Acceptability and Fidelity Towards Family Doctor Concept Program at Public Primary Care Clinics In Selangor: A Mixed Methods Study

Abstract

The Family Doctor Concept (FDC) program was introduced in Malaysian public primary care clinics in late 2013 for strengthening the primary care delivery system in the country. However, as the program was scaled up and implemented widely, the outcomes and the extent to which it was implemented in various settings varied. The objectives of this study were to measure the level of acceptability and fidelity, determine the factors influencing the program’s acceptability among healthcare workers and the fidelity of FDC program implementation, and to explain the variations. This study used an explanatory, sequential mixed-methods design and took three years to complete from September 2018 to July 2021. The quantitative phase involved a cross-sectional survey that included 261 respondents from six primary care clinics in Selangor. Then, four of the clinics were purposefully selected and followed up to explain the variations in the implementation using the multiple-case study strategy. There was low acceptability in more than half (53.3%) of the respondents. Three factors were significantly associated with acceptability: relative advantage (AOR = 3.712, 95% CI 1.995–6.906), inner setting facilitator (AOR = 4.257, 95% CI 2.203–8.226) and outer setting facilitator (AOR = 2.087, 95% CI 1.116–3.904). Five of the six clinics had low fidelity. Four factors had strong to moderate correlations with fidelity: inner and outer setting barriers (positive correlation), and inner setting facilitators and acceptability (negative correlation). In the qualitative follow-up multiple-case study, four major themes explained the variations: (1) top-down implementation approach; (2) alignment with the existing system; (3) diverse implementation climate; and (4) incongruences along the hierarchical structures. Adaptations for addressing the inner and outer setting barriers and multiple facilitation strategies are crucial for improving the program’s acceptability and fidelity. Program components with low fidelity should be revised to enhance the overall fidelity