Validation and Implementation of the Pictorial Fit Frail Scale-Malay Version (Pffs-M) in Publicly Funded Malaysian Primary Care Clinics
Date
2024
Authors
Ahip, Sally Suriani
Editors
Advisors
Visvanathan, Renuka
Shariff-Ghazali, Sazlina (Universiti Putra Malaysia)
Theou, Olga (Dalhousie University)
Shariff-Ghazali, Sazlina (Universiti Putra Malaysia)
Theou, Olga (Dalhousie University)
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Thesis
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Abstract
Frailty is a clinical and public health issue commonly encountered within an ageing population. Frailty is a state of vulnerability where the individual is at-risk of poor health outcomes following an acute event, and at-risk of disability, falls, institutionalization, hospitalization, and death. Developing community-based healthcare services to address frailty among the older persons in the community is essential for promoting healthy aging, enhancing quality of life, and ensuring that healthcare systems are better equipped to meet the needs of an aging population. Frailty is treatable and reversible in its early stages, with intervention, such as optimising medication, exercising, nutrition and cognitive stimulation. Therefore, identifying risk early through frailty screening in primary care settings and intervening to assist those at-risk could improve the person’s frailty status, which in turn could improve the person’s functional ability and quality of life. For this to be realised, a frailty screening tool that is reliable and valid is necessary. When the research presented in this thesis was conceived, no frailty screening tool had been developed in Malaysia. At the same time, the Pictorial Fit-Frail Scale (PFFS) had emerged in Canada. The pictorial nature of the PFFS had appeal for Malaysia where the population is culturally diverse and from varying educational backgrounds. It was also envisaged that a frailty screening program could be developed and implemented across the country through the existing publicly funded primary care clinic services in Malaysia once a reliable, valid, and easy to implement frailty screening tool was identified. As the PhD progressed, I also developed the GeKo-ISD (Community Geriatric- Integrated Service Delivery) model of care and established community geriatric clinics (GeKo), cost-neutrally, to implement frailty screening and management across Sarawak state in Malaysia. The research in this thesis had the following aims: 1. translate and adapt the PFFS to the Malay language, producing the PFFS-M; 2. investigate the reliability and convergent validity of the PFFS-M among patients, caregivers, nurses, healthcare assistants and doctors in Malaysian primary care clinics; 3. investigate the reliability (inter and test-retest) and convergent validity of the PFFS-M for people with different educational levels; 4. investigate the predictive validity of the PFFS-M for poor health at 18 months and develop cut-off values for frailty; and 5. explore the effectiveness and evaluate the implementation stage of community geriatric clinics (GeKo Integrated Service Delivery Model [ISD]) focused on frailty screening and management. The findings of this thesis have been published in four manuscripts. Through this research, it was confirmed that the PFFS-M could reliably be completed by patients with help from their caregivers. Where further assistance is required, help can be provided by the non-tertiary educated healthcare assistants at these clinics. Training modules to support this were developed as part of this research. Cut-off values for the PFFS-M were also identified and frailty was said to be present when the PFFS-M scores were 6 and above. The PFFS-M’s predictive validity was confirmed in this study, where patients at risk of frailty and those with frailty, are six times more likely to develop at least one adverse outcome over 18 months. Because of the research presented in this thesis, the PFFS-M has been implemented for frailty screening in Malaysia and GeKo-ISD (Geriatrik Komuniti Integrated Services Delivery) in primary care clinics have been established to intervene with patients identified as at-risk (PFFSM scores 4-5) and frail (PFFS-M scores 6 and above). The final effectiveness study in this thesis established that the three GeKo-ISD clinics studied had achieved a sustained implementation level when assessed using the World Health Organisation Integrated Care for Older People score card. Additionally, for the small subset of patients investigated from the inaugural GeKo-ISD clinic, frailty scores improved between baseline and three months following treatment in the clinic. These findings provided confidence to the Sarawak State Ministry of Health to support the roll out the GeKo-ISD to 29 additional clinics in 2023. There are now 32 GeKo-ISD primary care clinics in one state of Malaysia, Sarawak. Moving forward, the Ministry of Health of Malaysia has committed to funding and implementing a multi-centre quasi-experimental study to further evaluate the effectiveness and sustainability of the GeKo-ISD clinics in seven case and seven control publicly funded primary care clinics across seven states in Malaysia. The findings from that research will guide the future possible implementation of such services nationwide. To support GeKo service improvement and development, a GeKo electronic record system and registry have also been designed.
School/Discipline
Adelaide Medical School
Dissertation Note
Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 2025
Provenance
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