Primary care research is at a crossroad in South Pacific. A steering committee comprising a member of WONCA Asia Pacific Regional (APR) council and the President of Fiji College of General Practitioners garnered sponsorship from Fiji Ministry of Health, WONCA APR and pharmaceutical agencies to organize the event in October 2013. This paper describes the processes needed to set up a national primary research agenda through the collaborative efforts of local stakeholders and external facilitators using a test case in South Pacific.
Chronic obstructive pulmonary disease (COPD) is a clinical syndrome encompassing a group of chronic, progressive, and debilitating respiratory conditions, that are characterized by incompletely reversible airflow limitation. Within the Asia-Pacific region, prevalence estimates have been derived using various protocols and study methods, and there is little data on the impact of COPD exacerbations. This study aimed to provide a comprehensive picture of the current prevalence and burden of COPD in this region.
BACKGROUND: Hypertension is one of the world's most common health conditions and is a leading risk factor for mortality. Although blood pressure can be modified, there is a large proportion of patients whose blood pressure remains uncontrolled. The aim of this study, termed Edvantage 360°, was to gain a deeper understanding of hypertension management in Asia from the perspective of patients and doctors, and to propose strategies to improve blood pressure control.
METHODS: Conducted in Hong Kong, Indonesia, Malaysia, the Philippines, South Korea, Taiwan, and Thailand, Edvantage 360° was a mixed-methods observational study that used both qualitative and quantitative elements: qualitative interviews and focus groups with patients (N = 110), quantitative interviews with patients (N = 709), and qualitative interviews with doctors (N = 85).
RESULTS: This study found that, although there is good understanding of the causes and consequences of hypertension among Asian patients, there is a lack of urgency to control blood pressure. Doctors and patients have different expectations of each other and a divergent view on what constitutes successful hypertension management. We also identified a fundamental gap between the beliefs of doctors and patients as to who should be most responsible for the patients' hypertension management. In addition, because patients find it difficult to comply with lifestyle modifications (often because of a decreased understanding of the changes required), adherence to medication regimens may be less of a limiting factor than doctors believe.
CONCLUSIONS: Doctors may provide better care by aligning with their patients on a common understanding of successful hypertension management. Doctors may also find it helpful to provide a more personalized explanation of any needed lifestyle modifications. The willingness of the doctor to adjust their patient interaction style to form a 'doctor-patient team' is important. In addition, we recommend that doctors should not attribute ineffectiveness of the treatment plan to patient non-adherence to medications, but rather adjust the medication regimen as needed.
KEYWORDS: Attitude to health; Hong Kong; Hypertension; Indonesia; Malaysia; Philippines; Qualitative research; South Korea; Taiwan; Thailand
In Indonesia, Family Medicine as a discipline is being developed through short courses since 12 years ago. A conversion program to become Family Physicians has been introduced recently. Among the 70,000 primary care physicians there are variety of practitioners, from new interns who start general practice to senior general practitioners. This study aims to describe the current Indonesian Primary Care Physicians (PCPs) profile which includes services provided and facilities as well as comparing the profile according to participation in the conversion program and practice hours.
BACKGROUND: Malaysia is an upper middle income country that provides subsidized healthcare to ensure universal coverage to its citizens. The challenge of escalating health care cost occurs in most countries, including Malaysia due to increase in disease prevalence, which induced an escalation in drug expenditure. In 2009, the Ministry of Health has allocated up to Malaysian Ringgit (MYR) 1.402 billion (approximately USD 390 million) on subsidised drugs. This study was conducted to measure patients' willingness to pay (WTP) for treatment of chronic condition or acute illnesses, in an urbanized population.
METHODS: A cross-sectional study, through face-to-face interview was conducted in an urban state in 2012-2013. Systematic random sampling of 324 patients was selected from a list of patients attending ten public primary cares with Family Medicine Specialist service. Patients were asked using a bidding technique of maximum amount (in MYR) if they are WTP for chronic or acute illnesses.
RESULTS: Patients are mostly young, female, of lower education and lower income. A total of 234 respondents (72.2%) were not willing to pay for drug charges. WTP for drugs either for chronic or acute illness were at low at median of MYR10 per visit (USD 3.8). Bivariate analysis showed that lower numbers of dependent children (≤3), higher personal and household income are associated with WTP. Multivariate analysis showed only number of dependent children (≤3) as significant (p = 0.009; 95% CI 1.27-5.44) predictor to drugs' WTP.
CONCLUSION: The result indicates that primary care patients have low WTP for drugs, either for chronic condition or acute illness. Citizens are comfortable in the comfort zone whereby health services are highly subsidized through universal coverage. Hence, there is a resistance to pay for drugs.
Aim. Validation of the Malay version of the Edinburgh Postnatal Depression Scale (EPDS)
Methods. A validation study was done involving 52 mothers who were at 4-12 weeks post-delivery. The women completed the Malay versions of EPDS and the 30-item General Health Questionnaire (GHQ). They were then assessed with the Hamilton Depression Rating Scale (HDRS) and Clinical Interview Schedule (CIS). Psychiatric diagnoses were made based on ICD-10 criteria. The validity of EPDS was tested against this clinical diagnosis and the concurrent validity against the Malay version of 30-item GHQ and HDRS scores was also evaluated.
Results. The best cut-off score of the Malay version of EPDS was 11.5 with the sensitivity of 72.7% and specificity of 92.6 %.
Conclusion. The Malay version of EPDS is a valid and reliable screening tool for PND.
Aims: To evaluate the utilization of complementary and alternative medicine (CAM) in Kuching, Sarawak, Malaysia Methods: This was a cross-sectional study of patients who attended three randomly selected primary care clinics over 4 months from January to April 2004. Results: A total of 198 patients were recruited. One hundred and eighty-one (91.4%) patients agreed to participate by answering the anonymous questionnaire. Results: Ninety (51.4%) patients used CAM of which 43 (47.8%) patients used more than one type of CAM. Utilization rates of CAM were found to be associated with employment status but not with other socio-demographic factors. The common types of alternative medicine used were massage (n = 63; 36.2%) and herbal medicine (n = 44; 25.1%). Forty-two (46%) of the CAM users, used CAM for the problems that led to their current clinic visit. Thirty-four (37.8%) were using alternative and modern medicine at the same time. The reasons for CAM usage given by about half of the patients were that CAM was more effective and better for emotional or mental health problems. Conclusions: Usage of CAM was common in patients who visited primary care clinics. It is important to recognize this fact as combined use of CAM can create potentially dangerous interactions with pharmacotherapies Key words: complementary and alternative medicine (CAM), primary care
Aim: To explore the help-seeking behavior of primary care doctors during illness. Methods: This qualitative study used focus group discussions to explore participants' help-seeking behavior during illness. It involved 22 primary care doctors (5 lecturers, 12 postgraduate trainees, 5 medical officers) working in a hospital-based primary care clinic. Result: Most primary care doctors in this study managed their illnesses without seeking help. Although most preferred to seek professional help for chronic illnesses and antenatal care, they tend to delay the consultations and were less likely to comply with treatment and follow-up. Explanations for their behavior include their ability to assess and treat themselves, difficulty to find suitable doctors, work commitment, easy access to drugs, and reluctance to assume a sick role. Conclusions: This study found that the help-seeking behavior of primary care doctors was similar to those in other studies. Due to their professional ability, heavy workload and expectations from peer and patients, primary care doctors were more likely to delay in seeking treatment especially for chronic and serious diseases. This highlights the need to enhance support services for doctors during illness. Key words: doctors, help-seeking behavior, illness
Aims. To document the antibiotic prescribing rate for upper respiratory tract infections (URTI) in general practice and its associated factors. Methods. Data extracted from a morbidity survey of 150 general practice clinics in three urban areas in Malaysia. Participating general practitioners recorded demographic, morbidity and process of care data for 30 consecutive adult patients using a structured form. [year of study=1999] Results. URTI contributed 940 (27.0%) of the total of 3481 encounters recorded. Antibiotic was prescribed in 68.4% of encounters with URTI; a significant proportion of the antibiotic choice was inappropriate. Half the antibiotics prescribed in this study were due to URTI. [overall antibiotic prescribing rate for all encounters=33.4%] Conclusions. General practitioners need to re-examine their own prescribing for URTI and decide whether it is consistent with current guidelines. Rational prescribing is not just part of the professional role of doctors, but will go a long way to impede the emergence of antibiotic resistance.
The Community Follow-up Project involves a scheme by which clinical students follow the progress of patients after discharge from hospital. The Community Follow-up Project begins with the student choosing a hospital in-ward patient during their first clinical ward based attachment and follows this patient's progress after discharge from the hospital. The students do a series of home visits and also accompany their patients for some of their follow-ups to the hospital or government clinics; to their general practitioners and even to the palliative care or social welfare centres. The students assess the physical, psychological and social impact of the illness on the patient, family and community. This project supplements students' knowledge of the natural history of disease and emphasizes the importance of communication and the use of community resources. By commitment to the patient for a duration of time, the students are able to take an active role in patients' care, understand in depth the problems faced by patients and in assessing a patient's progress, students find themselves in the role of a teacher and advisor to their patient as well. We outline the main components of this project, describe its outcome and consider areas that invite further developments.
Aim: To determine the accuracy of urinalysis in the detection of urinary tract infection (UTI) in symptomatic patients at primary care level. Methods: A cross sectional study was undertaken on 100 patients with symptoms of UTI presenting at the Primary Care Clinic of University Malaya Medical Center, Kuala Lumpur, Malaysia during the months of August to November 1999. Their urine samples were tested simultaneously using urine dipstick, urine microscopy and urine culture. Urine culture was used as the gold standard and UTI was diagnosed when the urine culture showed a bacteria count of >= 105 organisms per mL. The sensitivity and specificity of each test was calculated. Results: The prevalence of UTI was 25% in symptomatic patients. The urine dipstick for leukocyte esterase, nitrite and red blood cell had sensitivities of 76, 56 and 76%, respectively. Their specificities were 60, 81 and 61%, respectively. Urine microscopy for leukocytes, red blood cells and bacterial count had sensitivities of 80, 52 and 84%, while their specificities were 76, 80 and 54%, respectively. Conclusion: The prevalence of UTI in the present study was low despite reported symptoms of UTI. Urinalysis is needed to support the diagnosis of UTI. In the present study, while there is accuracy in the urinalysis (as the sensitivities and specificities of various tests are comparable with other studies); lack of precision in each test because of the wide range of 95% confidence interval make it less reliable. Caution should be made in interpreting each test.
Aim: To assess the importance of continuity of care among diabetic patients attending a primary care clinic and to correlate degree of continuity of care with diabetic control. Methods: A cross sectional survey was carried out among diabetic patients (n = 166) attending follow-up consultations in a family practice clinic of a teaching hospital. Face-to-face interviews were carried out on patients' perception of continuity of care and various aspects related to diabetes. Diabetic control was assessed by glycosylated hemoglobin. Retrospective chart audits of each patient over the previous 28 months were done to assess the degree of continuity of care, measured with the Usual Provider Continuity Index (UPCI). Results: The UPCI ranged from 0.18 to 1.00 with a mean value of 0.60. The average number of visits per patient over the 28-month period was 11.7 visits. The majority of patients saw five different doctors for all their visits. There were no statistically significant associations between the degree of provider continuity with diabetic control (r = 0.054) and diabetic self-care behavior (r = 0.065). The majority of patients (89%) felt that it was important to have a regular doctor. The main reason given was that a regular doctor would know the patient's problems. Conclusions: Continuity of care was highly valued by diabetic patients attending a hospital-based family practice clinic. Even though the degree of continuity was not associated with the degree of diabetic control, patients felt that it was important to have doctors who are aware of their problems.
Patients who are entering the last phase of their illness and for whom life expectancy is short, have health needs that require particular expertise and multidisciplinary care. A combination of a rapidly changing clinical situation and considerable psychosocial and spiritual demands pose challenges that can only be met with competence, commitment and human compassion. This article is concerned with the definition of suffering, recognition of the terminal phase and application of the biopsychosocial-spiritual model of care where family physicians play an important role in the community. Key words: biopsychosocial-spiritual care, dying, family medicine, good death, palliative care, suffering.
Aim: This study explored the health beliefs, concerns and expectations of primary care patients presenting with abdominal pain, headache and chest pain. Methods: Over a 6-week period, 107 adult patients with symptoms of pain were interviewed using a semistructured questionnaire. Results: The presenting symptoms of these patients were: abdominal pain, 41; headache, 35; and chest pain, 31. Females made up 53.3%; the ethnic groups were Malay (35.5%), Chinese (18.7%) and Indian (45.8%); and 71.8% of the patients had primary or secondary education. The patients' attributions of their symptoms were predominantly non-medical in all three ethnic groups. The non-medical causes mentioned include food, trauma, stress, weather changes and winds ('angin'). Only two fifths of the patients mentioned disease-specific concerns. Three quarters of these patients expected either medications or wanted the doctor to look for serious causes. Very few patients specifically wanted referral or special tests. Conclusions: The patients in the study had health beliefs and concerns, in view of their non-medical focus, that was at variance with those of the health care providers. However, having decided to consult the health clinic, they were mainly looking for symptomatic relief or evaluation for serious pathology.
Aims: To determine whether the Edinburgh Claudication Questionnaire (ECQ) can be used as a screening tool for detecting peripheral arterial disease in patients with diabetes mellitus.
Methods: A cross-sectional study of 200 patients with diabetes over 18 years of age who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia. Face-to-face interviews were conducted using the ECQ for the presence of intermittent claudication. Blood pressure and peripheral neuropathy were assessed. Ankle brachial pressure index (ABPI) was measured and used as a gold standard for the diagnosis of eripheral arterial disease (PAD), which was defined as an ABPI of < 0.9 on either leg.
Results: The overall prevalence of PAD was found to be 16% among patients with diabetes based on ABPI. Among these 32 patients with PAD, eight (25%) had symptoms of intermittent claudication based on the ECQ. The ECQ was found to have a low sensitivity (25%) but a high specificity (99.4%), with a positive predictive value of 88.9% and a negative predictive value of 88% for diagnosing PAD in patients with diabetes.
Conclusions: The ECQ is not a good screening tool for detection of PAD among patients with diabetes due to its low sensitivity. Key words: ankle brachial pressure, diabetes mellitus, Edinburgh Claudication Questionnaires, intermittent claudication, peripheral arterial disease.
Aim: To explore primary care practitioners' experiences and feelings about treating their own family members. Methods: A qualitative study was carried out using focus group discussions. Five sessions were held among 22 primary care practitioners (five academic staff members and 17 medical officers). Results: Most participants treated their family members, especially their immediate families. They considered factors such as duration and severity of illness before seeking consultation with other doctors. Some participants felt satisfied knowing that they were able to treat their own families. However, most felt burdened and uncomfortable in doing so, mainly due to the fear of error in diagnosis and management. They were concerned that strong emotions may make them lose objectivity. Many were aware that negative outcomes resulting from their treatment may affect future relationships. Conclusions: While some doctors were comfortable about treating their own families, some faced significant conflict in doing so. Their decisions depended on the interplay of factors including the doctor, the family member and the relationship they share. A doctor needs to consider the potential conflict that may arise when carrying out one's professional role and at the same time being a concerned family member. Key words: doctors, family, Malaysia, primary care, self-treat.
Background: Menopause is a condition that every woman faces in later life and can have many associated effects which might disrupt the quality of life.
Aim: To determine both the prevalence of menopause and menopausal symptoms in a group of employed Malaysian women and to determine their sources of information regarding menopause.
Methods: A cross sectional study was conducted among female teachers aged 35 and above in Seremban, Negeri Sembilan, Malaysia between 1 June and 31 December 2000. A total of 550 self administered questionnaires were distributed to teachers selected through simple random sampling of selected schools.
Results: The response rate was 78.9%. The prevalence of menopause was 21.9%. There was a high prevalence of skin dryness (44.2%), hot flushes (43.2%), fatigue (41.0%) and excessive sweating (34.7%) among the menopausal respondents and there was a significant difference between menopausal and non menopausal symptoms of respondents (p<0.05).
Conclusion: The prevalence of menopause and each menopausal symptom are high in the present group of women. Improved health care programs about the menopause might help give women a better quality of life.
Background: Emotional disorder, one of the common human emotional states is defined as feelings of sadness and tiredness in response to life events, such as disappointments. It is one of the major problems among students and although it consists of more than half of all mental disorders, it is often left untreated each year worldwide. Aim: To determine the prevalence of emotional disorders among medical students at a university in Malaysia.
Methods: A cross sectional study design was used. All medical students at a local university in Malaysia were included in the study. A questionnaire similar to the General Health Questionnaire (GHQ-12) was used as a screening instrument.
Results: A total of 41.9% of the medical students were found to have emotional disorders. Factors found to have a significant association with emotional disorders were relationship of the respondents with their parents (chi-square=6.02, d.f.=1, p<0.05), siblings (chi-square=6.94, d.f.=1, p<0.05) and lecturers (chi-square=4.80, d.f.=1, p<0.05), as well as pressure prior to exams (chi-square=10.30, d.f.=1, p<0.05).
Conclusion: The prevalence of emotional disorders among medical students was high. There was significant association between emotional disorders and respondents' relationship with their parents, siblings and lecturers, as well as level of pressure prior to exam. Early detection of this condition is important to prevent psychological morbidity and its unwanted effects on medical students and young doctors.
Aim: To identify the factors associated with depression among elderly patients attending a primary health care clinic in Malaysia. Methods: A cross sectional study was conducted on patients aged 60 years and above in Klinik Kesihatan Butterworth, Seberang Perai Utara, Pulau Pinang, Malaysia from April to September 1999. The Geriatric Depression Scale questionnaire was used as a screening instrument. Results: The response rate was 99.0%. A total of 18% of the patients were found to have depression. The associated factors were females (odds ratio (OR) = 2.87, 95% confidence interval (CI) = 1.37-6.02), those who were unmarried (OR = 3.46, 95% CI = 1.66-7.21), without formal education (OR = 8.0, 95% CI = 2.97-21.48), low total family income (OR = 7.97, 95% CI = 2.71-23.46) and urban residence (OR = 2.23, 95% CI = 1.09-4.58). Conclusion: Depression is very common among the elderly. As this is an important problem in primary care practice, primary care doctors should be aware of this problem so that early detection and management can be implemented., (C) 2003 Blackwell Science Ltd