Collective Action for Wellness in the Malaysian Workplace: Protocol for a Feasibility Study.

BACKGROUND: Chronic diseases and the associated risk factors are preventable with lifestyle changes such as eating a healthier diet and being more physically active. In Malaysia, the prevalence of chronic diseases, including diabetes, hypertension, and heart diseases, has risen. In the present study, we explore the potential of co-designing and implementing a digital wellness intervention to promote socially-driven health knowledge and practices in the workplace in Malaysia, drawing on social cognitive theory, social impact theory, and social influence theory. OBJECTIVE: This study aims to co-design and assess the feasibility of a socially-driven digital health intervention to promote healthy behavior and prevent chronic diseases in a workplace in Malaysia. METHODS: This study involves two phases: (i) identifying the barriers and facilitators to healthy behaviors at work and co-designing the intervention activities with the employees, (ii) implementing and evaluating the intervention's feasibility. Phase 1 will involve qualitative data collection and analysis through semi-structured, in-depth interviews and co-design workshops with the employees, while Phase 2 will consist of a feasibility study employing quantitative measurements of health behaviors through accelerometers and questionnaires. RESULTS: This study was funded in June 2021 and ethics approval for Phase 1 was obtained from the Monash University Human Research Ethics Committee in January 2022. As of August 2022, qualitative interviews with 12 employees have been completed and the data has been transcribed and analyzed. These results will be published in a future paper with results from all Phase 1 activities. CONCLUSIONS: The study will help us to better understand the mechanisms through which digital technologies can promote socially-driven health knowledge and behaviors. This research will also result in a scalable wellness intervention that could be further tailored and expanded to other employers and social groups across the region. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/39238.

Assessing predictors of self-management intentions in people with type 2 diabetes.

BACKGROUND: Type 2 diabetes mellitus (T2D) is slowly turning into an international health emergency, evidenced by accelerated growth in prevalence rates worldwide. Experts have now called for greater integration of self-management interventions in clinical practice in light of these worrisome trends, supplanting the prevailing notion of a "glucocentric" approach. In this pilot study designed to complement a novel assessment program currently in development, we describe a concise screening tool designed to stratify the intention to follow through on self-management practices in people with T2D. METHODS: A cross-sectional survey was conducted at 3 regional primary care clinics. Individuals with T2D having the following characteristics were recruited into the study: (i) individuals with T2D between 18 and 65 years, (ii) fluent in English and, and iii) having been diagnosed with T2D for at least 2 years. We assessed the relevance of components in the Theory of Planned Behaviour (TPB) within the context of self-management behaviour in T2D. Participants were requested to complete a questionnaire containing questions related to intention, attitudes subjective norm and perceived behavioural control. Based on their responses, the psychometric properties of the scale were then evaluated using both reliability and validity analysis. RESULTS: The Cronbach α value for all direct measures of TPB was excellent: intention to adhere to self-management practices (0.98), attitude towards self-management behaviour (0.87), subjective norm (0.83), and perceived behaviour control (0.66). The correlation between intentions and all 3 constructs of TPB was excellent (p < 0.01). Structural equation modeling helped determine attitudes and subjective norms as important predictors of intentions to follow through self-management practices. CONCLUSIONS: By first understanding the dimensions that influence intentions associated with self-management behaviour, clinicians have the opportunity to "triage" individuals with T2D who require greater involvement to bring about better self-care practices. Thus, our research attempts to bridge this gap by devising a psychometric tool suited to a regional setting which allows for an improved person-centered communication between clinicians and patients.

The internal realities of individuals with type 2 diabetes-Psychological disposition in self-management behaviour via grounded theory approach.

BACKGROUND: A paradigm shift in the disease management of type 2 diabetes is urgently needed to stem the escalating trends seen worldwide. A "glucocentric" approach to diabetes management is no longer considered a viable option. Qualitative strategies have the potential to unearth the internal psychological attributes seen in people living with diabetes that are crucial to the sustenance of self-management behaviour. This study aims to identify and categorize the innate psychological dispositions seen in people with type 2 diabetes in relation to self-management behaviour. METHODS: We adopted a grounded theory approach to guide in-depth interviews of individuals with type 2 diabetes and healthcare professionals (HCP) at a regional primary care clinic in Malaysia. Twenty-four people with type 2 diabetes and 10 HCPs were recruited into the study to examine the inner narratives about disease management. Two focus group discussions (FGD) were also conducted for data triangulation. RESULTS: Participants' internal dialogue about the management of their disease is characterized by 2 major processes- 1) positive disposition and 2) negative disposition. Optimism, insight, and awareness are important positive values that influence T2D self-care practices. On the other hand, constructs such as stigma, worries, reservations, and pessimism connote negative dispositions that undermine the motivation to follow through disease management in individuals with type 2 diabetes. CONCLUSIONS: We identified a contrasting spectrum of both constructive and undesirable behavioural factors that influence the 'internal environment' of people with type 2 diabetes. These results coincide with the constructs presented in other well-established health belief theories that could lead to novel behavioural change interventions. Furthermore, these findings allow the implementation of psychosocial changes that are in line with cultural sensitivities and societal norms seen in a specific community.

The external realities of people with type 2 diabetes-Understanding disease perspective and self-management behaviour via Grounded Theory Approach.

BACKGROUND: Qualitative strategies can uncover the relationship between the external realities of people living with type 2 diabetes (T2D) and the barriers that are associated with disease self-management. Information from in-depth interviews (IDI) and focus group discussions (FGD) can be used to devise psychological models that could potentially facilitate behaviour changes in people with T2D. We aim to identify salient factors that govern the external realities of people with T2D in relation to disease management. METHODS: A qualitative study was conducted at a regional primary care clinic in Malaysia using a Grounded Theory Approach. People with T2D were recruited through purposeful sampling to determine their living experiences with the disease. A total of 34 IDIs with 24 people with T2D and 10 health care professionals, followed by two FGDs with people with T2D, were conducted. RESULTS: Three major processes that arbitrate self-management practices include- 1) external reality, 2) internal reality, 3) mediators of behaviour. Within the context of external reality, three important sub-themes were identified-intrinsic background status, personal experience, and worldview. Lifestyle habits of persons with T2D play a central role in their disease management. Another common recurring concern is the issue of a low-quality food environment in the country. More importantly, individuals with T2D have a high degree of expectations for a more person-centered approach to their illness. CONCLUSIONS: We identified modifiable and non-modifiable behavioural factors that influence the daily living environment of people with T2D. This information can be used to customize the management of T2D through targeted behavioural interventions.

An Evaluation of the Video Narrative Technique on the Self-Efficacy of Medication Understanding and Use Among Post-Stroke Patients: A Randomized-Controlled Trial.

INTRODUCTION: Self-efficacy is positively associated with medication understanding and use self-efficacy (MUSE) among post-stroke patients. It is also closely related to knowledge, belief, and perception, which vary among people from different socioeconomic backgrounds and cultures. As interventions using video and peer stories have emerged to be successful on behavior modification, this study aimed to explore the effectiveness of video narratives incorporated with Health Belief constructs on MUSE and its associated factors among patients with stroke at a local setting. METHODS: A randomized controlled trial (RCT) for 12 months was carried out on patients diagnosed with stroke at Hospital Kuala Lumpur, Malaysia. The RCT recruited up to 216 eligible patients who were requested to return for two more follow-ups within six months. Consented patients were randomized to either standard care or intervention with video narratives. The control of potential confounding factors was ensured, as well as unbiased treatment review with prescribed medications, only obtained onsite. RESULTS AND DISCUSSION: A repeated measure of MUSE mean score differences at T0 (baseline), T2 (6th month) and T4 (12th month) for antithrombotic, antihypertensive, and all medication categories indicated significant within and between groups differences in the intervention group (p<0.05). Moreover, this impact was reflected upon continuous blood pressure (BP) monitoring compared to the control group (F (1214) =5.23, p=0.023, ƞ2=0.024). Though BP measure differences were non-significant between the groups (p=0.552), repeated measure analysis displayed significant mean differences between intervention and control group on BP control over time (F (1.344, 287.55) =8.54, P<0.001, ƞ2=0.038). Similarly, the intervention's positive impact was also present with similar trends for knowledge, illness perception, and the belief about medicine. Though significant differences (p<0.05) of all outcome measures gradually decreased between T2 and T4 in the intervention group; nevertheless, these positive findings confirmed that personalized video narratives were able to motivate and influence MUSE and its associated factors among post-stroke patients. The significant improvement in medication-taking self-efficacy and the sustenance of BP monitoring habits among patients in the intervention group strengthened our conceptual framework's practicality.

Video Narratives Intervention Among Stroke Survivors: Feasibility and Acceptability Study of a Randomized Controlled Trial.

BACKGROUND: A large number of stroke survivors worldwide suffer from moderate to severe disability. In Malaysia, long-term uncontrolled stroke risk factors lead to unforeseen rates of recurrent stroke and a growing incidence of stroke occurrence across ages, predominantly among the elderly population. This situation has motivated research efforts focused on tapping into patient education, especially related to patient self-efficacy of understanding and taking medication appropriately. Video narratives integrated with health belief model constructs have demonstrated potential impacts as an aide to patient education efforts. OBJECTIVE: The aim of this study was to investigate the feasibility and acceptability of study procedures based on a randomized controlled trial protocol of a video narratives intervention among poststroke patients. We also aimed to obtain preliminary findings of video narratives related to medication understanding and use self-efficacy (MUSE) and blood pressure control. METHODS: A parallel group randomized controlled trial including a control group (without video viewing) and an intervention group (with video viewing) was conducted by researchers at a neurology outpatient clinic on poststroke patients (N=54). Baseline data included patients' sociodemographic characteristics, medical information, and all outcome measures. Measurements of MUSE and blood pressure following the trial were taken during a 3-month follow-up period. Feasibility of the trial was assessed based on recruitment and study completion rates along with patients' feedback on the burden of the study procedures and outcome measures. Acceptability of the trial was analyzed qualitatively. Statistical analysis was applied to ascertain the preliminary results of video narratives. RESULTS: The recruitment rate was 60 out of 117 patients (51.3%). Nevertheless, the dropout rate of 10% was within the acceptable range. Patients were aged between 21 and 74 years. Nearly 50 of the patients (>85%) had adequate health literacy and exposure to stroke education. Most of the patients (>80%) were diagnosed with ischemic stroke, whereby the majority had primary hypertension. The technicalities of randomization and patient approach were carried out with minimal challenge and adequate patient satisfaction. The video contents received good responses with respect to comprehension and simplicity. Moreover, an in-depth phone interview with 8 patients indicated that the video narratives were considered to be useful and inspiring. These findings paralleled the preliminary findings of significant improvement within groups in MUSE (P=.001) and systolic blood pressure control (P=.04). CONCLUSIONS: The queries and feedback from each phase in this study have been acknowledged and will be taken forward in the full trial. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN 12618000174280; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373554.

The Internal Realities of Individuals With Type 2 Diabetes: Mediators Influencing Self-Management Beliefs via Grounded Theory Approach.

Background: There has been an unabated rise in the prevalence of type 2 diabetes (T2D) worldwide. Although T2D is highly preventable, these trends suggest that a paradigm change is much needed in the way both clinicians and policy makers view what effective T2D strategies conventionally entail. Hence, it is becoming increasingly clear that T2D patients require more than just a pharmacological approach to their disease. Evidence indicate that culturally specific mediators can help foster better self-management practices. We intend to discover psychosocial mediators that influence and support self-management beliefs in T2D patients. Methods: We adopted the grounded theory approach to guide in-depth interviews with T2D patients and health care professionals (HCP) at a regional primary care clinic in Malaysia. Twenty-four T2D patients and 10 HCPs were recruited through purposive sampling method to examine the inner psychological narratives about how they perceive and what they believe beliefs about the disease. Two focus group discussions were also were conducted for data triangulation. Results: A functional framework for the psychosocial mediators influencing self-management beliefs in T2D patients was designed and characterized by 4 major processes: (1) health promotion, (2) personal expectations, (3) person-centered care, and (4) psychosocial support. The fulfillment of patients' personal expectations is central to better self-management beliefs. Conclusions: Positive emotional states are important in providing a positive environment to nurture self-management practices. A person-centered consultation that focuses on empathy and cultural sensitivities has the potential to foster behavioral change required to sustain self-care practices.

Exploring stroke survivors' self-efficacy in understanding and taking medication and determining associated factors: a cross-sectional study in a neurology clinic in Malaysia.

BACKGROUND AND AIM: Evidence-based prescribing practices for stroke-preventive medication have benefited stroke survivors; however, medication-nonadherence rates remain high. Medication understanding and use self-efficacy (MUSE) has shown great importance in medication-taking behavior, but its relationship with medication nonadherence in stroke-preventive regimens lacks exploration. The aim of this study was to determine the prevalence of MUSE and its association with nonadherence causes and other potential factors among stroke survivors in Malaysia. METHODS: This cross-sectional study was conducted among 282 stroke patients who provided informed consent and were in follow-up at the Neurology Outpatient Department of Hospital Kuala Lumpur, Malaysia. The study employed a data-collection form that gathered information on sociodemographics, clinical treatment, outcome measures on MUSE, and medication-nonadherence reasons. RESULTS: The prevalence of poor medication understanding and use self-efficacy among stroke patients was 46.5%, of which 29.1% had poor "learning about medication" self-efficacy, while 36.2% lacked self-efficacy in taking medication. Beliefs about medicine (74.02%) was the commonest reason for medication nonadherence, followed by medication-management issues (44.8%). In the multivariate model, independent variables significantly associated with MUSE were health literacy (AOR 0.2, 95% CI 0.069-0.581; P=0.003), medication-management issues (AOR 0.073, 95% CI 0.020-0.266; P<0.001), multiple-medication issues (AOR 0.28, 95% CI 0.085-0.925; P=0.037), beliefs about medicine (AOR 0.131, 95% CI 0.032-0.542; P=0.005), and forgetfulness/convenience issues (AOR 0.173, 95% CI 0.050-0.600; P=0.006). CONCLUSION: The relatively poor learning about medication and medication-taking self-efficacy in this study was highly associated with health literacy and modifiable behavioral issues related to nonadherence, such as medication management, beliefs about medicine, and forgetfulness/convenience. Further research ought to explore these underlying reasons using vigorous techniques to enhance medication understanding and use self-efficacy among stroke survivors to determine cause-effect relationships.

An Intervention to Promote Medication Understanding and Use Self-Efficacy: Design of Video Narratives for Aging Patients at Risk of Recurrent Stroke.

BACKGROUND: The debilitating effects of recurrent stroke among aging patients have urged researchers to explore medication adherence among these patients. Video narratives built upon Health Belief Model (HBM) constructs have displayed potential impact on medication adherence, adding an advantage to patient education efforts. However, its effect on medication understanding and use self-efficacy have not been tested. OBJECTIVE: The researchers believed that culturally sensitive video narratives, which catered to a specific niche, would reveal a personalized impact on medication adherence. Therefore, this study aimed to develop and validate video narratives for this purpose. METHODS: This study adapted the Delphi method to develop a consensus on the video scripts' contents based on learning outcomes and HBM constructs. The panel of experts comprised 8 members representing professional stroke disease experts and experienced poststroke patients in Malaysia. The Delphi method involved 3 rounds of discussions. Once the consensus among members was achieved, the researchers drafted the initial scripts in English, which were then back translated to the Malay language. A total of 10 bilingual patients, within the study's inclusion criteria, screened the scripts for comprehension. Subsequently, a neurologist and poststroke patient narrated the scripts in both languages as they were filmed, to add to the realism of the narratives. Then, the video narratives underwent a few cycles of editing after some feedback on video engagement by the bilingual patients. Few statistical analyses were applied to confirm the validity and reliability of the video narratives. RESULTS: Initially, the researchers proposed 8 learning outcomes and 9 questions based on HBM constructs for the video scripts' content. However, following Delphi rounds 1 to 3, a few statements were omitted and rephrased. The Kendall coefficient of concordance, W, was about 0.7 (P<.001) for both learning outcomes and questions which indicated good agreement between members. Each statement's Cronbach alpha was above .8 with SD values within a range below 1.5 that confirmed satisfactory content and construct validity. Approximately 75% (6/8) of members agreed that all chosen statements were relevant and suitable for video script content development. Similarly, more than 80% (8/10) of patients scored video engagement above average, intraclass correlation coefficient was above 0.7, whereas its Kendall W was about 0.7 with significance (P<.001), which indicated average agreement that the video narratives perceived realism. CONCLUSIONS: The Delphi method was proven to be helpful in conducting discussions systematically and providing precise content for the development of video narratives, whereas the Video Engagement Scale was an appropriate measurement of video realism and emotions, which the researchers believed could positively impact medication understanding and use self-efficacy among patients with stroke. A feasibility and acceptability study in an actual stroke care center is needed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000174280; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?id=373554&isReview=true.

The effectiveness of culturally tailored video narratives on medication understanding and use self-efficacy among stroke patients: A randomized controlled trial study protocol.

INTRODUCTION: A substantial number of the world's population appears to end with moderate to severe long-term disability after stroke. Persistent uncontrolled stroke risk factor leads to unpredicted recurrent stroke event. The increasing prevalence of stroke across ages in Malaysia has led to the adaptation of medication therapy adherence clinic (MTAC) framework. The stroke care unit has limited patient education resources especially for patients with medication understanding and use self-efficacy. Nevertheless, only a handful of studies have probed into the effectiveness of video narrative at stroke care centers. METHOD: This is a behavioral randomized controlled trial of patient education intervention with video narratives for patients with stroke lacking medication understanding and use self-efficacy. The study will recruit up to 200 eligible stroke patients at the neurology tertiary outpatient clinic, whereby they will be requested to return for follow-up approximately 3 months once for up to 12 months. Consenting patients will be randomized to either standard patient education care or intervention with video narratives. The researchers will ensure control of potential confounding factors, as well as unbiased treatment review with prescribed medications only obtained onsite. RESULTS: The primary analysis outcomes will reflect the variances in medication understanding and use self-efficacy scores, as well as the associated factors, such as retention of knowledge, belief and perception changes, whereas stroke risk factor control, for example, self-monitoring and quality of life, will be the secondary outcomes. DISCUSSION AND CONCLUSION: The study should be able to determine if video narrative can induce a positive behavioral change towards stroke risk factor control via enhanced medication understanding and use self-efficacy. This intervention is innovative as it combines health belief, motivation, and role model concept to trigger self-efficacy in maintaining healthy behaviors and better disease management. TRIAL REGISTRATION: ACTRN (12618000174280).

Seroprevalence of dengue among healthy adults in a rural community in Southern Malaysia: a pilot study.

BACKGROUND: The frequency and magnitude of dengue epidemics continue to increase exponentially in Malaysia, with a shift in the age range predominance toward adults and an expansion to rural areas. Despite this, information pertaining to the extent of transmission of dengue virus (DENV) in the rural community is lacking. This community-based pilot study was conducted to establish DENV seroprevalence amongst healthy adults in a rural district in Southern Malaysia, and to identify influencing factors. METHODS: In this study undertaken between April and May 2015, a total of 277 adult participants were recruited from households across three localities in the Sungai Segamat subdistrict in Segamat district. Sera were tested for immunoglobulin G (IgG) (Panbio® Dengue Indirect IgG ELISA/high-titer capture) and immunoglobulin M (IgM) (Panbio®) antibodies. The plaque reduction neutralization test (PRNT) was conducted on random samples of IgG-positive sera for further confirmation. Medical history and a recall of previous history of dengue were collected through interviews, whereas sociodemographic information was obtained from an existing database. RESULTS: The overall seroprevalence for DENV infection was 86.6% (240/277) (95% CI: 83-91%). Serological evidence of recent infection (IgM/high-titer capture IgG) was noted in 11.2% (31/277) of participants, whereas there was evidence of past infection in 75.5% (209/277) of participants (indirect IgG minus recent infections). The PRNT assay showed that the detected antibodies were indeed specific to DENV. The multivariate analysis showed that the older age group was significantly associated with past DENV infections. Seropositivity increased with age; 48.5% in the age group of <25 years to more than 85% in age group of >45 years (P < 0.001). No associations with occupation, study site, housing type, comorbidity, educational level, and marital status were observed, although the latter two were statistically significant in the univariate analysis. None of the studied factors were significantly associated with recent DENV infections in the multivariate analysis, although there was a pattern suggestive of recent outbreak in two study sites populated predominately by Chinese people. The majority of infections did not give rise to recognizable disease (either asymptomatic or nonspecific symptoms) as only 12.9% of participants (31/240) recalled having dengue in the past. CONCLUSIONS: The predominantly rural community under study had a very high previous exposure to dengue. The finding of a high proportion of unreported cases possibly due to subclinical infections underscores the need for enhanced surveillance and control methods. This finding also has implications for measuring disease burden, understanding transmission dynamics, and hypothesizing effects on DENV vaccine efficacy and uptake.

Type 2 diabetes patients are more amenable to change following a contextualised diabetes education programme in Malaysia.

The aim of the study is to determine the impact of diabetes education on patients' glycaemic control. A prospective 18-month intervention study was conducted at four ambulatory diabetes centres. Poorly controlled type 2 diabetes patients attended an hour of structured diabetes education at their respective diabetes centres. A month post-intervention patients were contacted through telephone and followed up for 18 months. Anthropometric measurements and socio-demographic details were collected during the first visit. HbA1C blood test for each patient was taken at beginning and end of study. Patients' diabetes knowledge showed 80% obtained Excellent or Very Good score. The Telephone Contact (TC) retention rate was 75.52% at 18 months. There was a significant improvement (p=0.001) in patients' glycaemic control with a reduction in HbA1C of ≥1% from baseline. Diabetes education intervention contributed positively to significant glycaemic improvement and should be embedded within a structured diabetes care delivery system.

Controlled release of insulin in blood from strontium-substituted carbonate apatite complexes.

Diabetes mellitus is a chronic disease accompanied by a multitude of problems worldwide with subcutaneously administered insulin being the most common therapy currently. Controlledrelease insulin is assumed to be of high importance for long-term glycaemic control by reducing the number of daily injections. Long-acting insulin also mimics the basal insulin levels in normal individuals that may be lacking in diabetic patients. Nanoparticles of carbonate apatite as established for efficient intracellular transport of DNA and siRNA have the potential to be used for sustained release of insulin as responsive nano-carriers. The flexibility in the synthesis of the particles over a wide range of pHs with eventual adjustment of pH-dependent particle dissolution and the manageable variability of particle-integrity by incorporating selective ions into the apatite structure are the promising features that could help in the development of sustained release formulations for insulin. In particular strontium-incorporated carbonate apatite particles were formulated and compared with those of unsubstituted apatite in the context of insulin binding and subsequent release kinetics in DMEM, simulated buffer and finally human blood over a period of 20 hours. Clearly, the former demonstated to have a stronger electrostatic affinity towards the acidic insulin molecules and facilitate to some extent sustained release of insulin by preventing the initial burst effect at physiological pH in comparison with the latter. Thus, our findings suggest that optimization of the carbonate apatite particle composition and structure would serve to design an ideal insulin nano-carrier with a controlled release profile.

A pilot study: the development of a culturally tailored Malaysian Diabetes Education Module (MY-DEMO) based on the Health Belief Model.

BACKGROUND: Diabetes education and self-care remains the cornerstone of diabetes management. There are many structured diabetes modules available in the United Kingdom, Europe and United States of America. Contrastingly, few structured and validated diabetes modules are available in Malaysia. This pilot study aims to develop and validate diabetes education material suitable and tailored for a multicultural society like Malaysia. METHODS: The theoretical framework of this module was founded from the Health Belief Model (HBM). The participants were assessed using 6-item pre- and post-test questionnaires that measured some of the known HBM constructs namely cues to action, perceived severity and perceived benefit. Data was analysed using PASW Statistics 18.0. RESULTS: The pre- and post-test questionnaires were administered to 88 participants (31 males). In general, there was a significant increase in the total score in post-test (97.34 ± 6.13%) compared to pre-test (92.80 ± 12.83%) (p < 0.05) and a significant increase in excellent score (>85%) at post-test (84.1%) compared to pre-test (70.5%) (p < 0.05). There was an improvement in post-test score in 4 of 6 items tested. The remaining 2 items which measured the perceived severity and cues to action had poorer post-test score. CONCLUSIONS: The preliminary results from this pilot study suggest contextualised content material embedded within MY DEMO maybe suitable for integration with the existing diabetes education programmes. This was the first known validated diabetes education programme available in the Malay language.