Development, Validation and Acceptability of a Newly Developed Nutrition Resource Kit for At-Risk and Malnourished Elderly in Health Clinics Setting

Introduction: The elderly population is highly vulnerable to malnutrition, including those in the community. The use of nutrition education as part of nutrition intervention is able to improve their nutritional status. Hence, provision of a nutrition resource kit addressing the needs of at-risk and malnourished elderly would be advantageous. This research aimed to develop, validate and evaluate the acceptance of a newly developed nutrition resource kit, which served as an educational material among at-risk and malnourished elderly in Malaysian health clinics. Methods: This study was conducted in three phases: Phase I comprised of qualitative needs assessment to identify the types of nutrition resource kit needed; Phase II was the development and validation of the nutrition resource kit; while Phase III was acceptance evaluation, which involved individual in-depth interview and triangulation. Results: An A5-sized booklet with incorporation of an educational video in a QR code was developed. Both printed material and educational video had excellent content and face validity. Suggestions by experts and elderly from validation were considered and revision was done accordingly. Acceptance evaluation revealed four themes: 1) positive acceptance, 2) elderly-friendly, 3) valuable, and 4) individual preference. Triangulation data revealed that all elderly positively evaluated both resources. Additional suggestions given by elderly were considered for improvement. Conclusion: This newly developed nutrition resource kit, both in the printed and electronic format, was well-accepted among the at-risk and malnourished elderly. It could be used as an important reference for the elderly, especially those attending health clinics, in treating and preventing malnutrition.

Case report of chronic cough in primary care: a diagnostic challenge and lessons to learn

Cough is one of the most common complaints seen at the outpatient primary health clinic. While the most common aetiologies of chronic cough are asthma, chronic obstructive pulmonary disease, postnasal drip, gastroesophageal reflux disease, drug-induced, and tuberculosis, we often overlook that chronic cough, especially in a young female, can be the initial presenting complaint of an autoimmune disease. In this case report, we present a case of 35-year-old woman with no known prior medical illness who presented with chronic cough for 1 year with no other symptoms initially; but later in the disease course, the patient complained of multiple, symmetrical small joint pain, which led us to the diagnosis of seronegative rheumatoid arthritis.

Impact of parental perinatal depressive and anxiety symptoms trajectories on early parent-infant impaired bonding: a cohort study in east and west coasts of Malaysia

The association between maternal depressive and anxiety symptoms and impaired bonding with infants were widely studied, but not in fathers and none in Malaysia. We investigated the impact of different trajectories of perinatal depressive and anxiety symptoms on parent-infant impaired bonding during 2-3 months postpartum in both mothers and fathers in two areas of Malaysia. This study originated from a psychiatric morbidity cohort study carried out in health clinics in east and west Malaysia. Edinburgh Postnatal Depression Scale and anxiety subscale of Depression, Anxiety, and Stress Scale at late pregnancy and 2-3 months postpartum and Postpartum Bonding Questionnaire were completed by 566 mothers and 457 fathers. About 11.7% mothers and 16.1% fathers reported depressive symptoms during pregnancy, 6.5% mothers and 10.5% fathers during 2-3 months postpartum, and 3-4% mothers and fathers both depressive and anxiety symptoms 2-3 months postpartum. The mean impaired bonding score was highest in mothers and fathers who had both depressive and anxiety symptoms 2-3 months postpartum. Impaired bonding is associated with higher EPDS and DASS (anxiety subscale) scores 2-3 months postpartum in both parents. Physical partner violence and deteriorated marital relationship were associated with increased risk of impaired bonding in mothers. The association between depressive, anxiety, and comorbidity of depressive and anxiety symptoms in both mothers and fathers and parent-infant impaired bonding during 2-3 months postpartum urges for screening and treatment of depressive and anxiety symptoms in both parents during early parenthood.

Insulin oedema in type 2 diabetes mellitus: A case report

Insulin oedema is a rare condition that may occur after the initiation or rapid intensification of insulin therapy in patients with long-standing hyperglycaemia, commonly with type 1 diabetes mellitus (DM). We reported a case of insulin oedema in a patient with type 2 DM who presented with swelling of the extremities and weight gain of 3 kg 1 week after insulin initiation. A course of furosemide was administered, but no significant immediate improvement was observed; however, the lower limb swelling resolved spontaneously after 3 months of follow-up. The patient also achieved adequate diabetic control with insulin, as shown by the reduction of her HbA1c from 10.7% to 6.9% over 6 months. Insulin oedema is a diagnosis of exclusion after ruling out other differential diagnoses, such as cardiac, renal, or liver failure. Although insulin oedema carries with it a good prognosis, physicians should be aware of the condition to avoid misdiagnosis.

The impact of a multifaceted intervention to reduce potentially inappropriate prescribing among discharged older adults: a before-and-after study

Background

Potentially inappropriate prescribing (PIP) is associated with the incidence of adverse drug reactions, drug-related hospitalization and other negative outcomes in older adults. After hospitalization, older adults might be discharged with several types of PIPs. Studies have found that the lack of healthcare professionals' (HCPs) knowledge regarding PIP is one of the major contributing factors in this issue. The purpose of this study is to investigate the impact of a multifaceted intervention on physicians' and clinical pharmacists' behavior regarding potentially inappropriate medication (PIM) and potential prescribing omission (PPO) among hospitalized older adults.

Methods

This is a before-and-after study that took place in a tertiary Malaysian hospital. Discharge medications of patients ≥65 years old were reviewed to identify PIMs/PPOs using version 2 of the STOPP/START criteria. The prevalence and pattern of PIM/PPO before and after the intervention were compared. The intervention targeted the physicians and clinical pharmacists and it consisted of academic detailing and a newly developed smartphone application (app).

Results

The study involved 240 patients before (control group) and 240 patients after the intervention. The prevalence of PIM was 22% and 27% before and after the intervention, respectively (P = 0.213). The prevalence of PPO in the intervention group was significantly lower than that in the control group (42% Vs. 53.3%); P = 0.014. This difference remained statistically significant after controlling for other variables (P = 0.015). The intervention was effective in reducing the two most common PPOs; the omission of vitamin D supplements in patients with a history of falls (P = 0.001) and the omission of angiotensin converting enzyme inhibitor in patients with coronary artery disease (P = 0.03).

Conclusions

The smartphone app coupled with academic detailing was effective in reducing the prevalence of PPO at discharge. However, it did not significantly affect the prevalence or pattern of PIM.

Prevalence of Risks for Obstructive Sleep Apnoea and Its Risk Factors among Adults Attending Government Primary Health Clinics in Kuantan

Introduction: Obstructive sleep apnoea (OSA) is a sleep related breathing disorder with recurrent episodes of apnoea or hypopnoea occurring during sleep. It is associated with increased risk of cardiovascular disease and prone to accidents. However, there is no applicable study that assess the risk for OSA at the primary care level. Objective: This study aims to assess the prevalence of risk for OSA and OSA symptoms and its associated risk factors among adults attending primary care clinics. Materials and method: This cross-sectional study was conducted among 252 adults attending four Klinik Kesihatan in Kuantan, Pahang. The inclusion criteria was adults age 30 years old and above. The exclusion criteria were a known case of Hypothyroidism, Depression and pregnancy. A self-administered validated Malay version of Berlin Questionnaire(BQ) was used to screen for high risk of OSA. The statistical analyses were done using IBM SPSS version 23.0. Results: Majority of the respondents were male (54%), Malay (87.7%), and married (79.4%). The prevalence of High Risk for OSA was 32.9%. Among these, 94% of them presented with snoring and 16.9% presented with excessive daytime sleepiness. Among male, Malay and married; 48%, 32.6% and 36.5% respectively was shown to be High Risk for OSA. The risk factors that were found significantly associated with High Risk of OSA includes younger age (AOR=0.951 CI=0.923-0.980); higher BMI classification with obese type 1 (AOR=2.604 CI=1.278-5.308), obese type 2 (AOR=3.882 CI=1.078-13.975) and obese type 3 (AOR=6.800 CI=1.164-39.717); higher neck circumference (AOR=1.109 CI=1.007-1.221); hypertension (AOR=2.297 CI=1.122-4.702); and hypercholestrolaemia (AOR=2.040 CI=1.050-3.965). Conclusions:  This study shows that nearly one third of the adults attending primary health clinic are at High Risk for OSA and nearly 17% of them presented with excessive daytime sleepiness. Further study need to be carry out particularly among those of younger age, higher BMI classification, and with co-morbidities.

Impact of maternal antepartum depressive and anxiety symptoms on birth outcomes and mode of delivery: a prospective cohort study in east and west coasts of Malaysia

BACKGROUND

Antepartum depressive and anxiety symptoms (ADS and AAS) are prevalent in Malaysia. Prior evidence linking maternal ADS and AAS with adverse birth outcomes and caesarean section (CS) or instrumental delivery is conflicting. There is no research in Malaysia on the association between maternal mental disorders and adverse birth outcomes and mode of delivery. This study aims to investigate the independent effect of maternal ADS and AAS on low birth weight (LBW), preterm birth (PTB) and CS or instrumental delivery among women in east and west coasts of Malaysia.

METHODS

We used data from a prospective cohort study of 799 pregnant women from health clinics of two states in east and west coasts of Malaysia. Baseline data were measured at the third trimester of pregnancy on ADS, AAS, socioeconomic condition, anthropometric status, reproductive history and intimate partner violence. Birth outcomes and mode of delivery were determined at the time of delivery. Univariate and multiple Cox's regressions were applied to assess the association between ADS and AAS and LBW, PTB and CS or instrumental delivery.

RESULTS

ADS was significantly associated with an increased risk of giving birth to LBW babies in both east coast (RR = 3.64; 95% CI 1.79-7.40) and west coast (RR = 3.82; 95% CI 1.86-7.84), but not with PTB. AAS was associated with increased risk of both LBW (RR = 2.47; 95% CI 1.39-4.38) and PTB (RR = 2.49; 95% CI 1.16-5.36) in the east coast, but not in west coast. The risk of CS or instrumental delivery was evident among women with ADS (RR = 2.44; 95% CI 1.48-4.03) in west coast only.

CONCLUSION

ADS predicts LBW in both coasts, AAS predicts LBW and PTB in east coast, and ADS predicts CS or instrumental delivery in west coast. Policies aimed at detection and management of ADS and AAS during antenatal check-up in health clinics may help improve birth outcomes and reduce obstetric interventions.

Knowledge, Attitude and Practice on Smoking Cessation Guideline among Medical Doctors attending Family Medicine Scientific Conference 2016

Introduction:  Prevalence of active smokers in Malaysia remains high despite the availability of stop-smoking services. Rather than focussing on patients’ demotivating factors, possible poor performance from providers should be evaluated. Thus, knowledge, attitude and practice of the healthcare professional on smoking cessation intervention needs to be assessed, especially among primary care doctors.  Materials and Methods:  A cross-sectional study was conducted among primary care medical doctors attending the 19th Family Medicine Scientific Conference 2016 held at the Grand Dorsett, Subang on the 10th to the 13th August 2016. Validated questionnaire of Knowledge, Attitude and Practice (KAP) of Medical Doctors on Smoking Cessation Guidelines consisting 17 questions were used to determine the KAP score. The difference between the median KAP scores between age, gender, ethnicity, religion, profession, location of clinic, availability of specialist in clinic, numbers of smokers seen and presence of smoking cessation training were assessed using Mann-Whitney U Test and Kruskal Wallis H Test. Results:  A total of 145 primary care doctors involved in the study. Majority were female (84.1%), Malay (73.1%) and haven’t undergone any kind of smoking cessation training (47.6%). The KAP score were statistically associated with presence of specialist, type of profession, history of attending training program, ethnicity and religion (p<0.05). Conclusion: Majority of the involved primary care doctors had low KAP score. Being a family medicine specialist, in charge of stop smoking clinic and having attended smoking cessation training program were significantly associated with high KAP score. Therefore, more smoking cessation training should be provided to the primary care doctors.

Depression, Anxiety, And Stress Among Adolescents In Kuantan And Its Association With Religiosity- A Pilot Study

Adolescence is a period of time when the development of personality and psychology is taking place. Studies have shown that religiosity can affect the mental health of a person. Many tools have been developed to assess religiosity of a person; one of them is the Santa Clara Strength of Religious Faith (SCSORF) scale. In this study, a translation and validation for SCSORF Malay Version (SCSORF-M) is done, and subsequently used to look for the association between religiosity and mental health in adolescents. Fifty questionnaire papers have been distributed to 50 students in secondary schools in district of Kuantan. The mean score for depression, anxiety, and stress are 5.83, 5.59, and 8.34 respectively. Only 10 (24.4%) have no depression, 9 (22%) have no anxiety, and 13 (31.7%) have no stress. The mean score for SCSORF-M scale was 35.3 (range 25-40). Family income has shown to correspond negatively with the depression, anxiety, and stress, while religiosity has shown to be correlating negatively with depression and stress, but positive correlation with anxiety. SCSORF-M has positive convergent correlation with Duke’s University Religiosity Index Malay Version (DUREL-M) in all domains. SCSORF-M has shown good Cronbach’s alpha value (0.84). In conclusion, religiosity is an important factor to contribute to the outcome of mental health among adolescents. SCSORF-M can be used as an assessment tool for religiosity.

Reliability and Construct Validity of Knowledge, Attitude, and Practice of Medical Doctors on Smoking Cessation Guidelines

Introduction: Islam forbids any forms of tobacco smoking. Prevalence of active smokers in Malaysia is increasing despite availability of stop-smoking clinics. Thus, the practice of healthcare professionals involved in providing smoking cessation intervention needs to be assessed using validated assessment tool. Objective: This study aimed to develop and validate a questionnaire that assesses the knowledge, attitude, and practice of medical doctors based on the national smoking cessation guideline. In addition, we aimed to evaluate factors that contribute to the score. Methods: The 26 items consists of mixture of true/false choice questions and Likert scaling response based on domain of 5A’s (ask, assess, advice, assist, arrange) and 5R’s (relevant, risks, rewards, roadblocks, repetitions) of the national stop-smoking guideline. The questionnaire was distributed to 141 medical doctors. Reliability was determined using Cronbach’s alpha for internal consistency while construct validity was assessed using factor analysis. Results: A high degree of internal consistency was observed for this 26 items (Cronbach’s alpha= 0.824) and for practice subscale (Cronbach’s alpha 0.83). Subsequently, three items were removed due to poor inter item correlation. Factor analysis extracted seven meaningful components from this remaining 23 items, in which three components with least items were deleted due to overlapping subscale with other components, leaving four meaningful components which consist of (1) practice of ask, advice and assess components and practice of 5R’s (total of 10 items); (2) practice of assist components for those willing to quit (two items); (3) knowledge (two items) and (4) attitude (three items).These final 17 items still demonstrate high internal consistency with Cronbach’s alpha of 0.832. Conclusion: This study indicates that this questionnaire is a reliable and valid tool to assess the knowledge, attitude, and practice of healthcare professionals on stop smoking guidelines.

Clinical Resolution Of Periodontitis Among Diabetic Patients With Chronic Periodontitis CoMorbidity Under Medical-Dental Coordinated Care: A Preliminary Study In Kuantan

Introduction: Clinical resolution of periodontitis (CRP) of type-2 diabetic patients with chronic periodontitis (T2DM-PD) after receiving non-surgical periodontal treatment (NSPT) has been reported in the previous studies. This study aimed to evaluate CRP of T2DM-PD under medicaldental coordinated care (M-DCC). Materials and Methods: A 6-months follow-up quasi-experimental study was conducted among 20 subjects who received M-DCC in 2016. M-DCC included standard diabetic care provided by medical professional from 3 health clinics and NSPT provided by periodontal specialists from two periodontal specialist clinics. Target glycemic control achievement (TGCA) HbA1c 6.5% was assessed at baseline and 6 months after NSPT. Clinical resolution of PD was measured in terms of BPE, BOP %, CAL(mm), PPD(mm), PPD 4mm, PPD =4 mm and PPD 6mm at baseline, 3 and 6 months. Paired simple t test and ANOVA F test were applied to infer clinical resolution of periodontitis and its relation to TGCA. Results:  Mean (SD) of average BPE at baseline, 3- and 6-months were 3.52(0.34), 3.12(0.33) and 3(0.45) with (p<0.05); average PPD(mm) were 3.33(0.5), 3.23(0.75) and 2.73(0.57) with (p<0.05); PPD(%) 4mm were 71.03(12.33), 82.77(9.9) and 85.85 (8.9) with (p<0.05); PPD(%) =4 mm were 27.94(11.9), 16.97(10.01) and 13.71(9.1) with (p<0.05) ; PPD(%) 6mm were 8.04(4.32), 2.66(2.3) and 1.87(2.32) with (p<0.05). Significant resolution of BPE, CAL(mm) and PPD(mm) was noticed among two subjects who has changed from uncontrolled TGCA to controlled TGCA. Conclusion(s):  CRP and TGCA results have verified the effectiveness of M-DCC. A further clinical control trial with adequate sample size needs to confirm the results of the present study.

Lifestyles and non-communicable diseases status among primary health care staff in Kuantan, Pahang

Introduction:  Unhealthy lifestyle is one of the risks of non-communicable diseases (NCDs) in our population even among the healthcare provider. They should be as the role model for their NCDs patients in the clinics. Therefore, this study was to determine the lifestyle practice and lifestyle-related NCDs (LR-NCDs) status among primary health care staffs. Methods:  A cross-sectional survey was done among 69 health-staff (20- physicians (PCPs), 16-nurses and 33-Para-Med) aged between 20-60 years from 3 selected governments primary health care clinics in Kuantan on April 2015. A pre-tested questionnaire is used to the collect history of LR-NCDs, smoking, exercise status and 24-hours- dietary recall. The BMI, systolic and diastolic blood pressure of the participants were also measured. The Nutritionist-Pro-(g) software was used to extract macronutrients (Carbohydrate, Protein and Total-Fat %) and balance-diet (within recommended %). Results: The most common LR-NCDs among health-staff were overweight (34.8%) and followed by obesity (24.6%), DM (8.7%) and hypertension (3.2%). The majority (95.7%) were non-smokers and 69.6% did not exercise regularly. Diet-recall analysis showed that only 8.9% (2-PCPs, 1-nurse & 3-ParaMed) had balanced-diet. The status of the DM, hypertension and smoking and practicing balance-diet were not significantly different (p>0.05) among the PCPs, registered-nurses and Para-Med except for the exercise. Most PCPs (90%) have inadequate exercise compared to registered-nurses (43.8%) and Para-Med (69.7%) (p<0.05). Conclusions: There is a high prevalence of overweight and obesity, inadequate exercise and having an unbalance-diet were noticed among all levels of health-staff.

Oral hygiene practices and periodontal disease status assessment among diabetic patients from three selected public medical primary care clinics in Kuantan, Malaysia

Introduction: Evidences on the bilateral relationship between diabetes mellitus (DM) and periodontal diseases (PD) have been growing. Oral hygiene practice (OHP) is one of major determinants for PD. Thus, the aim of this study was to assess periodontal disease status and oral hygiene practices of DM-patients from public medical primary care clinics (PMPCCs). Methods: A medical-dental research team conducted an active PD-screening among 193 DMpatients using both self-reported questions (SRQs) and basic periodontal examination (BPE)  by professionals at 3-PMPCCs in Kuantan in 2015. OHP was categorized into two groups; acceptable OHP (two/three-time tooth-brushing/day using with/without mouthwash/flossing) and need to improve OHP (one-time tooth brushing/day using with/without mouth-wash/flossing). HbA1C ≤ 6.5% was used as cut-off for glycaemic control achievement. A cross- analysis was done to infer the influences of demographic-background and OHP on PD- status and relationship between PD- status and glycaemic control achievement. Results: Out of 193 DM-patients, 72.5% (140/193) were PD-screening positive in self-reporting while 54.9% (106/193) had PD in professional screening. OHP of majority (86%) were acceptable. Only 14% (27/193) achieved glycaemic-control status. Influence of demographic and OHP on PD-status ( by BPE) and relationship between PD and glycaemic control achievement did not found out. There were no age and race difference in OHP; however, acceptable OHP was significantly higher (p<0.05) in female than male DM-patients (94% vs 77.4%). Conclusions:  High prevalence of PD indicated to promote oral health education/care among DM-patients from PMPCCs.  In-detailed OHP/PD assessment and other influencing factors on glycaemic-control achievement should be considered to get more valid results in further study.

Charateristics and reasons for diabetic-defaulters between primary care clinics and diabetic specialist clinic: A prospective cohort study in Kuantan, Malaysia

Introduction: Defaulted appointment in diabetic clinics is a great concern as it affects disease controlled and complications. Geographical location, clinic-types and quality of health services provided are known determinant reasons for defaulting. Thus, this study aimed to identify characteristics and reasons for default between diabetic-patients at public-primary-care-clinics (PPCCs) and public-hospital-diabetic-specialist-clinic (DS-OPD). Methods: A prospective one-year-cohort study was conducted among 405 diabetic patients from two PPCCs and DS-OPD in Kuantan (2015-2016). There were 2-point visits (at 6-month and 12-month) assessing follow-up appointments within one year. Defaulter is defined by at least one-time defaulted either at 6-month or 12-month. Regular-attendees were included as control. Type-1-DM-patients, missing-records, known-deceased and transferout cases were excluded. Background socio-demographic data of diabetic-defaulters were collected from DM-records and reasons for defaulting were traced via 3-times-telephone contacts which 51.6% diabetic-defaulters responded. A stratified cross-analysis was done to compare the prevalence and characteristics between defaulters and regular attendees. Reasons for defaults were analyzed using open-ended-questions analysis method. Results: Prevalence of defaulters was 18% (73/405); higher prevalence was found in DS-OPD than PPCCs (32.4% vs 10.3%). Gender, race, age, education, occupation and the duration of DM were not significantly different between defaulters and regular-attendees at DS-OPD. However, self-employment (25.9%), housewives (25.9%), aged less than 45-years (33.3%) and≥ 55 years-old (44.4%) were significant defaulters in PPCCs. Significant different of reasons for default found at DS-OPD compare to PPCCs for postponing the date (54.5% vs 12.5%), while refusing treatment/used alternative medicine (18.2% vs 43.8%); and movedout/transferred/referred cases (27.3% vs 31.2%) were more in PPCCs. Conclusions: Distinctive characteristics and diverse reasons for default between DS-OPD and PPCCs among diabetic-patients fortified to set tailored remedial to reduce defaulter-rate in different clinic.

Reliability and construct validity of knowledge, attitude and practice of medical doctors on smoking cessation guidelines

Introduction: Prevalence of active smokers in Malaysia is increasing despite availability of stop smoking clinics. Thus, practice of the healthcare professionals in providing smoking cessation intervention needs to be assessed. This study aimed to develop and validate a questionnaire to assess the knowledge, attitude and practice of medical doctors on national smoking cessation guidelines  and factors contributing to the score. Methods: The 26 items consists of mixture of                        true/false questions; strongly-agree/agree/don’tknow/disagree/strongly-disagree response; and always/frequent/seldom/never response were created based on domain of 5A’s (ask, assess, advice, assist, arrange) and 5R’s (relevant, risks, rewards, roadblocks, repetitions). The questionnaires were distributed to 141 medical doctors. Reliability was determined using Cronbach’s alpha for internal consistency while construct validity was assessed using factor analysis. Results: A high degree of internal consistency was observed for this 26 items (Cronbach’s alpha= 0.824). Subsequently, 2 items with poor inter-item correlations were removed. Factor analysis extracted 7 meaningful components from this remaining 24 items, in which 3 components with least items were deleted due to overlapping subscale with other components, leaving 4 meaningful components of (1st) practice ask, advice, assess and practice 5R’s, (2nd) practice of assist and arrange for those willing to quit, (3rd) knowledge and (4th) attitude. These final 17 items still demonstrate high internal consistency with Cronbach’s alpha of 0.832. Conclusions: This study indicates that this questionnaire is a reliable and valid tool to assess the knowledge, attitude and practice on stop smoking guidelines. Improvement can be made for attitude items in the future.