DEFINITIONS RESEARCH QUESTIONS INTRODUCTION

Chapter 2 Methodology ✁ ✂ ✄ ☎ ✁ ✆ ✝ ✞ ✟ ✄ ✠ ✁ ✆ ✠ ✁ ✡ ✞ ☛ ✂ ✁ ✂ ✄ ☛ ✂ ✄ ✠ ☛ ☞ ✌ ✍ ☞ ✜ ✧

CHAPTER 2: METHODOLOGY

The 2012 National Medical Care Survey NMCS is a prospective cross-sectional study. The observation unit was the patient encounters. As it was not possible to randomly select the encounters from all the study location, random sampling was done on the primary care clinics in the 5 selected regions instead. The chosen regions were ‡ Wilayah Persekutuan:3.XDODXPSXU:33XWUDMD\DDQG6HODQJRUWRUHÁHFWWKHFHQWUDO region of Peninsular Malaysia ‡ .HODQWDQWRUHÁHFWWKHDVWRDVWRI3HQLQVXODU0DOD\VLD ‡ .XFKLQJDQG.RWD.LQDEDOXWRUHÁHFWDVW0DOD\VLD A total period of 4 months was allocated for data collection from August 1st till November 30th 2012 where all sampled clinics were randomly allocated one day for data recording in their respective clinics.

2.1 SAMPLING FRAME AND SAMPLE SIZE CALCULATION

The sampling frame of public and private clinics was generated by matching the list of clinics from National Healthcare Establishments and Workforce Survey NHEWS 2010 with several sources: ‡ 7KHOLVWRISXEOLFFOLQLFVIURPWKHDPLO\+HDOWKHYHORSPHQWLYLVLRQ0LQLVWU\RI+HDOWK Malaysia. ‡ 7KHOLVWRIUHJLVWHUHGSULYDWHFOLQLFVIURPWKH3ULYDWH0HGLFDO3UDFWLFHLYLVLRQ0LQLVWU\RI+HDOWK Malaysia often referred to as CawanganUnit Kawalan Amalan Perubatan Swasta CKAPS UKAPS. Both lists were updated as of 31st December 2011 and these were the most recent lists of clinics at the point of survey. VIRUFOLQLFVWKDWZHUHQRWPDWFKHGIURPWKHOLVWVVXEVHTXHQWYHULÀFDWLRQE\SKRQHFDOOVZDVGRQHWR determine the existence or current operational status of the establishments. Those that were found to be closed were removed from the sampling frame. Inclusion and exclusion criteria for the clinics sampled in the survey were as follow: Inclusion criteria ‡ MOH Health Clinics Klinik Kesihatan providing primary care services by medical doctors ‡ Private medical clinics registered with CKAPS and providing primary care services Exclusion criteria ‡ Outpatient departments within hospital or maternity homes ‡ Public clinics with the following criteria: - Klinik Kesihatan without medical doctors - Clinics providing maternal and child health services only Klinik Kesihatan Ibu dan Anak - Rural clinics Klinik Desa - 1 Malaysia Clinics - Primary care clinics in universities ‡ Private clinics with the following criteria: - In-house clinicscompany clinics - Clinics providing specialised carespecialist clinics e.g. paediatric, cardiology, occupational therapy - Diagnostic centres - Aesthetic clinics - Charity clinics ✁ ✂ ✄ ☎ ✁ ✆ ✝ ✞ ✟ ✄ ✠ ✁ ✆ ✠ ✁ ✡ ✞ ☛ ✂ ✁ ✂ ✄ ☛ ✂ ✄ ✠ ☛ ☞ ✌ ✍ ☞ ✜ ✜ 6DPSOHVHOHFWLRQZDVFRQGXFWHGE\VWUDWLÀHGUDQGRPVDPSOLQJLQFRUSRUDWLQJVHYHUDOVWDJHVWRREWDLQWKH encounters needed. Stage 1: Selection of sampling regions conveniencepurposive sampling ‡ :3.XDODXPSXU6HODQJRUDQG:33XWUDMD\D.HODQWDQ.XFKLQJDQG.RWD.LQDEDOX 6WDJH6WUDWLÀFDWLRQE\VHFWRU ‡ DFKUHJLRQZDVIXUWKHUVWUDWLÀHGWRSXEOLFRUSULYDWHVHFWRU Stage 3: Sampling of clinics ‡ 5DQGRPVDPSOLQJRIFOLQLFVEDVHGRQUDQGRPQXPEHUVJHQHUDWHGXVLQJ0LFURVRIW[FHO,QFOXVLRQ and exclusion criteria were taken into account during sampling process. Stage 4: Sampling of doctors ‡ OOGRFWRUVLQWKHVDPSOHGFOLQLFVZKRZHUHSUDFWLVLQJRQWKHVXUYH\GD\ZHUHLQFOXGHG ‡ RFXPGRFWRUVZHUHLQFOXGHG ‡ 6SHFLDOLVWVZHUHH[FOXGHGZLWKH[FHSWLRQRIIDPLO\PHGLFLQHVSHFLDOLVWV Stage 5: Sampling of encounters ‡ OOHQFRXQWHUVVHHQE\WKHGRFWRUVRQWKHVXUYH\GDWHZLWKPLQLPXPRIHQFRXQWHUVUHTXLUHGIRU public clinics and minimum of 20 encounters per private clinic. The sample size which is the needed number of encounters for the NMCS 2012 was determined based on the morbidity data from NMCS 2010 as well as total primary care attendances from NHEWS Primary Care 2010. 7KHÀQDOVDPSOHFRQVLVWVRISXEOLFFOLQLFVDQGSULYDWHFOLQLFV7DEOH Table 2.1: Sample size for NMCS 2012 StateRegion Number of clinics Public Private Selangor WP Putrajaya 39 187 WP Kuala Lumpur 8 107 Kelantan 20 57 Kota Kinabalu 4 21 Kuching 4 11 Total 75 383 ✁ ✂ ✄ ☎ ✁ ✆ ✝ ✞ ✟ ✄ ✠ ✁ ✆ ✠ ✁ ✡ ✞ ☛ ✂ ✁ ✂ ✄ ☛ ✂ ✄ ✠ ☛ ☞ ✌ ✍ ☞ ✜ ✢

2.2 SURVEY DATES

All sampled clinics were given one randomly assigned date for data collection, which was a working day for all. The following days were excluded: ‡ SXEOLFKROLGD\V ‡ ZHHNHQGVLQFOXGLQJULGD\6DWXUGD\DQG6XQGD\ ‡ 0RQGD\0RQGD\VDUHXVXDOO\EXVLHVWIRUPRVWSULPDU\FDUHFOLQLFV ‡ DZHHNDIWHUPDMRUIHVWLYHFHOHEUDWLRQV ‡ ZRUNLQJGD\VLQEHWZHHQSXEOLFKROLGD\V If the clinic was closed on the survey date, the doctor had the option to change the survey date to the next available working day. The research team however was informed of the new survey date.

2.3 DATA COLLECTION AND FOLLOW-UP

7KH VDPSOHG FOLQLFV ZHUH HDFK VHQW DQ LQYLWDWLRQ OHWWHU WR DWWHQG D EULHÀQJ LQ HDFK VWDWH ULHÀQJV for doctors in the public clinics were held on weekdays whereas for private doctors, it was during the weekends from June to July 2012. A research pack which contained the survey forms and instructions ZHUHGLVWULEXWHGGXULQJWKHEULHÀQJV 7RHQFRXUDJHIXUWKHUSDUWLFLSDWLRQFOLQLFVWKDWGLGQRWDWWHQGWKHEULHÀQJZHUHODWHUFRQWDFWHGE\SKRQH If the doctor refused to participate in the survey, the team did not pursue further. However, if they agree to participate the research pack would be sent either ‡ E\FRXULHUIROORZHGE\WHOHSKRQHFDOOWRHQVXUHWKDWWKHUHVHDUFKNLWKDGEHHQUHFHLYHGULHÀQJ would be done over the phone to explain about the survey form. ‡ E\SHUVRQDOYLVLWWRWKHFOLQLFVZLWKLQWKHYLFLQLW\RI.ODQJ9DOOH\DQGDVKRUWSULYDWHEULHÀQJ would be given to the doctornurse in-charge Two weeks and one day before the survey date, a reminder via telephone was made to the clinic about the project and to answer any questions pertaining to the survey. Instructions would be repeated when necessary. After the survey date, follow-up phone calls were made if the research pack was not returned after 3 weeks, and subsequently at 5 weeks. Various approaches were also taken to increase the acceptance and response rate of private clinics. This included the following: a Approaching the managersenior management of the chain clinicsgroup practices E 2UJDQLVLQJSULYDWHLQGLYLGXDOEULHÀQJVDORQJVLGH0HGLFDO3UDFWLFHLYLVLRQ·VHQIRUFHPHQW activities c Getting support and assistance from Malaysian Medical Association MMA at the state level 8SRQFRPSOHWLRQRIGDWDFROOHFWLRQSDUWLFLSDQWVZHUHJLYHQFHUWLÀFDWHVZKLFKWKH\ZRXOGODWHUXVHWR claim for continuing professional development CPD points. An individualised feedback, questionnaire on primary care prescribers, and a copy of the National Medical Care Statistics 2012 report were also sent to all participants.