Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia.

BACKGROUND: In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia. METHODS: This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis. RESULTS: We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors. CONCLUSION: The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.

Factors influencing the practice of Smoking Cessation Assessment and Management among Primary Care Doctors (SCAAM-DOC) in three districts of Malaysia.

BACKGROUND: Smoking prevalence remains high in Malaysia. Primary care doctors have a good opportunity to motivate the smokers to quit smoking in view of the accessibility of primary healthcare clinics to the public. The objective of this study was to determine the practice of smoking cessation management among primary care doctors and its associated factors. METHODS: A cross-sectional online survey was carried out among 383 medical officers and interns in all government primary healthcare clinics in the district of Petaling, Klang and Hulu Langat from June to August 2020. All doctors were involved in the care of patients for smoking cessation. The knowledge, attitude and practice of smoking cessation management were assessed using a 17-items validated questionnaire which covered the components of 5As (Ask, advise, assess, assist, arrange) and 5Rs (Relevance, risk, reward, roadblocks, repetition). The management of pre-contemplation phase included the components of ask, advise, assess and 5Rs. The management of the contemplation phase included the components of assist and arrange. RESULT: The majority of the respondents had poor score of knowledge (62.4%); attitude (58%) and practice (pre-contemplation management:50.9%; contemplation management:75.7%). Using multivariate logistic regression analysis, the significant factors associated with the poor practice of smoking cessation management in the pre-contemplation phase were poor (OR = 2.14, 95% CI 1.11-4.12, p <0.01) or moderate knowledge (OR = 2.50, 95% CI 1.19-5.26, p<0.01), poor attitude (OR = 2.16, 95% CI 1.39-3.37, p<0.01), lacks smoking cessation banners, brochures and leaflets in the clinic (OR = 2.01, 95%CI 1.26-3.19, p<0.01) and lack of nicotine replacement medications (OR = 2.27. 95%CI 1.27-4.06, p<0.01). No significant factors were shown associated with the practice of the contemplation phase. CONCLUSION: The majority of primary care doctors had poor knowledge, attitude and practice of smoking cessation management. Factors that had increased the odds of the poor practice of smoking management at the pre-contemplation phase were poor knowledge, poor attitude, and insufficient organizational support for health promotion materials and nicotine replacement medication.

What are the determinants for individuals to undergo cardiovascular disease health checks? A cross sectional survey.

BACKGROUND: There is a need to improve public's participation in health checks for early identification of individuals at high risk of CVD for prevention. The objective of this study is to identify significant determinants associated with individuals' intention to undergo CVD health checks. These determinants could be used to develop effective strategies to improve CVD health check participation. METHODS: This was a cross sectional survey using mall intercept interviews. It was carried out in a hypermarket surrounded by housing estates with a population of varying socioeconomic backgrounds. Inclusion criteria were Malaysian nationality and age 30 years and older. The validated CVD health check questionnaire was used to assess participants' intention and the determinants that influenced their intention to undergo CVD health checks. RESULTS: A total of 413 participants were recruited. The median age of the participants was 45 years (IQR 17 years) and 60% of them were female. Participants indicated they were likely (45.0%) or very likely (38.7%) to undergo CVD health checks while 16.2% were not sure, unlikely or very unlikely to undergo health checks. Using ordinal regression analysis, perception of benefits, drawbacks of CVD health checks, perception of external barriers and readiness to handle outcomes following CVD health checks were the significant determinants of individuals' intention to undergo CVD health checks. CONCLUSIONS: To improve individuals' participation in CVD health checks, we need to develop strategies to address their perception of benefits and drawbacks of CVD health checks, the perceived external barriers and their readiness to handle outcomes following CVD health checks.

How useful is a history of rubella vaccination for determination of disease susceptibility? A cross-sectional study at a public funded health clinic in Malaysia.

BACKGROUND: Identification of pregnant women susceptible to rubella is important as vaccination can be given postpartum to prevent future risks of congenital rubella syndrome. However, in Malaysia, rubella antibody screening is not offered routinely to pregnant women in public funded health clinics due to cost constraint. Instead, a history of rubella vaccination is asked to be provided to establish the women's risk for rubella infection. The usefulness of this history, however, is not established. Thus, this paper aimed to determine the usefulness of a history of rubella vaccination in determining rubella susceptibility in pregnant women. METHODS: A cross-sectional study was conducted on 500 pregnant women attending a public funded health clinic. Face-to-face interviews were conducted, and demographic data and history of rubella vaccination were obtained. Anti-rubella IgG test was performed. RESULTS: A majority of the women (66.6%) had a positive vaccination history. Of these, 92.2% women were immune. A third (33.4%) of the women had a negative or unknown vaccination history, but 81.4% of them were immune to rubella. The sensitivity and specificity of a history of rubella vaccination in identifying disease susceptibility was 54.4% (95% CI: 40.7, 67.4%) and 69.3% (95% CI: 64.7, 73.5%) respectively; the positive predictive value was 18.6% (95% CI: 13.1, 25.5%) and the negative predictive value was 92.2% (95% CI: 88.6, 94.7%). CONCLUSIONS: A vaccination history of rubella had a poor diagnostic value in predicting rubella susceptibility. However, obtaining a vaccination history is inexpensive compared with performing a serological test. A cost-utility analysis would be useful in determining which test (history versus serological test) is more cost-effective in a country with resource constraint.