Study protocol for a mixed methods approach to optimize colorectal cancer screening in Malaysia: Integrating stakeholders insights and knowledge-to-action framework

INTRODUCTION

Colorectal cancer is a growing global health concern and the number of reported cases has increased over the years. Early detection through screening is critical to improve outcomes for patients with colorectal cancer. In Malaysia, there is an urgent need to optimize the colorectal cancer screening program as uptake is limited by multiple challenges. This study aims to systematically identify and address gaps in screening service delivery to optimize the Malaysian colorectal cancer screening program.

METHODS

This study uses a mixed methods design. It focuses primarily on qualitative data to understand processes and strategies and to identify specific areas that can be improved through stakeholder engagement in the screening program. Quantitative data play a dual role in supporting the selection of participants for the qualitative study based on program monitoring data and assessing inequalities in screening and program implementation in healthcare facilities in Malaysia. Meanwhile, literature review identifies existing strategies to improve colorectal cancer screening. Additionally, the knowledge-to-action framework is integrated to ensure that the research findings lead to practical improvements to the colorectal cancer screening program.

DISCUSSION

Through this complex mix of qualitative and quantitative methods, this study will explore the complex interplay of population- and systems-level factors that influence screening rates. It involves identifying barriers to effective colorectal cancer screening in Malaysia, comparing current strategies with international best practices, and providing evidence-based recommendations to improve the local screening program.

Prevalence and sociodemographic predictors of high-risk vaginal human papillomavirus infection: findings from a public cervical cancer screening registry

INTRODUCTION

High-risk human papillomavirus (HPV) screening is vital for early cervical cancer detection and treatment. With the introduction of the national cervical cancer screening programme and screening registry in Malaysia, there is a need to monitor population-based HPV screening uptake and high-risk HPV prevalence as part of cervical cancer surveillance.

OBJECTIVE

To determine the prevalence and sociodemographic factors predicting high-risk HPV infection in Malaysia based on a public, community-based cervical cancer screening registry targeting women at risk of getting HPV infection.

METHODS

The study used data from the Malaysian cervical cancer screening registry established by the Family Health Development Division from 2019 to 2021. The registry recorded sociodemographic data, HPV test details and results of eligible women who underwent HPV screening at public primary healthcare facilities. A vaginal sample (via self-sampling or assisted by a healthcare provider) was used for DNA extraction for HPV detection and genotyping. Registry data were extracted and analysed to determine prevalence estimates of high-risk HPV infection. Multifactorial logistic regression analysis was conducted to determine predictors of high-risk HPV infection. All analyses were performed using Stata version 14.

RESULTS

The programme screened a total of 36,738 women during the study period. Women who attended the screening programme were mainly from urban areas, aged 30-39 years, and of Malay ethnicity. The prevalence of high-risk HPV infection was 4.53% among women screened, with the yearly prevalence ranging from 4.27 to 4.80%. A higher prevalence was observed among urban settling women, those aged 30-49 years, those of Indian ethnicity, and those without children. The results from logistic regression showed that women from urban areas, lower age groups, of Indian or Chinese ethnicity, and who are self-employed were more likely to be infected with high-risk HPV.

CONCLUSION

Targeted and robust strategies to reach identified high-risk groups are needed in Malaysia. In addition, the registry has the potential to be expanded for an improved cervical cancer elimination plan.

TRIAL REGISTRATION

Trial registration number: NMRR ID-22-00187-DJU.

Embedding rapid reviews in health policy and systems decision-making: Impacts and lessons learned from four low- and middle-income countries

BACKGROUND

Demand for rapid evidence-based syntheses to inform health policy and systems decision-making has increased worldwide, including in low- and middle-income countries (LMICs). To promote use of rapid syntheses in LMICs, the WHO's Alliance for Health Policy and Systems Research (AHPSR) created the Embedding Rapid Reviews in Health Systems Decision-Making (ERA) Initiative. Following a call for proposals, four LMICs were selected (Georgia, India, Malaysia and Zimbabwe) and supported for 1 year to embed rapid response platforms within a public institution with a health policy or systems decision-making mandate.

METHODS

While the selected platforms had experience in health policy and systems research and evidence syntheses, platforms were less confident conducting rapid evidence syntheses. A technical assistance centre (TAC) was created from the outset to develop and lead a capacity-strengthening program for rapid syntheses, tailored to the platforms based on their original proposals and needs as assessed in a baseline questionnaire. The program included training in rapid synthesis methods, as well as generating synthesis demand, engaging knowledge users and ensuring knowledge uptake. Modalities included live training webinars, in-country workshops and support through phone, email and an online platform. LMICs provided regular updates on policy-makers' requests and the rapid products provided, as well as barriers, facilitators and impacts. Post-initiative, platforms were surveyed.

RESULTS

Platforms provided rapid syntheses across a range of AHPSR themes, and successfully engaged national- and state-level policy-makers. Examples of substantial policy impact were observed, including for COVID-19. Although the post-initiative survey response rate was low, three quarters of those responding felt confident in their ability to conduct a rapid evidence synthesis. Lessons learned coalesced around three themes - the importance of context-specific expertise in conducting reviews, facilitating cross-platform learning, and planning for platform sustainability.

CONCLUSIONS

The ERA initiative successfully established rapid response platforms in four LMICs. The short timeframe limited the number of rapid products produced, but there were examples of substantial impact and growing demand. We emphasize that LMICs can and should be involved not only in identifying and articulating needs but as co-designers in their own capacity-strengthening programs. More time is required to assess whether these platforms will be sustained for the long-term.

Effect of supplementary private health insurance on inpatient utilisation: Evidence from Malaysia

Supplementary private health insurance (PHI) provides better access to healthcare, improves health outcomes, potentially lowers the costs for health systems and supports the social security system. Improperly regulated PHI, however, may aggravate inequity of access towards preferential care and encourage moral hazard among PHI purchasers, altering the health-seeking behaviour, which is often observed through the pattern of health care utilisation. We investigated the effect of PHI ownership on private inpatient care utilisation, its frequency of admission and length of stay by conducting secondary data analysis of the Malaysian National Health Morbidity Survey (NHMS) 2015 data, a nationally representative community health survey. Malaysian adults 18 years of age and above who utilised inpatient healthcare facilities were included. In this cross-sectional study, we addressed the endogeneity effect of health insurance by employing instrumental variable estimation and a two-stage residual inclusion analysis. We found a significant increase in private inpatient utilisation among those who owned PHI compared to those who did not (β = 4.39, p < 0.001). There was no significant difference in the frequency of admission and length of stay. The increase in private inpatient utilisation among PHI owners may reflect the demand for timely care and hospitality provided by the private sector, potentially exacerbating the moral hazard behaviour among PHI owners. Further exploration of this issue could impact future healthcare systems financing designs and PHI regulation.

Health system preparedness in infectious diseases: perspective of Malaysia, a middle-income country, in the face of monkeypox outbreaks

The World Health Organization declared monkeypox as a Public Health Emergency of International Concern on July 23, 2022. As of July 25th, 2022, there were 16,016 laboratory-confirmed cases reported worldwide with 5 deaths. Malaysia's Health Ministry has developed a five-point strategy to prepare for the impending threat of the infectious disease, encompassing early detection of monkeypox, consolidation of laboratory diagnostic facilities, case management and treatment, cluster management, and strengthening public awareness. Crisis and disaster preparedness within a nation's health system is paramount to preventing disease spread. Various strategies for developing resilience in the face of global infectious disease spread were discussed. The current disease preparedness and response framework and guidelines in Malaysia have established a health system that is proactive and responsive to any potential infectious disease outbreaks. Despite this, the future remains unpredictable, and ongoing fortification is required as events unfold.

Factors Affecting the Use of Private Outpatient Services among the Adult Population in Malaysia

The proportion of Malaysians of all ages who use private outpatient services has dropped over time, highlighting the overstretched condition of public outpatient facilities compared to their private counterparts. This paper aims to determine the prevalence of outpatient care, characteristics of outpatient care users by sector, and the factors affecting the utilisation of private outpatient services among the adult population of Malaysia using Andersen's behavioural model. Data from the National Health Morbidity Survey 2019 (NHMS 2019), a nationwide survey, were analysed. Logistic regression analysis was performed to explore the association of predisposing (locality, age, sex, ethnicity, education level, and marital status), enabling (working status, health care coverage, and household income), and need factors (perceived and evaluated needs) with the use of private outpatient services. Variables with a statistical significance ≤ 0.25 in the univariate regression analysis were included in the final multivariable logistic regression analysis. A total of 11,674 respondents, estimated to represent 22.4 million adults aged 18 years and above in Malaysia, were included for analysis. Overall, 8.3% of the adult population of Malaysia used outpatient care and 33.9% used the private sector. Those living in urban areas (OR = 1.80, 95% CI = 1.02, 3.18), non-Malays (OR = 1.74, 95% CI = 1.04, 2.93), those working (OR = 2.47, 95% CI = 1.48, 4.10), those with employer coverage (OR = 4.73, 95% CI = 2.79, 8.01), and those with health problems (OR = 2.26, 95% CI = 1.26, 4.05) were more likely to utilise private outpatient services. Those who self-rated their health status as fair (OR = 0.54, 95% CI = 0.33, 0.91) and who had diabetes, hypertension, or hypercholesterolemia (OR = 0.56, 95% CI = 0.31, 1.02) were less likely to utilise private outpatient services. The predisposing and enabling factors were associated with the use of private outpatient services, and the need factors were strong predictors of private outpatient care utilisation among adults. Understanding the factors associated with the utilisation of private outpatient services could aid in the development of effective initiatives designed to enhance outpatient care access among the population of Malaysia and balance the burden of outpatient care provision on the public and private sector.

Healthcare provider person-centred practice: relationships between prerequisites, care environment and care processes using structural equation modelling

Background

The translation of person-centred care concepts into practice requires fulfilment of necessary components, including person-centred values and practice held by the employees and having a supportive system. The objectives of this study were multifold: firstly, to evaluate the measurement model, secondly, to examine the roles of prerequisite or attributes of healthcare providers and care environment and how they affect delivery of person-centred processes; and finally, to examine the mediating effect of care environment towards the relationship between prerequisite and care processes.

Methods

A cross sectional study was conducted among healthcare providers working in primary care facilities in a state in Malaysia. The Person-centred Practice Inventory-Staff instrument (PCPI-S) was distributed and completed by respondents. The instrument structure, reliability and validity were assessed through confirmatory factor analysis, while the framework’s unidirectional hypothesis and the mediation path hypothesis were analysed using structural equation modelling.

Results

The overall goodness of fit verifies the original Person-centred Practice Framework, allowing some correlation errors. There were significant relationships between prerequisites of healthcare providers and care environment (β = 0.826, p < 0.001), as well as between care environment and care processes (β = 0.785, p < 0.001). This analysis also proved that care environment plays a partial mediating role in the relationship between prerequisites and care processes.

Conclusions

In order to successfully move towards delivering person-centred practice, it is imperative to equip healthcare providers with person-centred values and beliefs, while at the same time transform current work culture to align with person-centred care. This will allow successful delivery of person-centred processes.

Trial registration

NMRR-18-309-40,447.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07917-3.

Private Health Insurance in Malaysia: Who Is Left Behind?

Despite various efforts introduced, private health insurance coverage is still low in Malaysia. The objective of this article is to find the factors associated with not having a private health insurance in Malaysia. We analyze data involving 19 959 respondents from the 2015 National Health Morbidity Survey. In this article, we describe the prevalence of not having health insurance and conducted binary logistic regression to identify determinants of uninsured status. A total of 56.6% of the study population was uninsured. After adjusting for other variables, the likelihood of being uninsured was higher among those aged 50 years and above, females, Malay/other Bumiputra ethnicities, rural, government/semigovernment, self-employed, unpaid workers and retirees, unemployed, lower education level, without home ownership and single/widowed/divorced, daily smoker, underweight body mass index, and current drinker. The likelihood of being uninsured also increased with increasing household size while the inversed trend was seen for household income. A substantial proportion of population in Malaysia did not have private health insurance, and these subgroups have limited preferential choices for provider, facility, and care.

Midwifery Qualification in Selected Countries: A Rapid Review

BACKGROUND

While the global maternal mortality ratio (MMR) shows a decreasing trend, there is room for improvement. Midwifery education has been under scrutiny to ensure that graduates acquire knowledge and skills relevant to the local context.

OBJECTIVE

To review the basic professional midwifery qualification and pre-practice requirements in countries with lower MMR compared with Malaysia.

METHODS

A rapid review of country-specific Ministry of Health and Midwifery Association websites and Advanced Google using standardised key words. English-language documents reporting the qualifications of midwives or other requirements to practise midwifery from countries with a lower MMR than Malaysia were included.

RESULTS

Sixty-three documents from 35 countries were included. The minimum qualification required to become a midwife was a bachelor's degree. Most countries require registration or licensing to practise, and 35.5% have implemented preregistration national midwifery examinations. In addition, 13 countries require midwives to have nursing backgrounds.

CONCLUSION

In countries achieving better maternal outcomes than Malaysia, midwifes often have a degree or higher qualification. As such, there is a need to reinvestigate and revise the midwifery qualification requirements in Malaysia.

Implications of Dual Practice on Cataract Surgery Waiting Time and Rescheduling: The Case of Malaysia

Background: Dual practice was implemented in selected Ministry of Health Malaysia hospitals to reduce brain drain and provide an alternative for patients willing to pay higher user fees to seek prompt treatment from the specialist of their choice. This study aimed to assess the implications of dual practice on waiting time and rescheduling for cataract surgery. Methods: A retrospective study was conducted in a referral hospital. Inpatient medical records of patients who underwent cataract procedures were used to study the waiting times to surgery and rescheduling between private and public groups. Results: Private patients had a considerably shorter waiting time for cataract surgery, seven times shorter compared to public patients where all surgeries were conducted after hours on weekdays or weekends. Additionally, 14.9% of public patients experienced surgery rescheduling, while all private patients had their surgeries as planned. The main reason for surgery rescheduling was the medical factor, primarily due to uncontrolled blood pressure and upper respiratory tract infection. Conclusion: Private service provision utilizing out-of-office hours slots for cataract surgery optimizes public hospital resources, allowing shorter waiting times and providing an alternative to meet healthcare needs.

Redesigning a Healthcare Demand Questionnaire for National Population Survey: Experience of a Developing Country

Since its inception in 1986, the contents of the National Health and Morbidity Survey (NHMS) have been periodically updated to support emerging health data needs for evidence-based policy and program development. In 2018, the healthcare demand questionnaire was redesigned to capture diverse and changing population demand for healthcare services and their utilization pattern. This paper describes the methods and processes undertaken in redesigning the questionnaire. We aim to highlight the systematic and inclusive approach, enabling all potential evidence users to be involved, indirectly encouraging research evidence uptake for policy and program planning. We applied a systematic approach of comprehensive literature search for national-level population survey instruments implemented globally and translated non-English tools to English. The development phases were iterative, conducted in parallel with active stakeholder engagements. Here, we detailed the processes in the planning and exploratory phase as well as a qualitative assessment of the questionnaire. We included instruments from 45 countries. The majority were from the Organisation for Economic Co-operation and Development (OECD) countries and focused on perceived health, health-related behavior, and healthcare use. Thirty-four stakeholders from 14 areas of expertise were involved. Stakeholders identified additional content areas required, such as chronic pain, alternative use of healthcare services (community pharmacy, home-visit, and private medical laboratory), family doctor, and informal caregiving. The questionnaire, redesigned based on existing literature with concordant involvement and iterative feedback from stakeholders, improved the choice of health topics through the identification of new topics and modification of existing questions to better meet future evidence needs on health problems, strategy, and program planning towards strengthening the nation’s health systems.

Cross-cultural adaptation and exploratory factor analysis of the Person-centred Practice Inventory - Staff (PCPI-S) questionnaire among Malaysian primary healthcare providers

Background

The Person-centred Practice Inventory-Staff (PCPI-S) instrument was developed to measure healthcare providers’ perception towards their person-centred practice. The study aimed to explore the influence of culture, context, language and local practice towards the PCPI-S instrument adaptation process for use among public primary care healthcare providers in Malaysia.

Methods

The original PCPI-S was reviewed and adapted for cultural suitability by an expert committee to ensure conceptual and item equivalence. The instrument was subsequently translated into the local Malay language using the forward-backward translation by two independent native speakers, and modified following pre-tests involving cognitive debriefing interviews. The psychometric properties of the corresponding instrument were determined by assessing the internal consistency, test-retest reliability, and correlation of the instrument, while the underlying structure was analysed using exploratory factor analysis.

Results

Review by expert committee found items applicable to local context. Pre-tests on the translated instrument found multiple domains and questions were misinterpreted. Many translations were heavily influenced by culture, context, and language discrepancies. Results of the subsequent pilot study found mean scores for all items ranged from 2.92 to 4.39. Notable ceiling effects were found. Internal consistency was high (Cronbach’s alpha > 0.9). Exploratory factor analysis found formation of 11 components as opposed to the original 17 constructs.

Conclusion

The results of this study provide evidence regarding the reliability and underlying structure of the PCPI-S instrument with regard to primary care practice. Culture, context, language and local practice heavily influenced the adaptation as well as interpretation of the underlying structure and should be given emphasis when translating person-centred into practice.

Protocol for a cross-sectional study measuring person-centredness among healthcare providers in Malaysian primary care clinics: the adaptation and validation of the Person-Centred Practice Inventory-Staff (PCPI-S) Questionnaire

INTRODUCTION

Person-centred care (PCC) has become a global movement in healthcare. Despite this, the level of PCC is not routinely assessed in clinical practice. This protocol describes the adaptation and validation of the Person-Centred Practice Inventory-Staff (PCPI-S) tool that will be used to assess person-centred practices of primary healthcare providers in Malaysia.

METHODS AND ANALYSIS

To ensure conceptual and item equivalence, the original version of the PCPI-S will be reviewed and adapted for cultural context by an expert committee. The instrument will subsequently be translated into Malay language using the forward-backward translation method by two independent bilingual speaking individuals. This will be pretested in four primary care clinics and refined accordingly. The instrument will be assessed for its psychometric properties, such as test-retest reliability, construct and internal validity, using exploratory and confirmatory factor analysis.

ETHICS AND DISSEMINATION

Study findings will be disseminated to healthcare professionals and academicians in the field through publication in peer-reviewed journals and conference presentations, as well as at managerial clinic sites for practice improvement. The study was approved by the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia (KKM/NIHSEC/ P18-766 (14) and Monash University Human Research Ethics Committee (2018-14363-19627).

Empanelment: A foundational component of primary health care

Empanelment is a foundational strategy for building or improving primary health care systems and a critical pathway for achieving effective universal health coverage. However, there is little international guidance for defining empanelment or understanding how to implement empanelment systems in low- and middle-income countries. To fill this gap, a multi-country collaborative within the Joint Learning Network for Universal Health Coverage developed this empanelment overview, proposing a people-centered definition of empanelment that reflects the responsibility to proactively deliver primary care services to all individuals in a target population. This document, building on existing literature on empanelment and representing input from 10 countries, establishes standard concepts of empanelment and describes why and how empanelment is used. Finally, it identifies key domains that may influence effective empanelment and that must be considered in deciding how empanelment can be implemented. This document is designed to be a useful resource for health policymakers, planners and decision-makers in ministries of health, as well as front line providers of primary care service delivery who are working to ensure quality people-centered primary care to everyone everywhere.

Pertussis clinical case definition: Time for change in developing countries?

Background

Developing countries still struggle with late detection and mortality from pertussis. A review of clinical case definitions is necessary for early disease detection. This paper aimed to study possible clinical characteristics for earlier pertussis detection in a sporadic setting.

Methods

We conducted a retrospective review of medical and laboratory records in a general paediatric ward of a district hospital in a developing country. Inclusion criteria were all children hospitalised with nasopharyngeal swab taken for Bordetella pertussis. We compared sensitivity and specificity of World Health Organization diagnostic criteria with other clinical characteristics. Polymerase chain reaction Bordetella pertussis was the gold standard used.

Results

Out of 207 eligible admissions, the study retrieved 128 complete records. Approximately half of the children were less than 3 months old. The World Health Organization diagnostic criteria had a low sensitivity (15%), but high specificity (92%). In comparison, combinations that included paroxysmal cough, ill contact and facial congestion had higher sensitivity. Increasing cough duration improved specificity while compromising sensitivity.

Conclusion

Several clinical characteristics such as paroxysmal cough, facial congestion and a history of ill contact have potential for early clinical detection. Conventional emphasis on cough duration may hamper early detection.

Research funding impact and priority setting - advancing universal access and quality healthcare research in Malaysia

BACKGROUND

Health Research Priority Setting (HRPS) in the Ministry of Health (MOH) Malaysia was initiated more than a decade ago to drive effort toward research for informed decision and policy-making. This study assessed the impact of funded prioritised research and identified research gaps to inform future priority setting initiatives for universal access and quality healthcare in Malaysia.

METHODS

Research impact of universal access and quality healthcare projects funded by the National Institutes of Health Malaysia were assessed based on the modified Payback Framework, addressing categories of informing policy, knowledge production, and benefits to health and health sector. For the HRPS process, the Child Health and Nutrition Research Initiative methodology was adapted and adopted, with the incorporation of stakeholder values using weights and monetary allocation survey. Workshop discussions and interviews with stakeholders and research groups were conducted to identify research gaps, with the use of conceptual frameworks to guide the search.

RESULTS

Seventeen ongoing and 50 completed projects were identified for research funding impact analysis. Overall, research fund allocation differed from stakeholders' expectation. For research impact, 48 out of 50 completed projects (96.0%) contributed to some form of policy-making efforts. Almost all completed projects resulted in outputs that contributed to knowledge production and were expected to lead to health and health sector benefits. The HRPS process led to the identification of research priority areas that stemmed from ongoing and new issues identified for universal access and quality healthcare.

CONCLUSION

The concerted efforts of evaluation of research funding impact, prioritisation, dissemination and policy-maker involvement were valuable for optimal health research resource utilisation in a resource constrained developing country. Embedding impact evaluation into a priority setting process and funding research based on national needs could facilitate health research investment to reach its potential.

The impact of a prescription review and prescriber feedback system on prescribing practices in primary care clinics: a cluster randomised trial

BACKGROUND

To evaluate the effectiveness of a structured prescription review and prescriber feedback program in reducing prescribing errors in government primary care clinics within an administrative region in Malaysia.

METHODS

This was a three group, pragmatic, cluster randomised trial. In phase 1, we randomised 51 clinics to a full intervention group (prescription review and league tables plus authorised feedback letter), a partial intervention group (prescription review and league tables), and a control group (prescription review only). Prescribers in these clinics were the target of our intervention. Prescription reviews were performed by pharmacists; 20 handwritten prescriptions per prescriber were consecutively screened on a random day each month, and errors identified were recorded in a standardised data collection form. Prescribing performance feedback was conducted at the completion of each prescription review cycle. League tables benchmark prescribing errors across clinics and individual prescribers, while the authorised feedback letter detailed prescribing performance based on a rating scale. In phase 2, all clinics received the full intervention. Pharmacists were trained on data collection, and all data were audited by researchers as an implementation fidelity strategy. The primary outcome, percentage of prescriptions with at least one error, was displayed in p-charts to enable group comparison.

RESULTS

A total of 32,200 prescriptions were reviewed. In the full intervention group, error reduction occurred gradually and was sustained throughout the 8-month study period. The process mean error rate of 40.7% (95% CI 27.4, 29.5%) in phase 1 reduced to 28.4% (95% CI 27.4, 29.5%) in phase 2. In the partial intervention group, error reduction was not well sustained and showed a seasonal pattern with larger process variability. The phase 1 error rate averaging 57.9% (95% CI 56.5, 59.3%) reduced to 44.8% (95% CI 43.3, 46.4%) in phase 2. There was no evidence of improvement in the control group, with phase 1 and phase 2 error rates averaging 41.1% (95% CI 39.6, 42.6%) and 39.3% (95% CI 37.8, 40.9%) respectively.

CONCLUSIONS

The rate of prescribing errors in primary care settings is high, and routine prescriber feedback comprising league tables and a feedback letter can effectively reduce prescribing errors.

TRIAL REGISTRATION

National Medical Research Register: NMRR-12-108-11,289 (5th March 2012).

Improving Health Care Coverage, Equity, And Financial Protection Through A Hybrid System: Malaysia's Experience

Malaysia has made substantial progress in providing access to health care for its citizens and has been more successful than many other countries that are better known as models of universal health coverage. Malaysia's health care coverage and outcomes are now approaching levels achieved by member nations of the Organization for Economic Cooperation and Development. Malaysia's results are achieved through a mix of public services (funded by general revenues) and parallel private services (predominantly financed by out-of-pocket spending). We examined the distributional aspects of health financing and delivery and assessed financial protection in Malaysia's hybrid system. We found that this system has been effective for many decades in equalizing health care use and providing protection from financial risk, despite modest government spending. Our results also indicate that a high out-of-pocket share of total financing is not a consistent proxy for financial protection; greater attention is needed to the absolute level of out-of-pocket spending. Malaysia's hybrid health system presents continuing unresolved policy challenges, but the country's experience nonetheless provides lessons for other emerging economies that want to expand access to health care despite limited fiscal resources.

Reducing Medical Errors in Primary Care Using a Pragmatic Complex Intervention

This study aimed to develop an intervention to reduce medical errors and to determine if the intervention can reduce medical errors in public funded primary care clinics. A controlled interventional trial was conducted in 12 conveniently selected primary care clinics. Random samples of outpatient medical records were selected and reviewed by family physicians for documentation, diagnostic, and management errors at baseline and 3 months post intervention. The intervention package comprised educational training, structured process change, review methods, and patient education. A significant reduction was found in overall documentation error rates between intervention (Pre 98.3% [CI 97.1-99.6]; Post 76.1% [CI 68.1-84.1]) and control groups (Pre 97.4% [CI 95.1-99.8]; Post 89.5% [85.3-93.6]). Within the intervention group, overall management errors reduced from 54.0% (CI 49.9-58.0) to 36.6% (CI 30.2-43.1) and medication error from 43.2% (CI 39.2-47.1) to 25.2% (CI 19.9-30.5). This low-cost intervention was useful to reduce medical errors in resource-constrained settings.

Medical errors in primary care clinics--a cross sectional study

BACKGROUND

Patient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics.

METHODS

This was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors.

RESULTS

The majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable.

CONCLUSIONS

The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors.

Effective implementation of a structured psychoeducation programme among caregivers of patients with schizophrenia in the community

BACKGROUND

Psychoeducation has shown promising benefits in managing patients with schizophrenia. In Malaysia, the use of psychoeducation is rather limited and its impact indeterminate.

AIMS

To assess the effectiveness of a structured psychoeducation programme for the community in improving caregiver knowledge, decreasing caregivers' burden, reducing patients' readmission and defaulter follow up rates.

METHOD

In a controlled interventional study, 109 caregivers were included, 54 and 55 in the intervention and control groups respectively. Caregivers were assessed at baseline, 3 and 6 months post-intervention for knowledge and burden. Patients were monitored for relapse and defaulting follow up in the clinic.

RESULTS

Caregivers in the intervention group showed significant improvement in knowledge, reduction in burden in assistance in daily living (severity) and a reduced defaulter rate was seen in the patients' follow up.

CONCLUSION

The findings shows that structured psychoeducation programme among caregivers has the potential to improve outcome of care for patients with schizophrenia.

Validity and reliability of the SF-36: the Malaysian context

Results of construct validity and reliability of the SF-36 are described, based on data from a multi-centre study on asthmatics and a population based survey. Questionnaire refinement was carried out between the two studies. Quality of data was good, with all items having less than 0.5% missing values. Floor and/or ceiling effects were observed for REE, REP, PF and SF. For scaling assumptions, correlations between each items and its hypothesized scale were all above 0.50, except for one item in PF. and for both items in SF. Item discriminant validity was an issue for items in VT, SF and MH scales. Cronbach's as for all scales exceeded the recommended 0.70 level, except for SF. Only one latent dimension was identified in principal component analysis, and only 52-53% of variance accounted for. As expected, PF shows high correlations with the physical component while MH was highly correlated with the mental component. Contrasting findings in the loadings of other scales were observed in the asthma data. Age, disease severity and presence of self-reported handicap/disability significantly affect PF, while MH demonstrates no obvious pattern with declining age. In essence, the Malay version of SF-36 could be used in Malaysia, with its generally acceptable internal consistency and validity. The caveat is in the call for additional domains of importance to Malaysians that is not covered by the instrument, and in the caution to be employed when using and construing the instrument.

Quality of life of the Malaysian general population: results from a postal survey using the SF-36

Population norms for Health Related Quality of Life using SF-36 are described. A national sample was canvassed in 2000 using a self-administered SF-36 in Bahasa Malaysia and English. Response rate was 30.6%, with 3072 usable data. Male: Female ratio was 1.04 and mean age was 39.8 years. Quality of life was affected by age and sex. Older population and women had a poorer quality of life. Population norms for Malaysia differed from those of US, Canada and Australia. The malaysian general population norm described is useful as reference point for studies in Malaysia. Variability in scores by age and sex emphasize the need to use appropriate age- or sex-specific normative data.

Quality of life--how do Malaysian asthmatics fare?

Asthma can place considerable restrictions on the physical, emotional and social aspects of the lives of patients. The assessment of quality of life aims to provide a means of measuring the impact of this disease on patients' lives, from the patients' perspective. A cross sectional multi-centre study was conducted in six government hospitals throughout the country. Self-administered SF-36 was used, and clinical information obtained through interviews and examination. 1612 asthmatics responded. Females constituted 63% of the respondents; mean age was 40.9 years; Malays were the majority ethnic group, while 70.8% had secondary level education and 53.7% were employed. Half had suffered from asthma for at least 13 years, while 46.8% and 23.6% have moderate and severe disease respectively. Quality of life was affected by severity of disease. Asthmatics, had a significantly poorer quality of life than the general US population. Severe asthma disease was associated with a compromised quality of life, similar to that of COPD.

Demotivating factors among government doctors in Negeri Sembilan

Motivation, especially on the relationship of remuneration of government doctors to it, has long been an issue of concern. This study sought to elucidate the demotivating factors in service and the perceived discrepancy in income. It was conducted amongst doctors serving in the Ministry of Health, Negeri Sembilan, using self-administered questionnaires. Factors considered demotivating were remuneration, workload and recognition given. Career development, promotion prospects, issues with superiors, resources and patient attitudes were other factors identified. On average, respondents expect an income of 1.63 times more than their current drawn salary and 87.2% cited rewards as a recommendation to improve their satisfaction in service. In-service training was desired by almost all. Though the medical profession has traditionally been viewed as altruistic in nature, doctors in service are voicing out their views and perception, and they should be heard.

Job satisfaction of doctors in Negeri Sembilan

A cross sectional study was carried out in Negeri Sembilan to identify factors associated with job satisfaction of doctors serving in Ministry of Health and their intentions to resign. All Ministry of Health doctors currently working in Negeri Sembilan were included in the study and data collection was done via a self-administered postal questionnaire. The response rate was 69.4%. Out of those who responded, only 31.3% had global job satisfaction, with the majority dissatisfied. Intention to resign was high among 32.7% of the respondents. Factors found to be significantly associated with job satisfaction were age, job designation, income, duration of service and intention to resign. Intention to resign was found to be significantly associated with ethnicity and income. From logistic regression, predictors of job satisfaction identified were age, place of first graduation, and satisfaction with status and autonomy, satisfaction with career development, satisfaction with workload and satisfaction with transfers. Predictors of intention to resign were race, income and global job satisfaction.