Family planning behaviours among women with diabetes mellitus: a scoping review.

INTRODUCTION: Diabetes mellitus in pregnancies is associated with adverse outcomes both for the mothers and babies. Postponing pregnancy in unoptimized conditions and stabilisation of glucose should be prioritized. This scoping review is aimed to determine the scope and at the same time map the types of evidence available that is related to family planning behaviours among women with diabetes mellitus, with a particular focus on their factors which influence family planning usage and subsequently enable the identification of knowledge gaps in preventing unintended pregnancies among this high-risk population. METHODS: This scoping review is guided by the methodological framework by Arksey and O'Malley's and Prisma-ScR checklist. PubMed, EBSCO and OVID were searched for empirical studies between 2000 and February 2022 using the search terms "family planning", "contraceptive" and "diabetes mellitus". Data were summarized according to the study characteristics and levels of factors influencing family planning behaviours. RESULTS: Thirty-five articles that met the eligibility criteria included 33 quantitative studies, one qualitative study and one mixed-methods study. The prevalence of family planning methods used by women with diabetes mellitus varied ranging from 4.8 to 89.8% among the studied population. Women with diabetes mellitus were reported to be less likely to utilise any family planning methods compared to women without diabetes mellitus. CONCLUSIONS: Most of the evidence to date on family planning behaviours among women with diabetes mellitus focuses on the role of individual level sociodemographic factors. Few studies focused on exploring determinants at multiple levels. In this review we found that there is limited evidence on disease control and pregnancy intention in relation to their family planning practices. Future studies with more clinical and contextual factors are needed to guide the strengthening of family planning services for high-risk group women specifically for women with diabetes mellitus.

Women's autonomy in healthcare decision making: a systematic review.

OBJECTIVES: Although there are calls for women's empowerment and gender equity globally, there are still large disparities regarding women's autonomy in healthcare decision making. The autonomy of women is believed to be crucial in improving their health-related outcomes. This review discusses factors that influence autonomy among women in healthcare decision making. DESIGN: Systematic review. DATA SOURCES: PubMed, Web of Science and Scopus were searched from 2017-2022. ELIGIBILITY CRITERIA: The inclusion criteria include original articles, case studies and reports that has been written in the English Language, while manuscripts with no full article, reviews, newspaper reports, grey literatures, and articles that did not answer the review objectives were excluded. DATA EXTRACTION AND SYNTHESIS: We carried out data extraction using a standardized data extraction form, that has been organized using Microsoft Excel. A narrative synthesis was carried out to combine the findings of all included articles. RESULTS: A total of 70 records were identified and 18 were reviewed, yielding eight articles to be included in the accepted list of studies. All studies were conducted in developing countries and most of the studies were cross sectional. Factors that were associated with women's autonomy in healthcare decision making were age, women's education and occupation, husbands'/partners' education and occupation, residential location or region of residence, household wealth index as well as culture and religion. CONCLUSIONS: Identification of these factors may help stakeholders in improving women's autonomy in healthcare decision making. Policymakers play a crucial role in healthcare decision making by enacting laws and policies that protect women's rights, promoting gender-sensitive healthcare services, ensuring access to comprehensive information, promoting health education, and supporting vulnerable populations. These efforts ensure women's autonomy including able to access to unbiased and effective healthcare services.

Does Quit Smoking Desire Influence E-Cigarette Smoking Behaviour? Malaysian Perspectives.

Recent years have witnessed an emerging trend of e-cigarette smoking in Southeast Asia. On the basis of Malaysian perspectives, this cross-sectional study explored the relationship between e-cigarette smoking behaviour and variables such as perceived health benefit, the desire to quit, social acceptance, social impact and product usefulness. Individuals aged 17 years old and older were recruited via purposive convenience sampling, yielding a total sample of 503 respondents. Collected data were analysed via partial least squares-structural equational modelling. The results showed that perceived heath benefit (ß = 0.19, P < 0.01), social acceptance (ß = 0.23, P < 0.01) and social impact (ß = 0.49, P < 0.01) positively influence e-cigarette smoking behaviour. No such effect is exerted by the desire to quit smoking (ß = 0.08, P < 0.05) and product usefulness t (ß = -0. 10, P < 0.05). Future studies should examine whether demographic variables affect e-cigarette smoking behaviour.

A Comparison of the National Cervical Cancer Policies in Six Developing Countries with the World Health Organization Recommendations: A Narrative Review.

Background: This study reviewed cervical cancer policies implemented in developing countries that adhered to WHO standards. Despite long being known as a preventable disease, cervical cancer is still one of the leading causes of mortality among women. Nine out of ten cervical cancer deaths occurred in less-developed countries, suggesting that the preventive and control approaches in these countries might differ from those in developed nations. Methods: Cervical cancer policies in six developing countries from each WHO region were selected while related data from the Cervical Cancer Country Profiles 2021 by WHO were retrieved for comparison. Results: The cervical cancer policies that were included in this review were from Malaysia, Thailand, Iran, Kenya, Argentina, and Ukraine. According to the latest guidelines on the management of cervical cancers, WHO recommendations have been elaborated on primary, secondary, and tertiary prevention. A comparison of policies among these selected countries showed variation in each level of prevention. The cancer burden in each country was also found to determine the progression of cervical cancer prevention and policy controls in these countries. Conclusion: This review emphasizes the dissimilarities of cervical cancer policies in six developing countries compared to recommendations by the WHO. Identifying these discrepancies could help policymakers in developing nations to recognize the pressing issues surrounding cervical cancer prevention and establish more effective prevention and control approaches.

The effectiveness of a theory-based intervention program for pregnant women with anemia: A randomized control trial.

Anemia in pregnancy is a public health concern. It has been diagnosed in 27% of pregnant women in Malaysia and up to 40% of pregnant women globally. This study aimed to develop and evaluate the effectiveness of an intervention initiative based on the health belief model. The MyPinkMom program was disseminated through a mobile messaging application to pregnant women to educate them on the prevention of anemia in pregnancy. We conducted a two-arm cluster-assignment, single-blinded, randomized control trial at two government antenatal clinics in Selangor. One clinic was randomly chosen as the intervention group, and the other was chosen as the control group. Sixty pregnant women with anemia from the intervention group received the MyPinkMom intervention program in the form of six infographic video clips, and 60 pregnant women with anemia from the control group received routine counseling on anemia in pregnancy. Pregnant women who had anemia secondary to hemoglobinopathy or other chronic diseases were excluded from this study. MANOVA showed significant increases in hemoglobin, knowledge, attitude, subjective norms, and perceived behavioral control scores for adherence to iron supplements, dietary iron, and dietary vitamin C intake (p < 0.001) in the intervention group at week 6. A significant reduction also occurred in dietary tannin intake (p < 0.001) in the intervention group at week 6. The intervention group at week 6 showed a large effect on hemoglobin level increments (partial eta squared, È p2 0.268), dietary iron intake (È p2 0.213), knowledge of anemia in pregnancy (È p2 0.622), subjective norm scores for adherence to iron supplements (È p2 0.167), and reduction in dietary tannin intake (È p2 0.353). Similarly, repeated measures ANOVA showed that changes in hemoglobin levels were significantly different over time (i.e., at baseline, week 6, and week 12) between the intervention and control groups (p < 0.001). Hemoglobin increased rapidly over time among participants in the intervention group but gradually in the control group. To conclude, the newly developed MyPinkMom program that was delivered through a messaging application showed effectiveness in preventing anemia during pregnancy.

A Qualitative Study to Explore the Determinants of Risky Sexual Behaviors and Pregnancy among Female Adolescents in Sabah, Malaysia.

This investigation was performed in Kota Kinabalu, Sabah state, where the highest number of pregnancies is recorded. The purpose of this study was to determine variables associated with hazardous sexual activity and adolescent pregnancy in Sabah, Malaysia. The findings indicate that familial variables, peer interactions, self-esteem, psychiatric concerns, economic considerations, and sex knowledge all play a significant role in hazardous sexual conduct and adolescent pregnancy in Sabah, Malaysia. Information obtained from this study will help the Malaysian government and other officials to design and establish proper interventions that will help alleviate the challenge of high prevalence of teenage pregnancy. It is suggested that sex education be included in the high school curriculum, along with physical and health education in Sabah, Malaysia.

Influence of sociocultural beliefs and practices on contraception: a systematic review.

In this systematic review, we aimed to explore the influence of sociocultural beliefs and practices on contraception and their uptake among women in low-income countries (LICs) and lower-middle-income countries (LMICs). For this purpose, a literature search was conducted using four databases, namely Scopus, Web of Science, PubMed and EBSCOhost Research Platform. Twenty-five articles were selected and analyzed out of a total of 5180 retrieved and screened articles. We used thematic analysis to identify, interpret and report patterns and themes from these records. The analysis identified six factors influencing the uptake of contraceptive methods among women aged 13 to 65-years in LICs and LMICs in relation to their sociocultural beliefs and practices. We found that women's social status and responsibility were recognized at the individual level and the unique patriarchal culture at the partner level, while community-level factors included myths and misconceptions, cultural differences and religious beliefs. Thus, the main challenges to the uptake of contraceptive methods among women in terms of sociocultural norms occur at varying levels of society. This review suggests the need for future family planning programs and health education to target specific community levels and especially to consider diverse social and cultural backgrounds.

Quality of Life among Mothers of High Functioning Autism Spectrum Disorder (HFASD)Adolescents.

Autism Spectrum Disorder (ASD) has become more prevalent globally. The disorder is predominantly characterised by low social skills noted explicitly in people with High Functioning Autism Spectrum Disorder (HFASD). The individuals usually possess a normal or superior intelligence quotient (IQ) but the disability impedes the achievement of their actual high potential, hence compromising their quality of life (QoL). Managing adversities encountered by children with HFASD often compromises the QoL of the entire family. Thus, this study aimed to identify specific domains of QoL among mothers of high-functioning autistic adolescents. The study assessed seven mothers of adolescents with HFASD using a semi-structured interview format. A thematic qualitative analysis was conducted to analyse the data. The results suggested that mothers perceived their QoL based on physical and emotional well-being, material well-being, interpersonal relationship, and environmental well-being. Intervention for HFASD is multidisciplinary, which targets a broad spectrum of symptoms and skills deficits and customises the programme to meet each individual's different needs. Nonetheless, intervention facilities in Malaysia are seriously limited, particularly in supporting QoL for children with HFASD. Therefore, by identifying the domains of QoL would improve the mothers' resilience in raising their children with HFASD.

The Prevalence and Risk Factors of Iron Deficiency Anemia Among Pregnant Women in Malaysia: A Systematic Review.

Anemia in pregnancy is defined as a hemoglobin level of <11 g/dl, and is commonly due to iron deficiency. This systematic review was conducted to determine the prevalence and risk factors of anemia and iron deficiency among pregnant women in Malaysia. A systematic literature search was conducted in Google Scholar, PubMed, and Cochrane Library databases. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. Eight studies comprising a total number of 2,638 pregnant women were included in this review. Only two studies focused on iron deficiency, whereas the other six investigated anemia in pregnancy without specifying iron deficiency or any other nutritional cause for the anemia, signifying the lack of published literature on this important public health nutritional issue in Malaysia. The overall prevalence of anemia in pregnancy ranged from 19.3 to 57.4%, while the prevalence of iron deficiency was 31.6 to 34.6%. Factors that were significantly associated with anemia in pregnancy were extremes of reproductive age, late antenatal booking, non-compliance to hematinics, Indian ethnicity, being in the second or third trimester, low maternal educational level, low family income, and unemployment. The prevalence of anemia in pregnancy was found to be higher in rural compared to urban areas. Meanwhile, in terms of iron deficiency anemia, grandmultiparity, late antenatal booking and Indian ethnicity were significant determinants. It is certainly plausible that the anemia in pregnancy reported in these studies is not entirely secondary to iron deficiency and may be attributable to other nutritional deficiencies, emphasizing the importance of researching deeper into this subject. Nevertheless, in the meantime, focusing on iron supplementation in high-risk mothers with emphasis on compliance, seems to be the best option, in view of the high prevalence of iron deficiency found in this review.

The Acceptance of Human Papillomavirus Self-Sampling Test among Muslim Women:A Systematic Review.

INTRODUCTION: Human Papillomavirus (HPV) self-sampling test has the potential to increase cervical cancer screening rate. Although every screening test has its own advantages and disadvantages, culture and religion can be significant predictors for the acceptability of screening tests among patients, including the HPV self-sampling test. This systematic review intends to identify and review published literature on the acceptance of HPV self-sampling test among Muslim women globally. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) review protocol was utilised to guide this systematic review. We also used the Mixed Method Appraisal Tool (MMAT) for the evaluation of articles, and data from selected papers were retrieved and analysed using thematic analysis. RESULTS: This systematic review includes seven publications that discussed on Muslim women's perceptions of HPV self-sampling test. This comprises articles that revealed Muslim women's acceptance of the HPV self-sampling test, including considerable positive factors that influenced their approval. On the other hand, the test's disadvantages were mentioned, which served as barriers for these women's participation. Convenience, cultural sensitivity, and availability were positive features, whereas religious taboo, low self-confidence, and perceived cost were some of the negative factors that were discussed. CONCLUSION: This review emphasises the positive and negative aspects that have an impact on the acceptance of HPV self-sampling test among Muslim women. Identifying the elements that influence HPV self-sampling test acceptance will help policymakers to better understand cervical cancer screening programmes and further guide future plans in reducing the incidence of cervical cancer.

Physical inactivity in early pregnancy and the determinants in an urban city setting of Kuala Lumpur, Malaysia.

BACKGROUND: Physical inactivity in pregnancy has been associated with excessive gestational weight gain, hypertensive disorders, gestational diabetes mellitus and postpartum depression. Despite these risks, physical inactivity level remains high especially in higher income countries. The prevalence of physical inactivity among women in Malaysia aged ≥16 years was 28.2% in 2019 exceeding men by 6.1%. However, little is known regarding the subpopulation of pregnant women especially in Kuala Lumpur which is the most urbanized and highly populated city in Malaysia. Therefore, the aim of this study is to measure the physical inactivity prevalence among first trimester pregnant women in Kuala Lumpur and to identify its determining factors. METHODS: This was a cross-sectional study in which 339 first trimester pregnant women were sampled from 13 maternal and child health clinics located in all four parliament districts of Kuala Lumpur. Self-administered questionnaires which contained the Malay version of the pregnancy physical activity questionnaire (PPAQ) were used. Descriptive analysis was conducted to determine the physical inactivity prevalence followed by simple and multiple logistic regression to identify the determinants of physical inactivity with significant level of 5%. RESULTS: The prevalence of physical inactivity was 38.3%. The highest activity was seen in the household activity domain, despite only 24.8% of the respondents were housewives/unemployed. There was little to no participation observed in the vigorous intensity category. The determinants of physical inactivity were primigravida (aOR 3.54 95% CI 1.40, 8.97), education level (aOR 3.77 95% CI 1.35, 10.52) and body mass index (aOR 0.88 95% CI 0.80, 0.97) which explained 22.6% variation of physical inactivity in the final adjusted model. CONCLUSION: The prevalence of physical inactivity among first trimester pregnant mothers in this study was 38.3%, and the highest activity was seen in the household category. Health education on physical activity in pregnancy should be focused on those who are primigravida and have no tertiary education. The educational content should be updated and tailored to current pandemic situation where self-isolation is the new norm, by advocating for home-based, moderate to vigorous intensity physical activities.

Bullying and Its Associated Individual, Peer, Family and School Factors: Evidence from Malaysian National Secondary School Students.

Adolescents involved in bullying can be at risk of developing behavioural problems, physical health problems and suicidal ideation. In view of this, a quantitative research design using a cross-sectional study was conducted to determine the prevalence of bullying and associated individual, peer, family and school factors. The study involved 4469 Malaysian public-school students who made up the response rate of 89.4%. The students were selected using a randomized multilevel sampling method. The study found that 79.1% of student respondents were involved in bullying as perpetrators (14.4%), victims (16.3%), or bully-victims (48.4%). In a multivariate analysis, the individual domain showed a significant association between students' bullying involvement and age (OR = 1.38; 95% CI 1.12-1.70), gender (OR = 1.73; 95% CI 1.47-0.91), ethnicity (OR = 0.66; 95% CI 0.47-0.91), duration of time spent on social media during the weekends (OR = 1.43; 95% CI 1.09-1.87) and psychological distress level (OR = 2.55; 95% CI 1.94-3.34). In the peer domain, the significantly associated factors were the number of peers (OR = 0.69; 95% CI 0.56-0.86) and frequency of quarrels or fights with peers (OR = 2.12; 95% CI 1.24-3.26). Among the items in the school domain, the significantly associated factors were students being mischievous in classrooms (OR = 1.52; 95% CI 1.06-2.06), student's affection towards their teachers (OR = 1.53; 95% CI 1.06-2.20), frequency of appraisal from teachers (OR = 1.49; 95% CI 1.16-1.94), frequency of friends being helpful in classrooms (OR = 1.92; 95% CI 1.09-3.38) and frequency of deliberately skipping class (OR = 2.91; 95% CI 2.90-1.72). As a conclusion, the study revealed high levels and widespread bullying involvement among students in Malaysia. As such, timely bullying preventions and interventions are essential, especially in terms of enhancing their mental health capacity, which substantially influences the reduction in the prevalence rates of bullying involvement among students in Malaysia.

Factors affecting successful scale-up of health-related pilot projects.

OBJECTIVE: To identify the key factors that contribute to the successful scale-up of pilot projects, with emphasis on factors that are proven helpful in the successful scaling up of health interventions. METHODS: Grey literature was searched at the library of the University of Kebangsaan, Malaysia, on database engines Google Scholar and Science Direct with specific key words to screen papers published from January 2001 to June 2016. They were reviewed to identify the key factors affecting scaling up of health-related pilot projects. Full-text articles were selected, and their reference lists were checked to look for relevant papers. They were short-listed and analysed using thematic approach. RESULTS: Of the 47 articles initially screened, 14(29.78%) were shortlisted. Thematic analysis of the selected articles suggested several key factors contributed to the successful scale-up of pilot projects. These factors included evidence-based and effective intervention, community readiness, government support, stakeholders' engagement, and monitoring and supervision. CONCLUSIONS: To maximise health coverage in developing and low middle-income countries, scaling up of health interventions on a large scale is essential to improve the health and wellbeing of people. The identified key factors should be considered while planning the scale-up of any health project.

The Reliability and Validity of the Malay Parent-Report Version of the Strengths and Difficulties Questionnaire.

[This retracts the article DOI: 10.21315/mjms2019.26.1.12.].

The Impacts of Illegal Toxic Waste Dumping on Children's Health: A Review and Case Study from Pasir Gudang, Malaysia.

Poor management of hazardous waste can lead to environmental pollution, injuries, and adverse health risks. Children's exposure to hazardous waste may cause serious acute and chronic health problems due to their higher vulnerability to the toxic effects of chemicals. This study examines an incident of illegal chemical dumping in Pasir Gudang, Malaysia and its potential health impacts on children. The study introduced a risk assessment of possible health-related effects due to chemical contamination based on a real case scenario where quantification of the contamination was not feasible. A literature review and spatial analysis were used as research methods. On 6th March 2019, tons of hazardous waste were illegally disposed into Kim Kim River, Pasir Gudang, Malaysia. They were identified as benzene, acrolein, acrylonitrile, hydrogen chloride, methane, toluene, xylene, ethylbenzene, and d-limonene. As a result, 975 students in the vicinity developed signs and symptoms of respiratory disease due to the chemical poisoning. The findings of this study indicate that more effective policies and preventive actions are urgently needed to protect human health, especially children from improper hazardous waste management.

A systematic review on noncommunicable diseases among working women.

The increasing involvement of women in the paid-labor market has led to multifactorial exposure towards the development of noncommunicable diseases (NCDs). This review aims to identify the prevalence of NCDs and the associated risk factors among working women. A systematic review was performed using PubMed and Scopus databases. Twelve articles published between 2015 and 2019 satisfied the inclusion and exclusion criteria and were selected for qualitative synthesis. Among working women, the prevalence of NCDs was as follows: coronary heart disease, 0.3%-5.9%; metabolic syndrome, 52.0%; diabetes mellitus, 8.9%-16.0%; hypertension, 16.6%-66.4%; non-skin cancer, 3.7%. The prevalence of NCD risk factors was as follows: overweight/obesity, 33.8%-77.0%; low physical activity, 51.0%; unhealthy diet, 44.9%-69.9%; dyslipidemia, 27.8%-44.0%. The factors associated with NCDs were long working hours, double work burden, and stress. NCD is an important burden of working women that will lead to reduced work quality and affect family well-being. Disease prevention approaches, such as the intervention of common workplace risk factors and specific work schedule design, are among the strategies for improving the situation.

Relationship between anthropometric and biochemical changes of metabolic syndrome with retinal nerve fiber layer and macular thickness.

OBJECTIVE: To evaluate the retinal nerve fiber layer (RNFL) and macular thicknesses and identify systemic risk factors for thinning of these layers in patients with metabolic syndrome (MetS). METHODOLOGY: A cross-sectional observational study was performed on patients diagnosed with MetS and compared to normal controls. All patients underwent ophthalmic and anthropometric examination, serological and biochemical blood investigations; and ocular imaging using spectral-domain optical coherence tomography. Patients with ocular pathology were excluded. Unpaired t-test was used to compare mean thickness between the two groups. One-way ANOVA with Bonferroni correction for multiple comparisons was used to compare mean thickness between different tertiles of MetS parameters, and a generalized estimating equation was used to correct for inter-eye correlation and to assess association between mean thickness and covariates. RESULTS: Two hundred and forty-eight eyes from 124 participants (1:1 ratio of MetS patients to controls) were included. Age ranged between 30 to 50 years old, and mean age was 40 ± 6.6 years. RNFL thickness was lower globally (93.6 ± 9.9 µm vs 99.0 ± 9.3, p<0.001) and in the inferior (124.5 ± 17.5 µm vs 131.0 ± 16.4 µm, p = 0.002), superior (117.2 ± 16.0 µm vs 126.3 ± 14.4 µm, p<0.001) and temporal (65.5 ± 10.2 µm vs 69.5 ± 9.8, p = 0.002) sectors in MetS patients compared to controls. Only the central (237.0 ± 14.0 µm vs 243.6 ± 18.0 µm, p = 0.002) and inferior parafoveal (307.8 ± 20.9 vs 314.6 ± 14.6, p = 0.004) area of the macula was significantly thinner. The inferior RNFL sector had the most difference (mean difference = 9.1 µm). The Generalized Estimating Equation found that, after adjusting for age, diastolic blood pressure, BMI, HDL and obesity; the number of MetS components and elevated triglyceride levels were independent risk factors for reduced thickness in global RNFL (ß = -4.4, 95% CI = -7.29 to -1.5, p = 0.003) and inferior parafovea (ß = -6.85, 95% CI = -11.58 to -2.13, p = 0.004) thickness respectively. CONCLUSION: RNFL thinning was seen more than macula thinning in MetS patients, suggesting RNFL susceptibility to neurodegeneration than the macula. A higher number of metabolic components and elevated triglyceride levels were independent risk factors for retinal thinning in this group of patients.

Factors Associated with Mental Health Problems among Malaysian Children: A Large Population-Based Study.

Mental health problems are a major public health issue, particularly among children. They impair children's development, academic achievement, and ability to live a productive life. The present study aimed to determine the prevalence and factors associated with mental health problems among children aged 5 to 15 years old in Malaysia. Data from the National Health and Morbidity Survey (NHMS) 2015 were analyzed. A validated Strengths and Difficulties Questionnaire (SDQ) was used. The overall prevalence of mental health problems among children in Malaysia was 11.1%. Multiple logistic regression analysis revealed that for every year increment in age, mental health problems decreased by 5%. Further analysis found that children who had fathers with a non-formal education and worked in the private sector, had parents who were widowed or divorced, and had either parent with mental health problems were more likely to have mental health problems themselves. Children from the lower socioeconomic group and who had either parent with mental health problems had higher odds of having mental health problems in Malaysia.

Understanding the Turning Point of Patients with Diabetes.

BACKGROUND: The patient's intention to engage in diabetes care is the hallmark of role acceptance as a health manager and implies one's readiness to change. The study aimed to understand the process of having the intention to engage in diabetes care. METHODS: A qualitative study using narrative inquiry was conducted at a public primary care clinic. Ten participants with type 2 diabetes of more than a 1-year duration were selected through purposive sampling. In-depth interviews were conducted using a semi-structured protocol guide and were audio-taped. The interviews were transcribed and the texts were analyzed using a thematic approach with the Atlas.ti ver. 8.0 software (Scientific Software Development GmbH, Berlin, Germany). RESULTS: Three themes emerged from the analysis. The first theme, "Initial reactions toward diabetes," described the early impression of diabetes encompassing negative emotions, feeling of acceptance, a lack of concern, and low level of perceived efficacy. "Process of discovery" was the second overarching theme marking the journey of participants in finding the exact truth about diabetes and learning the consequences of ignoring their responsibility in diabetes care. The third theme, "Making the right decision," highlighted that fear initiated a decision-making process and together with goal-setting paved the way for participants to reach a turning point, moving toward engagement in their care. CONCLUSION: Our findings indicated that fear could be a motivator for change, but a correct cognitive appraisal of diabetes and perceived efficacy of the treatment as well as one's ability are essentially the pre-requisites for patients to reach the stage of having the intention to engage.

Missed Appointments at a Child Development Centre and Barriers to Access Special Needs Services for Children in Klang Valley, Malaysia: A Mixed Methods Study.

Attending appointments is vital for children with special needs, as such appointments involve long-term interdisciplinary care to ensure continuity of care and improve health and well-being. This study was performed to determine the prevalence of missed clinic appointments and identify the factors among those who have ever missed appointments and barriers of access to children's special needs services at the Child Development Centre (CDC) at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Moreover, suggestions for improvement from the caregivers' perspectives were explored. This is an explanatory sequential mixed methods study among caregivers of children with developmental disabilities aged up to 17 years old. Of 197 caregivers, 62 (31.5%) had missed clinic appointments. Forgetfulness was the most frequently cited reason. The bi-variable analysis showed significant differences in missed appointment rates by gender of caregivers and duration of follow-up. The final logistic regression model demonstrated that, when combined with the effect of being a male caregiver as an independent variable, follow-up duration of more than 6 years increased 2.67 times the risk of missing an appointment. Caregivers' perceived barriers were transportation, caregiver, child and healthcare services factors. Policies and strategic plans should be focused on key findings from these factors to improve appointment adherence and accessibility to services for children with special needs.