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Developing a primary care research agenda through collaborative efforts – a proposed “6E” model

Developing a primary care research agenda through collaborative efforts – a proposed “6E” model Background: Primary care research is at a crossroad in South Pacific. A steering committee comprising a member of WONCA Asia Pacific Regional (APR) council and the President of Fiji College of General Practitioners garnered sponsorship from Fiji Ministry of Health, WONCA APR and pharmaceutical agencies to organize the event in October 2013. This paper describes the processes needed to set up a national primary research agenda through the collaborative efforts of local stakeholders and external facilitators using a test case in South Pacific. Method: The setting was a 2-day primary care research workshop in Fiji. The steering committee invited a team of three external facilitators from the Asia-Pacific region to organize and operationalize the workshop. The eventual participants were 3 external facilitators, 6 local facilitators, and 29 local primary care physicians, academics, and local medical leaders from Fiji and South Pacific Islands. Pre-workshop and main workshop programs were drawn up by the external facilitators, using participants’ input of research topics relating to their local clinical issues of interest. Course notes were prepared and distributed before the workshop. In the workshop, proposed research topics were shortlisted by group discussion and consensus. Study designs were proposed, scrutinized, and adopted for further research development. Results: The facilitators reviewed the processes in setting the research agenda after the workshop and conceived the proposed 6E model. These processes can be grouped for easy reference, comprising the pre-workshop stages of “entreat”, “enlist”, “engage”, and the workshop stages of “educe”, “empower”,and “encapsulate”. Conclusion: The 6E model to establish a research agenda is conceptually logical. Its feasibility can be further tested in its applicationinother situationwhere research agenda setting is the critical step to improve the quality of primary care. Keywords: Primary care, Research agenda, Collaboration, Workshop, process, Model Introduction income countries. Strategic directives are thus necessary Effective and efficient primary care in a healthcare system to optimize the limited resources in these countries for is fundamental towards improving global health and re- primary care research. This includes identifying the key duces healthcare expenditure [1]. Naturally research in healthcare issues in the local population, evaluating their primary care allows the measurements of these attributes clinical relevance and significance and collating them into and provides a beacon to determine its direction towards a community-centric primary care research agenda. Such achieving the desired goal of providing quality healthcare an agenda will serve as a platform to engage the local re- to the population. However research itself requires re- searchers and the health policy makers to review, deliber- sources such as infrastructure, facilities, expertise and ate and prioritize resources that is needed to support any funding, which are often lacking in low and middle research endeavors in the local primary care community. Drawing up a primary care research agenda requires care- ful planning and organization. Nonetheless, there is a * Correspondence: tan.ngiap.chuan@singhealth.com.sg 1 dearth of information on the processes that are effective in SingHealth Polyclinics, Singapore, 167, Jalan Bukit Merah, #15-10, its development. Connection One, Tower 5, Singapore 538134, Singapore Full list of author information is available at the end of the article © 2014 Tan et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 2 of 6 Fiji and other South Pacific nations are developing coun- Method tries. Strengthening the health system and primary care in Pre-workshop the Western Pacific countries is one of the resolutions set A steering committee comprising a member of WONCA by the World Health Organization (WHO) [2]. Primary APR council and the President of FCGP garnered sponsor- and preventative healthcare services provide key healthcare ship from Ministry of Health, WONCA APR and pharma- services to the local populations on these island nations ceutical agencies to organize the primary care research and research would have been instrumental to measure its workshop in Fiji. They invited a team of three external fa- effectiveness and efficiency [3]. However in 2004, Cuboni cilitators from the Asia-Pacific region to organize and et al reported that health research in the Pacific was operationalize the workshop. hithertho driven by non-Fijian researchers, with little local The steering committee proceeded to enlist and engage healthcare professionals’ involvement, processed the data local physicians (largely from primary care clinics and sev- and published them externally and brought meek benefits eral from hospitals) from both the public and private sec- to the communities [4]. tors, academics from universities and research support Five years later in 2009, the inaugural National Health officials (including those from research ethics office) from Systems Research Workshop was organized in conjunc- Ministry of Health to participate in the workshop. They tion with the WHO, Ministry of Health Fiji and the Fiji also enlisted local public health researchers to co-facilitate School of Medicine [5]. This workshop was executed like the workshop. a typical scientific meeting in which participants were Enlisted participants were invited to describe clinical invited to present their research papers for peer review issues encountered in their respective practices or their on-site. A total of 27 papers covering oral health, nurs- areas of research interest using a standardized template, ing to human resource, including only a single paper on highlighting the clinical relevance and significance. They primarycarewerepresented.A SWOT (Strength, submitted to the Fiji College of General Practitioners Weakness, Opportunities and Threats) analysis of the (FCGP) for collation and then emailed to the external workshop was performed which reported heightened facilitators. participants’ interests in research, predominance of External facilitators reviewed these submissions to public health topics, lack of awareness of local research have an overview of the local clinical issues. They used resources and recommended the need to engage the them as resource materials in the workshop to prepare healthcare professionals in the private sector. There was and enable the participants to convert these clinical is- no further progress report in the aftermath of this work- sues into research questions. shop. The absence of a focused research agenda and de- To gain better insight into the healthcare infrastructure, finitive action plan could explain the paucity of progress resources and material for research, the external facilita- to bring this initiative forward. tors visited local healthcare institutions, including private A fresh initiative to accelerate the momentum of re- solo and group primary care clinics, a public primary care search in Fiji was mooted in 2012 when discussion began health center and a district hospital. They rode on the op- at the WONCA Asia Pacific Regional (APR) Conference portunity to interact with local healthcare professionals to in Jeju in South Korea to sponsor a research workshop to appreciate and understand the magnitude and clinical sig- train primary healthcare professionals in Fiji and neigh- nificance of endemic healthcare issues, which helped boring South Pacific nations. With the support and spon- prioritize the key areas of research. sorship of the Fiji Ministry of Health (MOH), the Fiji The 3 external and 7 local facilitators (academics, practi- College of General Practitioners (FCGP) and WONCA tioners, local leaders) met for a briefing to identify local re- APR, the two days “Primary Care Research Workshop” search expertise and resource personals to support the took place in October 2013. novice primary care researchers after the workshop. During workshop Aim Participants were introduced to the scope of primary This article aims to present a proposed 6E model to de- care research at the workshop with reference to the scribe the processes needed to develop the primary care Larry Green’s primary care research model [6]. The ex- research agenda, which is to address the health care ternal facilitators converted the participants’ pre- needs of the local populations and build the research workshop clinical issues into broad potential research capacity of the local research communities, through in- questions and framed them into the domains in the creasing the quantity and quality of research output and Larry Green “Generalist Wheel of knowledge and un- application in Fiji and South Pacific nations. It is hoped derstanding” [6]. The intent was to enable the partici- this proposed model can find applicability in the setting pants to appreciate the wider scope of primary care of national primary care research agendas. research beyond the domain of clinical research in Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 3 of 6 diseases and treatment to the domains of the patients, The team representatives presented their respective pro- their families and the community; the healthcare profes- posals at day 2 of workshop and invited comments and cri- sionals; health service and policy; as well as topics relating tique from peers amongst the audience, with feedback from to the interface between domains such as doctor-patient the external facilitators on the content of the proposal and relationship. input about logistic feasibility from the local facilitators. The external facilitators incorporated the research Each presentation included (1) the relevance and signifi- topics from the pre-workshop submissions into the cance of the research question and topic in relation to gaps workshop modules and presented them to the partici- in the local healthcare context, and (2) the appropriateness pants to contextualize the areas of research interests to of the methodology for each respective research question. local setting. The external facilitators collated the initial research Participants were divided into three teams, each sup- proposals, assembled them into a preliminary research ported by one external and two local facilitators. During agenda, analyzed the content and classified them into h scheduled group discussions, each team of facilitators the domains of the Generalist Wheel of Knowledge. guided the participants through the research process by deliberating on the proposed clinical issues, refining them Results into answerable research questions, choosing appropriate The range of 17 topics proposed by participants collated research design, and developing the research idea into a by external facilitators before the workshop is presented in feasible research proposal. Table 1. Table 2 depicts the 6 short-listed proposals de- The external facilitators provided participants with op- veloped and presented by teams of participants on Day portunities to highlight other or new research ideas and 2 of the workshop. The external facilitators grouped the proposals during informal sessions or refreshment inter- research topics into four research domains based on vals. The participants grouped themselves to form teams Larry Green’s Generalist Wheel of Understanding, in for each proposal. Tables 1and 2[6]. Table 1 Clinical issues proposed by the participants before the workshop Clinical areas Specific clinical issues Research domains Maternal and child health Effectiveness of CTG in the monitoring of maternal labor during childbirth Disease Diagnostic investigations for rheumatic health diseases amongst affected Disease children; issues relating to referral to secondary care Communicable diseases Management of patients with undifferentiated symptoms in early phase Disease of dengue, typhoid and Leptospirosis. Inappropriate use of antibiotics for viral infection such as dengue Disease Accuracy of simple test to diagnose dengue using tourniquet in Disease resource-poor community Management of hemoptysis amongst patients with pneumonia Disease Non-communicable diseases Rising prevalence of hypertension and diabetes mellitus: managing at risk Disease patients with these chronic diseases in rural communities Management of diabetic-related complications in primary care Disease Perception of diabetic patients for their foot care Patient Management of type 2 diabetes mellitus: evidence-based pharmacotherapy Disease Physician management of hypercholesterolemia amongst diabetic patients Disease Management of acute asthma exacerbation: effectiveness of Disease pharmacotherapy at an emergency setting Effectiveness of evidence-based pharmacotherapy to achieve and Disease maintain asthma control Trauma and injuries Epidemiology of road traffic accidents in Cook Islands Disease Alternative medicine Impact of Livomyn on the liver function amongst kava drinkers Disease Training of primary care physicians Patients’ perception of the continuous medical education of their Patient general practitioners Medical defense for primary care physician Mandatory implementation of medical indemnity for general practitioners in Fiji Physician Research Domains as classified in the “Generalist Wheel of Knowledge” [6]. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 4 of 6 Table 2 Research proposals presented by the participants during the workshop Potential lead Team members Research question Proposed research method Research domain Academics and researchers GPs from singleton and What is the prevalence of depression amongst A questionnaire survey of Fijians Disease from university and MOH group practices Fijians aged 18 to 40 years who are managed who consulted primary care clinics in primary care? Academics and researchers Researchers from MOH What is the prevalence of Yaqola (Piper methysticum) A questionnaire survey of Disease from university and MOH (Western division) consumption among high school students in the high school students in Fiji Western Division? Fiji College of General GP and primary care physician (PCP) Amongst primary care physicians (both in public A cross-sectional survey of PCPs Physician Practitioners in public health centers in Fiji and private sectors) in Fiji, what are their treatment in Fiji who managed T2DM patients targets for patients with type 2 diabetes mellitus (T2DM)? Primary care physician PCP in public health centers in What is the association between air pollutants from A prospective study of patients who present Disease Vanuatu and academic from Fiji volcanic eruption and the health of residents on with acute respiratory conditions in one hospital Tanna Island in Vanuatu? and 9 health centers on Tanna Island in relation to local volcanic pollution indicator Primary care physician PCPs from health centers and What is the correlation between the asthma Prospective study of asthma patients in Ba, Disease medical officers from hospital exacerbation rate and pollution from the Cakaudrove and Macuata district on Viti burning of sugarcane plantation? Levu island in Fiji Ministry of Health Medical officers from hospitals What are the factors associated with diagnostic A retrospective study of tuberculosis Primary health care and researchers from disease-specific and treatment delays of patients with active patients who are managed in DOTS and system Fiji College of General public health agency tuberculosis? centres in Fiji Practitioners Research Domains as classified in the “Generalist Wheel of Knowledge” [6]. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 5 of 6 Discussion workshop (refer to Table 1). The authors postulated Summary of main ideas that time constraint and dynamics of the team and This article describes the development of a national pri- their selection of presenter at the workshop could be mary care research agenda through collaborative efforts possible reasons. by local stakeholders and external facilitators. Tables 1 What is novel is that it presents a plausible model for and 2 show the breath of topics highlighted by the par- understanding of the processes involved in the creation of ticipants, which can be potentially incorporated into the a national primary care research agenda. The processes in- research agenda. However time constraints at the work- volved can be categorized into six essential stages, starting shop limited the number of research proposal presenta- with the alphabet E (Table 3). tions by the teams, which explained the reduction in the This model uses a logical and sequential framework to number of presented proposals. illustrate its development, with the local steering com- The external facilitators condensed the research mittee members played an active role in the first three agenda into four main research domains for ease of con- stages as part of the pre-workshop preparation. The ex- ceptualizing, understanding and further communication ternal facilitators anchored the remaining three stages with local health authority for the latter’ssupport to during the workshop execution. actualize the research endeavor [6]. The research agenda It began with “Entreat” for the steering workgroup also gained a broader perspective using this framework to members to secure support and sponsorship from gov- avoid a skewed focus on clinical research and to ensure a ernmental agency to fund the workshop. The next stage more equitable resource distribution to support research involved their enlistment of the key primary care stake- in the other domains. However, the lack of presentation of holders to participate in the workshop, followed by their any proposal focusing on the patient domain is note- engagement of external and local facilitators to execute worthy, despite such proposal being submitted in the pre- the workshop. Table 3 Developing a research agenda using the six “E” steps Stage Process Illustration Stakeholders Pre-workshop Entreat Local FM leaders form steering group actively seeks official sponsorship from the College of GP, MOH, Academic local Ministry of Health and concerted support from local primary care physicians institution, WONCA experts from the College of General Practitioners and academic staff from FM department in local university. Steering group also entreats external primary care organization such as WONCA to identify regional expertise and sponsor external facilitators to operate the workshop. Enlist The steering group identifies and puts up a list of primary care physicians from Primary care researcher both public and private health sectors with research inclination to be potential participants in a primary care research workshop. Engage The steering group members engage academic staff and established researchers Academic institution, from academic institutions to co-facilitate the research workshop and to provide MOH, WONCA experts input on local resources and expertise to support research. The external facilitators also engage and partner the local researchers and resource personnel (to identify funding sources and to direct to relevant approval agencies such as ethical committee for research) to define specific roles at the workshop and streamlines the program at a pre-workshop briefing. This is to ensure that the program is contextualized to the local healthcare and academic system. At workshop Educe External facilitators educe the participants to identify key local healthcare issues WONCA experts, and form research questions and develop respective research proposals. primary care researcher Participants are encouraged to form research teams to further develop their respective proposals. Empower External facilitators train the participants to apply appropriate research design WONCA experts, MOH, to answer their research questions in their proposal. Local facilitators introduce primary care researchers and highlight local resources and expertise to participants who can potentially assist and support the latter when they proceed with their research project. Participants present and share their proposals to each other for clarifications and mutual understanding. Encapsulate External facilitators collate the research proposals, organize them into a research WONCA experts, agenda and to seek advice from the local FM steering group regarding feasibility. primary care researchers This is followed by classification into broad research domains and identification of key drivers to lead specific areas of research. Lastly, the external facilitators and the workshop participants agreed on the next steps and ways to operationalize the research proposals. WONCA: World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. MOH: Ministry of Health (or National Department of Health equivalent in the respective country). Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 6 of 6 During the workshop, the external facilitators educed Authors’ contributions LG, CJ and NC conceptualized the program, facilitated the execution of the the participants to identify major healthcare issues of Primary Care Research workshop, analyzed the data and developed the clinical relevance and significance in the local commu- model. WK and RM were the local facilitators and co-designed the workshop. nity. They empowered the participants with the relevant NC wrote the preliminary draft article and all authors contributed to and approved the final manuscript. research skills and guided them to use the appropriate research methodology to bridge the highlighted gaps. Authors’ information During this stage, the local facilitators also availed the NC is the Director of the Department of Research in SingHealth Polyclinics, a public primary care institution with an ACGME accredited Family Medicine participants to the funding resources and expertise to Residency Program in Singapore. CJ is a Professor in the Department of support their research projects. Finally the external facil- Primary Care Medicine in the University of Malaya, who organizes regular itators encapsulated the variety of research proposals de- research related training programs for primary care doctors in Malaysia. RM is the current President of FCGP. WK is the past President FCGP and current veloped during the workshop into easily assimilated honorary secretary in WONCA APR. Both are GPs in Fji. LG is the past President research domains (disease, patient, healthcare profes- WONCA APR and now teaches at another ACGME accredited Family Medicine sionals, and health system) and developed concrete plans Residency Program at the National University Hospital in Singapore. with the participants on ways to operationalize the re- Acknowledgement search proposals. The authors are grateful to the participation and contribution of the delegates at the workshop and the support rendered by Litia, administrator of the FCGP and the research support staff from the Ministry of Health of Fiji. Application for future research The authors were also appreciative to Prof Lee Jung kwon, current President The model can serve as a template for other nations of the WONCA APR for his personal support of the workshop. who are planning to develop their unique community- Author details centric primary care research agenda. It is configured SingHealth Polyclinics, Singapore, 167, Jalan Bukit Merah, #15-10, into six steps, with three as pre-workshop processes and Connection One, Tower 5, Singapore 538134, Singapore. Department of the next three during the workshop. Further evaluation Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Mitchells Clinic (Family Practice), 4th floor Tappoos City is needed to assess its ease of implementation when op- 4 5 Mall, Suva, Fiji. JP Bayly Clinic, Suva, Fiji. Division of Family Medicine, portunity arises for other countries with such intent. National University Hospital System, NUHS Tower Block, 1E, Kent Ridge Road, Level 9, Singapore 119 228, Singapore. Limitations of this study Received: 15 April 2014 Accepted: 11 December 2014 Whether primary care research continues to progress will depend on a multitude of factors such as the dynamics and References perseverance of the research teams, their access to adequate 1. Starfield B, Shi L, Macinko J: Contribution of primary care to health consultancy from local experts and support and sponsor- systems and health. Milbank Q 2005, 83:457–502. ship from the official and other funding agencies. Nonethe- 2. Regional committee for the Western pacific. World Health organization. Health systems strengthening and primary healthcare (2008). less, the participants are primed during the workshop to Accessed on 25 Nov 2013: http://www.wpro.who.int/health_systems/ continue their efforts to translate the proposals into actual wpr59R4_primary_health_care_resolution.pdf projects. The steering group and local facilitators will play a 3. Graham R, Wayne I, Timaima T, Rigieta N, Sisa O, Sheetal S et al. The Fiji islands health system review. (Health Systems in Transition, Vol. 1 No. 1 2011). catalytic role to facilitate this effectuation of the projects ISBN 978 92 9061 543 9 and evaluate the progress of their implementation. 4. Cuboni HD, Finau SA, Wainiqolo I, Cuboni G: Fijian participation in health research: analysis of Medline publications 1965-2002. Pac Health Dialog 2004, 11(1):59–78. Conclusion 5. Ali SS: Fiji National Health Systems Research Workshop report. Pac Health The proposed “six E” model, consisting of “entreat”, “en- Dialog 2009, 15(2):7–12. list”, “engage”, “educe”, “empower”, and “encapsulate”, 6. Green LA: Research domain in Family Medicine. Ann Fam Med 2004, 2:S23–S29. defines the development of the research agenda and pro- vides a staged model that is visible and translatable in building a country’s primary care research agenda. Submit your next manuscript to BioMed Central Abbreviations and take full advantage of: WONCA: World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians; APR: Asia Pacific • Convenient online submission Region; MOH: Ministry of Health; FCGP: Fiji College of General Practitioners; • Thorough peer review GP: General practitioner. • No space constraints or color figure charges • Immediate publication on acceptance Competing interests • Inclusion in PubMed, CAS, Scopus and Google Scholar The workshop was co-sponsored by WONCA Asia Pacific Regional division, Fiji College of General Practitioners and Ministry of Health of Fiji. LG, CJ and NC • Research which is freely available for redistribution received partial sponsorship from the organizers for flight and accommodation expenses during the workshop. The authors declare that there is no further Submit your manuscript at competing interest in the publication of this manuscript. www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Developing a primary care research agenda through collaborative efforts – a proposed “6E” model

Developing a primary care research agenda through collaborative efforts – a proposed “6E” model

Background: Primary care research is at a crossroad in South Pacific. A steering committee comprising a member of WONCA Asia Pacific Regional (APR) council and the President of Fiji College of General Practitioners garnered sponsorship from Fiji Ministry of Health, WONCA APR and pharmaceutical agencies to organize the event in October 2013. This paper describes the processes needed to set up a national primary research agenda through the collaborative efforts of local stakeholders and external facilitators using a test case in South Pacific. Method: The setting was a 2-day primary care research workshop in Fiji. The steering committee invited a team of three external facilitators from the Asia-Pacific region to organize and operationalize the workshop. The eventual participants were 3 external facilitators, 6 local facilitators, and 29 local primary care physicians, academics, and local medical leaders from Fiji and South Pacific Islands. Pre-workshop and main workshop programs were drawn up by the external facilitators, using participants’ input of research topics relating to their local clinical issues of interest. Course notes were prepared and distributed before the workshop. In the workshop, proposed research topics were shortlisted by group discussion and consensus. Study designs were proposed, scrutinized, and adopted for further research development. Results: The facilitators reviewed the processes in setting the research agenda after the workshop and conceived the proposed 6E model. These processes can be grouped for easy reference, comprising the pre-workshop stages of “entreat”, “enlist”, “engage”, and the workshop stages of “educe”, “empower”,and “encapsulate”. Conclusion: The 6E model to establish a research agenda is conceptually logical. Its feasibility can be further tested in its applicationinother situationwhere research agenda setting is the critical step to improve the quality of primary care. Keywords: Primary care, Research agenda, Collaboration, Workshop, process, Model Introduction income countries. Strategic directives are thus necessary Effective and efficient primary care in a healthcare system to optimize the limited resources in these countries for is fundamental towards improving global health and re- primary care research. This includes identifying the key duces healthcare expenditure [1]. Naturally research in healthcare issues in the local population, evaluating their primary care allows the measurements of these attributes clinical relevance and significance and collating them into and provides a beacon to determine its direction towards a community-centric primary care research agenda. Such achieving the desired goal of providing quality healthcare an agenda will serve as a platform to engage the local re- to the population. However research itself requires re- searchers and the health policy makers to review, deliber- sources such as infrastructure, facilities, expertise and ate and prioritize resources that is needed to support any funding, which are often lacking in low and middle research endeavors in the local primary care community. Drawing up a primary care research agenda requires care- ful planning and organization. Nonetheless, there is a * Correspondence: tan.ngiap.chuan@singhealth.com.sg 1 dearth of information on the processes that are effective in SingHealth Polyclinics, Singapore, 167, Jalan Bukit Merah, #15-10, its development. Connection One, Tower 5, Singapore 538134, Singapore Full list of author information is available at the end of the article © 2014 Tan et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 2 of 6 Fiji and other South Pacific nations are developing coun- Method tries. Strengthening the health system and primary care in Pre-workshop the Western Pacific countries is one of the resolutions set A steering committee comprising a member of WONCA by the World Health Organization (WHO) [2]. Primary APR council and the President of FCGP garnered sponsor- and preventative healthcare services provide key healthcare ship from Ministry of Health, WONCA APR and pharma- services to the local populations on these island nations ceutical agencies to organize the primary care research and research would have been instrumental to measure its workshop in Fiji. They invited a team of three external fa- effectiveness and efficiency [3]. However in 2004, Cuboni cilitators from the Asia-Pacific region to organize and et al reported that health research in the Pacific was operationalize the workshop. hithertho driven by non-Fijian researchers, with little local The steering committee proceeded to enlist and engage healthcare professionals’ involvement, processed the data local physicians (largely from primary care clinics and sev- and published them externally and brought meek benefits eral from hospitals) from both the public and private sec- to the communities [4]. tors, academics from universities and research support Five years later in 2009, the inaugural National Health officials (including those from research ethics office) from Systems Research Workshop was organized in conjunc- Ministry of Health to participate in the workshop. They tion with the WHO, Ministry of Health Fiji and the Fiji also enlisted local public health researchers to co-facilitate School of Medicine [5]. This workshop was executed like the workshop. a typical scientific meeting in which participants were Enlisted participants were invited to describe clinical invited to present their research papers for peer review issues encountered in their respective practices or their on-site. A total of 27 papers covering oral health, nurs- areas of research interest using a standardized template, ing to human resource, including only a single paper on highlighting the clinical relevance and significance. They primarycarewerepresented.A SWOT (Strength, submitted to the Fiji College of General Practitioners Weakness, Opportunities and Threats) analysis of the (FCGP) for collation and then emailed to the external workshop was performed which reported heightened facilitators. participants’ interests in research, predominance of External facilitators reviewed these submissions to public health topics, lack of awareness of local research have an overview of the local clinical issues. They used resources and recommended the need to engage the them as resource materials in the workshop to prepare healthcare professionals in the private sector. There was and enable the participants to convert these clinical is- no further progress report in the aftermath of this work- sues into research questions. shop. The absence of a focused research agenda and de- To gain better insight into the healthcare infrastructure, finitive action plan could explain the paucity of progress resources and material for research, the external facilita- to bring this initiative forward. tors visited local healthcare institutions, including private A fresh initiative to accelerate the momentum of re- solo and group primary care clinics, a public primary care search in Fiji was mooted in 2012 when discussion began health center and a district hospital. They rode on the op- at the WONCA Asia Pacific Regional (APR) Conference portunity to interact with local healthcare professionals to in Jeju in South Korea to sponsor a research workshop to appreciate and understand the magnitude and clinical sig- train primary healthcare professionals in Fiji and neigh- nificance of endemic healthcare issues, which helped boring South Pacific nations. With the support and spon- prioritize the key areas of research. sorship of the Fiji Ministry of Health (MOH), the Fiji The 3 external and 7 local facilitators (academics, practi- College of General Practitioners (FCGP) and WONCA tioners, local leaders) met for a briefing to identify local re- APR, the two days “Primary Care Research Workshop” search expertise and resource personals to support the took place in October 2013. novice primary care researchers after the workshop. During workshop Aim Participants were introduced to the scope of primary This article aims to present a proposed 6E model to de- care research at the workshop with reference to the scribe the processes needed to develop the primary care Larry Green’s primary care research model [6]. The ex- research agenda, which is to address the health care ternal facilitators converted the participants’ pre- needs of the local populations and build the research workshop clinical issues into broad potential research capacity of the local research communities, through in- questions and framed them into the domains in the creasing the quantity and quality of research output and Larry Green “Generalist Wheel of knowledge and un- application in Fiji and South Pacific nations. It is hoped derstanding” [6]. The intent was to enable the partici- this proposed model can find applicability in the setting pants to appreciate the wider scope of primary care of national primary care research agendas. research beyond the domain of clinical research in Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 3 of 6 diseases and treatment to the domains of the patients, The team representatives presented their respective pro- their families and the community; the healthcare profes- posals at day 2 of workshop and invited comments and cri- sionals; health service and policy; as well as topics relating tique from peers amongst the audience, with feedback from to the interface between domains such as doctor-patient the external facilitators on the content of the proposal and relationship. input about logistic feasibility from the local facilitators. The external facilitators incorporated the research Each presentation included (1) the relevance and signifi- topics from the pre-workshop submissions into the cance of the research question and topic in relation to gaps workshop modules and presented them to the partici- in the local healthcare context, and (2) the appropriateness pants to contextualize the areas of research interests to of the methodology for each respective research question. local setting. The external facilitators collated the initial research Participants were divided into three teams, each sup- proposals, assembled them into a preliminary research ported by one external and two local facilitators. During agenda, analyzed the content and classified them into h scheduled group discussions, each team of facilitators the domains of the Generalist Wheel of Knowledge. guided the participants through the research process by deliberating on the proposed clinical issues, refining them Results into answerable research questions, choosing appropriate The range of 17 topics proposed by participants collated research design, and developing the research idea into a by external facilitators before the workshop is presented in feasible research proposal. Table 1. Table 2 depicts the 6 short-listed proposals de- The external facilitators provided participants with op- veloped and presented by teams of participants on Day portunities to highlight other or new research ideas and 2 of the workshop. The external facilitators grouped the proposals during informal sessions or refreshment inter- research topics into four research domains based on vals. The participants grouped themselves to form teams Larry Green’s Generalist Wheel of Understanding, in for each proposal. Tables 1and 2[6]. Table 1 Clinical issues proposed by the participants before the workshop Clinical areas Specific clinical issues Research domains Maternal and child health Effectiveness of CTG in the monitoring of maternal labor during childbirth Disease Diagnostic investigations for rheumatic health diseases amongst affected Disease children; issues relating to referral to secondary care Communicable diseases Management of patients with undifferentiated symptoms in early phase Disease of dengue, typhoid and Leptospirosis. Inappropriate use of antibiotics for viral infection such as dengue Disease Accuracy of simple test to diagnose dengue using tourniquet in Disease resource-poor community Management of hemoptysis amongst patients with pneumonia Disease Non-communicable diseases Rising prevalence of hypertension and diabetes mellitus: managing at risk Disease patients with these chronic diseases in rural communities Management of diabetic-related complications in primary care Disease Perception of diabetic patients for their foot care Patient Management of type 2 diabetes mellitus: evidence-based pharmacotherapy Disease Physician management of hypercholesterolemia amongst diabetic patients Disease Management of acute asthma exacerbation: effectiveness of Disease pharmacotherapy at an emergency setting Effectiveness of evidence-based pharmacotherapy to achieve and Disease maintain asthma control Trauma and injuries Epidemiology of road traffic accidents in Cook Islands Disease Alternative medicine Impact of Livomyn on the liver function amongst kava drinkers Disease Training of primary care physicians Patients’ perception of the continuous medical education of their Patient general practitioners Medical defense for primary care physician Mandatory implementation of medical indemnity for general practitioners in Fiji Physician Research Domains as classified in the “Generalist Wheel of Knowledge” [6]. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 4 of 6 Table 2 Research proposals presented by the participants during the workshop Potential lead Team members Research question Proposed research method Research domain Academics and researchers GPs from singleton and What is the prevalence of depression amongst A questionnaire survey of Fijians Disease from university and MOH group practices Fijians aged 18 to 40 years who are managed who consulted primary care clinics in primary care? Academics and researchers Researchers from MOH What is the prevalence of Yaqola (Piper methysticum) A questionnaire survey of Disease from university and MOH (Western division) consumption among high school students in the high school students in Fiji Western Division? Fiji College of General GP and primary care physician (PCP) Amongst primary care physicians (both in public A cross-sectional survey of PCPs Physician Practitioners in public health centers in Fiji and private sectors) in Fiji, what are their treatment in Fiji who managed T2DM patients targets for patients with type 2 diabetes mellitus (T2DM)? Primary care physician PCP in public health centers in What is the association between air pollutants from A prospective study of patients who present Disease Vanuatu and academic from Fiji volcanic eruption and the health of residents on with acute respiratory conditions in one hospital Tanna Island in Vanuatu? and 9 health centers on Tanna Island in relation to local volcanic pollution indicator Primary care physician PCPs from health centers and What is the correlation between the asthma Prospective study of asthma patients in Ba, Disease medical officers from hospital exacerbation rate and pollution from the Cakaudrove and Macuata district on Viti burning of sugarcane plantation? Levu island in Fiji Ministry of Health Medical officers from hospitals What are the factors associated with diagnostic A retrospective study of tuberculosis Primary health care and researchers from disease-specific and treatment delays of patients with active patients who are managed in DOTS and system Fiji College of General public health agency tuberculosis? centres in Fiji Practitioners Research Domains as classified in the “Generalist Wheel of Knowledge” [6]. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 5 of 6 Discussion workshop (refer to Table 1). The authors postulated Summary of main ideas that time constraint and dynamics of the team and This article describes the development of a national pri- their selection of presenter at the workshop could be mary care research agenda through collaborative efforts possible reasons. by local stakeholders and external facilitators. Tables 1 What is novel is that it presents a plausible model for and 2 show the breath of topics highlighted by the par- understanding of the processes involved in the creation of ticipants, which can be potentially incorporated into the a national primary care research agenda. The processes in- research agenda. However time constraints at the work- volved can be categorized into six essential stages, starting shop limited the number of research proposal presenta- with the alphabet E (Table 3). tions by the teams, which explained the reduction in the This model uses a logical and sequential framework to number of presented proposals. illustrate its development, with the local steering com- The external facilitators condensed the research mittee members played an active role in the first three agenda into four main research domains for ease of con- stages as part of the pre-workshop preparation. The ex- ceptualizing, understanding and further communication ternal facilitators anchored the remaining three stages with local health authority for the latter’ssupport to during the workshop execution. actualize the research endeavor [6]. The research agenda It began with “Entreat” for the steering workgroup also gained a broader perspective using this framework to members to secure support and sponsorship from gov- avoid a skewed focus on clinical research and to ensure a ernmental agency to fund the workshop. The next stage more equitable resource distribution to support research involved their enlistment of the key primary care stake- in the other domains. However, the lack of presentation of holders to participate in the workshop, followed by their any proposal focusing on the patient domain is note- engagement of external and local facilitators to execute worthy, despite such proposal being submitted in the pre- the workshop. Table 3 Developing a research agenda using the six “E” steps Stage Process Illustration Stakeholders Pre-workshop Entreat Local FM leaders form steering group actively seeks official sponsorship from the College of GP, MOH, Academic local Ministry of Health and concerted support from local primary care physicians institution, WONCA experts from the College of General Practitioners and academic staff from FM department in local university. Steering group also entreats external primary care organization such as WONCA to identify regional expertise and sponsor external facilitators to operate the workshop. Enlist The steering group identifies and puts up a list of primary care physicians from Primary care researcher both public and private health sectors with research inclination to be potential participants in a primary care research workshop. Engage The steering group members engage academic staff and established researchers Academic institution, from academic institutions to co-facilitate the research workshop and to provide MOH, WONCA experts input on local resources and expertise to support research. The external facilitators also engage and partner the local researchers and resource personnel (to identify funding sources and to direct to relevant approval agencies such as ethical committee for research) to define specific roles at the workshop and streamlines the program at a pre-workshop briefing. This is to ensure that the program is contextualized to the local healthcare and academic system. At workshop Educe External facilitators educe the participants to identify key local healthcare issues WONCA experts, and form research questions and develop respective research proposals. primary care researcher Participants are encouraged to form research teams to further develop their respective proposals. Empower External facilitators train the participants to apply appropriate research design WONCA experts, MOH, to answer their research questions in their proposal. Local facilitators introduce primary care researchers and highlight local resources and expertise to participants who can potentially assist and support the latter when they proceed with their research project. Participants present and share their proposals to each other for clarifications and mutual understanding. Encapsulate External facilitators collate the research proposals, organize them into a research WONCA experts, agenda and to seek advice from the local FM steering group regarding feasibility. primary care researchers This is followed by classification into broad research domains and identification of key drivers to lead specific areas of research. Lastly, the external facilitators and the workshop participants agreed on the next steps and ways to operationalize the research proposals. WONCA: World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. MOH: Ministry of Health (or National Department of Health equivalent in the respective country). Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 6 of 6 During the workshop, the external facilitators educed Authors’ contributions LG, CJ and NC conceptualized the program, facilitated the execution of the the participants to identify major healthcare issues of Primary Care Research workshop, analyzed the data and developed the clinical relevance and significance in the local commu- model. WK and RM were the local facilitators and co-designed the workshop. nity. They empowered the participants with the relevant NC wrote the preliminary draft article and all authors contributed to and approved the final manuscript. research skills and guided them to use the appropriate research methodology to bridge the highlighted gaps. Authors’ information During this stage, the local facilitators also availed the NC is the Director of the Department of Research in SingHealth Polyclinics, a public primary care institution with an ACGME accredited Family Medicine participants to the funding resources and expertise to Residency Program in Singapore. CJ is a Professor in the Department of support their research projects. Finally the external facil- Primary Care Medicine in the University of Malaya, who organizes regular itators encapsulated the variety of research proposals de- research related training programs for primary care doctors in Malaysia. RM is the current President of FCGP. WK is the past President FCGP and current veloped during the workshop into easily assimilated honorary secretary in WONCA APR. Both are GPs in Fji. LG is the past President research domains (disease, patient, healthcare profes- WONCA APR and now teaches at another ACGME accredited Family Medicine sionals, and health system) and developed concrete plans Residency Program at the National University Hospital in Singapore. with the participants on ways to operationalize the re- Acknowledgement search proposals. The authors are grateful to the participation and contribution of the delegates at the workshop and the support rendered by Litia, administrator of the FCGP and the research support staff from the Ministry of Health of Fiji. Application for future research The authors were also appreciative to Prof Lee Jung kwon, current President The model can serve as a template for other nations of the WONCA APR for his personal support of the workshop. who are planning to develop their unique community- Author details centric primary care research agenda. It is configured SingHealth Polyclinics, Singapore, 167, Jalan Bukit Merah, #15-10, into six steps, with three as pre-workshop processes and Connection One, Tower 5, Singapore 538134, Singapore. Department of the next three during the workshop. Further evaluation Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Mitchells Clinic (Family Practice), 4th floor Tappoos City is needed to assess its ease of implementation when op- 4 5 Mall, Suva, Fiji. JP Bayly Clinic, Suva, Fiji. Division of Family Medicine, portunity arises for other countries with such intent. National University Hospital System, NUHS Tower Block, 1E, Kent Ridge Road, Level 9, Singapore 119 228, Singapore. Limitations of this study Received: 15 April 2014 Accepted: 11 December 2014 Whether primary care research continues to progress will depend on a multitude of factors such as the dynamics and References perseverance of the research teams, their access to adequate 1. Starfield B, Shi L, Macinko J: Contribution of primary care to health consultancy from local experts and support and sponsor- systems and health. Milbank Q 2005, 83:457–502. ship from the official and other funding agencies. Nonethe- 2. Regional committee for the Western pacific. World Health organization. Health systems strengthening and primary healthcare (2008). less, the participants are primed during the workshop to Accessed on 25 Nov 2013: http://www.wpro.who.int/health_systems/ continue their efforts to translate the proposals into actual wpr59R4_primary_health_care_resolution.pdf projects. The steering group and local facilitators will play a 3. Graham R, Wayne I, Timaima T, Rigieta N, Sisa O, Sheetal S et al. The Fiji islands health system review. (Health Systems in Transition, Vol. 1 No. 1 2011). catalytic role to facilitate this effectuation of the projects ISBN 978 92 9061 543 9 and evaluate the progress of their implementation. 4. Cuboni HD, Finau SA, Wainiqolo I, Cuboni G: Fijian participation in health research: analysis of Medline publications 1965-2002. Pac Health Dialog 2004, 11(1):59–78. Conclusion 5. Ali SS: Fiji National Health Systems Research Workshop report. Pac Health The proposed “six E” model, consisting of “entreat”, “en- Dialog 2009, 15(2):7–12. list”, “engage”, “educe”, “empower”, and “encapsulate”, 6. Green LA: Research domain in Family Medicine. Ann Fam Med 2004, 2:S23–S29. defines the development of the research agenda and pro- vides a staged model that is visible and translatable in building a country’s primary care research agenda. Submit your next manuscript to BioMed Central Abbreviations and take full advantage of: WONCA: World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians; APR: Asia Pacific • Convenient online submission Region; MOH: Ministry of Health; FCGP: Fiji College of General Practitioners; • Thorough peer review GP: General practitioner. • No space constraints or color figure charges • Immediate publication on acceptance Competing interests • Inclusion in PubMed, CAS, Scopus and Google Scholar The workshop was co-sponsored by WONCA Asia Pacific Regional division, Fiji College of General Practitioners and Ministry of Health of Fiji. LG, CJ and NC • Research which is freely available for redistribution received partial sponsorship from the organizers for flight and accommodation expenses during the workshop. The authors declare that there is no further Submit your manuscript at competing interest in the publication of this manuscript. www.biomedcentral.com/submit
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Springer Journals
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Copyright © 2014 by Tan et al.; licensee BioMed Central.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/s12930-014-0017-9
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25606021
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Abstract

Background: Primary care research is at a crossroad in South Pacific. A steering committee comprising a member of WONCA Asia Pacific Regional (APR) council and the President of Fiji College of General Practitioners garnered sponsorship from Fiji Ministry of Health, WONCA APR and pharmaceutical agencies to organize the event in October 2013. This paper describes the processes needed to set up a national primary research agenda through the collaborative efforts of local stakeholders and external facilitators using a test case in South Pacific. Method: The setting was a 2-day primary care research workshop in Fiji. The steering committee invited a team of three external facilitators from the Asia-Pacific region to organize and operationalize the workshop. The eventual participants were 3 external facilitators, 6 local facilitators, and 29 local primary care physicians, academics, and local medical leaders from Fiji and South Pacific Islands. Pre-workshop and main workshop programs were drawn up by the external facilitators, using participants’ input of research topics relating to their local clinical issues of interest. Course notes were prepared and distributed before the workshop. In the workshop, proposed research topics were shortlisted by group discussion and consensus. Study designs were proposed, scrutinized, and adopted for further research development. Results: The facilitators reviewed the processes in setting the research agenda after the workshop and conceived the proposed 6E model. These processes can be grouped for easy reference, comprising the pre-workshop stages of “entreat”, “enlist”, “engage”, and the workshop stages of “educe”, “empower”,and “encapsulate”. Conclusion: The 6E model to establish a research agenda is conceptually logical. Its feasibility can be further tested in its applicationinother situationwhere research agenda setting is the critical step to improve the quality of primary care. Keywords: Primary care, Research agenda, Collaboration, Workshop, process, Model Introduction income countries. Strategic directives are thus necessary Effective and efficient primary care in a healthcare system to optimize the limited resources in these countries for is fundamental towards improving global health and re- primary care research. This includes identifying the key duces healthcare expenditure [1]. Naturally research in healthcare issues in the local population, evaluating their primary care allows the measurements of these attributes clinical relevance and significance and collating them into and provides a beacon to determine its direction towards a community-centric primary care research agenda. Such achieving the desired goal of providing quality healthcare an agenda will serve as a platform to engage the local re- to the population. However research itself requires re- searchers and the health policy makers to review, deliber- sources such as infrastructure, facilities, expertise and ate and prioritize resources that is needed to support any funding, which are often lacking in low and middle research endeavors in the local primary care community. Drawing up a primary care research agenda requires care- ful planning and organization. Nonetheless, there is a * Correspondence: tan.ngiap.chuan@singhealth.com.sg 1 dearth of information on the processes that are effective in SingHealth Polyclinics, Singapore, 167, Jalan Bukit Merah, #15-10, its development. Connection One, Tower 5, Singapore 538134, Singapore Full list of author information is available at the end of the article © 2014 Tan et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 2 of 6 Fiji and other South Pacific nations are developing coun- Method tries. Strengthening the health system and primary care in Pre-workshop the Western Pacific countries is one of the resolutions set A steering committee comprising a member of WONCA by the World Health Organization (WHO) [2]. Primary APR council and the President of FCGP garnered sponsor- and preventative healthcare services provide key healthcare ship from Ministry of Health, WONCA APR and pharma- services to the local populations on these island nations ceutical agencies to organize the primary care research and research would have been instrumental to measure its workshop in Fiji. They invited a team of three external fa- effectiveness and efficiency [3]. However in 2004, Cuboni cilitators from the Asia-Pacific region to organize and et al reported that health research in the Pacific was operationalize the workshop. hithertho driven by non-Fijian researchers, with little local The steering committee proceeded to enlist and engage healthcare professionals’ involvement, processed the data local physicians (largely from primary care clinics and sev- and published them externally and brought meek benefits eral from hospitals) from both the public and private sec- to the communities [4]. tors, academics from universities and research support Five years later in 2009, the inaugural National Health officials (including those from research ethics office) from Systems Research Workshop was organized in conjunc- Ministry of Health to participate in the workshop. They tion with the WHO, Ministry of Health Fiji and the Fiji also enlisted local public health researchers to co-facilitate School of Medicine [5]. This workshop was executed like the workshop. a typical scientific meeting in which participants were Enlisted participants were invited to describe clinical invited to present their research papers for peer review issues encountered in their respective practices or their on-site. A total of 27 papers covering oral health, nurs- areas of research interest using a standardized template, ing to human resource, including only a single paper on highlighting the clinical relevance and significance. They primarycarewerepresented.A SWOT (Strength, submitted to the Fiji College of General Practitioners Weakness, Opportunities and Threats) analysis of the (FCGP) for collation and then emailed to the external workshop was performed which reported heightened facilitators. participants’ interests in research, predominance of External facilitators reviewed these submissions to public health topics, lack of awareness of local research have an overview of the local clinical issues. They used resources and recommended the need to engage the them as resource materials in the workshop to prepare healthcare professionals in the private sector. There was and enable the participants to convert these clinical is- no further progress report in the aftermath of this work- sues into research questions. shop. The absence of a focused research agenda and de- To gain better insight into the healthcare infrastructure, finitive action plan could explain the paucity of progress resources and material for research, the external facilita- to bring this initiative forward. tors visited local healthcare institutions, including private A fresh initiative to accelerate the momentum of re- solo and group primary care clinics, a public primary care search in Fiji was mooted in 2012 when discussion began health center and a district hospital. They rode on the op- at the WONCA Asia Pacific Regional (APR) Conference portunity to interact with local healthcare professionals to in Jeju in South Korea to sponsor a research workshop to appreciate and understand the magnitude and clinical sig- train primary healthcare professionals in Fiji and neigh- nificance of endemic healthcare issues, which helped boring South Pacific nations. With the support and spon- prioritize the key areas of research. sorship of the Fiji Ministry of Health (MOH), the Fiji The 3 external and 7 local facilitators (academics, practi- College of General Practitioners (FCGP) and WONCA tioners, local leaders) met for a briefing to identify local re- APR, the two days “Primary Care Research Workshop” search expertise and resource personals to support the took place in October 2013. novice primary care researchers after the workshop. During workshop Aim Participants were introduced to the scope of primary This article aims to present a proposed 6E model to de- care research at the workshop with reference to the scribe the processes needed to develop the primary care Larry Green’s primary care research model [6]. The ex- research agenda, which is to address the health care ternal facilitators converted the participants’ pre- needs of the local populations and build the research workshop clinical issues into broad potential research capacity of the local research communities, through in- questions and framed them into the domains in the creasing the quantity and quality of research output and Larry Green “Generalist Wheel of knowledge and un- application in Fiji and South Pacific nations. It is hoped derstanding” [6]. The intent was to enable the partici- this proposed model can find applicability in the setting pants to appreciate the wider scope of primary care of national primary care research agendas. research beyond the domain of clinical research in Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 3 of 6 diseases and treatment to the domains of the patients, The team representatives presented their respective pro- their families and the community; the healthcare profes- posals at day 2 of workshop and invited comments and cri- sionals; health service and policy; as well as topics relating tique from peers amongst the audience, with feedback from to the interface between domains such as doctor-patient the external facilitators on the content of the proposal and relationship. input about logistic feasibility from the local facilitators. The external facilitators incorporated the research Each presentation included (1) the relevance and signifi- topics from the pre-workshop submissions into the cance of the research question and topic in relation to gaps workshop modules and presented them to the partici- in the local healthcare context, and (2) the appropriateness pants to contextualize the areas of research interests to of the methodology for each respective research question. local setting. The external facilitators collated the initial research Participants were divided into three teams, each sup- proposals, assembled them into a preliminary research ported by one external and two local facilitators. During agenda, analyzed the content and classified them into h scheduled group discussions, each team of facilitators the domains of the Generalist Wheel of Knowledge. guided the participants through the research process by deliberating on the proposed clinical issues, refining them Results into answerable research questions, choosing appropriate The range of 17 topics proposed by participants collated research design, and developing the research idea into a by external facilitators before the workshop is presented in feasible research proposal. Table 1. Table 2 depicts the 6 short-listed proposals de- The external facilitators provided participants with op- veloped and presented by teams of participants on Day portunities to highlight other or new research ideas and 2 of the workshop. The external facilitators grouped the proposals during informal sessions or refreshment inter- research topics into four research domains based on vals. The participants grouped themselves to form teams Larry Green’s Generalist Wheel of Understanding, in for each proposal. Tables 1and 2[6]. Table 1 Clinical issues proposed by the participants before the workshop Clinical areas Specific clinical issues Research domains Maternal and child health Effectiveness of CTG in the monitoring of maternal labor during childbirth Disease Diagnostic investigations for rheumatic health diseases amongst affected Disease children; issues relating to referral to secondary care Communicable diseases Management of patients with undifferentiated symptoms in early phase Disease of dengue, typhoid and Leptospirosis. Inappropriate use of antibiotics for viral infection such as dengue Disease Accuracy of simple test to diagnose dengue using tourniquet in Disease resource-poor community Management of hemoptysis amongst patients with pneumonia Disease Non-communicable diseases Rising prevalence of hypertension and diabetes mellitus: managing at risk Disease patients with these chronic diseases in rural communities Management of diabetic-related complications in primary care Disease Perception of diabetic patients for their foot care Patient Management of type 2 diabetes mellitus: evidence-based pharmacotherapy Disease Physician management of hypercholesterolemia amongst diabetic patients Disease Management of acute asthma exacerbation: effectiveness of Disease pharmacotherapy at an emergency setting Effectiveness of evidence-based pharmacotherapy to achieve and Disease maintain asthma control Trauma and injuries Epidemiology of road traffic accidents in Cook Islands Disease Alternative medicine Impact of Livomyn on the liver function amongst kava drinkers Disease Training of primary care physicians Patients’ perception of the continuous medical education of their Patient general practitioners Medical defense for primary care physician Mandatory implementation of medical indemnity for general practitioners in Fiji Physician Research Domains as classified in the “Generalist Wheel of Knowledge” [6]. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 4 of 6 Table 2 Research proposals presented by the participants during the workshop Potential lead Team members Research question Proposed research method Research domain Academics and researchers GPs from singleton and What is the prevalence of depression amongst A questionnaire survey of Fijians Disease from university and MOH group practices Fijians aged 18 to 40 years who are managed who consulted primary care clinics in primary care? Academics and researchers Researchers from MOH What is the prevalence of Yaqola (Piper methysticum) A questionnaire survey of Disease from university and MOH (Western division) consumption among high school students in the high school students in Fiji Western Division? Fiji College of General GP and primary care physician (PCP) Amongst primary care physicians (both in public A cross-sectional survey of PCPs Physician Practitioners in public health centers in Fiji and private sectors) in Fiji, what are their treatment in Fiji who managed T2DM patients targets for patients with type 2 diabetes mellitus (T2DM)? Primary care physician PCP in public health centers in What is the association between air pollutants from A prospective study of patients who present Disease Vanuatu and academic from Fiji volcanic eruption and the health of residents on with acute respiratory conditions in one hospital Tanna Island in Vanuatu? and 9 health centers on Tanna Island in relation to local volcanic pollution indicator Primary care physician PCPs from health centers and What is the correlation between the asthma Prospective study of asthma patients in Ba, Disease medical officers from hospital exacerbation rate and pollution from the Cakaudrove and Macuata district on Viti burning of sugarcane plantation? Levu island in Fiji Ministry of Health Medical officers from hospitals What are the factors associated with diagnostic A retrospective study of tuberculosis Primary health care and researchers from disease-specific and treatment delays of patients with active patients who are managed in DOTS and system Fiji College of General public health agency tuberculosis? centres in Fiji Practitioners Research Domains as classified in the “Generalist Wheel of Knowledge” [6]. Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 5 of 6 Discussion workshop (refer to Table 1). The authors postulated Summary of main ideas that time constraint and dynamics of the team and This article describes the development of a national pri- their selection of presenter at the workshop could be mary care research agenda through collaborative efforts possible reasons. by local stakeholders and external facilitators. Tables 1 What is novel is that it presents a plausible model for and 2 show the breath of topics highlighted by the par- understanding of the processes involved in the creation of ticipants, which can be potentially incorporated into the a national primary care research agenda. The processes in- research agenda. However time constraints at the work- volved can be categorized into six essential stages, starting shop limited the number of research proposal presenta- with the alphabet E (Table 3). tions by the teams, which explained the reduction in the This model uses a logical and sequential framework to number of presented proposals. illustrate its development, with the local steering com- The external facilitators condensed the research mittee members played an active role in the first three agenda into four main research domains for ease of con- stages as part of the pre-workshop preparation. The ex- ceptualizing, understanding and further communication ternal facilitators anchored the remaining three stages with local health authority for the latter’ssupport to during the workshop execution. actualize the research endeavor [6]. The research agenda It began with “Entreat” for the steering workgroup also gained a broader perspective using this framework to members to secure support and sponsorship from gov- avoid a skewed focus on clinical research and to ensure a ernmental agency to fund the workshop. The next stage more equitable resource distribution to support research involved their enlistment of the key primary care stake- in the other domains. However, the lack of presentation of holders to participate in the workshop, followed by their any proposal focusing on the patient domain is note- engagement of external and local facilitators to execute worthy, despite such proposal being submitted in the pre- the workshop. Table 3 Developing a research agenda using the six “E” steps Stage Process Illustration Stakeholders Pre-workshop Entreat Local FM leaders form steering group actively seeks official sponsorship from the College of GP, MOH, Academic local Ministry of Health and concerted support from local primary care physicians institution, WONCA experts from the College of General Practitioners and academic staff from FM department in local university. Steering group also entreats external primary care organization such as WONCA to identify regional expertise and sponsor external facilitators to operate the workshop. Enlist The steering group identifies and puts up a list of primary care physicians from Primary care researcher both public and private health sectors with research inclination to be potential participants in a primary care research workshop. Engage The steering group members engage academic staff and established researchers Academic institution, from academic institutions to co-facilitate the research workshop and to provide MOH, WONCA experts input on local resources and expertise to support research. The external facilitators also engage and partner the local researchers and resource personnel (to identify funding sources and to direct to relevant approval agencies such as ethical committee for research) to define specific roles at the workshop and streamlines the program at a pre-workshop briefing. This is to ensure that the program is contextualized to the local healthcare and academic system. At workshop Educe External facilitators educe the participants to identify key local healthcare issues WONCA experts, and form research questions and develop respective research proposals. primary care researcher Participants are encouraged to form research teams to further develop their respective proposals. Empower External facilitators train the participants to apply appropriate research design WONCA experts, MOH, to answer their research questions in their proposal. Local facilitators introduce primary care researchers and highlight local resources and expertise to participants who can potentially assist and support the latter when they proceed with their research project. Participants present and share their proposals to each other for clarifications and mutual understanding. Encapsulate External facilitators collate the research proposals, organize them into a research WONCA experts, agenda and to seek advice from the local FM steering group regarding feasibility. primary care researchers This is followed by classification into broad research domains and identification of key drivers to lead specific areas of research. Lastly, the external facilitators and the workshop participants agreed on the next steps and ways to operationalize the research proposals. WONCA: World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. MOH: Ministry of Health (or National Department of Health equivalent in the respective country). Tan et al. Asia Pacific Family Medicine (2014) 13:17 Page 6 of 6 During the workshop, the external facilitators educed Authors’ contributions LG, CJ and NC conceptualized the program, facilitated the execution of the the participants to identify major healthcare issues of Primary Care Research workshop, analyzed the data and developed the clinical relevance and significance in the local commu- model. WK and RM were the local facilitators and co-designed the workshop. nity. They empowered the participants with the relevant NC wrote the preliminary draft article and all authors contributed to and approved the final manuscript. research skills and guided them to use the appropriate research methodology to bridge the highlighted gaps. Authors’ information During this stage, the local facilitators also availed the NC is the Director of the Department of Research in SingHealth Polyclinics, a public primary care institution with an ACGME accredited Family Medicine participants to the funding resources and expertise to Residency Program in Singapore. CJ is a Professor in the Department of support their research projects. Finally the external facil- Primary Care Medicine in the University of Malaya, who organizes regular itators encapsulated the variety of research proposals de- research related training programs for primary care doctors in Malaysia. RM is the current President of FCGP. WK is the past President FCGP and current veloped during the workshop into easily assimilated honorary secretary in WONCA APR. Both are GPs in Fji. LG is the past President research domains (disease, patient, healthcare profes- WONCA APR and now teaches at another ACGME accredited Family Medicine sionals, and health system) and developed concrete plans Residency Program at the National University Hospital in Singapore. with the participants on ways to operationalize the re- Acknowledgement search proposals. The authors are grateful to the participation and contribution of the delegates at the workshop and the support rendered by Litia, administrator of the FCGP and the research support staff from the Ministry of Health of Fiji. Application for future research The authors were also appreciative to Prof Lee Jung kwon, current President The model can serve as a template for other nations of the WONCA APR for his personal support of the workshop. who are planning to develop their unique community- Author details centric primary care research agenda. It is configured SingHealth Polyclinics, Singapore, 167, Jalan Bukit Merah, #15-10, into six steps, with three as pre-workshop processes and Connection One, Tower 5, Singapore 538134, Singapore. Department of the next three during the workshop. Further evaluation Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Mitchells Clinic (Family Practice), 4th floor Tappoos City is needed to assess its ease of implementation when op- 4 5 Mall, Suva, Fiji. JP Bayly Clinic, Suva, Fiji. Division of Family Medicine, portunity arises for other countries with such intent. National University Hospital System, NUHS Tower Block, 1E, Kent Ridge Road, Level 9, Singapore 119 228, Singapore. Limitations of this study Received: 15 April 2014 Accepted: 11 December 2014 Whether primary care research continues to progress will depend on a multitude of factors such as the dynamics and References perseverance of the research teams, their access to adequate 1. Starfield B, Shi L, Macinko J: Contribution of primary care to health consultancy from local experts and support and sponsor- systems and health. Milbank Q 2005, 83:457–502. ship from the official and other funding agencies. Nonethe- 2. Regional committee for the Western pacific. World Health organization. Health systems strengthening and primary healthcare (2008). less, the participants are primed during the workshop to Accessed on 25 Nov 2013: http://www.wpro.who.int/health_systems/ continue their efforts to translate the proposals into actual wpr59R4_primary_health_care_resolution.pdf projects. The steering group and local facilitators will play a 3. Graham R, Wayne I, Timaima T, Rigieta N, Sisa O, Sheetal S et al. The Fiji islands health system review. (Health Systems in Transition, Vol. 1 No. 1 2011). catalytic role to facilitate this effectuation of the projects ISBN 978 92 9061 543 9 and evaluate the progress of their implementation. 4. Cuboni HD, Finau SA, Wainiqolo I, Cuboni G: Fijian participation in health research: analysis of Medline publications 1965-2002. Pac Health Dialog 2004, 11(1):59–78. Conclusion 5. Ali SS: Fiji National Health Systems Research Workshop report. Pac Health The proposed “six E” model, consisting of “entreat”, “en- Dialog 2009, 15(2):7–12. list”, “engage”, “educe”, “empower”, and “encapsulate”, 6. Green LA: Research domain in Family Medicine. Ann Fam Med 2004, 2:S23–S29. defines the development of the research agenda and pro- vides a staged model that is visible and translatable in building a country’s primary care research agenda. Submit your next manuscript to BioMed Central Abbreviations and take full advantage of: WONCA: World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians; APR: Asia Pacific • Convenient online submission Region; MOH: Ministry of Health; FCGP: Fiji College of General Practitioners; • Thorough peer review GP: General practitioner. • No space constraints or color figure charges • Immediate publication on acceptance Competing interests • Inclusion in PubMed, CAS, Scopus and Google Scholar The workshop was co-sponsored by WONCA Asia Pacific Regional division, Fiji College of General Practitioners and Ministry of Health of Fiji. LG, CJ and NC • Research which is freely available for redistribution received partial sponsorship from the organizers for flight and accommodation expenses during the workshop. The authors declare that there is no further Submit your manuscript at competing interest in the publication of this manuscript. www.biomedcentral.com/submit

Journal

Asia Pacific Family MedicineSpringer Journals

Published: Dec 20, 2014

References