In view of the alarming increase in the incidence of diabetes mellitus in Malaysia, we conducted a study to assess the awareness of complications of diabetes among the diabetics attending the peripheral clinics in Melaka. The study period was from January 2007 to December 2007. 351 patients were included in the study. 79.8% were aware of the complications of diabetes mellitus and 87.2% were aware that diabetes can affect the eyes. However, only 50% of the patients underwent an ophthalmological evaluation. Although awareness was good, the motivation to undergo the assessment was poor.
Study site: Klinik Kesihatan Peringgit, Klinik Kommunity Ayer Keroh, Melaka, Malaysia
Depression among elderly primary care patients is a serious problem with significant morbidity and mortality. This is a cross sectional study to determine the prevalence of depression and its associated factors among the elderly patients attending the outpatient clinic, Universiti Sains Malaysia Hospital. This study utilized Malay version Geriatric Depression Scale 14 (M-GDS 14) to screen for elderly depression among Malaysian population. It also looked into associated risk factors for elderly depression using sociodemographic, family dynamics, and medically related questionnaires. Out of 244 subjects, 34 or 13.9% were found to have depression. Three variables were found to be significantly associated with depression. Elderly patient with any illness that limits the patient's activity or mobility has more risk of developing depression (OR 2.68 CI 1.15 - 6.24). Elderly patients who were satisfied with their personal incomes (OR 0.29 CI 0.10 - 0.85), and who had children or son/daughter-in-law to take care of them when they are sick (OR 0.10 CI 0.01 - 0.83) have a lower chance of having depression. Screening the elderly for depression, would help in diagnosing the elderly depression better and offer them the treatment needed.
Study site: Outpatient clinics, Hospital Universiti Sains Malaysia (HUSM)
The increase in life expectancy observed over the last decade has particular relevance for conditions such as cognitive decline and dementia. This is a cross sectional study to determine the rate of dementia and to identify its associated factors among 399 elderly patients attending outpatient clinics of Universiti Sains Malaysia Hospital. This study was conducted in 2 phases. In the first phase, the literate subjects were screened using validated Malay version of Mini Mental State Examination (MMSE) and the illiterate subjects with Malay version of Elderly Cognitive Assessment Questionnaire (ECAQ). All subjects suspected to have dementia were selected for further evaluation in phase 2 of this study. The second phase involved full clinical examination in order to establish clinical diagnosis of dementia. The proportion of dementia in this study was 2.5% (10). Although history of exposure to pesticide (p < 0.05) and history of stroke (p < 0.05) were significant, they were not significant factors. These were because vast discrepancy in number between those exposed to pesticide and having stroke between dementia and non dementia.
Study site: Outpatient clinics, Hospital Universiti Sains Malaysia (HUSM)
This paper seeks to determine the client's compliance level towards Methadone Maintenance Therapy (MMT) and identify its associated factors. A cross sectional study was conducted from June to September 2007 where 288 samples were interviewed. The outcomes were divided into good compliance and partial compliance categories. Overall client's compliance level is good at 86.1%. There are significant difference between mean age of groups (t = -2.041, p = 0.04); and significant associations of job's status (chi2 = 9.54, p = 0.008); client's confident score (t = -3.12, p = 0.023), client'ssocial function score (t = -2.308, p = 0.002) and client's social function level (chi2 = 5.43, p = 0.02) with compliance toward program. With multivariate analysis, only client's age, client's confidence score and client's job status were related to compliance status. It was concluded that there is high compliance rate among client's who received the program. Younger clients, low scores on client's confident and social function, and clients with unsteady jobs are at risk not to comply with treatment.
The quality of physician prescribing is suboptimal. Patients are at risk of potentially adverse reaction because of inappropriate or writing error in the drug prescriptions. We assess the effect of "group academic detailing" to reduce writing drug name using brand name and short form in the drug prescriptions in a controlled study at two primary health care clinics in Negeri Sembilan. Five medical officers in Ampangan Health Clinic received an educational intervention consisting of group academic detailing from the resident Family Medicine Specialist, as well as a drug summary list using generic names. The academic detailing focused on appropriate prescribing habit and emphasized on using the full generic drug name when writing the drug prescription. Analyses were based on 3371 prescriptions that were taken from two clinics. The other health clinic was for comparison. The prescribing rates were assessed by reviewing the prescriptions (two months each for pre- and post-intervention phase). Statistically significant reduction in writing prescription using brand name and using short form were observed after the educational intervention. Writing prescription using brand name for pre- and postintervention phase were 33.9% and 19.0% (postintervention vs pre-intervention RR 0.56, 95% CI 0.48 to 0.66) in the intervention clinic. Prescription writing using any short form for pre- and post-intervention phase were 49.2% and 29.2% (post-intervention vs pre-intervention RR 0.59, 95% CI 0.53 to 0.67). This low cost educational intervention focusing on prescribing habit produced an important reduction in writing prescription using brand name and short form. Group detailing appears to be feasible in the public health care system in Malaysia and possibly can be used for other prescribing issues in primary care.
Despite being a common skin dermatosis in the tropics, physicians in the tropics may miss the diagnosis of cutaneous larva migrans for other pruritic skin manifestation. This is especially in those who live in urban housing with no history of travel. Cutaneous larva migrans, an intensely pruritic skin pathology is mainly contracted by people with history of beach holiday or contact with moist soft sand which had been contaminated with dog or cat faeces. This article reports a patient who presented with intensely itchy papular spots over the dorsum of his foot after walking barefooted in an urban toilet soiled with cat faeces. The patient had initially seen an urban general practitioner who diagnosed the papular skin lesion as an allergic reaction, and prescribed antihistamines. The patient subsequently developed creeping skin lesions and was seen by the author who prescribed albendazole 400 mg twice daily for three days. The patient reported reduction in itching after two days of albendazole treatment and a follow up at ten days revealed a healed infection.
This study described the practice profile of an open access exercise stress test (EST) service to the primary care physicians at a teaching hospital in 2000. We performed a retrospective review of all ESTs ordered and conducted by the primary care physicians. A total of 145 ESTs were conducted, of which 80.7% were referred for assessment of chest pain. Proportions of positive, negative, uninterpretable and inconclusive ESTs were: 22.1%, 52.8%, 18.1% and 6.9%. Typical chest pain was independently associated with a positive EST in this study (p = 0.008, OR 5.50, 95% CI 1.56-19.37). Although referral to the open access EST service seemed appropriate, there is a need to reduce the number of uninterpretable and inconclusive results.
Diabetes is a chronic condition that is one of the major causes of illness, disability, and death in Malaysia. Cost in managing diabetes plus indirect cost of lost work, pain, and suffering have all increased. The optimal management of patients with diabetes require the tracking of patients over time to monitor the progression of the disease, compliance with treatment, and preventive care. Diabetes care can be improved by standardizing access to, and improving the use of, clinical information. Access to timely, accurate and well-organized electronic data will improve the quality of care for patients with diabetes. Clinical Research Center convened an expert workshop to forecast how physicians, hospitals and clinics will employ clinical information technology (IT) applications to diabetes care over the next year. Workshop participants included experts from research organizations, government, and the IT vendor. This is a summary of the workshop organised for the purpose of the Audit of Diabetes Control and Management (ADCM) project. We hope to identify the gaps, if any, that exists in delivering diabetes care and to improve the quality of care. In future, we hope to develop an expansion of this project for the Adult Diabetes Registry that will be implemented for the whole country.
The aims of the study were to determine the prevalence of peripheral arterial disease (PAD) in diabetic patients and in different ethnic groups at a primary care setting, and to evaluate risk factors associated with PAD in these diabetic patients. A cross sectional study of 200 diabetic patients over 18 years old who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia was carried out. Face-to-face interviews were conducted using structured questionnaires for demographic characteristics and risk factors evaluation. Blood pressure measurements, assessment of peripheral neuropathy and ankle brachial pressures were performed. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.9 on either leg. The overall prevalence of PAD was 16% in this diabetic population. The prevalence of PAD was 5.8% in Malays, 19.4% in Chinese and 19.8% in Indians. The prevalence of peripheral neuropathy was 41%, foot ulcer 9.5%, and gangrene 3.0%. The presence of foot ulcer was weakly associated with PAD (P=0.052). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, dyslipidaemia, and PAD. PAD is common in the diabetic population of this study.
Study site: primary care clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
The aims of this study were (i) to determine the prevalence of self-monitoring of blood glucose (SMBG) among Type 2 diabetes patients attending government health clinics and (ii) to ascertain the factors influencing SMBG. Five hundred and fifty-six Type 2 diabetes patients from two government health clinics in Selangor and Negeri Sembilan were interviewed using a structured questionnaire. The total subjects of the study were 556 patients. Eighty-five patients (15.3%) of patients; performed SMBG. However, 170 subjects were included in the statistical analysis, 85 patients who were not self-monitoring were randomly selected and was compared with 85 patients who were self-monitoring. Among those who performed SMBG, the majority (83.5%) monitored less than once per day and only 16.5% monitored at least once a day. One-third of patients adjusted their medications based on their SMBG results. The higher patient's level of education (p= 0.024, CI 1.29 - 35.3); the higher total family income (p= 0.041, CI 1.26 - 4.79); the longer duration of diabetes (p<0.01, CI 2.22 - 7.29); and treatment regime which includes insulin (p< 0.001, CI 2.05 -9.24) were significant predictors of SMBG practice. Although SMBG is recognised to be useful and effective in achieving diabetes control, this study has found that only a minority of patients with diabetes performed SMBG. Hence healthcare personnel must increase awareness on the importance of SMBG and strongly promote the practice among diabetic patients.
A study was undertaken to assess the accuracy of the Omron HEM-907 blood pressure measuring device for use in community studies. A modified version of the British Hypertension Society (BHS) and American Association for the Advancement Medical Instrumentation (AAMI) protocol for measuring the accuracy of a blood pressure measuring device was used. A total of 104 subjects were recruited from two clinics. Observer-observer agreement for readings within the 5 mmHg was good; 80.8% and 84.6% of systolic blood pressure (SBP) and diastolic blood pressure (DBP) agreement respectively. Of the two, the better observer-device agreement readings within the 5 mmHg were 66.4% and 50.0% for SBP and DBP respectively, giving an overall grade B. The mean differences and standard deviation of the differences were within < or =5 mmHg with a standard deviation (SD) of < or =8 mmHg. The Omron HEM-907 satisfied both the AAMI and BHS protocols for accuracy for a non-invasive blood pressure monitoring device using single observer readings.
Study site: Klinik Kesihatan Shah Alam, Selangor; Hypertension clinic, Hospital Kuala Lumpur, Malaysia
Device: Standard device: mercury sphygmomanometer (brand?); test device: oscillometric automated electronic BP monitor (Omron HEM-907).
The National Medicines Use Survey (NMUS) which started in 2004 and is still ongoing was conducted with the intent to continuously and systematically collect data on the use of medicines, to provide an overview on the use of medicines in Malaysia. The objective of the NMUS is therefore to quantify the present state and time trends of medicines utilization at various levels of our health care system whether national, regional, local or institutional. From the data available, for the Year 2005, the most commonly used medicine in Malaysia were anti-diabetic medications, of which glibenclamide is the most common followed by metformin, were the top 2 of the list of drugs utilized in DDD/1000 population/day. Collectively, however, taking into account the various antihypertensives by therapeutic groups, anti-hypertensive medicines were more commonly used than anti-diabetics. Hypertension and diabetes mellitus are the two most prevalent chronic disorders in the country and thus, such high medicines utilization rates for these conditions are to be expected. From the general practice prescription data, it was estimated that a patient with hypertension was prescribed a median of only one (1) anti-hypertensive medication. This means, the vast majority of patients (81%) were on monotherapy, which is hardly sufficient to achieve treatment target. Clearly then, given the prevalence of hypertension, many patients were not on drug treatment at all, and of those treated, their drug treatment are likely to be inadequate.
This is a cross-sectional study investigating the profile of children with disability registered with the primary health care clinics in Malaysia. The purpose of the study was to assess the developmental stage of children with disability. Secondary data from the pilot project conducted by the Family Health Development Division, Ministry of Health Malaysia was used in this study. The study period was for six months from 1st August 2004 until 31st January 2005. A total of 900 disabled children were selected in this study. Schedule of Growing Scale (SGS) II was used for analysis. Results showed more boys than girls were affected with a ratio of 6:4. The mean total SGS score increases as the age of the child increased. The score was highest in delayed speech cases and lowest in cerebral palsy cases. The performance among children with delayed speech was the highest while children with cerebral palsy were the lowest. There was a statistically significant difference between the major ethnic groups in delayed speech and attention deficit hyperactive disorder.
Questionnaire: Denver Developmental Assessment Test II chart; DSST; Schedule of Growing Scale II; SGS
The purpose of this study was to study the determinants of self rated health in the low-risk pregnant women of Melaka Tengah in Malaysia. A total of 387 subjects were analysed. The role of mental health, psychosocial stressors, support from husband, coping skills, socio-economic status and pregnancy characteristics in determining self- rated health were studied. Health items were taken from the Duke Health Profile. Bad obstetric history, poor mental health, stress from the family were found to be significantly associated with poor self - rated health whereas good support from the husband was related to good self - rated health.
Thrombocytopaenia is often relied upon as an important criterion for the diagnosis of dengue infection among patients presenting with an acute non-specific febrile illness. This study was aimed to assess usefulness of thrombocytopaenia in the diagnosis of acute dengue virus infection. This was a clinic based prospective cohort study from May to November 2003. Consecutive patients presenting with acute non-specific febrile illness of less than two weeks were selected from two urban primary care centres. We did full blood count examination (FBC) on the day of visit and dengue serology on day five of illness for all patients enrolled. We repeated the FBC examination for patients who had initial normal platelet counts. Thrombocytopaenia was defined as platelet count < 150 X 10(9)/L. Eighty-seven patients enrolled in the study. Complete data was available for 73 patients. The prevalence of acute dengue virus infection was 27.6%. The sensitivity and specificity were 88% and 71% respectively. The likelihood of acute dengue infection in the presence of thrombocytopaenia was 2.52 and likelihood of not having dengue infection in normal platelet count patients was 5.22. Thrombocytopaenia has fair predictive value in diagnosing acute dengue virus infection. It was more useful to exclude than to diagnose dengue infection.
Study site: Primary Care Centre of Hospital Universiti
Kebangsaan Malaysia (HUKM) and Batu 9 Health Clinic Hulu Langat,
The increasing prevalence of childhood asthma has become a concern among health practitioners. Effective management emphasizes long-term management and inhaled therapy has become the mainstay home management for children. However, proper utilization of medication is pertinent in improving control. Proper asthma education is mandatory in improving skills and confidence amongst parents. To assess the skills of using the metered-dose inhaler (MDI) with a spacer among asthmatic children before and after educational intervention and to analyse any difficulties which may occur amongst the participants in executing the assessment steps. A cross-sectional clinic based study involving 85 parents and children with asthma. A standardized metered-dose inhaler-spacer checklist of eight steps of medication usage and five steps of cleaning the spacer were used as the assessment tools for pre and post intervention. The performance on using the inhaler-spacer and spacer cleaning knowledge pre and two months post intervention was evaluated. One point was given for each correct step and zero points for incorrect answers/steps. The mean score for skills of inhaler technique improved significantly after educational intervention (3.51 to 6.01, p < 0.0001) as did the mean score for parental knowledge of spacer cleaning technique (1.35 to 3.16, p 0.001). Analysis showed only a limited improvement even after an educational session in three steps of inhalation technique: step 5 (23.5%/69.4%), step 6 (28.2%/68.2%) and step 7 (25.9%/61.2%). Parents with asthmatic children had poor skills in utilizing their children's medication. A short-term educational intervention was able to improve overall knowledge and skill but certain skills need more emphasizing and training.
Study site: Klink HUKM Taman Jaya, Cheras, Kuala Lumpur, Malaysia (primary care clinic for Hospital University Kebangsaan Malaysia)
We assessed the effectiveness of an educational intervention in reducing antibiotic prescribing in public primary care clinics in Malaysia. Twenty-nine medical officers in nine clinics received an educational intervention consisting of academic detailing from the resident Family Medicine Specialist, as well as an information leaflet. The antibiotic prescribing rates were assessed for six months - three months before and three months after the intervention. A total of 28,562 prescriptions were analyzed. Among participating doctors, general antibiotic prescribing rates for pre- and post-intervention phases were 14.3% and 11.0% (post-intervention vs pre-intervention RR 0.77, 95% CI 0.72 to 0.83). The URTI-specific antibiotic prescribing rates for pre- and post-intervention phases were 27.7% and 16.6%, respectively (post-intervention vs pre-intervention RR 0.60, 95% CI 0.54 to 0.66). No significant change in antibiotic prescribing rates was observed among primary care practitioners who did not participate in the study. This low cost educational intervention using both active and passive strategies focusing on URTI produced a statistically significant (and clinically important) reduction in antibiotic prescribing.
Study site: Klinik Kesihatan, Negeri Sembilan, Malaysia
The Malaysian Ministry of Health has undertaken various campaigns on healthy lifestyle and health promotion over the years. The impact of these campaigns has been mixed and not well documented. This cross-sectional study evaluated the knowledge level of patients with and without diabetes in a large urban polyclinic using a 41-item questionnaire. One hundred and forty-nine adults (83 with diabetes, 66 without diabetes) participated in this study. Patients with diabetes had higher overall knowledge scores than those without diabetes (81.8% vs 64.0%, p < 0.001). While the overall knowledge of patients without diabetes appeared to be acceptable, several areas of knowledge deficiency were identified in this group--areas that should be filled by the on-going health promotion activities.
Study site: Klinik Kesihatan Seremban, Seremban, Negeri Sembilan, Malaysia
On review of 3117 patients' records (all were female Indonesian foreign workers over the span of eight years (1997 to 2004 in a private clinic in Johor Bahru, 223 cases (7.2%) were found to have various medical problems. These 3117 foreigners were to be employed as domestic helpers in Malaysia. They were examined upon arrival in Johor Bahru even though our government did not require this pre-requisite (before 1st August 2005) as they were examined and certified fit in their country of origin before embarking to Malaysia. The proportion of female Indonesian foreign workers who were afflicted with category 1 conditions was 55.6% (which rendered them unfit for employment) and category 2 conditions was 44.4%. The medical problem detected most frequently was hypertension. Sixty-one (80.3%) out of 76 workers had stage 2 hypertension (JNC 7 report). Pulmonary tuberculosis ranked second in this review and is a category 1 condition. This paper supports the recent move by the Malaysian Ministry of Health to implement mandatory medical examinations for all foreign workers arriving in Malaysia within one month of arrival regardless of whether or not they are certified fit in their countries of origin.
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.