Issues and Challenges in Implementing Care Coordinator in Primary Healthcare in Malaysia: A Qualitative Study.

BACKGROUND: Primary healthcare is the earliest gateway for patient care, and improvisations are often needed to accommodate the ever-increasing demand in public health. The Enhanced Primary Healthcare (EnPHC) initiative is aimed at improving such needs, and one core intervention is the introduction of a care coordinator (CC). The purpose of this study was to identify barriers and facilitators in implementing a new intervention in primary healthcare clinics. METHODS: This qualitative exploration study. All healthcare providers who were involved in EnPHC at the intervention clinics were selected as participants. In-depth interviews and focus group discussions were carried out among healthcare providers working in the intervention clinic. Thematic analysis was used to categorize data, based on the consolidated framework for implementation research (CFIR) theoretical framework domains. RESULTS: A total of 61 healthcare providers participated. All 5 domains with 19 CFIR constructs emerged from the analysis. Inner setting played a significant role in facilitating CC intervention, in which culture, networking, and collaboration and leadership engagement played an essential role in supporting CC activities. Although CC tasks are complex, concerns of losing clinical skill and resource constraints were identified as potential barriers in CC implementations. Criteria for appointing new CCs emerged from the characteristics of individual constructs, in which the individual must be familiar and interested in community health, have good communication skills, and at least 3 years' experience in the primary healthcare setting. CONCLUSION: The implementation of the CC intervention faces varying challenges in different settings. This is partially resolved through teamwork, guidance from mentors, and support from superiors. The complexity of the responsibility of the CC intervention is perceived as both a validation and a burden. Above all, it is seen as paramount in EnPHC intervention.

Assessing receptiveness to change among primary healthcare providers by adopting the consolidated framework for implementation research (CFIR).

BACKGROUND: Amid the current burden of non-communicable (NCD) diseases in Malaysia, there is a growing demand for more efficient service delivery of primary healthcare. A complex intervention is proposed to improve NCD management in Malaysia. This exploratory study aimed to assess primary healthcare providers' receptiveness towards change prior to implementation of the proposed complex intervention. METHOD: This study was conducted using an exploratory qualitative approach on purposely selected healthcare providers at primary healthcare clinics. Twenty focus group discussions and three in-depth interviews were conducted using a semi-structured interview guide. Consent was obtained prior to interviews and for audio-recordings. Interviews were transcribed verbatim and thematically analysed, guided by the Consolidated Framework for Implementation Research (CFIR), a framework comprised of five major domains promoting implementation theory development and verification across multiple contexts. RESULTS: The study revealed via CFIR that most primary healthcare providers were receptive towards any proposed changes or intervention for the betterment of NCD care management. However, many challenges were outlined across four CFIR domains-intervention characteristics, outer setting, inner setting, and individual characteristics-that included perceived barriers to implementation. Perception of issues that triggered proposed changes reflected the current situation, including existing facilitating aspects that can support the implementation of any future intervention. The importance of strengthening the primary healthcare delivery system was also expressed. CONCLUSION: Understanding existing situations faced at the primary healthcare setting is imperative prior to implementation of any intervention. Healthcare providers' receptiveness to change was explored, and using CFIR framework, challenges or perceived barriers among healthcare providers were identified. CFIR was able to outline the clinics' setting, individual behaviour and external agency factors that have direct impact to the organisation. These are important indicators in ensuring feasibility, effectiveness and sustainability of any intervention, as well as future scalability considerations.

Maternal Cognitive Impairment Associated with Gestational Diabetes Mellitus-A Review of Potential Contributing Mechanisms.

Gestational diabetes mellitus (GDM) carries many risks, where high blood pressure, preeclampsia and future type II diabetes are widely acknowledged, but less focus has been placed on its effect on cognitive function. Although the multifactorial pathogenesis of maternal cognitive impairment is not completely understood, it shares several features with type 2 diabetes mellitus (T2DM). In this review, we discuss some key pathophysiologies of GDM that may lead to cognitive impairment, specifically hyperglycemia, insulin resistance, oxidative stress, and neuroinflammation. We explain how these incidents: (i) impair the insulin-signaling pathway and/or (ii) lead to cognitive impairment through hyperphosphorylation of τ protein, overexpression of amyloid-ß and/or activation of microglia. The aforementioned pathologies impair the insulin-signaling pathway primarily through serine phosphorylation of insulin receptor substances (IRS). This then leads to the inactivation of the phosphatidylinositol 3-kinase/Protein kinase B (PI3K/AKT) signaling cascade, which is responsible for maintaining brain homeostasis and normal cognitive functioning. PI3K/AKT is crucial in maintaining normal cognitive function through the inactivation of glycogen synthase kinase 3ß (GSκ3ß), which hyperphosphorylates τ protein and releases pro-inflammatory cytokines that are neurotoxic. Several biomarkers were also highlighted as potential biomarkers of GDM-related cognitive impairment such as AGEs, serine-phosphorylated IRS-1 and inflammatory markers such as tumor necrosis factor α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), leptin, interleukin 1ß (IL-1ß), and IL-6. Although GDM is a transient disease, its complications may be long-term, and hence increased mechanistic knowledge of the molecular changes contributing to cognitive impairment may provide important clues for interventional strategies.

Animal Model of Gestational Diabetes Mellitus with Pathophysiological Resemblance to the Human Condition Induced by Multiple Factors (Nutritional, Pharmacological, and Stress) in Rats.

This study attempts to develop an experimental gestational diabetes mellitus (GDM) animal model in female Sprague-Dawley rats. Rats were fed with high fat sucrose diet, impregnated, and induced with Streptozotocin and Nicotinamide on gestational day 0 (D0). Sleeping patterns of the rats were also manipulated to induce stress, a lifestyle factor that contributes to GDM. Rats were tested for glycemic parameters (glucose, C-peptide, and insulin), lipid profiles (total cholesterol, triglycerides, HDL, and LDL), genes affecting insulin signaling (IRS-2, AKT-1, and PCK-1), glucose transporters (GLUT-2 and GLUT-4), proinflammatory cytokines (IL-6, TNF-α), and antioxidants (SOD, CAT, and GPX) on D6 and D21. GDM rats showed possible insulin resistance as evidenced by high expression of proinflammatory cytokines, PCK-1 and CRP. Furthermore, low levels of IRS-2 and AKT-1 genes and downregulation of GLUT-4 from the initial to final phases indicate possible defect of insulin signaling. GDM rats also showed an impairment of antioxidant status and a hyperlipidemic state. Additionally, GDM rats exhibited significantly higher body weight and blood glucose and lower plasma insulin level and C-peptide than control. Based on the findings outlined, the current GDM animal model closely replicates the disease state in human and can serve as a reference for future investigations.