Do General Practitioners Improve Compliance of Disease Monitoring
by Patients with Chronic Hepatitis B Infection in Primary Care? A
Ngiap-Chuan Tan 1, MBBS, MMed (Family Medicine), FCFP
Director, SingHealth Polyclinics - Pasir Ris
Seng-Lian Cheah 2 , SRN, MPC, SMB, BHSc (Nursing)
Nurse Manager, SingHealth Polyclinics - Pasir Ris
Background: Compliance to disease monitoring by patients with chronic
hepatitis B infection (HBV carriers) presented a major obstacle to
their management in primary care.
Objective: The study determined the measures that general practitioners
adopt to improve the compliance of disease monitoring by patients
with chronic hepatitis B infection in primary care.
Method: Focus group qualitative study of 43 general practitioners
in primary care in Singapore.
GPs stressed that devoting time and effort to educate the HBV carriers
on the natural disease and the reasons for disease monitoring would
enhance compliance in the follow up of these patients. The GPs suggested
that a patient-recall system and aides-memoirs for doctors would also
improve the compliance rate.
Improving the HBV carriers' understanding of the natural disease process
of hepatitis B, clarifying the need and relevance of hepatocellular
carcinoma surveillance via disease monitoring was key to improving
compliance. A patient-recall system and various aides-memoirs were
perceived by the GPs to be useful measures to improve their compliance
to follow-ups in primary care.
words: Hepatitis B carriers, compliance, disease monitoring,
patient recall, aides-memoirs
Over 350 million people are infected with chronic hepatitis B virus (HBV)
infection worldwide, resulting in over a million deaths annually from
related complications such as cirrhosis and/or hepatocellular carcinoma.
4-5% of the multi-racial Singapore population is similarly infected(1).
indicated that early detection of these pathologies would lead to improved
morbidity and mortality of these HBV carriers and hence the need for regular
monitoring of the liver status. They are commonly monitored in liver clinics
in hospitals and primary care centers such as GP clinics or government-aided
polyclinics. However, as many of these HBV carriers are asymptomatic,
compliance to follow up is a problem faced by many general practitioners
in primary care.
This study aimed to determine the strategies suggested by general practitioners
in Singapore to improve the HBV carriers' compliance to their follow up
in primary care. Sharing of these ideas would enhance the overall management
of HBV carriers in monitoring their disease and hence detection of early
HBV related complications.
theory-based sampling, data collection and analysis were used. The first
author closely supervised the research to ensure a rigorous study. 43
GPs, who had managed HBV carriers in their respective practices, were
recruited. A variety sample was constructed to include GPs of both sexes,
a range of ages and years of practices and from both the public and private
sectors to capture a wide spectrum of views. The GPs were provided with
introduction letters via the post or e-mails, which clearly stated the
objectives of the study. Follow-up calls were made to the GPs to confirm
focus groups involving these GPs were carried out at four government-aided
polyclinics, two private GP clinics and at the College of General Practitioners.
Both authors facilitated the focus group discussions based on a semi-structured
discussion guideline. The guideline covered a whole range of topics related
to GPs' management of chronic HBV infection. These include GPs' assessment
of HBV carriers in terms of history, physical examination and investigations,
problems encountered and ascertainment of their roles in the management
of this chronic condition.
purpose and objectives of the study were explained to the participants
at the onset of the FGD and confidentiality of their identities was ensured.
Each participant signed a consent form and was required to fill in basic
socio-demographic data. Each focus group was audio taped with participants'
permission and each session lasted about 45-90 minutes. Participants were
encouraged to speak freely and described their experience in managing
HBV carriers. Prompts were also used if the participants did not mention
certain related topics spontaneously.
study was terminated with saturation of ideas after eight FGDs. The tape-recorded
interviews were transcribed in their entirety into text files. The transcripts
were read and checked independently by the researchers to ensure consistency.
qualitative data were analyzed using standard content analysis technique.
Broad themes were first identified followed by a more grounded approach.
The prevalent themes that were identified formed broad categories, which
were then subjected to more detailed data investigation of subcategories
nested within the broad categories. All transcripts were read several
times and simultaneously coded to explore potential conceptual and content
related themes. The data was coded using a qualitative data analysis software
NUD*IST Version 6.0TM. (6)
The quotes included in the results were typical views expressed by the
participants and were used to exemplify emergent themes.
background of participants
The participants included 43 GPs with years of practice ranging from three
years to thirty-six years with mean duration of 11.3 years (SD 6.7 years).
79.1% of them were in the government-aided polyclinics with the rest were
working in private practice. Out
of the 9 participants in private practice, 4 of them were solo practices
and the rest were group practices. 65.2% of the participants treated an
average of 1 to 4 HBV carriers per month while the rest saw 5-9 carriers
Socio- demographic background and practice profile of participating General
N = 43
of years of practice
0 - <10years
10 and above years
Private - solo
Private - group
of polyclinic doctors (n=34)
Residents / Medical officers
Number of HBV carriers consulted in GP's practice per month
1 - 4
measures to improve disease monitoring of their HBV carrier patients were
presented in themes.
2: Themes derived from the various focus group discussions indicated by
"You tell them the natural history; after that you tell that's
the reason why we want to monitor. You not only tell them the potential
problem, you also tell them the solution. It's a way of motivating
them to come back."
"I actually spent a lot of time trying to get the education
part of the disease to the patients. Once you get the understanding,
then the compliance comes in easier.
"I would emphasize that it is chronic; basically this stays
with you for the rest of your life and the implications are huge.
If you get a tumor of if you get cirrhosis, it will be quite disastrous."
"We must educate them, that we must be on our toes watching
out for some complications that have been well known to set in,
so that if they are there, we are ready to manage it.
"I sort of redefine them cognitively: we are hoping that you
do not need treatment, because it's the best thing it could happen.
Once you need treatment, that means big trouble. The virus is flaring
and disturbs you. You just hope that the virus is sleeping in your
liver and doesn't disturb you."
"Anatomical model. The virus, basically they make friends.
The virus actually lives inside (the liver) but perhaps one fine
day, the virus may betray you. So they remember it that way. The
betrayal takes the form of cancer of cirrhosis."
the correct perspective and priority
"You set the expectations so that they know what is expected
for lifelong. If they realise that expectation, I guess, (it) is
easier for them to come back."
"What if I am the 1% (at risk), it is still important to me.
Statistics is giving a whole picture of what it is all about but
the critical thing is that it has to be individualized."
'Convince them to do the blood test, which is the high yield kind
of activity and to explain to them what it means to them. In my
practice, we are not sure if they ever come back to you again...
if he is wandering around out there and whichever clinic he is going
to, at least he is aware of this part (of education) which stays
with him. So I just concentrate on these two minimum activities."
"I'll tell them if you are a carrier, you have up to 40% risk
of dying from liver cancer or cirrhosis. The percentage is too high
that's the reason why you should monitor."
form paramedical staff:
"You can send (the carrier) to the nurse practitioner (for
"If you do not have the dedicated team to trace people and
call them up if they default (follow up), it could run into big
" Let him know that we are not just sitting down and let things
happen. We are also actively participating and get him to involve
in his own health and management of his conditions."
Gp): "We actually set up Hepatitis B register... we actively
refer to the nurse practitioner to make a note that they had attended
and to make projection when they are supposed to come back."
"We have the ( HBV documentation) form too... we write it on the jacket cover too, together with all the key labels. I think
that is probably the most useful reminders."
"Like immunization...if they miss, some computer print - out
will be posted to their house."
"Som of us will make it a habit to write it near the drug allergy
column or the essential information column or case summary...or
use stickers to remind you."
Educating the HBV carriers to enhance their understanding of the disease
appeared to be the key initiative advocated by the participants to improve
the patients' compliance to follow-up. There were variable methods and
emphasis proposed by the participants but the underlying aim was to let
the HBV carriers understand their condition and the purpose of regular
monitoring of the disease. The first visit by the HBV carrier to the GP
was thought to be critical in setting the right platform for patient education
due to the walk-in primary healthcare system in Singapore.
GPs would emphasize the chronicity of the disease and used layman terms
to describe the activity of the virus in the liver. The use of analogy
was one method to bring across the message. It was deemed important to
provide the HBV carriers with an overview of the disease and educate them
on the HBV related complications such as cirrhosis and hepatocellular
carcinoma. Many would stress that the main purpose of monitoring was to
detect the HBV related liver complications from the biochemical, serological
and imaging investigations. The participants reckoned that the information
should be pitched at the educational level and understanding of the individual
from paramedical staff
Few GPs from the polyclinics suggested delegating the task of educating
the HBV carriers to the nurses in view of the heavy patient workload,
which inevitably compromised on the consultation time for the patients.
It would seem plausible to engage the paramedical personnel in these large
primary care centers, which are supported by more manpower.
participants suggested engaging the nurses to track the patients in a
manual form of patient recall system.
correct perspective and priority
Setting the correct perspective, priority and expectation for their HBV
carrier patients during the follow up was regarded by the GPs to be a
crucial task. The focus should be monitoring of potential derangement
of liver function for the well carriers instead of resolution of the disease.
This would avoid disappointment, misunderstanding and frustration for
of complication was suggested by one participant to be used tactfully
to persuade the carriers to monitor their disease regularly although not
all the FGDs shared the same sentiments. Several GPs indicated that they
would involve the HBV carriers directly in decision making for their self-care
management in the long term. The objective would be to empower the carrier
with the necessary information so that they understood personally the
needs for the regular monitoring of their condition.
statistics of the risk of complications to the carriers was another option.
One FGD suggested that this approach could be applied to the more educated
patients. It would present an overview of risk from a different perspective;
it was argued that the carriers were more concerned of the direct impact
of the disease to the individual which mattered most and statistical information
may not have seemed to be relevant.
should show that they were actively supporting the HBV carriers in the
management of the latter's own health. The image that the GPs were passively
monitoring the numeric parameters of the investigations should be abolished.
A "too pessimistic, too complacent" impression of the doctor
would also deter the patients from their follow up. It was also important
not to paint a dismal picture of the disease but use the consultation
to motivate them to continue their follow up.
remind both the doctor and the HBV carrier of the follow up, a recall
system was perceived by the participants to be useful. Various suggestions
were put forward, including:
documentation of the diagnosis on the case folders
use of color coded stickers
repeat documentation of the HBV carrier after each consultation
IT based automatic patient recall system.
specific documentation forms were available in selected polyclinics but
their aim was not as reminders. There was an isolated active recall system
in one polyclinic but the practice was almost non-existent elsewhere.
participants would pre-empt the patients by giving them the blood investigation
forms with the dates for the next round of monitoring. This method again
relied on the doctor's initiative and the memory of the carriers, which
could often lapse.
to regular disease monitoring was identified as a major barrier in the
management of chronic HBV infection in general practice. The paucity of
symptoms and the perceived lack of understanding of the disease by the
carriers were contributory factors to the poor compliance. The participants
in the study had suggested their approaches and initiatives to reduce
this hurdle. Educating the carriers to understand the disease and the
need for regular monitoring was the penultimate goal. The GPs considered
it worthwhile to invest time to educate and set the correct perspective
for their carriers, preferably to be executed during the carrier's first
consultation for this purpose. However no participant mentioned that these
situations presented opportunities for pharmaceutical interventions to
reduce further consequences.
authors regarded these suggestions as feasible strategies to improve compliance
and could be assimilated into the routine consultation. What matter are
the will and motivation of the GPs themselves to undertake such endeavor
in every consultation with their HBV carriers. However, whether such strategies
prove to be effective in persuading HBV carriers to comply with their
follow up have yet to be determined.
GPs should also capitalize on the opportunity in the consultation to set
priorities and rectify any negative perspectives harboured by their HBV carriers
about their disease.
the impression that GPs were partners in the care of their chronic condition
through warm and optimistic interaction in the consultation would also
motivate the HBV carriers to comply with their regular disease monitoring.
nurses in the polyclinics are trained to educate the public and patients
in the management of many chronic diseases such as diabetes mellitus,
hypertension and asthma. The proposal to recruit the assistance of paramedical
staff to educate the HBV carriers has yet to be implemented, as there
is currently an absence of any structured programme to train the nurses or
other paramedical staff in the management of chronic HBV infection. The
authors considered the training of paramedical staff to handle the HBV
carriers to be an achievable task. They could also cater to a wider audience
as group discussion or workshop could be more cost effective than the
more labour-intensive person-to-person education. It would also present
opportunities for the HBV carriers to share their experiences with the
other carriers and a platform for the establishment of support groups
to motivate each other in the monitoring of their condition. Even so the
general shortage of trained nurses in primary care is a handicap to introduce
this outreach programme. The smaller or solo GP clinics would face even
more restricted manpower resource.
recall systems and doctor-reminders have proven to be effective in improving
compliance in the utilization of various preventive care or screening
programmes for breast and cervical cancer, childhood and adult immunization.(7
Based on the same principle, such strategies could extend to screening
HBV carriers for complications and malignancy. The use of prompts, alert
or reminders will provide information for GPs to make appropriate patient
Vigorous application of this simple and effective measure could probably
remind the GPs to regularly check their HBV carriers of their liver status.
relied on educating the HBV carriers to understand the natural history
and potential complications of the disease to improve their compliance
to follow up. Recruitment of paramedical staff to educate the patients
was another option. A patient-recall system and various types of aide-memoirs
to remind the GPs to monitor their patient's condition were suggestions
to enhance the compliance.
authors were grateful to all participating GPs who had contributed to
the study and thankful to the research nurses, Violet and Vasanti, who
had rendered their assistance during the FGDs and diligently transcribed
all the voice recordings. The study was approved by the SingHealth Polyclinics
Ethics Committee and supported by research grant from SingHealth Research
Council to establish a HBV carrier database in SingHealth Polyclinics.
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