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Asthma exacerbations are among the commonest reasons for hospitalizations in Malaysian pilgrims during the Hajj. We interviewed 21 stakeholders involved in the pre-Hajj health examination at 14 primary care clinics, to explore their perceptions on barriers to and facilitators of asthma care for Hajj pilgrims. The disadvantages of the short time frame and centralized organization of the pre-Hajj health examinations were viewed as compromising clinicians' level of competencies in asthma care, which could potentially be enhanced through more training, audit, and supervision by specialists. Longer time frame to permit sufficient disease control, provision of care by a dedicated asthma team, asthma registry to support continuous care, more resources of long-acting β-agonist/inhaled corticosteroid, and provision of influenza and pneumococcal vaccines at no cost were the perceived facilitators. Delivery of asthma education, especially the asthma action plan, should be tailored to the level of the pilgrim's health literacy and facilitated by educational resources, family engagement, and regular health briefing.

Background: Primary healthcare workers (PHCWs) are at the frontline of dealing with viral pandemics. They may experience significant psychological stresses, which have hitherto not been examined in depth. We aimed to explore the impact of the COVID-19 pandemic on the psychological health and wellbeing of frontline PHCWs in Malaysia., Method: We purposively recruited PHCWs with diverse backgrounds in Klang Valley, Malaysia. Using longitudinal qualitative methods, we conducted two sequential semi-structured telephone interviews, 3 to 4 weeks apart, to capture different stages of the pandemic. Interviews were audio-recorded, transcribed verbatim, and analysed thematically., Result: Twenty-one PHCWs participated yielding a total of forty-two interviews. Themes clustered around stressors associated with work, home, and leisure activities, emotional changes, and modifying factors. In the first interviews, COVID-19 had just started in Malaysia. Participants expressed fear about the actual and perceived personal risk of COVID-19 infection. Most were worried about transmitting COVID-19 to their family members. Some felt stigmatized because of this perceived risk of infection. By the second interviews, participants felt safer, but instead focused on the need to keep other people safe. Participants' emotions were influenced by their perceived risk of contracting COVID-19 infection. Internal factors such as religion enabled them to manage their concerns and develop personal coping strategies. Support from family members, colleagues, and employers promoted wellbeing during the pandemic. Training sessions, daily roll calls, and psychological support services were important in maintaining their psychological health and wellbeing. Many participants were hopeful and believed normalcy would return by the end of 2020., Conclusion: PHCW's psychological health and wellbeing evolved throughout the early stages of the pandemic and were influenced by their perceived risk of contracting the disease and personal belief structures. Clear updates on the disease and strategies for keeping safe at work and socially are essential to maintaining PHCWs' psychological health and wellbeing., (© 2022. The Author(s).)

Supported self-management reduces asthma-related morbidity and mortality. This paper is on a feasibility study, and observing the change in clinical and cost outcomes of pictorial action plan use is part of assessing feasibility as it will help us decide on outcome measures for a fully powered RCT. We conducted a pre-post feasibility study among adults with physician-diagnosed asthma on inhaled corticosteroids at a public primary-care clinic in Malaysia. We adapted an existing pictorial asthma action plan. The primary outcome was asthma control, assessed at 1, 3 and 6 months. Secondary outcomes included reliever use, controller medication adherence, asthma exacerbations, emergency visits, hospitalisations, days lost from work/daily activities and action plan use. We estimated potential cost savings on asthma-related care following plan use. About 84% (n = 59/70) completed the 6-months follow-up. The proportion achieving good asthma control increased from 18 (30.4%) at baseline to 38 (64.4%) at 6-month follow-up. The proportion of at least one acute exacerbation (3 months: % difference -19.7; 95% CI -34.7 to -3.1; 6 months: % difference -20.3; 95% CI -5.8 to -3.2), one or more emergency visit (1 month: % difference -28.6; 95% CI -41.2 to -15.5; 3 months: % difference -18.0; 95% CI -32.2 to -3.0; 6 months: % difference -20.3; 95% CI -34.9 to -4.6), and one or more asthma admission (1 month: % difference -14.3; 95% CI -25.2 to -5.3; 6 months: % difference -11.9; 95% CI -23.2 to -1.8) improved over time. Estimated savings for the 59 patients at 6-months follow-up and for each patient over the 6 months were RM 15,866.22 (USD3755.36) and RM268.92 (USD63.65), respectively. Supported self-management with a pictorial asthma action plan was associated with an improvement in asthma control and potential cost savings in Malaysian primary-care patients.Trial registration number: ISRCTN87128530; prospectively registered: September 5, 2019, http://www.isrctn.com/ISRCTN87128530 ., (© 2022. The Author(s).)

The main objective of this study was to develop and validate the Awareness and Knowledge of Diabetes Distress (AKODD) questionnaire, so that it can be used to assess the knowledge attitude and practice of doctors who treat patients with diabetes distress. This validation study was conducted at the University Malaya Medical Centre, Kuala Lumpur, Malaysia from June to July 2019. Doctors from the Departments of Primary Care Medicine, Medicine, Psychological Medicine, Emergency Medicine and Staff Health Unit, who could understand English were recruited, as they treat patients with diabetes or diabetes distress. The AKODD was developed based on literature review. Next, an expert panel met to review findings from literature and to develop the items for AKODD. The AKODD has 3 sections: socio-demographic information, awareness and knowledge. It was then piloted among 7 doctors from the Departments of Primary Care Medicine, Medicine, Psychological Medicine and Emergency Medicine. No problems were encountered. Hence, no changes were made, and the AKODD was administered twice: at 0 and 2 weeks as part of the validation process. Discriminative validity was assessed by comparing scores of doctors who had/had not attended a diabetes course before. A total of 103/119 doctors agreed to participate (response rate = 86.6%). Flesch Reading Ease was 51.1. Thirty-three doctors (32.0%) have heard of diabetes distress before. Doctors had a good level of knowledge regarding diabetes distress with a median score of 77.8% (IQR:66.7-88.9). The AKODD had adequate discriminative validity between participants who had (83.3%)/had not attended a diabetes course before (72.2%; p<0.049). The AKODD had good internal consistency (Kuder-Richardson = 0.931) and adequate reliability as 9/18 items were not statistically significant at test-retest. The AKODD was found to be a valid and reliable questionnaire to assess the awareness and knowledge of diabetes distress among doctors in Malaysia as it had adequate psychometric properties., Competing Interests: The authors have declared that no competing interests exist.

Background: Asthma was one of the top causes of hospitalization and unscheduled medical attendances due to acute exacerbations and its complications. In Malaysia, all pilgrims must undergo a mandatory health examination and certified fit to perform pilgrimage. We studied the current organisational and clinical routines of Hajj health examination in Malaysia with a focus on the delivery of care for pilgrims with asthma., Methods: We conducted non-participant observation to obtain ethnographic understanding of Hajj health examination activities for 2019. Observations were guided by a checklist and recorded as notes that were analysed thematically. The study was conducted at 11 public (from each region in Malaysia, namely, North, South, East, West of Peninsular Malaysia, and Sabah and Sarawak of East Malaysia) and two private primary care clinics., Results: We observed considerable variation in the implementation and practice of Hajj health examinations among the 11 public clinics but no marked variation among the private clinics. The short time span of between three to four months was inadequate for disease control measures and had put pressure on health care providers. They mostly viewed the Hajj health examination as merely a certification of fitness to perform the pilgrimage, though respiratory health assessment was often inadequate. The opportunity to optimise the health of pilgrims with asthma by providing the appropriate medications, asthma action plan and asthma education including the preventive measures was disregarded. The preliminary health screening, which aimed to optimise pilgrims' health before the actual Hajj health examination was not appreciated by either pilgrims or health care providers., Conclusions: There is great potential to reform the current system of Hajj health certification in order to optimise its potential benefits for pilgrims with asthma. A systematic approach to restructuring the delivery of Hajj health examination could address the time constraints, clinical competency of primary health care providers and resources limitations., Competing Interests: Competing interests: This study is written on behalf of the RESPIRE collaborators. E.M.K. reports grant from the National Institute for Health Research Global Health Research Unit on Respiratory Health (RESPIRE) and Seqirus UK; personal fees from AstraZeneca and GlaxoSmithKline; and is board director of the International Primary Care Respiratory Group. The other authors have completed the ICJME Declaration of Interest Form (available upon request from the corresponding author) and declare no further conflicts of interest., (Copyright © 2022 by the Journal of Global Health. All rights reserved.)

Background: Supported self-management improves asthma outcomes, but implementation requires adaptation to the local context. Barriers reported in Western cultures may not resonate in other cultural contexts. We explored the views, experiences and beliefs that influenced self-management among adults with asthma in multicultural Malaysia., Methods: Adults with asthma were purposively recruited from an urban primary healthcare clinic for in-depth interviews. Audio-recordings were transcribed verbatim and analysed thematically., Results: We interviewed 24 adults. Four themes emerged: (1) Participants believed in the 'hot and cold' concept of illness either as an inherent hot/cold body constitution or the ambient temperature. Hence, participants tried to 'neutralize' body constitution or to 'warm up' the cold temperature that was believed to trigger acute attacks. (2) Participants managed asthma based on past experiences and personal health beliefs as they lacked formal information about asthma and its treatment. (3) Poor communication and variable advice from healthcare practitioners on how to manage their asthma contributed to poor self-management skills. (4) Embarrassment about using inhalers in public and advice from family and friends resulted in a focus on nonpharmacological approaches to asthma self-management practice., Conclusions: Asthma self-management practices were learnt experientially and were strongly influenced by sociocultural beliefs and advice from family and friends. Effective self-management needs to be tailored to cultural norms, personalized to the individuals' preferences and clinical needs, adapted to their level of health literacy and underpinned by patient-practitioner partnerships., Patient and Public Contributions: Patients contributed to data. Members of the public were involved in the discussion of the results., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Implementing asthma guideline recommendations is challenging in low- and middle-income countries. We aimed to explore healthcare provider (HCP) perspectives on the provision of recommended care. Twenty-six HCPs from six public primary care clinics in a semi-urban district of Malaysia were purposively sampled based on roles and experience. Focus group discussions were guided by a semi-structured interview guide and analysed thematically. HCPs had access to guidelines and training but highlighted multiple infrastructure-related challenges to implementing recommended care. Diagnosis and review of asthma control were hampered by limited access to spirometry and limited asthma control test (ACT) use, respectively. Treatment decisions were limited by poor availability of inhaled combination therapy (ICS/LABA) and free spacer devices. Imposed Ministry of Health programmes involving other non-communicable diseases were prioritised over asthma. Ministerial policies need practical resources and organisational support if quality improvement programmes are to facilitate better management of asthma in public primary care clinics., (© 2021. The Author(s).)

Background: Our previous scoping review revealed limitations and inconsistencies in population surveys of chronic respiratory disease. Informed by this review, we piloted a cross-sectional survey of adults in four South/South-East Asian low-and middle-income countries (LMICs) to assess survey feasibility and identify variables that predicted asthma or chronic obstructive pulmonary disease (COPD)., Methods: We administered relevant translations of the BOLD-1 questionnaire with additional questions from ECRHS-II, performed spirometry and arranged specialist clinical review for a sub-group to confirm the diagnosis. Using random sampling, we piloted a community-based survey at five sites in four LMICs and noted any practical barriers to conducting the survey. Three clinicians independently used information from questionnaires, spirometry and specialist reviews, and reached consensus on a clinical diagnosis. We used lasso regression to identify variables that predicted the clinical diagnoses and attempted to develop an algorithm for detecting asthma and COPD., Results: Of 508 participants, 55.9% reported one or more chronic respiratory symptoms. The prevalence of asthma was 16.3%; COPD 4.5%; and 'other chronic respiratory disease' 3.0%. Based on consensus categorisation (n = 483 complete records), "Wheezing in last 12 months" and "Waking up with a feeling of tightness" were the strongest predictors for asthma. For COPD, age and spirometry results were the strongest predictors. Practical challenges included logistics (participant recruitment; researcher safety); misinterpretation of questions due to local dialects; and assuring quality spirometry in the field., Conclusion: Detecting asthma in population surveys relies on symptoms and history. In contrast, spirometry and age were the best predictors of COPD. Logistical, language and spirometry-related challenges need to be addressed., Competing Interests: Competing interests: EMK reports grants from the National Institute for Health Research Global Health Research Unit on Respiratory Health (RESPIRE) and Seqirus UK; personal fees from AstraZeneca and GlaxoSmithKline; and is board director of the International Primary Care Respiratory Group. All authors have completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author), and declare no further conflicts of interest., (Copyright © 2021 by the Journal of Global Health. All rights reserved.)

Background: Chronic respiratory diseases (CRDs) contribute significantly towards the global burden of disease, but the true prevalence and burden of these conditions in adults is unknown in the majority of low- and middle-income countries (LMICs). We aimed to identify strategies - in particular the definitions, study designs, sampling frames, instruments, and outcomes - used to conduct prevalence surveys for CRDs in LMICs. The findings will inform a future RESPIRE Four Country ChrOnic Respiratory Disease (4CCORD) study, which will estimate CRD prevalence, including disease burden, in adults in LMICs., Methods: We conducted a scoping review to map prevalence surveys conducted in LMICs published between 1995 and 2018. We followed Arksey and O'Malley's six-step framework. The search was conducted in OVID Medline, EMBASE, ISI Web of Science, Global Health, WHO Global Index Medicus and included three domains: CRDs, prevalence and LMICs. After an initial title sift, eight trained reviewers undertook duplicate study selection and data extraction. We charted: country and populations, random sampling strategies, CRD definitions/phenotypes, survey procedure (questionnaires, spirometry, tests), outcomes and assessment of individual, societal and health service burden of disease., Results: Of 36 872 citations, 281 articles were included: 132 from Asia (41 from China). Study designs were cross-sectional surveys (n = 260), cohort studies (n = 11) and secondary data analysis (n = 10). The number of respondents in these studies ranged from 50 to 512 891. Asthma was studied in 144 studies, chronic obstructive pulmonary disease (COPD) in 112. Most studies (100/144) based identification of asthma on symptom-based questionnaires. In contrast, COPD diagnosis was typically based on spirometry findings (94/112); 65 used fixed-ratio thresholds, 29 reported fixed-ratio and lower-limit-of-normal values. Only five articles used the term 'phenotype'. Most studies used questionnaires derived from validated surveys, most commonly the European Community Respiratory Health Survey (n = 47). The burden/impact of CRD was reported in 33 articles (most commonly activity limitation)., Conclusion: Surveys remain the most practical approach for estimating prevalence of CRD but there is a need to identify the most predictive questions for diagnosing asthma and to standardise diagnostic criteria., Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest., (Copyright © 2021 by the Journal of Global Health. All rights reserved.)

Background: Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions., Methods: Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literature. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis., Results: Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and steadfast despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs., Conclusions: Women may choose unassisted home birth to express their personal views and values, at the expense of the health risks. Apart from increasing mothers' awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers' beliefs and values.

It is common for primary care providers (PCPs) to manage complex multimorbidity. When caring for patients with multimorbidity, PCPs face challenges to tackle several issues within a short consultation in order to address patients' complex needs. Furthermore, some PCPs may lack access to a multidisciplinary team and need to manage multimorbidity within the confine of a PCP-patient partnership only. Instead of attempting to address multiple health issues within a single consultation, it would be more feasible and time effective for PCPs and patients to jointly prioritize the health issue to focus on. Using the Malaysian primary care setting as a case study, a dual-layer-shared decision-making approach is proposed whereby PCPs and patients make decisions on which disease(s) (layer 1) and treatment(s) (layer 2) to prioritize. This dual-layer model aims to address the challenges of short consultation time and limited healthcare resources by encouraging PCPs and patients to discuss, negotiate, and agree on the decision during the consultation to ensure patients' health needs are addressed., (© 2019 John Wiley & Sons, Ltd.)

This study aimed to evaluate the usability (ease of use) and utility (impact on user's decision-making process) of a web-based patient decision aid (PDA) among older-age users. A pragmatic, qualitative research design was used. We recruited patients with type 2 diabetes who were at the point of making a decision about starting insulin from a tertiary teaching hospital in Malaysia in 2014. Computer screen recording software was used to record the website browsing session and in-depth interviews were conducted while playing back the website recording. The interviews were analyzed using the framework approach to identify usability and utility issues. Three cycles of iteration were conducted until no more major issues emerged. Thirteen patients participated: median age 65 years old, 10 men, and nine had secondary education/diploma, four were graduates/had postgraduate degree. Four usability issues were identified (navigation between pages and sections, a layout with open display, simple language, and equipment preferences). For utility, participants commented that the website influenced their decision about insulin in three ways: it had provided information about insulin, it helped them deliberate choices using the option-attribute matrix, and it allowed them to involve others in their decision making by sharing the PDA summary printout.