Exploring primary care physicians’ challenges in using home blood pressure monitoring to manage hypertension in Singapore: a qualitative study

ObjectiveHypertension guidelines recommend using home blood pressure (HBP) to diagnose, treat and monitor hypertension. This study aimed to explore the challenges primary care physicians (PCPs) face in using HBP to manage patients with hypertension.MethodA qualitative study was conducted in 2022 at five primary care clinics in Singapore. An experienced qualitative researcher conducted individual in-depth interviews with 17 PCPs using a semi-structured interview guide. PCPs were purposively recruited based on their clinical roles and seniority until data saturation. The interviews were audio-recorded, transcribed verbatim and managed using NVivo qualitative data management software. Analysis was performed using thematic analysis.ResultsPCPs identified variations in patients’ HBP monitoring practices and inconsistencies in recording them. Access to HBP records relied on patients bringing their records to the clinic visit. A lack of seamless transfer of HBP records to the EMR resulted in an inconsistency in documentation and additional workload for PCPs. PCPs struggled to interpret the HBP readings, especially when there were BP fluctuations; this made treatment decisions difficult.ConclusionDespite strong recommendations to use HBP to inform hypertension management, PCPs still faced challenges accessing and interpreting HBP readings; this makes clinical decision-making difficult. Future research should explore effective ways to enhance patient self-efficacy in HBP monitoring and support healthcare providers in documenting and interpreting HBP

How to disseminate a health screening mobile app to men? A qualitative study

Background: Mobile health is increasingly being used to improve healthcare. There is a potential of using health-related mobile apps to reach out to “difficult to reach” populations, including young working men, to improve their health, particularly in health screening. However, few studies have been done on how to implement a health screening mobile app from the perspective of men. The aim of this study was to explore men's preferred strategies on how a mobile app can be disseminated to them. It was part of a bigger study to develop, evaluate and implement a mobile app to increase the uptake of screening in men. Methods: We conducted in-depth interviews and focus group discussions with 31 men from a banking institution in Kuala Lumpur, the capital city of Malaysia in 2015. The participants were purposively sampled according to their job position, age, ethnicity and screening status. We stopped the recruitment once data saturation was achieved. The audio-recorded interviews were transcribed verbatim and thematic approach was used for analysis. Findings: Men proposed a range of dissemination strategies that they preferred including: mass media (television and radio), printed media (banners and men’s magazines), online platforms (website, social media and emails), health events and recommendations from doctors and friends. The most often cited dissemination strategies were online platforms and mass media. Facebook was highlighted by participants because most participants have a Facebook account thus enabling the mobile app to reach them through the platform. WhatsApp was also mentioned as it enabled users to easily send ‘links’ of the mobile app to other users, thus facilitating the dissemination of the app. Television and radio was also cited as a facilitator to the dissemination of the mobile app as most men had access to these media. Implications for D&I Research: This study highlighted that, for men, social media platforms and mass media were important strategies to disseminate the mobile app because these two platforms were very much part of everyday life of men in this region. These two strategies should be considered when disseminating health screening mobile app to men

What will make patients use a patient decision aid? a qualitative study on patients' perspectives on implementation barriers and facilitators

Rationale, aims, and objectives: Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting. Methods: This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1 year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach. Results: Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it). Conclusions: Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation

Factors influencing implementation of a patient decision aid in a developing country: an exploratory study

Background: Most studies on barriers and facilitators to implementation of patient decision aids (PDAs) are conducted in the west; hence, the findings may not be transferable to developing countries. This study aims to use a locally developed insulin PDA as an exemplar to explore the barriers and facilitators to implementing PDAs in Malaysia, an upper middle-income country in Asia. Methods: Qualitative methodology was adopted. Nine in-depth interviews (IDIs) and three focus group discussions (FGDs) were conducted with policymakers (n = 6), medical officers (n = 13), diabetes educators (n = 5) and a nurse, who were involved in insulin initiation management at an academic primary care clinic. The interviews were conducted with the aid of a semi-structured interview guide based on the Theoretical Domains Framework. The interviews were audio-recorded, transcribed verbatim and analyzed using a thematic approach. Results: Five themes emerged, and they were lack of shared decision-making (SDM) culture, role boundary, lack of continuity of care, impact on consultation time and reminder network. Healthcare providers’ (HCPs) paternalistic attitude, patients’ passivity and patient trust in physicians rendered SDM challenging which affected the implementation of the PDA. Clear role boundaries between the doctors and nurses made collaborative implementation of the PDA challenging, as nurses may not view the use of insulin PDA to be part of their job scope. The lack of continuity of care might cause difficulties for doctors to follow up on insulin PDA use with their patient. While time was the most commonly cited barrier for PDA implementation, use of the PDA might reduce consultation time. A reminder network was suggested to address the issue of forgetfulness as well as to trigger interest in using the PDA. The suggested reminders were peer reminders (i.e. HCPs reminding one another to use the PDA) and system reminders (e.g. incorporating electronic medical record prompts, displaying posters/notices, making the insulin PDA available and visible in the consultation rooms). Conclusions: When implementing PDAs, it is crucial to consider the healthcare culture and system, particularly in developing countries such as Malaysia where concepts of SDM and PDAs are still novel

Relationships between cancer pattern, country income and geographical region in Asia.

BACKGROUND: Cancer incidence and mortality varies across region, sex and country\u27s economic status. While most studies focused on global trends, this study aimed to describe and analyse cancer incidence and mortality in Asia, focusing on cancer site, sex, region and income status. METHODS: Age-standardised incidence and mortality rates of cancer were extracted from the GLOBOCAN 2012 database. Cancer mortality to incidence ratios (MIRs) were calculated to represent cancer survival. The data were analysed based on the four regions in Asia and income. RESULTS: Cancer incidence rate is lower in Asia compared to the West but for MIR, it is the reverse. In Asia, the most common cancers in men are lung, stomach, liver, colorectal and oesophageal cancers while the most common cancers in women are breast, lung, cervical, colorectal and stomach cancers. The MIRs are the highest in lung, liver and stomach cancers and the lowest in colorectal, breast and prostate cancers. Eastern and Western Asia have a higher incidence of cancer compared to South-Eastern and South-Central Asia but this pattern is the reverse for MIR. Cancer incidence rate increases with country income particularly in colorectal and breast cancers but the pattern is the opposite for MIR. CONCLUSION: This study confirms that there is a wide variation in cancer incidence and mortality across Asia. This study is the first step towards documenting and explaining the changing cancer pattern in Asia in comparison to the rest of the world

Implementation strategies for web-based applications for screening: a scoping review

1. Chor Yau Ooi, Chirk Jenn Ng, Anne E. Sales, & Lim, H. M

Health literacy research in Malaysia: a systematic review

Introduction: Health literacy has emerged as an important determinant of health and a key component of self-care and patient centered medicine. In Malaysia, the recent National Health Morbidity Survey found that the adult l health literacy level was worryingly low. Local research in health literacy is urgently needed. The aim of this systematic review is to identify and synthesize research publications on health literacy carried out in Malaysia. Methods: The search was conducted up to February 2017 using the MEDLINE, Scopus and Malaysian Medical Repository databases. The free text search terms used were “health literacy” (all fields) and Malaysia (all fields). Inclusion criteria were that the study population was Malaysian and the study reported on health literacy. There was no restriction on study designs in order to maximize the scope of the review. Two reviewers independently selected the articles based on the titles and abstracts, followed by full-text screening. Study quality was not assessed. The following data were extracted from the full-text articles independently by two reviewers: year of publication, name of authors, geographical location, research focus, and key findings. Any disagreement was resolved by consensus. Results: In total, 10 articles were eligible for inclusion in the review with the earliest article published in 1985. Six were on general health literacy, two on medication literacy and two on mental health. Most were quantitative studies (n=9) with only one qualitative study eligible for inclusion. The number of studies increased over time with most studies being published in 2016 (n=3). Validated health literacy tools, such as the Newest Vital Signs (NVS) and HLS-EU-Q47 were used in studies published after 2015. Three studies used NVS to measure health literacy levels and the prevalence of limited health literacy levels ranged from 79.4 to 94.2%. HLS-EU-Q47 was used in two studies: a validation study of its’ Malay version and as an outcome measure in a study protocol. The majority of the studies (n=7) were conducted in central urban regions namely Kuala Lumpur, Selangor and Negeri Sembilan. The qualitative study explored the mental illness literacy among caregivers and found care givers have some understanding on mental illness and consider doctors as the primary source of health information. Conclusions: Even though the first paper was published nearly 32 years ago, much work remains to be done for health literacy research in Malaysia. The use of locally validated tools for the assessment of health literacy is recommended for future research

Implementation strategies for web-based applications for screening : a scoping review

Introduction: Screening is an effective primary prevention strategy in healthcare. However, uptake of screening remains low. Many strategies have been developed and found to be effective in increasing uptake of screening including using web-based applications (web-apps). However, not much is known about effective implementation of web-apps for screening in the real-world setting. Objectives: This scoping review aimed to identify (1) implementation strategies to implement web-apps for screening; (2) implementation frameworks used for implementing web-apps for screening; (3) outcome measures of implementation strategies and (4) implementation strategies that were effective. Method: This scoping review was conducted based on Arksey O’Malley’s framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, CINAHL, PsycINFO, ISRCTN registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform and Web of Science. This was followed by charting of the data using a standardized form. Finally, a researcher collated, summarised, and reported the results quantitatively and qualitatively based on the review objectives. Results: 16476 studies were retrieved where 5669 were duplicates. From a total of 10807 studies, 10784 studies were excluded based on screening of title and abstract. Twenty-three full-text articles were reviewed and 4 articles were included in the final analysis. Many studies were excluded because they did not focus on implementation of web-apps. Facilitation was the most cited implementation strategy used followed by reminders, clinical champions, educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings and clinical champions. Discussion/ Conclusion: There is a dearth of literature on implementation of web-apps for screening and therefore there is a need to conduct more research in development and evaluation of implementation of web-apps screening interventions

Innovation in patient decision support

Patient decision aids (PDAs) help to support patients in making an informed and value-based decision. Despite advancement in decision support technologies over the past 30 years, most PDAs are still inaccessible and few address individual needs. Health innovation may provide a solution to bridge these gaps. Information and computer technology provide a platform to incorporate individual profiles and needs into PDAs, making the decision support more personalised. Health innovation may enhance accessibility by using mobile, tablet and Internet technologies; make risk communication more interactive; and identify patient values more effectively. In addition, using databases to capture patient data and the usage of PDAs can help: developers to improve PDAs’ design; clinicians to facilitate the decision-making process more effectively; and policy makers to make shared decision making more feasible and cost-effective. Health innovation may hold the key to advancing PDAs by creating a more personalised and effective decision support tool for patients making healthcare decisions

How do health care professionals assess patients when initiating insulin therapy? A qualitative study

Aims: To explore how health care professionals (HCPs) assess patients when initiating insulin therapy in type 2 diabetes. Methods: Focus group discussions and in-depth interviews were conducted with 41 health care professionals in Malaysia in 2010–2011. A semi-structured topic guide was used for the interview. The interviews were transcribed verbatim and analysed using the Nvivo9 software based on a thematic approach. Results: HCPs were less likely to initiate insulin therapy in patients who were older, with irregular dietary patterns and poor financial status. They also assessed patients’ knowledge, views and misconceptions of insulin. However, there was a variation in how doctors assessed patients’ comorbidities before starting insulin therapy. Medical officers were more likely to initiate insulin therapy in patients with comorbidities and complications, whereas family medicine specialists were more cautious. In addition, most HCPs considered patients’ psychosocial status, including self-care ability, social support and quality of life. Conclusions: HCPs’ assessment of patients’ need to start insulin therapy depends on their perception rather than objective evaluation of patients’ background, knowledge, perception and abilities. The background and the type of practice of HCPs influence their assessment