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  1. Francis J, Toh LS, Sellappans R, Loo JSE
    Int J Clin Pharm, 2021 Jun;43(3):604-612.
    PMID: 33507463 DOI: 10.1007/s11096-020-01169-z
    Background The incidence of osteoporosis in Malaysia is increasing due to a fast-ageing population. Because of its silent nature, various osteoporosis risk assessment tools exist to detect high-risk patients and facilitate referrals for bone mineral density measurements. As an accessible point of contact, community pharmacists would benefit from the utilization of these tools and familiarity with guideline recommendations for osteoporosis screening. Aim This study aimed to investigate the awareness of osteoporosis risk assessment tools, practice behaviour towards osteoporosis, and knowledge of guideline recommendations among community pharmacists in the Klang Valley, Malaysia. Setting Community pharmacies. Methods This study was a cross-sectional study which sampled 284 community pharmacists practicing in the Klang Valley, using a stratified sampling approach. The study was conducted using a self-administered questionnaire which was divided into three sections: demographic data, knowledge of osteoporosis risk assessment tools and guideline recommendations, and practice behaviour towards osteoporosis. Practice behaviour was assessed with 15 items using a 5-point Likert scale. Main outcome measure. Proportion of respondents aware of osteoporosis risk assessment tools and respondent knowledge on guideline recommendations for osteoporosis screening. Results A total of 284 community pharmacists participated in the study. 84.1% of the respondents were aware of at least one risk assessment tool. However, only a small proportion of pharmacists (14.9%) regularly used these tools in their practice. Respondents perceived these tools to be relevant and beneficial, but perception towards their accessibility, ease-of-use, and administration time was mixed, suggesting unfamiliarity. Respondents preferred to conduct clinical assessments based on risk factors, with respondents identifying a mean of 10.1 ± 3.4 out of 15 risk factors. However, several clinically relevant risk factors were frequently unidentified. Knowledge of guideline recommendations among respondents was low. Conclusion There is some awareness of osteoporosis risk assessment tools but use in practice remains low among community pharmacists in Malaysia. There is potential to increase the use of these tools and knowledge of recommendations for osteoporosis screening and referral among community pharmacists.
  2. Lai PSM, Chung WW, Toh LS, Othman S
    Int J Clin Pharm, 2018 Oct;40(5):1309-1316.
    PMID: 30155774 DOI: 10.1007/s11096-018-0721-x
    Background Assessing patient satisfaction regarding a pharmacy ambulatory care service is important as patient satisfaction is a determinant of the viability and sustainability of the service provided. Objective To develop and validate the Ambulatory Care Patient Satisfaction Questionnaire in Malaysia. Setting A public hospital in Malaysia with two outpatient pharmacies. The main outpatient pharmacy has an average waiting time of 1-2 h; whilst PharmCARE (which prepares repeat prescriptions in advance) has an average waiting time of 5-15 min. Method Our instrument was developed based on literature review, a theoretical framework and an expert panel. The initial version consisted of 20 Likert-type items (where a higher score indicates higher satisfaction) was administered to patients/carers who were ≥ 21 years, from November 2015 to June 2016 at baseline and 2 weeks later. Main outcome measure The psychometric properties of the instrument. Results A total of 200/220 participants agreed to participate (response rate = 90.9%): main outpatient pharmacy = 114, PharmCARE = 86. Flesch reading ease was 51.9. The final version consists of 17 items with five domains measuring information (4 items), accessibility (4 items), relationship (4 items), outcomes (2 items) and continuity of care (3 items). Participants who collected their medications from PharmCARE [78.0% (72.8-81.3)] were significantly more satisfied than participants from the main outpatient pharmacy [72.0% (68.0-76.0), p 
  3. Toh LS, Lai PS, Wu DB, Wong KT, Low BY, Anderson C
    PLoS One, 2015;10(5):e0124553.
    PMID: 25938494 DOI: 10.1371/journal.pone.0124553
    Objectives: To develop and validate Osteoporosis Prevention and Awareness Tool (OPAAT) in Malaysia.
    Methods: The OPAAT was modified from the Malaysian Osteoporosis Knowledge Tool and developed from an exploratory study on patients. Face and content validity was established by an expert panel. The OPAAT consists of 30 items, categorized into three domains. A higher score indicates higher knowledge level. English speaking non-osteoporotic postmenopausal women 50 years of age and pharmacists were included in the study.
    Results: A total of 203 patients and 31 pharmacists were recruited. Factor analysis extracted three domains. Flesch reading ease was 59.2. The mean±SD accuracy rate was 0.60±0.22 (range: 0.26-0.94). The Cronbach’s α for each domain ranged from 0.286-0.748. All items were highly correlated (Spearman’s rho: 0.761-0.990, p<0.05), with no significant change in the overall test-retest scores, indicating that OPAAT has achieved stable reliability. Pharmacists had higher knowledge score than patients (80.9±8.7vs63.6±17.4, p<0.001), indicating
    that the OPAAT was able to discriminate between the knowledge levels of pharmacists and patients.
    Conclusion: The OPAAT was found to be a valid and reliable instrument for assessing patient’s knowledge about osteoporosis and its prevention in Malaysia. The OPAAT can be used to identify individuals in need of osteoporosis educational intervention.
    Study site:: Primary care clinic, tertiary hospital, Malaysia
  4. Toh LS, Lai PSM, Low BY, Wong KT, Anderson C
    Int J Clin Pharm, 2020 Feb;42(1):11-17.
    PMID: 32221825 DOI: 10.1007/s11096-019-00960-x
    Background Population screening for osteoporosis using bone mineral density scan is not feasible in Malaysia as this test is costly. Hence, there is a need to develop a more efficient method to screen for osteoporosis.Objectives To determine the feasibility of an interprofessional collaborative osteoporosis screening programme (IPC-OSP). Methods Postmenopausal women aged ≥ 50 years, who had not been diagnosed with osteoporosis were recruited from a primary care clinic from June to August 2014. Patients were assessed for their osteoporosis risk and were counselled on prevention methods. Patients at risk were referred to the doctor with a recommendation for a bone mineral density (BMD) scan. Results Fifty out of 55 patients were recruited (response rate = 90.9%). A total 26/50 (52.0%) went for a bone mineral density scan, none were osteoporotic, 17/50 (34%) were osteopenic, 2/50 (4.0%), were started on osteoporosis medications and 14/50 (28%) modified their lifestyle to improve bone health or started on calcium supplements. Osteoporosis knowledge significantly increased from baseline to month two (46.3 ± 21.4 vs. 79.1 ± 14.3, p 
  5. Toh LS, Lai PSM, Othman S, Wong KT, Low BY, Anderson C
    Res Social Adm Pharm, 2017 11;13(6):1142-1150.
    PMID: 27780658 DOI: 10.1016/j.sapharm.2016.10.004
    OBJECTIVES: This study describes the perspective of patients, nurses, pharmacists, doctors and policy makers to identify the level of collaboration and the areas for improvement to achieve inter-professional collaboration between doctors, nurses, pharmacists and policy makers in a primary care clinic.

    METHODS: Patients (n = 20), Nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) from a primary care were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis informed by constant comparison.

    RESULTS: Patients, doctors, nurses, pharmacists and policy makers were eager for pharmacists to be more proactive in creating health awareness and conducting osteoporosis screening at the primary care clinic via inter-professional collaboration. These findings were further examined using the D'Amour's structural model of collaboration which encompasses four main themes: shared goals and visions, internalization, formalization and governance. This model supports our data which highlights a lack of understanding of the pharmacists' role among the doctors, nurses, policy makers and pharmacists themselves. There is also a lack of governance and formalization, that fosters consensus, leadership, protocol and information exchange. Nonetheless, the stakeholders trust that pharmacists have sufficient knowledge to contribute to the screening of osteoporosis. Our primary care clinic can be described as developing towards an inter-professional collaboration in managing osteoporosis but is still in its early stages.

    CONCLUSIONS: Inter-professional collaboration in osteoporosis management at the primary care level is beginning to be practised. Efforts extending to awareness and acceptance towards the pharmacists' role will be crucial for a successful change.
  6. Toh LS, Lai PSM, Othman S, Shah A, Dang CPL, Low BY, et al.
    Int J Clin Pharm, 2018 Apr;40(2):450-457.
    PMID: 29380234 DOI: 10.1007/s11096-018-0597-9
    Background: Several studies have found that pharmacists can assist in screening and prevention of osteoporosis by referring patients for bone mineral density scans and counselling on lifestyle changes. In Malaysia, screening osteoporosis in all elderly women is not mandatory due to its cost. One approach to address this gap is to develop a pharmacist-led osteoporosis screening and prevention program. However, there is a paucity of data on the perspectives of Malaysian pharmacists in this area.
    Objective: To explore the perspective of stakeholders (policy makers, doctors, pharmacists, nurses and patients) towards the role of pharmacists in osteoporosis screening and management.
    Setting: A primary care clinic located within a teaching hospital in Kuala Lumpur, Malaysia.
    Method: Patients (n = 20), nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis. Main outcome measure Perspective of stakeholders on the current and future role of pharmacists.
    Results: All participants perceived pharmacists to be suppliers of medication, although there was some recognition of roles in providing medication advice. Nonetheless, these stakeholders were eager for pharmacists to expand their non-dispensing roles towards counselling, creating awareness and screening of osteoporosis. Interviewed pharmacists referred to their current role as 'robotic dispensers' and unanimously agreed to spread out to osteoporosis management role.
    Conclusion: Under stakeholders there is a willingness to expand the role of pharmacists in Malaysia to non-dispensing roles, particularly in osteoporosis screening and management.
    Study site: Primary care clinic, teaching hospital, Kuala Lumpur, Malaysia
  7. Sandhu AK, Toh LS, Lee YK, Tan ATB, Ratnasingam J, Thiagarajan N, et al.
    Patient Prefer Adherence, 2021;15:1383-1395.
    PMID: 34188455 DOI: 10.2147/PPA.S314641
    PURPOSE: The English Satisfaction Questionnaire for Osteoporosis Prevention (SQOP) is validated in Malaysia. However, Malay is the national language of Malaysia spoken by the majority of Malaysians. The aim of this study was to cross-culturally adapt and validate the Malay Satisfaction Questionnaire for Osteoporosis Prevention (SQOP-M) in Malaysia.

    PATIENTS AND METHODS: This study was carried out from March to October 2018 at a tertiary hospital in Kuala Lumpur. The SQOP was translated from English to Malay according to international guidelines. Malay-speaking postmenopausal women ≥50 years were recruited and randomized into control and intervention groups. The intervention group received an osteoporosis prevention information booklet and a 15-minute pharmacist counselling session. All patients were asked to answer the SQOP-M questionnaire at baseline and two weeks later. The control group received the intervention after the study was completed.

    RESULTS: Overall, 230/348 patients were recruited (C=115, I=115, response rate=66.1%). Exploratory factor analysis extracted four domains. Cronbach's α ranged from 0.230 to 0.938. Kappa measurement of agreement values ranged from 0.124 to 0.627, where 10/23 (43.5%) items were in moderate to substantial agreement. Wilcoxon signed rank test values were statistically significant (p<0.005) for 4/23 items. Item 17 was an optional question and excluded from analysis. Total satisfaction score was significantly higher for intervention group patients [76.9 (47.6-53.9) vs 50.4 (47.6-53.9), p<0.001] indicating higher satisfaction compared to control group.

    CONCLUSION: The SQOP-M was found to be valid and reliable in assessing patient satisfaction of osteoporosis screening and prevention services provided to Malay-speaking patients in Malaysia.

  8. Toh LS, Lai PS, Wu DB, Wong KT, Low BY, Tan AT, et al.
    Patient Prefer Adherence, 2014;8:1365-81.
    PMID: 25328386 DOI: 10.2147/PPA.S65718
    Purpose: To develop and validate the English version of the Satisfaction Questionnaire for Osteoporosis Prevention (SQOP) in Malaysia.
    Methods: The SQOP was modified from the Osteoporosis Patient Satisfaction Questionnaire and developed based on literature review and patient interviews. Face and content validity were established via an expert panel. The SQOP consists of two sections: clinical services and types of counseling. There were 23 items in total, each with a five-point Likert-type response. Satisfaction score was calculated by converting the total score to a percentage. A higher score indicates higher satisfaction. English speaking, non-osteoporotic, postmenopausal women aged 50 years were included in the study. Participants were randomized to either the control or intervention group. Intervention participants were provided counseling, whereas control participants received none. Participants answered the SQOP at baseline and 2 weeks later.
    Results: A total of 140 participants were recruited (control group: n=70; intervention group: n=70). No significant differences were found in any demographic aspects. Exploratory factor analysis extracted seven domains. Cronbach’s α for the domains ranged from 0.531–0.812. All 23 items were highly correlated using Spearman’s correlation coefficient 0.469–0.996 (P<0.05), with no significant change in the control group’s overall test–retest scores, indicating that the
    SQOP achieved stable reliability. The intervention group had a higher score than the control group (87.91±5.99 versus 61.87±8.76; P<0.05), indicating that they were more satisfied than control participants. Flesch reading ease was 62.9.
    Conclusion: The SQOP was found to be a valid and reliable instrument for assessing patients’ satisfaction towards an osteoporosis screening and prevention service in Malaysia.
    Keywords: patient satisfaction, randomized controlled trial, postmenopausal women, screening
    Study site: primary care clinic, tertiary hospital, Malaysia
  9. Toh LS, Lai PSM, Wu DB, Bell BG, Dang CPL, Low BY, et al.
    Osteoporos Sarcopenia, 2019 Sep;5(3):87-93.
    PMID: 31728426 DOI: 10.1016/j.afos.2019.09.001
    Objectives: To compare and assess the performance of 6 osteoporosis risk assessment tools for screening osteoporosis in Malaysian postmenopausal women.

    Methods: Six osteoporosis risk assessments tools (the Simple Calculated Osteoporosis Risk Estimation [SCORE], the Osteoporosis Risk Assessment Instrument, the Age Bulk One or Never Estrogen, the body weight, the Malaysian Osteoporosis Screening Tool, and the Osteoporosis Self-Assessment Tool for Asians) were used to screen postmenopausal women who had not been previously diagnosed with osteoporosis/osteopenia. These women also underwent a dual-energy X-ray absorptiometry (DXA) scan to confirm the absence or presence of osteoporosis.

    Results: A total of 164/224 participants were recruited (response rate, 73.2%), of which only 150/164 (91.5%) completed their DXA scan. Sixteen participants (10.7%) were found to have osteoporosis, whilst 65/150 (43.3%) were found to have osteopenia. Using precision-recall curves, the recall of the tools ranged from 0.50 to 1.00, whilst precision ranged from 0.04 to 0.14. The area under the curve (AUC) ranged from 0.027 to 0.161. The SCORE had the best balance between recall (1.00), precision (0.04-0.12), and AUC (0.072-0.161).

    Conclusions: We found that the SCORE had the best balance between recall, precision, and AUC among the 6 screening tools that were compared among Malaysian postmenopausal women.

  10. Sloan JM, Mujab AAM, Mashitah J, Zulkarami B, Wilson MJ, Toh LS, et al.
    Rice (N Y), 2023 Mar 22;16(1):16.
    PMID: 36947269 DOI: 10.1186/s12284-023-00629-0
    Tillering and yield are linked in rice, with significant efforts being invested to understand the genetic basis of this phenomenon. However, in addition to genetic factors, tillering is also influenced by the environment. Exploiting experiments in which seedlings were first grown in elevated CO2 (eCO2) before transfer and further growth under ambient CO2 (aCO2) levels, we found that even moderate exposure times to eCO2 were sufficient to induce tillering in seedlings, which was maintained in plants grown to maturity plants in controlled environment chambers. We then explored whether brief exposure to eCO2 (eCO2 priming) could be implemented to regulate tiller number and yield in the field. We designed a cost-effective growth system, using yeast to increase the CO2 level for the first 24 days of growth, and grew these seedlings to maturity in semi-field conditions in Malaysia. The increased growth caused by eCO2 priming translated into larger mature plants with increased tillering, panicle number, and improved grain filling and 1000 grain weight. In order to make the process more appealing to conventional rice farmers, we then developed a system in which fungal mycelium was used to generate the eCO2 via respiration of sugars derived by growing the fungus on lignocellulosic waste. Not only does this provide a sustainable source of CO2, it also has the added financial benefit to farmers of generating economically valuable oyster mushrooms as an end-product of mycelium growth. Our experiments show that the system is capable of generating sufficient CO2 to induce increased tillering in rice seedlings, leading eventually to 18% more tillers and panicles in mature paddy-grown crop. We discuss the potential of eCO2 priming as a rapidly implementable, broadly applicable and sustainable system to increase tillering, and thus yield potential in rice.
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