Table 1

Cultural adaptions of the UM PDA to develop the SHP PDA

Features (codes)Qualitative feedbacks from primary healthcare providers (verbatim)PDA (UM)PDA (SHP)
Design and presentation
Dimensions and pages





‘If the PDA has more pages, information about ‘insulin therapy’ … (we) can explain each symptom … what happens when your blood sugar is high?’ Doctor20.2×20.2 cm booklet, comprising 16 pages17.3×25.0 cm booklet, comprising 20 pages
Colour schemeInvestigators propose warm colour scheme and align to corporate brandingBlue and green backgroundPredominantly orange background
Key feature on cover page‘The PDA doesn’t really show the pictures of the needle itself.’ DoctorInsulin Pen without revealing the needleA pair of hands showing insulin pen with needle
Font typeThe font type was recommended by designerHelvetica Neue (regular)Futura Std (medium)
Text font size‘The font size could be bigger’ Doctor
‘For old people, they might prefer a bit bigger font.’ Nurse
Font size (height): 10 ptFont size (height): 12 pt
Illustrations‘Pictures of various complications can be added … will be (of) concern of patients’ Doctor
‘some pictures showing how pancreas releases sugar … pictures will be catchy for the patients and they will understand better’ Nurse
Entirely text-based contentPictograms inserted in segments on: ‘what happens when your blood sugar is high?’ and ‘Type 2 Diabetes and Insulin’
Summary Page of Treatment Options‘the flow (diagram) will be more clear’ DoctorPresentation in the form of six branches: each branch represents one treatment optionPresentation in the form of seven cogwheels: each cogwheel represents one treatment option.
Design on page on ‘support’ and ‘decision’‘As in the sort of diagrams like tables …. if possible to put flow chart’ DoctorDesign in the format of leafs with ‘yes‘ and ‘no’ responses as extension of each leaf, which are consistent with the general design of the entire PDA.Design for ‘support’ in the form of machinery and ‘decision’ in two columns
Personal notes‘(make it) personalized - there is an option to write your name, put your IC number, put your primary care provider’ Doctor
‘there should be column for them to write their views’ Doctor
Provision for entry of personal notes at the rear of the PDAProvision for entry of personal notes at the rear of the PDA
Content
Languages‘With regards to the language used, we need to customize to our multi ethnic group needs.’ NurseAvailable in four languagesAvailable in three languages
Listing and number of treatment options‘SGLT2 inhibitors are missing.’ DoctorSix treatment options: no specification of types of oral or parenteral medicationsSeven treatment options. For oral and parenteral medications, specific categories of medication are presented, together with common examples. For example SGLT-2 inhibitors (Example: DapaglfloZin)
Cost of treatment options‘We can state the cost range for the insulin usage. It is quite difficult because the cost fluctuates; the insulin cost and the glucose monitoring glucometer and the strip will fluctuate. You can state as estimated cost. Of course, it is in Ringgit. When reproduce make it into Sing Dollars.’ DoctorRange of costing in Malaysian currency (Ringgit) per unit (pen) or duration (per day or per month)Range of costing in Singapore currency (Singapore dollars), which includes consumables such as needles per 4 weeks based on specific quantum of medication used (10 units of insulin per day). Context: the patient is charged each medication per week.
Glycaemic control targets‘in the local context, people may be followed up somewhere else (hospitals) than polyclinic setting … (to indicate) blood sugar control (page 2) expressed in both millimoles per litre and milligram per litre.’ DoctorTarget in ranges for fasting (4.4–6.1 mmol/L); non-fasting blood sugar (4.4–8.0 mmol/L) and single HbA1c target (<6.5%)Pre-meal glucose range (4–7 mmol/L or 72–126 mg/dL);
2-hour post meal glucose range (<10 mmol/L or <180 mg/dL);
HbA1c target options (6.5% or <7% or<8%)
Highlighting risk of treatment‘not all the common concerns were addressed in the booklet’ Doctor
‘Complications like physical impairment (blindness) … patients cannot see properly to inject. Some people may have tremor, so they cannot hold the needle properly.’ Doctor
‘more can be added about the small side effects of the insulin therapy like atrophy, that kind of skin changes.’ Doctor
Entitled ‘Does insulin have side effects?’ on half a page, focusing on recognising and managing hypoglycaemia and weight gainGrouped under ‘What are your concerns?’ over two pages. Enlist treatment-related concerns on pain from injection; side-effects on kidney (perceived damage); weight gain; hypoglycaemia; lipodystrophy; inconvenience; expenses; discontinuity of insulin; whether insulin is halal; continuity of oral medications; addiction to insulin; necessity of use of insulin; disease progression after insulin initiation; social embarrassment; family support and open option to discuss other concerns, if any.
Understanding of treatment options‘Generally it is sufficient to provide the required information for the patient who we have given the option for the first time to choose their treatment.’ NurseEntitled ‘Do you know enough about the treatment options?’
Assessment using four questions. No answer is provided.
Entitled ‘Quiz Time!’ Assessment using four questions. Answers are provided.
Understanding personal values and preferences in relation to treatment selection‘Page 10 (What is important to you?): I think it is quite useful. It’s a kind of assurance. Patients can go through this booklet and make an effort to answer the questions. So they get to see what this option does and another option does. It clears their mind … to make a decision.’ DoctorPage is entitled ‘What is important to you?’
Presented as three overlapping circles and text in two circles subtitled ‘Starting Insulin’ and ‘Not Starting Insulin’ followed by ‘I want to…’ and ‘I want to avoid…’
Page is entitled ‘What is important to you?’
Presented in two columns entitled ‘I want to…’ and ‘I want to avoid…’
Understanding concerns‘…more on the insulin side-effects; right now it just addresses two only. Actually there may be more than few; the patient may be concerned about ‘Insulin may damage my kidney’, which is not the case; that concern (has to be) addressed.’ DoctorListing of known or common concerns in phrases, including ‘whether insulin is halal’Listing of known or common concerns more succinctly in single words or short phases. ‘Whether insulin is halal’ is not explicitly listed as a concern
  • PDA, patient decision-aid; SHP, SingHealth Polyclinics; UM, University of Malaya.