0.91-0.987; P: 0.009) were significant predictors of medication noncompliance. Therefore, younger age, poor patient satisfaction and medication barrier were identified as independent psychosocial predictors of medication noncompliant in hypertensive patients.

Matched MeSH terms: Treatment Refusal/psychology*
A descriptive study of nasogastric tube feeding among geriatric inpatients in Malaysia: utilization, complications, and caregiver opinions

Nordin N, Kamaruzzaman SB, Chin AV, Poi PJ, Tan MP

J Nutr Gerontol Geriatr, 2015;34(1):34-49.
PMID: 25803603 DOI: 10.1080/21551197.2014.998326

The strong emphasis on feeding in Asian cultures may influence decisions for nasogastric (NG) tube feeding in geriatric inpatients. We evaluated the utility, complications, and opinions of caregivers toward NG tube feeding in an acute geriatric ward in a teaching hospital in Kuala Lumpur. Consecutive patients aged 65 years and older receiving NG tube feeding were included. Sociodemographic, clinical, and laboratory indices were recorded. Opinion on NG tube feeding were evaluated through face-to-face interviews with caregivers, recruited through convenience sampling. Of 432 patients admitted, 96 (22%), age ± standard deviation = 80.8 ± 7.4 years, received NG tube feeding. The complication and mortality rates were 69% and 38%, respectively. Diabetes (odds ratio [95% confidence interval] = 3.34 [1.07, 10.44], aspiration pneumonia (8.15 [2.43, 27.24]), impaired consciousness (3.13 [1.05, 9.36]), and albumin ≤26 g/dl (4.43 [1.46, 13.44]) were independent predictors of mortality. Other relatives were more likely than spouses (23.5 [3.59, 154.2]) and caregivers with tertiary education more likely than those with no formal education ( 18 [1.23, 262.7]) to agree to NG feeding. Sixty-four percent of caregivers felt NG tube feeding was appropriate at the end of life, mostly due to the fear of starvation. NG tube feeding is widely used in our setting, despite high complication and mortality rates, with likely influences from cultural emphasis on feeding.

Matched MeSH terms: Treatment Refusal/ethnology
Fulltext Rate and associated factors of refusal to perform immunochemical Faecal Occult Blood Test (iFOBT) among semi-urban communities

Syed Soffian SS, Safian N, Nawi AM, Ahmad SB, Chan HK, Abu Hassan MR

PLoS One, 2021;16(10):e0258129.
PMID: 34618854 DOI: 10.1371/journal.pone.0258129

The uptake of the immunochemical faecal occult blood test (iFOBT) in many countries with an opportunistic colorectal cancer (CRC) screening programme remains suboptimal. This study aimed to determine the rate, associated factors and reasons of refusal to perform the iFOBT test offered under an opportunistic CRC screening programme in semi-urban communities. This cross-sectional study was conducted among the average-risk individuals living in semi-urban areas, who sought care from public primary care centres across Kedah state, Malaysia. The information regarding the sociodemographic and clinical characteristics of individuals who were offered the iFOBT between January and April 2019, along with their willingness to perform the test, was gathered. The factors associated with the refusal were further explored using the logistic regression analysis. The individuals offered the iFOBT (n = 920) were mainly female (52.4%) and had a mean age of 58.7±10.6 years. The refusal rate of the iFOBT was 32.2%. Patients who did not have hypertension (adjusted OR: 3.33; 95% CI: 2.44, 4.54), did not have CRC symptoms (adjusted OR: 3.15; 95% CI:1.26, 7.89), had the test offered by either medical assistants (adjusted OR: 2.44; 95% CI: 1.71, 3.49) or nurses (adjusted OR: 2.41; 95% CI 1.65, 3.51), did not have diabetes (adjusted OR: 1.99; 95% CI: 1.42, 2.77),and were not active smokers (adjusted OR: 1.74; 95% CI: 1.22, 2.47), were more likely to refuse the iFOBT. The common reasons of refusing the test included "feeling not ready for the test" (21.6%) and "feeling healthy" (14.9%). The iFOBT was refused by one-third of the average-risk individuals from semi-urban communities. The associated factors and reasons of refusal found in this study could guide policymakers in developing targeted interventions to boost the uptake of CRC screening in Malaysia.

Matched MeSH terms: Treatment Refusal/psychology*
Fulltext Major surgery in an osteosarcoma patient refusing blood transfusion: case report

Dhanoa A, Singh VA, Shanmugam R, Rajendram R

World J Surg Oncol, 2010;8:96.
PMID: 21059231 DOI: 10.1186/1477-7819-8-96

We describe an unusual case of osteosarcoma in a Jehovah's Witness patient who underwent chemotherapy and major surgery without the need for blood transfusion. This 16-year-old girl presented with osteosarcoma of the right proximal tibia requiring proximal tibia resection, followed by endoprosthesis replacement. She was successfully treated with neoadjuvant chemotherapy and surgery with the support of haematinics, granulocyte colony-stimulating factor, recombinant erythropoietin and intraoperative normovolaemic haemodilution. This case illustrates the importance of maintaining effective, open communication and exploring acceptable therapeutic alternative in the management of these patients, whilst still respecting their beliefs.

Matched MeSH terms: Treatment Refusal*
Challenges to health workers and their opinions about parents' refusal of oral polio vaccination in the Khyber Pakhtoon Khawa (KPK) province, Pakistan

Khan TM, Sahibzada MU

Vaccine, 2016 Apr 19;34(18):2074-81.
PMID: 26993330 DOI: 10.1016/j.vaccine.2016.03.008

A qualitative study design was adapted to explore the challenges faced by health workers (HWs) during the polio health campaign. In addition, HWs' opinions about the factors causing parents to refuse oral polio vaccination (OPV) were also explored. Four focus group discussions (FGDs) were held (from 1st January 2015-31st March 2015) with the HWs who participated in the OPV campaigns in the polio red zones of Khyber Pakhtoon Khawa (KPK) province of Pakistan, namely Kohat (FG 1), Domel and Bannu (FG 2), Hangoo (FG 3), and Peshawar (FG 4). A total of N=42 HWs (10-11 in each FG) agreed to participate in this study. Overall, HWs disclosed that public attitude and harsh behaviour towards the HWs and security threats are the two main challenges they face. Common issues hindering parents' willingness to vaccinate their children against OPV are: OPV is seen as haram and not permitted in Islam, it is said to contain the blood of pigs (Khinzir) and monkeys, and parents are afraid that it is done to induce sterility among their children. HWs also shared that parents have a strong belief in the conspiracies that are associated with OPV, i.e. the USA and CIA, are spying on us and our government is helping them to achieve their agenda. Furthermore, HWs revealed that frequent visits may further strengthen parents' perceptions and make them more resistant to OPV. The common side effects of OPV reported by parents were mainly gastro-intestinal problems and in some cases mild to moderate fever with some respiratory symptoms. There is a great need to improve the logistics and facilities for HWs assisting in vaccination programmes. Furthermore, it is necessary to improve education, so people understand the basic concept of revaccination and booster doses, thereby assisting in creating a basic understanding of vaccinations, which may trigger changes in attitudes and make people believe in the benefits of OPV rather than following the conspiracies that lead them to refuse it.

Matched MeSH terms: Treatment Refusal/psychology*
Fulltext Gender bias in training of medical students in obstetrics and gynaecology: a myth or reality?

Mohd Zahid AZ, Ismail Z, Abdullah B, Daud S

Eur J Obstet Gynecol Reprod Biol, 2015 Mar;186:17-21.
PMID: 25614093 DOI: 10.1016/j.ejogrb.2014.12.018

OBJECTIVE: To investigate the experience of medical students during a clinical attachment in obstetrics and gynaecology (O&G).
STUDY DESIGN: A questionnaire was distributed to medical students who completed their O&G posting between August 2012 and August 2013. The first part included basic demographic details (age, gender, and ethnicity) and frequency of actual clinical experience; the second part explored students' perception of their training and their relationship with other staff, in particular feeling of discrimination by specified groups of medical personnel. The responses were recorded using a Likert scale and were recategorised during analysis.
RESULTS: A total of 370 questionnaires were distributed, and 262 completed questionnaires were returned, giving a response rate of 71%. Female students had a significantly higher median (IqR) number of vaginal examinations performed 0.25(0.69) (p=0.002) compared to male students. Male students experienced a higher proportion of patient rejections during medical consultation, 87% vs. 32% of female students (p<0.001), a higher rate of refusal for clerking (71.4% vs. 57.5% of females, p=0.035) and a higher rate of patients declining consent for internal examination (93.3% vs. 67.6% of females, p<0.001). The majority of male students felt that their gender negatively affected their learning experience (87% vs. 27.4% of the female students, p<0.001). Male students reported a significantly higher proportion of discrimination against their gender by medical officers (p=0.018) and specialists/consultants (p<0.001) compared to females but there was no discrimination between genders by staff nurses or house officers. A majority (58%) of female students stated an interest in pursuing O&G as a future career compared to 31.2% of male students.
CONCLUSIONS: Our study confirmed that gender bias exists in our clinical setting as male students gain significantly less experience than female students in pelvic examination skills. We also demonstrated that compared to female students, male students experience higher levels of discrimination against their gender by trainers who are medical officers and specialists/consultants. Trainers must improve their attitudes towards male students, to encourage them and make them feel welcome in the clinical area. We must minimize gender discrimination and educational inequities experienced by male students, in order to improve their learning experience.
KEYWORDS: Gender discrimination; Obstetrics and gynaecology; Training

Matched MeSH terms: Treatment Refusal
Infantile fibrosarcoma of the penis in a 2-year-old boy

Taib F, Mohamad N, Mohamed Daud MA, Hassan A, Singh MS, Nasir A

Urology, 2012 Oct;80(4):931-3.
PMID: 22854139 DOI: 10.1016/j.urology.2012.05.021

Fibrosarcoma is rare in the pediatric age group. It generally involves the extremities and the trunk but rarely involves the genital area. We report a case of a large fungating infantile fibrosarcoma of the penis in a 2-year-old Malay boy. Partial recovery of the penile structure was achieved after chemotherapy. The difficulty in managing the social and surgical aspect of this case is discussed in our report. To the best of our knowledge, this is the first case report of infantile fibrosarcoma involving the penis in an Asian region.

Matched MeSH terms: Treatment Refusal
Fulltext Relapsed Hodgkin's disease presenting as a right knee swelling

Leong CF, Soo PY, Fadilah SAW, Cheong SK

Med J Malaysia, 2003 Mar;58(1):131-4.
PMID: 14556340

A 49 year-old Indian housewife was diagnosed with Hodgkin's disease in 1995. She was given combination chemotherapy comprising Chlorambucil, Vincristine, Procarbazine and Prednisolone. Unfortunately she defaulted after two courses of chemotherapy. One year later, she developed progressive right knee swelling and pain, associated with loss of appetite, loss of weight, intermittent fever, night sweats and pruritus. The right knee swelling measured 15 cm x 20 cm and was warm and tender. A plain radiograph of the right knee revealed osteolytic lesions at the distal end of the right femur and the proximal ends of the right tibia and fibula, associated with gross periosteal reaction and soft tissue swelling. Apart from left cervical lymphoadenopathy, examination of other systems was unremarkable. Pelvic bone marrow biopsy was inconclusive. An open biopsy of the lower end of the right femur was consistent with Hodgkin's disease. She was given salvage combination therapy comprising Chlorambucil, Vincristine, Procarbazine, Prednisolone, Doxorubicin, Bleomycin and Vinblastine. She tolerated the treatment well and responded with significant reduction in the swelling and pain of the right knee. Unfortunately, she again defaulted treatment after 2 courses of chemotherapy. This case illustrates an unusual presentation of Hodgkin's disease in relapse.

Matched MeSH terms: Treatment Refusal
Fulltext Adult idiopathic thrombocytopenic purpura without the option of splenectomy

Jackson N, Mustapha M, Baba AA

Med J Malaysia, 1995 Sep;50(3):250-5.
PMID: 8926904

In this part of Malaysia, consent of splenectomy is virtually unobtainable, so we studied the outcome of ITP without this treatment option. Thirty-two adult patients were seen, but 7 defaulted before therapy evaluation. Of the remaining 25, 17 achieved a complete remission with prednisolone, but in only 8 was this prolonged. Twelve patients, who failed to respond to prednisolone or who required > 15 mg/day as maintenance, were offered splenectomy, but all fused. Of these 12: one has died from an intracranial haemorrhage; three others have defaulted while on no treatment with platelet counts of < 16 x 10(9)/1; one has had a baby who died from intracranial bleeding. The other seven patients have platelet counts ranging from 4 - 202 x 10(9)/1 with moderate bleeding on doses of prednisolone of 0-60 mg/day: long-term corticosteroid side-effect are evident in all but one of them. This study demonstrates that ITP patients who refuse splenectomy have a high morbidity.

Matched MeSH terms: Treatment Refusal
Fulltext The Mentakab hypertension study project. Part V--Drug compliance in hypertensive patients

Lim TO, Ngah BA, Rahman RA, Suppiah A, Ismail F, Chako P, et al.

Singapore Med J, 1992 Feb;33(1):63-6.
PMID: 1598610

Poor compliance with drug treatment is a barrier to effective management of hypertension. Drug compliance behaviour of 168 patients were studied, their drug compliance was measured by the pill-counting method. The prevalence of non-compliance with medication was 26%. Thirteen variables were examined for their association with compliance; these were age, sex, duration of hypertension since diagnosis, adequacy of blood pressure control, complexity of drug regimen and side-effect of drug, history of previous admission for hypertension related reason, patient's knowledge of hypertensive complications, patient's belief that drug was 'panas' or 'san', previous use of traditional treatment for hypertension, patient's fatalistic attitude, their social support and satisfaction with the health services. None of these variables were significantly related to compliance (p greater than 0.05) except adequacy of blood pressure control. The performance of patient self-report was compared with pill-count as a measure of drug compliance; it was poorly predictive of non-compliance (sensitivity = 71%, specificity = 50%). An inverse relationship was found between non-compliance with medication and patient subsequent drop-out rate. Patients who were compliant were more likely to remain on treatment and vice versa. As a measure of drug compliance, detection of drop-out compared well with pill-count (sensitivity 97%, specificity 66%, positive predictive value 89%, negative predictive value 88%).
Study site: outpatient clinic, Hospital Mentakab, Pahang, Malaysia

Matched MeSH terms: Treatment Refusal

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