METHODS: A parallel, open-label, 2-arm prospective, pilot randomised controlled trial was conducted at a long-term stroke service at a university based primary care clinic. All stroke caregivers aged ≥ 18 years, proficient in English or Malay and smartphone operation were invited. From 147 eligible caregivers, 76 participants were randomised to either SRA™ intervention or conventional care group (CCG) after receiving standard health counselling. The intervention group had additional SRA™ installed on their smartphones, which enabled self-monitoring of modifiable and non-modifiable stroke risk factors. The Stroke Riskometer app (SRATM) and Life's Simple 7 (LS7) questionnaires assessed stroke risk and lifestyle practices. Changes in clinical profile, lifestyle practices and calculated stroke risk were analysed at baseline and 3 months. The trial was registered in the Australia-New Zealand Clinical Trial Registry, ACTRN12618002050235.
RESULTS: The demographic and clinical characteristics of the intervention and control group study participants were comparable. Better improvement in LS7 scores were noted in the SRA™ arm compared to CCG at 3 months: Median difference (95% CI) = 0.88 (1.68-0.08), p = 0.03. However, both groups did not show significant changes in median stroke risk and relative risk scores at 5-, 10-years (Stroke risk 5-years: Median difference (95% CI) = 0.53 (0.15-1.21), p = 0.13, 10-years: Median difference (95% CI) = 0.81 (0.53-2.15), p = 0.23; Relative risk 5-years: Median difference (95% CI) = 0.84 (0.29-1.97), p = 0.14, Relative risk 10-years: Median difference (95% CI) = 0.58 (0.36-1.52), p = 0.23).
CONCLUSION: SRA™ is a useful tool for familial stroke caregivers to make lifestyle changes, although it did not reduce personal or relative stroke risk after 3 months usage.
TRIAL REGISTRATION: No: ACTRN12618002050235 (Registration Date: 21st December 2018).
METHODS: A qualitative descriptive research study using in-depth semi-structured interviews was conducted with Year 3 medical students and patients to study their experiences at a primary care clinic, over two weeks. Data were transcribed verbatim and analysed using Braun and Clark's thematic analysis. Both students' and patients' views on communication skills were obtained.
RESULTS: Three themes were established based on student-patient communication in primary care settings: socio-cultural elements in student-patient communication; cognitive and emotional challenges for effective communication; and enablers for effective student-patient communication. The themes and sub-themes describe both students and patients valuing each other as individuals with socio-cultural beliefs and needs.
CONCLUSION: The findings can be used to structure new approaches to communication skills education that is patient-centred, culturally sensitive, and informed by patients. Communication skills training should encourage students to prioritise and reflect more on patient perspectives while educators should engage patients to inform and assess the outcomes.
MATERIALS AND METHODS: This qualitative study involved five public healthcare clinics in the Kuching district with indepth interviews (IDI) conducted on 14 primary care doctors (PCDs). Semi-structured interviews and in-depth discussions were conducted via videoconferencing. One representative was selected from each clinic at initiation, followed by snowball method for subsequent subject selection until saturation of themes. Interviews were transcribed verbatim, and analysis based on framework analysis principles via NVivo software. Themes were analysed deductively according to study objectives and evidence from literature.
RESULTS: Three main themes emerged from the IDI: (1) The perception of depression in elderly patients, (2) The perceived barriers to screening, and (3) The screening processes. Majority of the PCDs perceived depression as part of ageing process. Time constraints, lack of privacy in consultation rooms, dominant caregivers and failure to recognise recurrent somatic symptoms as part of depression influenced PCDs decision to screen. Screening was technically challenging for PCDs to use the DASS-21, which was not socio-culturally validated for local native population. Only 21.4% of respondents (3/14) reported screening at least three out 10 elderly patients seen over 1- month period. During the covid pandemic, due to the same human resource support and practices, most participants thought their screening for depression in elderlies had not changed.
CONCLUSION: Awareness of depression among PCDs needs to be re-enforced via continuous medical education programs to use appropriate screening tools, address infrastructure related barriers to optimise screening practices. The use of appropriate locally validated and socio-culturally adapted tool is vital to correctly interpret the screening test for patients.
METHODS: This cross-sectional study was conducted among patients with MetS attending a university primary care clinic in Selangor, Malaysia. The usability score was measured using a previously translated and validated EMPOWER-SUSTAIN Usability Questionnaire (E-SUQ) with a score of > 68 indicating good usability. Multiple logistic regressions determined the factors associated with its usability.
RESULTS: A total of 391 patients participated in this study. More than half (61.4%) had a good usability score of > 68, with a mean (± SD) usability score of 72.8 (± 16.1). Participants with high education levels [secondary education (AOR 2.46, 95% CI 1.04, 5.83) and tertiary education (AOR 2.49, 95% CI 1.04, 5.96)], those who used the booklet at home weekly (AOR 2.94, 95% CI 1.63, 5.33) or daily (AOR 2.73, 95% CI 1.09, 6.85), and those who had social support to use the booklet (AOR 1.64, 95% CI 1.02, 2.64) were significantly associated with good usability of the booklet.
CONCLUSIONS: The usability of the EMPOWER-SUSTAIN Global Cardiovascular Risks Self-Management Booklet© was good among patients with MetS in this primary care clinic, which supports its widespread use as a patient empowerment tool. The findings of this study also suggest that it is vital to encourage daily or weekly use of this booklet at home, with the support of family members. The focus should also be given to those with lower education to improve the usability of this booklet for this group of patients.
METHODS: Adults with asthma were purposively recruited from an urban primary healthcare clinic for in-depth interviews. Audio-recordings were transcribed verbatim and analysed thematically.
RESULTS: We interviewed 24 adults. Four themes emerged: (1) Participants believed in the 'hot and cold' concept of illness either as an inherent hot/cold body constitution or the ambient temperature. Hence, participants tried to 'neutralize' body constitution or to 'warm up' the cold temperature that was believed to trigger acute attacks. (2) Participants managed asthma based on past experiences and personal health beliefs as they lacked formal information about asthma and its treatment. (3) Poor communication and variable advice from healthcare practitioners on how to manage their asthma contributed to poor self-management skills. (4) Embarrassment about using inhalers in public and advice from family and friends resulted in a focus on nonpharmacological approaches to asthma self-management practice.
CONCLUSIONS: Asthma self-management practices were learnt experientially and were strongly influenced by sociocultural beliefs and advice from family and friends. Effective self-management needs to be tailored to cultural norms, personalized to the individuals' preferences and clinical needs, adapted to their level of health literacy and underpinned by patient-practitioner partnerships.
PATIENT AND PUBLIC CONTRIBUTIONS: Patients contributed to data. Members of the public were involved in the discussion of the results.
METHODS: A mixed methods study was conducted at 20 participating EnPHC clinics in Johor and Selangor, two months after the intervention was initiated. Data collected from self-reported forms and a structured observation checklist were descriptively analysed. In-depth interviews were also conducted with 20 participants across the clinics selected to clarify any information gaps observed in each clinic, and data were thematically analysed.
RESULTS: Evaluation showed that all components of EnPHC intervention had been successfully implemented except for the primary triage counter and visit checklist. The challenges were mainly discovered in terms of human resource and physical structure. Although human resource was a common implementation challenge across all interventions, clinic-specific issues could still be identified. Among the adaptive measures taken were task sharing among staff and workflow modification to match the clinic's capacity. Despite the challenges, early benefits of implementation were highlighted especially in terms of service outcomes.
CONCLUSIONS: The evaluation study disclosed issues of human resource and physical infrastructure when a supplementary intervention is implemented. To successfully achieve a scaled-up PHC service delivery model based on comprehensive management of NCDs patient-centred care, the adaptive measures in local clinic context highlight the importance of collaboration between good organisational process and good clinical practice and process.
BACKGROUND: Low research participation by primary care doctors, especially those working in the private sector, is a challenge to quality benchmarking.
METHODS: Primary care doctors were sampled through multi-stage sampling. The first stage-sampling unit was the primary care clinics, which were randomly sampled from five states in Malaysia to reflect their proportions in two strata - sector (public/private) and location (urban/rural). Strategies through endorsement, personalised invitation, face-to-face interview and non-monetary incentives were used to recruit public and private doctors. Data collection was carried out by fieldworkers through structured questionnaires.
FINDINGS: A total of 221 public and 239 private doctors participated in the study. Among the public doctors, 99.5% response rates were obtained. Among the private doctors, a 32.8% response rate was obtained. Totally, 30% of private clinics were uncontactable by telephone, and when these were excluded, the overall response rate is 46.8%. The response rate of the private clinics across the states ranges from 31.5% to 34.0%. A total of 167 answered the non-respondent questionnaire. Among the non-respondents, 77.4 % were male and 22.6% female (P = 0.011). There were 33.6% of doctors older than 65 years (P = 0.003) and 15.9% were from the state of Sarawak (P = 0.016) when compared to non-respondents. Reason for non-participation included being too busy (51.8%), not interested (32.9%), not having enough patients (9.1%) and did not find it beneficial (7.9%). Our study demonstrated the feasibility of obtaining favourable response rate in a survey involving doctors from public and private primary care settings.
Design: Qualitative study using focus group discussions. Participants' responses were audio recorded, transcribed, grouped under various domains and listed out and analysed.
Setting: A private medical college in Perak state, Malaysia.
Participants: Forty-six medical students from years 2 to 5 were included. Eight focus groups were formed with two focus groups from each academic year (six students each in seven groups and four students in one group). Students were informed through their respective student leader of each year and received a participant information sheet and an informed consent form which were completed and returned if they decided to participate in the focus group discussions.
Results: The participants had different levels of understanding of primary care depending on their level of exposure to primary care. Senior students with more exposure had a better understanding about primary care and its services. Attractive factors towards choosing primary care as a career included short working hours with a more balanced family and social life, being able to treat patients as a whole with continuity of care and closer relationship with patients. Unattractive factors included routine, unchallenging and boring practice, poor salary, work overload and administrative work in government clinics, being less recognised by other specialties; and the poor perception by other doctors that those pursuing primary care were not 'brilliant enough' for more 'sophisticated disciplines like surgery or paediatrics'.
Conclusion: This study showed that the medical students' level of exposure to primary care played a crucial role in determining their understanding of primary care practice and their choice of career in primary care. Issues to be addressed include remuneration, workload and the prejudice against primary care as a career pathway. Suggestions included introducing early exposure to fun and challenging primary care postings in the medical curriculum and producing well trained, skilled and enthusiastic role models.
METHODS: The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools.
RESULTS: Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing.
CONCLUSIONS: Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.
DESIGN: Systematic review and meta-ethnography.
DATA SOURCES: Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015).
ELIGIBILITY CRITERIA: Primary qualitative studies focused on adult community-dwelling stroke survivors' and/or informal caregivers' experiences of primary care and/or community healthcare services.
DATA SYNTHESIS: A set of common second order constructs (original authors' interpretations of participants' experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods' criteria.
RESULTS: 51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke.
LIMITATIONS: Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems.
CONCLUSIONS: Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services.
SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO 2015:CRD42015026602.