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1.  Health innovations in patient decision support: Bridging the gaps and challenges 
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 decisionmaking 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.
PMCID: PMC3593527  PMID: 23483776
Patient decision aids; shared decision making; health innovation
2.  Why do some people with type 2 diabetes who are using insulin have poor glycaemic control? A qualitative study 
BMJ Open  2015;5(1):e006407.
To explore factors influencing poor glycaemic control in people with type 2 diabetes using insulin.
Research design
A qualitative method comprising in-depth individual interviews. A semistructured interview guide was used. The interviews were audiorecorded, transcribed verbatim and analysed using a thematic approach.
Seventeen people with type 2 diabetes using insulin with glycated haemoglobin (HbA1c) ≥9% for >1 year.
The Primary Care Clinic and Diabetes Clinic in the University of Malaya Medical Centre (UMMC), Malaysia.
Data analysis uncovered four themes: lifestyle challenges in adhering to medical recommendations; psychosocial and emotional hurdles; treatment-related factors; lack of knowledge about and self-efficacy in diabetes self-care.
Factors that explain the poor glycaemic control in people with type 2 diabetes using insulin were identified. Healthcare providers could use these findings to address patients’ concerns during consultations and help to improve glycaemic control.
PMCID: PMC4316456  PMID: 25633285
3.  Developing a primary care research agenda through collaborative efforts – a proposed “6E” model 
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.
The setting was a 2-day primary care research workshop in Fiji. The steering committee invited a team of three external facilitators from the Asia-Pacific region to organize and operationalize the workshop. The eventual participants were 3 external facilitators, 6 local facilitators, and 29 local primary care physicians, academics, and local medical leaders from Fiji and South Pacific Islands. Pre-workshop and main workshop programs were drawn up by the external facilitators, using participants’ input of research topics relating to their local clinical issues of interest. Course notes were prepared and distributed before the workshop. In the workshop, proposed research topics were shortlisted by group discussion and consensus. Study designs were proposed, scrutinized, and adopted for further research development.
The facilitators reviewed the processes in setting the research agenda after the workshop and conceived the proposed 6E model. These processes can be grouped for easy reference, comprising the pre-workshop stages of “entreat”, “enlist”, “engage”, and the workshop stages of “educe”, “empower”, and “encapsulate”.
The 6E model to establish a research agenda is conceptually logical. Its feasibility can be further tested in its application in other situation where research agenda setting is the critical step to improve the quality of primary care.
PMCID: PMC4300150  PMID: 25606021
Primary care; Research agenda; Collaboration; Workshop; process; Model
4.  Men's Health Index: A Pragmatic Approach to Stratifying and Optimizing Men's Health 
Korean Journal of Urology  2014;55(11):710-717.
The proposed Men's Health Index (MHI) aims to provide a practical and systematic framework for comprehensively assessing and stratifying older men with the intention of optimising their health and functional status.
Materials and Methods
A literature search was conducted using PubMed from 1980 to 2012. We specifically looked for instruments which: assess men's health, frailty and fitness; predict life expectancy, mortality and morbidities. The instruments were assessed by the researchers who then agreed on the tools to be included in the MHI. When there was disagreements, the researchers discussed and reached a consensus guided by the principle that the MHI could be used in the primary care setting targetting men aged 55-65 years.
The instruments chosen include the Charlson's Combined Comorbidity-Age Index; the International Index of Erectile Function-5; the International Prostate Symptom Score; the Androgen Deficiency in Aging Male; the Survey of Health, Ageing and Retirement in Europe Frailty Instrument; the Sitting-Rising Test; the Senior Fitness Test; the Fitness Assessment Score; and the Depression Anxiety Stress Scale-21. A pilot test on eight men was carried out and showed that the men's health index is viable.
The concept of assessing, stratifying, and optimizing men's health should be incorporated into routine health care, and this can be implemented by using the MHI. This index is particularly useful to primary care physicians who are in a strategic position to engage men at the peri-retirement age in a conversation about their life goals based on their current and predicted health status.
PMCID: PMC4231147  PMID: 25405012
Health status indicators; Men; Physical fitness; Retirement
5.  A ‘combined framework’ approach to developing a patient decision aid: the PANDAs model 
There is a lack of practical research frameworks to guide the development of patient decision aids [PtDAs]. This paper described how a PtDA was developed using the International Patient Decision Aids (IPDAS) guideline and UK Medical Research Council (UKMRC) frameworks to support patients when making treatment decisions in type 2 diabetes mellitus.
This study used mixed methods to develop a PtDA for use in a UK general practice setting. A 10-member expert panel was convened to guide development and patients and clinicians were also interviewed individually using semi-structured interview guides to identify their decisional needs. Current literature was reviewed systematically to determine the best available evidence. The Ottawa Decision Support Framework was used to guide the presentation of the information and value clarification exercise. An iterative draft-review-revise process by the research team and review panel was conducted until the PtDA reached content and format ‘saturation’. The PtDA was then pilot-tested by users in actual consultations to assess its acceptability and feasibility. The IPDAS and UKMRC frameworks were used throughout to inform the development process.
The PANDAs PtDA was developed systematically and iteratively. Patients and clinicians highlighted the needs for information, decisional, emotional and social support, which were incorporated into the PtDA. The literature review identified gaps in high quality evidence and variations in patient outcome reporting. The PtDA comprised five components: background of the treatment options; pros and cons of each treatment option; value clarification exercise; support needs; and readiness to decide.
This study has demonstrated the feasibility of combining the IPDAS and the UKMRC frameworks for the development and evaluation of a PtDA. Future studies should test this model for developing PtDAs across different decisions and healthcare contexts.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0503-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4210601  PMID: 25341370
Patient decision aids; Decision making; Diabetes mellitus; Insulin; Complex intervention
6.  Development and pilot testing of a National Men’s Health Index 
BMC Health Services Research  2014;14(Suppl 2):P126.
PMCID: PMC4122908
8.  Investigating active ingredients in a complex intervention: a nested study within the Patient and Decision Aids (PANDAs) randomised controlled trial for people with type 2 diabetes 
BMC Research Notes  2014;7:347.
Randomised trials provide evidence that patient decision aids improve outcomes with respect to patient knowledge, involvement and satisfaction in decision making. It is less clear how these complex interventions are implemented within patient-clinician interactions and which components are active for improving decision processes. To investigate the experiences of using a diabetes treatment decision aid and to explore how components within a complex intervention influenced the decision making process.
A pragmatic mixed methods study nested within the PANDAs cluster randomised trial of a patient decision aid. Themes inductively derived from interviews and observation of consultations with further triangulation with results of decision quality and involvement measurements and case analyses.
The decision aid intervention was employed flexibly within the consultation with both the patient and clinician active in marshalling elements. The decision aid improved processing and organization of information needed for decision making within the consultation interaction. It also improved decision quality by preparing the patient for active involvement within the clinical consultation.
The intervention was acceptable, flexible and readily implemented in primary care consultations. The decision aid was effective in facilitating cognitive processing. The intervention also facilitated rehearsal in preparation for active roles in a shared decision process.
Trial registration
Trials Register Number: ISRCTN14842077. Date registered: 24.06.2010.
PMCID: PMC4062287  PMID: 24908099
Patient decision aid; Process evaluation; Type 2 diabetes; Primary care
9.  Statins use is associated with poorer glycaemic control in a cohort of hypertensive patients with diabetes and without diabetes 
The US Federal and Drug Administration (FDA) recently revised statin drug labels to include the information that increases in fasting serum glucose and glycated haemoglobin levels have been reported with the use of statins. Yet in a survey, 87% of the doctors stated that they had never or infrequently observed increases in glucose or HbA1c levels in patients on statin. In this study we would like to determine the association between the use of statins and glycaemic control in a retrospective cohort of patients with hypertension.
A retrospective review of 1060 medical records of patients with hypertension at a primary care clinic was conducted. These records were selected using systematic random sampling (1:4). Data on patient socio-demographic factors; clinical profile; investigation results and prescribed medications were collected. Independent t-test was used for continuous variables while Pearson’s χ2 test was used for categorical variables. Logistic regression was done to adjust for confounders.
810 (76.4%) patients with hypertension were on statins, out of which 792 (97.8%) were taking simvastatin 10 mg or 20 mg daily. Analysis of the whole group regardless of diabetes status showed that the statin user group had higher HbA1c and fasting blood glucose values. The difference in HbA1c levels remained significant (adjusted OR = 1.290, p = 0.044, 95% CI 1.006, 1.654) after adjustment for diabetes, diabetic medication and fasting blood glucose. In the study population who had diabetes, statin users again had significantly higher HbA1c level compared to statin non-users. This difference remained significant (adjusted OR 1.208, p = 0.037, 95% CI 1.012, 1.441) after adjustment for age and diabetic medications.
Statins use is associated with increased HbA1c levels among hypertensive patients and hypertensive patients with diabetes. Clinicians managing hypertensive patients on statins should consider monitoring the HbA1c level and ensure that those with diabetes have their hyperglycaemia kept under control.
PMCID: PMC4003286  PMID: 24782916
Hypertension; Diabetes mellitus; Statin; HbA1c
10.  Barriers and facilitators to self-monitoring of blood glucose in people with type 2 diabetes using insulin: a qualitative study 
Self-monitoring of blood glucose (SMBG) helps to improve glycemic control and empowerment of people with diabetes. It is particularly useful for people with diabetes who are using insulin as it facilitates insulin titration and detection of hypoglycemia. Despite this, the uptake of SMBG remains low in many countries, including Malaysia.
This study aimed to explore the barriers and facilitators to SMBG, in people with type 2 diabetes using insulin.
Patients and methods
Qualitative methodology was employed to explore participants’ experience with SMBG. Semistructured, individual in-depth interviews were conducted on people with type 2 diabetes using insulin who had practiced SMBG, in the primary care clinic of a teaching hospital in Malaysia. Participants were purposively sampled from different age groups, ethnicity, education level, and level of glycemic control (as reflected by the glycated hemoglobin [HbA1c]), to achieve maximum variation in sampling. All interviews were conducted using a topic guide and were audio-recorded, transcribed verbatim, checked, and analyzed using a thematic approach.
A total of 15 participants were interviewed, and thematic saturation was reached. The factors that influenced SMBG were mainly related to cost, participants’ emotion, and the SMBG process. The barriers identified included: frustration related to high blood glucose reading; perception that SMBG was only for insulin titration; stigma; fear of needles and pain; cost of test strips and needles; inconvenience; unconducive workplace; and lack of motivation, knowledge, and self-efficacy. The facilitators were: experiencing hypoglycemic symptoms; desire to see the effects of dietary changes; desire to please the physician; and family motivation.
Participants’ perceptions of the purpose of SMBG, the emotions associated with SMBG, and the complexity, pain, and cost related to SMBG as well as personal and family motivation are the key factors that health care providers must consider when advising people with diabetes on SMBG.
PMCID: PMC3931581  PMID: 24627628
blood glucose self-monitoring; diabetes mellitus; in-depth interviews; qualitative study
11.  A systematic development process for patient decision aids 
The original version of the International Patient Decision Aid Standards (IPDAS) recommended that patient decision aids (PtDAs) should be carefully developed, user-tested and open to scrutiny, with a well-documented and systematically applied development process. We carried out a review to check the relevance and scope of this quality dimension and, if necessary, to update it.
Our review drew on three sources: a) published papers describing PtDAs evaluated in randomised controlled trials and included in the most recent Cochrane Collaboration review; b) linked papers cited in the trial reports that described how the PtDAs had been developed; and c) papers and web reports outlining the development process used by organisations experienced in developing multiple PtDAs. We then developed an extended model of the development process indicating the various steps on which documentation is required, as well as a checklist to assess the frequency with which each of the elements was publicly reported.
Key features common to all patient decision aid (PtDA) development processes include: scoping and design; development of a prototype; ‘alpha’ testing with patients and clinicians in an iterative process; ‘beta’ testing in ‘real life’ conditions (field tests); and production of a final version for use and/or further evaluation. Only about half of the published reports on the development of PtDAs that we reviewed appear to have been field tested with patients, and even fewer had been reviewed or tested by clinicians not involved in the development process. Very few described a distribution strategy, and surprisingly few (17%) described a method for reviewing and synthesizing the clinical evidence. We describe a model development process that includes all the original elements of the original IPDAS criterion, expanded to include consideration of format and distribution plans as well as prototype development.
The case for including each of the elements outlined in our model development process is pragmatic rather than evidence-based. Optimal methods for ensuring that each stage of the process is carried out effectively require further development and testing.
PMCID: PMC4044159  PMID: 24625093
12.  Establishing the effectiveness of patient decision aids: key constructs and measurement instruments 
Establishing the effectiveness of patient decision aids (PtDA) requires evidence that PtDAs improve the quality of the decision-making process and the quality of the choice made, or decision quality. The aim of this paper is to review the theoretical and empirical evidence for PtDA effectiveness and discuss emerging practical and research issues in the measurement of effectiveness.
This updated overview incorporates: a) an examination of the instruments used to measure five key decision-making process constructs (i.e., recognize decision, feel informed about options and outcomes, feel clear about goals and preferences, discuss goals and preferences with health care provider, and be involved in decisions) and decision quality constructs (i.e., knowledge, realistic expectations, values-choice agreement) within the 86 trials in the Cochrane review; and b) a summary of the 2011 Cochrane Collaboration’s review of PtDAs for these key constructs. Data on the constructs and instruments used were extracted independently by two authors from the 86 trials and any disagreements were resolved by discussion, with adjudication by a third party where required.
The 86 studies provide considerable evidence that PtDAs improve the decision-making process and decision quality. A majority of the studies (76/86; 88%) measured at least one of the key decision-making process or decision quality constructs. Seventeen different measurement instruments were used to measure decision-making process constructs, but no single instrument covered all five constructs. The Decisional Conflict Scale was most commonly used (n = 47), followed by the Control Preference Scale (n = 9). Many studies reported one or more constructs of decision quality, including knowledge (n = 59), realistic expectation of risks and benefits (n = 21), and values-choice agreement (n = 13). There was considerable variability in how values-choice agreement was defined and determined. No study reported on all key decision-making process and decision quality constructs.
Evidence of PtDA effectiveness in improving the quality of the decision-making process and decision quality is strong and growing. There is not, however, consensus or standardization of measurement for either the decision-making process or decision quality. Additional work is needed to develop and evaluate measurement instruments and further explore theoretical issues to advance future research on PtDA effectiveness.
PMCID: PMC4044563  PMID: 24625035
13.  Exploring Patient Values in Medical Decision Making: A Qualitative Study 
PLoS ONE  2013;8(11):e80051.
Patient decisions are influenced by their personal values. However, there is a lack of clarity and attention on the concept of patient values in the clinical context despite clear emphasis on patient values in evidence-based medicine and shared decision making. The aim of the study was to explore the concept of patient values in the context of making decisions about insulin initiation among people with type 2 diabetes.
Methods and Findings
We conducted individual in-depth interviews with people with type 2 diabetes who were making decisions about insulin treatment. Participants were selected purposively to achieve maximum variation. A semi-structured topic guide was used to guide the interviews which were audio-recorded and analysed using a thematic approach. We interviewed 21 participants between January 2011 and March 2012. The age range of participants was 28–67 years old. Our sample comprised 9 women and 12 men. Three main themes, ‘treatment-specific values’, ‘life goals and philosophies’, and ‘personal and social background’, emerged from the analysis. The patients reported a variety of insulin-specific values, which were negative and/or positive beliefs about insulin. They framed insulin according to their priorities and philosophies in life. Patients’ decisions were influenced by sociocultural (e.g. religious background) and personal backgrounds (e.g. family situations).
This study highlighted the need for expanding the current concept of patient values in medical decision making. Clinicians should address more than just values related to treatment options. Patient values should include patients’ priorities, life philosophy and their background. Current decision support tools, such as patient decision aids, should consider these new dimensions when clarifying patient values.
PMCID: PMC3839918  PMID: 24282518
14.  An overview of patient involvement in healthcare decision-making: a situational analysis of the Malaysian context 
Involving patients in decision-making is an important part of patient-centred care. Research has found a discrepancy between patients’ desire to be involved and their actual involvement in healthcare decision-making. In Asia, there is a dearth of research in decision-making. Using Malaysia as an exemplar, this study aims to review the current research evidence, practices, policies, and laws with respect to patient engagement in shared decision-making (SDM) in Asia.
In this study, we conducted a comprehensive literature review to collect information on healthcare decision-making in Malaysia. We also consulted medical education researchers, key opinion leaders, governmental organisations, and patient support groups to assess the extent to which patient involvement was incorporated into the medical curriculum, healthcare policies, and legislation.
There are very few studies on patient involvement in decision-making in Malaysia. Existing studies showed that doctors were aware of informed consent, but few practised SDM. There was limited teaching of SDM in undergraduate and postgraduate curricula and a lack of accurate and accessible health information for patients. In addition, peer support groups and 'expert patient’ programmes were also lacking. Professional medical bodies endorsed patient involvement in decision-making, but there was no definitive implementation plan.
In summary, there appears to be little training or research on SDM in Malaysia. More research needs to be done in this area, including baseline information on the preferred and actual decision-making roles. The authors have provided a set of recommendations on how SDM can be effectively implemented in Malaysia.
PMCID: PMC3852442  PMID: 24119237
16.  What are the barriers faced by patients using insulin? A qualitative study of Malaysian health care professionals’ views 
Patients with type 2 diabetes often require insulin as the disease progresses. However, health care professionals frequently encounter challenges when managing patients who require insulin therapy. Understanding how health care professionals perceive the barriers faced by patients on insulin will facilitate care and treatment strategies.
This study explores the views of Malaysian health care professionals on the barriers faced by patients using insulin.
Semi-structured qualitative interviews and focus group discussions were conducted with health care professionals involved in diabetes care using insulin. Forty-one health care professionals participated in the study, consisting of primary care doctors (n = 20), family medicine specialists (n = 10), government policymakers (n = 5), diabetes educators (n = 3), endocrinologists (n = 2), and one pharmacist. We used a topic guide to facilitate the interviews, which were audio-recorded, transcribed verbatim, and analyzed using a thematic approach.
Five themes were identified as barriers: side effects, patient education, negative perceptions, blood glucose monitoring, and patient adherence to treatment and follow-up. Patients perceive that insulin therapy causes numerous negative side effects. There is a lack of patient education on proper glucose monitoring and how to optimize insulin therapy. Cost of treatment and patient ignorance are highlighted when discussing patient self-monitoring of blood glucose. Finally, health care professionals identified a lack of a follow-up system, especially for patients who do not keep to regular appointments.
This study identifies five substantial barriers to optimizing insulin therapy. Health care professionals who successfully identify and address these issues will empower patients to achieve effective self-management. System barriers require government agency in establishing insulin follow-up programs, multidisciplinary diabetes care teams, and subsidies for glucometers and test strips.
PMCID: PMC3559078  PMID: 23378747
primary care; focus groups; noncommunicable disease; diabetes; insulin; qualitative study
17.  Clinical effectiveness of a patient decision aid to improve decision quality and glycaemic control in people with diabetes making treatment choices: a cluster randomised controlled trial (PANDAs) in general practice 
BMJ Open  2012;2(6):e001469.
To determine the effectiveness of a patient decision aid (PDA) to improve decision quality and glycaemic control in people with diabetes making treatment choices using a cluster randomised controlled trial (RCT).
A cluster RCT.
49 general practices in UK randomised into intervention (n=25) and control (n=24).
General practices Inclusion criteria: >4 medical partners; list size >7000; and a diabetes register with >1% of practice population. 191 practices assessed for eligibility, and 49 practices randomised and completed the study. Patients People with type 2 diabetes mellitus (T2DM) taking at least two oral glucose-lowering drugs with maximum tolerated dose with a glycosolated haemoglobin (HbA1c) greater than 7.4% (IFCC HbA1c >57 mmol/mol) or advised in the preceeding 6 months to add or consider changing to insulin therapy. Exclusion criteria: currently using insulin therapy; difficulty reading or understanding English; difficulty in understanding the purpose of the study; visual or cognitive impairment or mentally ill. A total of 182 assessed for eligibility, 175 randomised to 95 intervention and 80 controls, and 167 completion and analysis.
Brief training of clinicians and use of PDA with patients in single consultation.
Primary outcomes
Decision quality (Decisional Conflict Scores, knowledge, realistic expectations and autonomy) and glycaemic control (glycosolated haemoglobin, HbA1c).
Secondary outcomes
Knowledge and realistic expectations of the risks and benefits of insulin therapy and diabetic complications.
Intervention group: lower total Decisional Conflict Scores (17.4 vs 25.2, p<0.001); better knowledge (51.6% vs 28.8%, p<0.001); realistic expectations (risk of ‘hypo’, ‘weight gain’, ‘complications’; 81.0% vs 5.2%, 70.5% vs 5.3%, 26.3% vs 5.0% respectively, p<0.001); and were more autonomous in decision-making (64.1% vs 42.9%, p=0.012). No significant difference in the glycaemic control between the two groups.
Use of the PANDAs decision aid reduces decisional conflict, improves knowledge, promotes realistic expectations and autonomy in people with diabetes making treatment choices in general practice.
ISRCTN Trials Register Number
PMCID: PMC3532975  PMID: 23129571
Primary Care
18.  Knowledge, attitudes and practices among people with chronic hepatitis B attending a hepatology clinic in Malaysia: A cross sectional study 
BMC Public Health  2012;12:601.
Hepatitis B (HBV) is the leading cause of cirrhosis and hepatocellular carcinoma worldwide. This study assessed the knowledge, attitudes and practices of people with chronic HBV and the associated factors.
This cross-sectional study was conducted at an outpatient adult hepatology clinic at a tertiary hospital in Kuala Lumpur. A self-administered questionnaire was administered on a one-to-one basis to assess knowledge, attitudes, and lifestyle practices of people with chronic HBV.
The response rate was 89% (n = 483/543). Participants had a mean age of 46.3 (±14.7) years and the mean duration of HBV from time of diagnosis was 12.2 (±8.8) years. The mean knowledge score was 12.57/20 (standard deviation: ±4.4, range: 0–19). Participants aged 30–39 years, with higher educational attainment, employed in professional jobs, longer duration of diagnosis and those without cirrhosis had significantly higher knowledge scores. Age, education level and duration of diagnosis were significant predictors of the knowledge score on standard multiple regression analysis. More than half of the participants were worried of spreading HBV infection to family and friends and worried since the diagnosis. A third of the participants (33.5%) were embarrassed to reveal their diagnosis to the public but most of them (93.6%) would inform their family. Those who reported feeling worried since their diagnosis were more likely to be middle-aged, of Malay ethnicity, have shorter duration of diagnosis of less than 10 years and have received therapy. About half of the participants (50.6%) did not share dining utensils and the majority (93.2%) believed that HBV can be transmitted by sharing of eating and drinking utensils. Older patients were significantly less likely to share utensils. Those who felt worried since diagnosis had significant higher knowledge of HBV.
The findings highlight the stigma and misconceptions that still exist among the HBV patients. More patient and public education about HBV and its prevention are essential to increase awareness and to demystify the disease.
PMCID: PMC3528623  PMID: 22856889
Hepatitis B; Knowledge; Attitude; Practice
19.  A qualitative study on healthcare professionals’ perceived barriers to insulin initiation in a multi-ethnic population 
BMC Family Practice  2012;13:28.
Nationwide surveys have shown that the prevalence of diabetes rates in Malaysia have almost doubled in the past ten years; yet diabetes control remains poor and insulin therapy is underutilized. This study aimed to explore healthcare professionals’ views on barriers to starting insulin therapy in people with type 2 diabetes.
Healthcare professionals consisting of general practitioners (n = 11), family medicine specialists (n = 10), medical officers (n = 8), government policy makers (n = 4), diabetes educators (n = 3) and endocrinologists (n = 2) were interviewed. A semi-structured topic guide was used to guide the interviews by trained facilitators. The interviews were transcribed verbatim and analysed using a thematic analysis approach.
Insulin initiation was found to be affected by patient, healthcare professional and system factors. Patients’ barriers include culture-specific barriers such as the religious purity of insulin, preferred use of complementary medication and perceived lethality of insulin therapy. Healthcare professionals’ barriers include negative attitudes towards insulin therapy and the ‘legacy effect’ of old insulin guidelines; whilst system barriers highlight the lack of resources, language and communication challenges.
Tackling the issue of insulin initiation should not only happen during clinical consultations. It requires health education to emphasise the progressive nature of diabetes and the eventuality of insulin therapy at early stage of the illness. Healthcare professionals should be trained how to initiate insulin and communicate effectively with patients from various cultural and religious backgrounds.
PMCID: PMC3389339  PMID: 22469132
20.  Effect of long-acting testosterone undecanoate treatment on quality of life in men with testosterone deficiency syndrome: a double blind randomized controlled trial 
Asian Journal of Andrology  2012;14(4):604-611.
This study aimed to investigate the effect of intramuscular injection of testosterone undecanoate on overall quality of life (QoL) in men with testosterone deficiency syndrome (TDS). A randomized controlled trial over a 12-month period was carried out in 2009. One hundred and twenty men aged 40 years and above with a diagnosis of TDS (serum total testosterone <12 nmol l−1 and total Aging Male Symptom (AMS) scores ≥27) were invited to participate. Interventions comprised intramuscular injection of either placebo or 1000 mg testosterone undecanoate, given at weeks 0, 6, 18, 30 and 42. This paper presents the secondary analysis of QoL changes measured in the scores of Short-Form-12 (SF-12) scale at baseline, weeks 30 and 48 after the first injection. A total of 56/60 and 58/60 men from the active treatment and placebo group, respectively, completed the study. At week 48, before adjusting for baseline differences, the QoL of men in the treatment group improved significantly in five out of the eight domains on SF-12. The physical health composite scores improved 4.0 points from a baseline of 41.9±7.0 in the treatment group compared to 0.8 point from a baseline of 43.7±7.1 in the placebo group (F=3.652, P=0.027). The mental health composite scores improved 4.4 points from a baseline of 37.1±9.0 in the treatment group compared to 1.0 points from a baseline of 37.6±7.9 in the placebo group (F=4.514, P=0.018). After adjusting for baseline differences, significant improvement was observed in mental health composite scores, but not in physical health composite scores. Long-acting testosterone undecanoate significantly improved the mental health component of QoL in men with TDS.
PMCID: PMC3720089  PMID: 22635164
hypogonadism; randomized controlled trial; quality of life; testosterone deficiency syndrome (TDS); testosterone therapy
21.  How can insulin initiation delivery in a dual-sector health system be optimised? A qualitative study on healthcare professionals’ views 
BMC Public Health  2012;12:313.
The prevalence of type 2 diabetes is increasing at an alarming rate in developing countries. However, glycaemia control remains suboptimal and insulin use is low. One important barrier is the lack of an efficient and effective insulin initiation delivery approach. This study aimed to document the strategies used and proposed by healthcare professionals to improve insulin initiation in the Malaysian dual-sector (public–private) health system.
In depth interviews and focus group discussions were conducted in Klang Valley and Seremban, Malaysia in 2010–11. Healthcare professionals consisting of general practitioners (n = 11), medical officers (n = 8), diabetes educators (n = 3), government policy makers (n = 4), family medicine specialists (n = 10) and endocrinologists (n = 2) were interviewed. We used a topic guide to facilitate the interviews, which were audio recorded, transcribed verbatim and analysed using a thematic approach.
Three main themes emerged from the interviews. Firstly, there was a lack of collaboration between the private and public sectors in diabetes care. The general practitioners in the private sector proposed an integrated system for them to refer patients to the public health services for insulin initiation programmes. There could be shared care between the two sectors and this would reduce the disproportionately heavy workload at the public sector. Secondly, besides the support from the government health authority, the healthcare professionals wanted greater involvement of non-government organisations, media and pharmaceutical industry in facilitating insulin initiation in both the public and private sectors. The support included: training of healthcare professionals; developing and disseminating patient education materials; service provision by diabetes education teams; organising programmes for patients’ peer group sessions; increasing awareness and demystifying insulin via public campaigns; and subsidising glucose monitoring equipment. Finally, the healthcare professionals proposed the establishment of multidisciplinary teams as a strategy to increase the rate of insulin initiation. Having team members from different ethnic backgrounds would help to overcome language and cultural differences when communicating with patients.
The challenges faced by a dual-sector health system in delivering insulin initiation may be addressed by greater collaborations between the private and public sectors and governmental and non-government organisations, and among different healthcare professionals.
PMCID: PMC3533841  PMID: 22545648
Insulin initiation; Dual-sector health system; Malaysia; Diabetes; Public sector; Private sector
22.  Profile of men's health in Malaysia: problems and challenges 
Asian Journal of Andrology  2011;13(4):526-533.
Men's health concerns have evolved from the traditional andrology and male sexual health to a more holistic approach that encompasses male psychological, social and physical health. The poor state of health in men compared to their female counterparts is well documented. A review of the epidemiological data from Malaysia noted a similar trend in which men die at higher rates in under 1 and above 15 years old groups and most disease categories compared to women. In Malaysia, the main causes of death in men are non-communicable diseases and injuries. Risk factors, such as risk-taking behaviour, smoking and hypertension, are prevalent and amenable to early interventions. Erectile dysfunction, premature ejaculation and prostate disorders are also prevalent. However, many of these morbidities go unreported and are not diagnosed early; therefore, opportunities for early intervention are missed. This reflects poor health knowledge and inadequate health-care utilisation among Malaysian men. Their health-seeking behaviour has been shown to be strongly influenced by family members and friends. However, more research is needed to identify men's unmet health-care needs and to develop optimal strategies for addressing them. Because the Malaysian population is aging and there is an increase in sedentary lifestyles, optimizing men's health will remain a challenge unless effective measures are implemented. The existing male-unfriendly health-care system and the negative influence of masculinity on men's health behaviour must be addressed. A national men's health policy based on a male-friendly approach to health-care delivery is urgently needed to provide a framework for addressing these challenges.
PMCID: PMC3739619  PMID: 21358664
aging male; cause of death; epidemiology; health promotion; Malaysia; men's health; non-communicable diseases; risk factors
23.  Text messaging reminders to reduce non-attendance in chronic disease follow-up: a clinical trial 
Non-attendance results in administrative problems and disruption in patient care. Several interventions have been used to reduce non-attendance, with varying degree of success. A relatively new intervention, text messaging, has been shown to be as effective as telephone reminders in reducing non-attendance. However, no study has looked specifically at using text messaging reminders to reduce non-attendance in chronic disease care.
To determine if text messaging would be effective in reducing non-attendance in patients on long-term follow-up, compared with telephone reminders and no reminder.
Design of study
A randomised controlled trial with three arms: text messaging reminder, telephone reminder, and control.
Two primary care clinics in Malaysia.
A total of 931 subjects who had been on at least 6 months of follow-up were randomised into the three groups. Demographic variables were recorded at the first visit. In the intervention arms, a reminder was sent 24–48 hours prior to the appointment. Non-attendance rate was documented at the second visit. Non-attenders were defined as those who did not attend, attended early, or attended late without rescheduling their appointment. Attenders were defined as participants who had turned up for their scheduled appointment and those who had changed or cancelled their appointment with notification.
The non-attendance rates in the text messaging group (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.41 to 0.93, P = 0.020) and the telephone reminder group (OR = 0.53, 95% CI = 0.35 to 0.81), P = 0.003) were significantly lower than the control group. The absolute non-attendance rate for telephone reminders was lower by 2% compared to the text messaging group. This difference was not found to be statistically significant (P = 0.505).
Text messaging was found to be as effective as telephone reminder in reducing non-attendance in patients who required long-term follow-up for their chronic illnesses in this study. It could be used as an alternative to conventional reminder systems.
PMCID: PMC2784529  PMID: 19712544
non attendance; primary health care; randomised

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